Based on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#68), of 24 sampled residents. Specifically, the facility failed to ensure the call system was accessible to the Resident to call for staff assistance. Findings include: Review of the facility's policy titled Call System, dated as revised September 2022, indicated but was not limited to: -each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Resident #68 was admitted to the facility in March 2020 with the following diagnoses: dementia, venous insufficiency, and chronic wounds to lower extremities. Review of the Minimum Data Set (MDS) assessment, dated 7/29/24, indicated Resident #68 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated Resident #68 had impaired mobility to both lower extremities. On 9/17/24 at 10:14 A.M., the surveyor observed Resident #68 lying in bed, on his/her right side positioned at an angle with the pillow only partially under his/her head, the call light was hanging against the wall and was not within reach. During an interview on 9/17/24 at 10:15 A.M., Resident #68 said he/she did not have any way of notifying the facility staff that he/she needed help. On 9/17/24 at 2:56 P.M., the surveyor observed Resident #68 lying in bed, the call light was hanging against the wall and was not within reach. On 9/18/24 at 8:22 A.M., the surveyor observed Resident #68 lying in bed, on his/her back with the head of bed elevated, the Resident was closer to the foot of the bed than the head of the bed and the call light was hanging against the wall and was not within reach. On 9/18/24 at 11:22 A.M., the surveyor observed Resident #68 sitting in his/her wheelchair on the right side of the bed, the call light was hanging against the wall (on the left side of the bed) and was not within reach. On 9/19/24 at 1:56 P.M., the surveyor observed Resident #68 lying in bed on his/her right side, the call light was hanging against the wall and was not within reach. On 9/23/24 at 10:26 A.M., the surveyor observed Resident #68 lying in bed on his/her back positioned at an angle closer to the foot of the bed than the head of the bed, the call light was hanging against the wall and was not within reach. During an interview on 9/23/24 at 10:26 A.M., Resident #68 said he/she did not have any way to get help and that he/she would probably just holler. During an interview on 9/23/24 at 10:28 A.M., Rehab Staff #1 said Resident #68 could not reach his/her call light and whoever was with Resident #68 last should have made sure his/her call light was within reach and could have secured it to the railing. During an interview on 9/23/24 at 10:53 A.M., Certified Nursing Assistant (CNA) #4 said residents should always have a call light within reach. During an interview on 9/23/24 at 10:56 A.M., Unit Manager #2 said call lights should always be within reach. During an interview on 9/23/24 at 11:06 A.M., Nurse #4 said call lights should be within reach at all times. On 9/24/24 at 12:32 P.M., the surveyor observed Resident #68 lying in bed on his/her back positioned at an angle, with the pillow only partially under his/her head, the call light was hanging against the wall and was not within reach. During an interview on 9/24/24 at 12:35 P.M., the surveyor and Unit Manager #2 observed Resident #68 without access to his/her call light. Unit Manager #2 said Resident #68 should have his/her call light within reach at all times and maybe he/she should have a hand bell as an alternative. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said call lights should be within reach at all times.

Based on observation, interview, record review, and policy review, the facility failed to review and revise the care plan for one Resident (#31), out of a total sample of 24 residents. Specifically, the facility failed to ensure the care plan was updated to reflect the discontinuation of anticoagulant therapy (medication to break down existing clots or prevent clots from forming). Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised July 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #31 was admitted to the facility in August 2017 and had diagnoses including a history of traumatic fracture and presence of right artificial knee joint. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and did not receive anticoagulant therapy. Review of the medical record indicated Resident #31 had surgery to his/her right knee in June 2023 and had physician's ordered for Eliquis (anticoagulant) 2.5 milligrams (mg), give one tablet by mouth every 12 hours for prophylaxis for deep vein thrombosis (DVT-a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs) for 14 days (initiated 6/26/23). Review of Resident #31's comprehensive care plans indicated but was not limited to: -Focus: Resident is on anticoagulation therapy related to post-surgical right knee replacement (initiated 6/27/23) -Interventions: Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness every shift; Monitor bleeding every shift (initiated 6/27/23) -Goal: Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date (initiated 6/27/23; target date: 10/8/24) Further review of the medical record indicated on 6/27/23, Resident #31 had bleeding from the surgical site and was sent out to hospital for evaluation. The order for Eliquis was discontinued on 6/27/23 and a new order for aspirin enteric coated 81 mg twice daily was initiated for 30 days, from 6/28/23 to 7/26/23. Review of interdisciplinary care plan meeting documentation indicated care plan meetings were held on 11/22/23, 3/6/24, 4/10/24 and 7/24/24 without a revision to the care plan to reflect the discontinuation of Eliquis on 6/27/23. During an interview on 9/23/24 at 2:22 P.M., Unit Supervisor #6 reviewed Resident #31's care plan for anticoagulant therapy. He said 81 mg of aspirin is not considered anticoagulant therapy and the care plan should have been revised to reflect the discontinuation of anticoagulant therapy when the Eliquis was discontinued on 6/27/23.

Based on observations, interviews, and policy review, the facility failed to maintain an environment free of accident hazards. Specifically, the facility failed to ensure smoking material was stored securely for one Resident (#100), out of 17 identified facility smokers, out of 24 sampled residents. Findings include: Review of the facility's policy titled Smoking Policy & Procedure, undated, indicated but was not limited to: -[Facility Name] shall establish and maintain safe resident smoking practices. -No lighters or matches will be retained in the possession of the residents. -All lighting material will be kept with staff to be given out to independent smokers as they go out and shall be returned to the designated area once done with your cigarette, either at the front desk or nurses' station. -Staff will ensure smoking materials are stored safely. Review of the facility provided list of residents who smoke indicated Resident #100 was an independent smoker. Resident #100 was admitted to the facility in April 2024 with the following diagnoses including peripheral vascular disease and hypertension. Review of Resident #100's medical record indicated smoking assessments were completed on 6/25/24 and 4/26/24 which indicated the Resident could smoke independently. During an interview on 9/19/24 at 10:10 A.M., Resident #100 said he/she stores his/her lighter in their locked bedside drawer. During an interview on 9/24/24 at 12:57 P.M., Resident #100 said he/she keeps his/her lighter in their room. During an interview on 9/24/24 at 1:24 P.M., Unit Supervisor #6 said lighters are kept at the front desk. Unit Supervisor #6 said he believed that independent smokers could keep their own smoking materials, including lighters, in their rooms. During an observation with interview on 9/25/24 at 9:05 A.M., the surveyor observed Resident #100 returning to his/her room from smoking. Resident #100 said he/she had their lighter on their person and he/she kept it close. During an interview on 9/25/24 at 11:00 A.M., the Director of Nursing (DON) said she expected independent smokers to store lighting materials at the front desk and not in a resident's room or on their person. During an interview on 9/25/24 at 11:01 A.M., the front desk secretary said she has one lighter, securely stored, for residents who smoke. The front desk secretary said Resident #100 sometimes has his/her own lighter and does not use the secured lighter stored at the front desk. The front desk secretary said she did not exchange a lighter with Resident #100 today. On 9/25/24 at 1:05 P.M., the surveyor observed Resident #100 coming out of the elevator, bypassing the front desk, and going straight to the outdoor smoking area. The surveyor observed Resident #100 retrieve a lighter from his/her personal bag and light his/her cigarette.

Based on record review and interview, the facility failed to assess a history of trauma and failed to assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#31), with a history of trauma, out of a total sample of 24 residents. Findings include: Resident #31 was admitted to the facility in April 2022 with diagnoses including schizoaffective disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD- occurs in some individuals who have encountered a shocking, scary, or dangerous situation). Review of the Minimum Data Set (MDS) assessment, dated 7/12/24, indicated that Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had PTSD. Review of the facility's consultant psychiatric service provider's documentation indicated the clinician identified trauma as one of the areas of focus for the therapy sessions on 5/22/24, 6/13/24, and 6/19/24. Review of the medical record indicated Resident #31's diagnosis of PTSD was identified in social service progress notes dated 8/2/23 and 11/14/23. However, further review of the medical record failed to indicate that neither an assessment for trauma nor a care plan with individualized interventions for the prevention of potential re-traumatization had been developed. During an interview on 9/24/24 at 2:10 P.M., Certified Nursing Assistant (CNA) #7 said he is not aware Resident #31 had any past trauma. During an interview on 9/24/24 at 2:24 P.M., Nurse #9 said she is not aware Resident #31 had any past trauma. During an interview on 9/25/24 at 10:10 A.M., Social Worker #1 said they don't do PTSD or trauma assessments. She said she has mentioned the lack of assessment tools to the administration and was told they would look into it, but it has never been implemented. She said she usually develops a care plan for residents with PTSD but must have missed it for Resident #31. The Social Worker said she is aware Resident #31 has a diagnosis of PTSD but does not know any specifics about the trauma or any triggers to prevent re-traumatization of the Resident.

Based on interview and record review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two Residents (#10 and #69), out of a total sample of 24 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendations to obtain labs in order to help assess the efficacy of medications. Findings include: Review of the facility's policy titled Medication Regimen Review (MRR), dated as revised May 2019, indicated but was not limited to: -the consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports -the attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it -copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record 1. Resident #10 was admitted to the facility in August 2023 with diagnoses which included dementia and hyperlipidemia (high cholesterol). Review of Resident #10's medical record indicated he/she was seen by the Consultant Pharmacist in March 2024 and recommendations were made. Further review of Resident #10's medical record indicated no documented evidence of a March 2024 MRR. After inquiry, the facility provided Resident #10's March 2024 MRR which indicated recommendations to obtain a Valproic Acid (used to treat seizure disorders) Level, Liver Function Tests (LFTs), and a Vitamin D level in order to assess efficacy and potential side effects of medication use. Further review of the March 2024 MRR indicated the physician/prescriber response section was blank. During an interview on 9/19/24 at 11:57 A.M., Unit Manager #2 said the MRR reports were sent from the Consultant Pharmacist to the Executive Director or the Director of Nurses (DON) who then gave them to the prescriber. Unit Manager #2 said the prescriber should review the MRR and sign the form with their response. During an interview on 9/23/24 at 12:50 P.M., the DON said the facility did not provide the physician/provider with Resident #10's March MRR until last week and it had not been implemented prior to that. 2. Resident #69 was admitted to the facility in November 2019 with diagnoses which included dementia and heart disease. Review of Resident #69's medical record indicated he/she was seen by the Consultant Pharmacist in February 2024 and recommendations were made. Further review of Resident #69's medical record indicated no documented evidence of a February 2024 MRR. After inquiry, the facility provided Resident #69's February 2024 MRR which indicated recommendations to obtain LFTs, a Vitamin B12 level, and a folate level in order to assess efficacy and potential side effects of medication use. Further review of the February 2024 MRR indicated the physician/prescriber response section was blank. During an interview on 9/23/24 at 5:00 P.M., the DON said Resident #69's February MRR had not been provided to the provider.

Based on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed for one Resident (#173), out of a total sample of 24 residents, to ensure medicated mouthwash was not left unsecured and unattended in the Resident's room. Findings include: Review of the facility's policy titled Medication Labeling and Storage, dated 2001, indicated but was not limited to the following: Medication Storage - The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Resident #173 was admitted to the facility in July 2024 with diagnoses including presence of a gastrostomy (feeding tube). Review of the Minimum Data Set (MDS) assessment, dated 7/17/24, indicated Resident #173 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, and had a feeding tube. Review of Physician's Orders indicated but was not limited to: -Chlorhexidine Gluconate Mouth/Throat Solution 0.12%, give 10 milliliters by mouth one time a day (7/15/24) On 9/20/24 at 10:22 A.M., the surveyor observed a 16-ounce bottle of prescription Chlorhexidine Gluconate mouthwash on Resident #173's overbed table. The Resident said earlier that morning, he/she told the nurse that he/she didn't want the mouthwash that day, and the nurse left it on the table. According to the National Capital Poison Center (poison.org), Chlorhexidine is not well absorbed when swallowed, and some stomach irritation or nausea is typically all that will occur after ingestion of small amounts. However, serious adverse effects can occur when larger amounts of chlorhexidine are swallowed. During an interview on 9/20/24 at 10:31 A.M., Nurse #6 picked up the prescription mouthwash off the overbed table in Resident #173's room and said she should not have left it at the Resident's bedside. During an interview on 9/23/24 at 2:22 P.M., Unit Supervisor #6 said the prescription mouthwash should have been securely stored and not left out at the Resident's bedside.

Based on observation, record review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for two Residents (#19 and #112), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #19, to document weekly comprehensive skin assessment per physician orders; and 2. For Resident #112, to ensure a diagnosis of allergic dermatitis from adhesives, diagnosed by the facility's consultant wound physician, was prominently documented in the medical record as an allergy. Findings include: 1. Review of the facility's policy titled Prevention of Pressure Injuries, last revised April 2020, indicated but was not limited to: - Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. - Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat risk assessment weekly and upon any changes in condition. 1. Resident #19 was admitted to the facility in January 2024 with diagnoses including peripheral vascular disease (a slow and progressive disorder of the blood vessels) and diabetes mellitus. Review of Resident #19's current Physician's Orders indicated but was not limited to: - Weekly Skin Assessment every evening shift every Fri (Friday) open assessments tab to complete BHCC - Skin Assessment, dated 1/3/2024 Review of Resident #19's July, August, and September Treatment Administration Records (TAR) indicated a nurse had signed off weekly skin checks as being completed on 7/5/24, 7/12/24, 7/19/24, 7/26/24, 8/2/24, 8/9/24, 8/16/24, 8/23/24, 8/30/24, 9/6/24, 9/13/24, and 9/20/24. Further Review of Resident #19's medical record failed to indicate a weekly skin check assessment form had been filled out on the following days: - 7/12/24 - 7/19/24 - 7/26/24 - 8/2/24 - 8/23/24 - 9/13/24 - 9/20/24 During an interview on 9/24/24 at 8:58 A.M., Unit Supervisor #6 said skin checks are completed weekly. Unit Supervisor #6 said the nurse assigned to a resident would sign off on the TAR that a skin check was completed, then the nurse would fill out skin assessment utilizing the Skin Assessment user defined assessment. Unit Supervisor #6 reviewed Resident #19's TAR and user defined assessments and said Resident #19 was missing numerous skin assessments and should not be missing them. During an interview with record review on 9/25/24 at 3:32 P.M., the Director of Nursing (DON) said skin checks are completed weekly on shower days and should be signed off on the TAR and a skin assessment should be completed. The DON reviewed Resident #19's TAR and skin assessments and said Resident #19 did have his/her weekly skin checks signed off on the TAR, but he/she was missing some skin assessments. 2. Resident #112 was admitted to the facility in January 2024 with a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe (trachea) to allow air to flow into the lungs). Review of the medical record included a wound evaluation and management summary, dated 4/3/24, from the facility's consultant wound physician. The physician's evaluation note indicated the Resident had a rash at the tracheostomy site and diagnosed the rash as allergic dermatitis to adhesives. The note indicated the patient's plan of care was discussed with a nursing staff member and clinical documentation for this consultation was made available for access to the appropriate personnel and placement in the medical record. Further review of the medical record failed to indicate Resident #112's allergic dermatitis for adhesives was added to the medical record as an allergy. During an interview on 9/23/24 at 2:22 P.M., Unit Supervisor #6 reviewed the consultant wound physician's 4/3/24 note and said the diagnosis of allergic dermatitis to adhesives should have been added to Resident #112's allergy list so the attending physician and Nurse Practitioner/Physician's assistant would be aware of the allergy. During an interview on 9/25/24 at 9:29 A.M., Physician's Assistant #1 said he was not aware that Resident #112 had an allergy to adhesives. He said if the allergy is not documented under allergies in the medical record, there is no way he would know about it.

3. Resident #14 was admitted to the facility in May 2023 with diagnoses including major depressive disorder, anxiety, and psychosis. Review of Resident #14's MDS assessment, dated 8/1/24, indicated Resident #14 had a moderate cognitive impairment as evidenced by staff assessment for mental status. Further review of the MDS indicated Resident #14 had received antidepressant and antipsychotic medications daily. a. Review of Resident #14's current Physician's Orders indicated but was not limited to: - Duloxetine (antidepressant) 30 mg capsule, give 1 capsule by mouth two times a day (dated 5/30/23) - Remeron (antidepressant) 15 mg, give 15 mg by mouth at bedtime (6/3/24) Review of Resident #14's August and September MARs indicated he/she received Duloxetine and Remeron as ordered. Review of Resident #14's care plan included but was not limited to: - Focus: Resident #14 uses antidepressant medication r/t (related to) depression (date initiated 8/22/23) - Goal: Resident #14 will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (date initiated 8/22/23) - Interventions: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift (date initiated 8/22/23) Further review of Resident #14's medical record indicated the facility failed to implement Resident #14's care plan to monitor potential side effects of antidepressant medications. During an interview on 9/24/24 at 12:43 P.M., Nurse #2 said Resident #14 was receiving antidepressant medication but was not being monitored for side effects of antidepressant medication. b. Review of Resident #14's current Physician's Orders indicated but was not limited to: - Olanzapine (antipsychotic medication) 2.5 mg, Give 1 tablet at bedtime (date 10/20/23) Review of Resident #14's August and September MARs indicated he/she received Olanzapine as ordered. Review of comprehensive care plans failed to indicate Resident #14 was prescribed antipsychotic medication and failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 9/25/24 at 10:10 A.M., Social Worker #1 said nursing is responsible for developing care plans for psychotropic medication. She said she develops care plans for mood, behaviors, advanced directives, discharge planning and psychosocial needs. During an interview on 9/25/24 at 3:32 P.M., the DON said any resident on an antipsychotic medication should have a care plan for the medication. The DON reviewed Resident #14's care plans and said he/she did not have a care plan for an antipsychotic medication. 4. Resident #2 was admitted to the facility in October 2021 with diagnoses including major depressive disorder. Review of Resident #2's MDS assessment, dated 9/9/24, indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated Resident #2 had received antipsychotic medications. Review of Resident #2's current Physician's Orders indicated but was not limited to: - Vraylar (antipsychotic) 1.5 mg, Give 1 capsule one time a day (date 6/10/2024) Review of comprehensive care plans failed to indicate Resident #2 was prescribed antipsychotic medication and failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 9/25/24 at 3:32 P.M., the DON said any resident on an antipsychotic medication should have a care plan for the medication. The DON reviewed Resident #2's care plans and said he/she did not have a care plan for an antipsychotic medication but should have one. Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for four Residents (#5, #112, #14, and #2), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #5, a comprehensive care plan was developed and implemented to address the Resident's constipation; 2. For Resident #112, a comprehensive care plan was developed to address the use of antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; 3. For Resident #14, a comprehensive care plan was a. implemented to monitor for adverse consequence (side effects) of antidepressant medications; and b. developed for an antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; and 4. For Resident #2, a comprehensive care plan was developed for an antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised July 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The IDT includes, but is not limited to the resident's attending physician. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The comprehensive, person-centered care plan: -includes measurable objectives and timeframes; -describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -includes the resident's stated goals upon admission and desired outcomes; -builds on the resident's strengths; -reflects currently recognized standards of practice for problem areas and conditions -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Resident #5 was admitted to the facility in May 2021 with diagnoses including gastroesophageal reflux disease (GERD-chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach). Review of the medical record indicated Resident #5 was sent to the hospital on three occasions within eight months and was treated for conditions including a new diagnosis of constipation: -On 1/10/24, Resident #5 was admitted to the hospital with nausea, coffee ground emesis (vomit that appears like coffee grounds due to presence of old, coagulated blood in the gastrointestinal tract) and abdominal pain. Review of hospital documentation, including the patient visit information and discharge summary, indicated Resident #5 had an abdominal computed tomography scan (CT scan-a medical imaging procedure that uses a combination of X-rays and computer technology to produce detailed images of the inside of your body) that revealed a moderate to large amount of solid colonic stool. The Resident was treated for constipation and discharged back to the facility on 1/11/24 with a new order for Polyethylene glycol (laxative used to treat constipation by softening hard stools or stimulating the bowels) 17 grams (gm) daily. Review of the Minimum Data Set (MDS) assessment, dated 1/10/24, indicated Resident #5 had a new diagnosis of constipation. Review of the medical record failed to indicate a comprehensive care plan that included a plan of care with measurable objectives and timeframes was developed and implemented for the Resident's new diagnosis of constipation. -On 7/1/24, Resident #5 was admitted to the hospital with vomiting dark colored vomit. An endoscopy (involves passing a tiny lighted camera down the throat, through the esophagus and into the stomach) was performed and revealed a food bezoar (large ball of undigested food in the stomach). The food bezoar was removed, the Resident was treated for constipation and discharged back to the facility on 7/5/24. Discharge medications included but were not limited to the following laxatives: bisacodyl 10 milligram (mg) suppository daily as needed; lactulose 10 gm packet, one packet three times a day as needed (if no bowel movement (BM) for greater than 1 day); Senna 8.6 mg take two tablets two times a day, and Polyethylene glycol 17 gm, take 17 gm daily. Instructions listed on the discharge paperwork indicated the Resident should have at least one soft bowel movement every day. Review of the medical record failed to indicate a comprehensive care plan that included interventions, measurable objectives and timeframes was developed and implemented for the Resident's ongoing diagnosis of constipation. -On 8/20/24, Resident #5 was transferred to the hospital with nausea and vomiting. Review of the hospital patient visit information indicated a CT scan was performed and showed the Resident had constipation and was treated. The Resident returned to the facility the same day with discharge instructions for Resident #5 to increase the frequency of administration of Polyethylene glycol 17 gm to twice daily. Review of comprehensive care plans failed to indicate a person-centered comprehensive care plan that included a plan of care with measurable objectives and timeframes was developed and implemented for the Resident's ongoing diagnosis of constipation. During an interview on 9/24/24 at 1:28 P.M., Unit Supervisor #6 reviewed Resident #5's medical record including comprehensive care plans and said there was no care plan in place to address the Resident's diagnosis of constipation. He said a care plan should have been developed and include the plan of care to treat the Resident's constipation. 2. Resident #112 was admitted to the facility in January 2024 and had diagnoses including dementia with agitation, depression, and anxiety. Review of the most recent MDS assessment, dated 7/3/24, indicated Resident #112 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15, and received antipsychotic medication daily. Review of Resident #112's medical record indicated Physician's Orders for the following antipsychotic medication: Zyprexa 2.5 mg, give 2.5 mg three times a day (1/9/24); and Zyprexa 5.0 mg, give 5.0 mg at bedtime (1/9/24) Review of January 2024 through September 2024 Medication Administration Records (MAR) indicated Zyprexa 2.5 mg and 5.0 mg were administered as ordered by the physician. Review of comprehensive care plans failed to indicate Resident #112 was prescribed antipsychotic medication and failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 9/25/24 at 10:10 A.M., Social Worker #1 said nursing is responsible for developing care plans for psychotropic medication. She said she develops care plans for mood, behaviors, advanced directives, discharge planning and psychosocial needs. During an interview on 9/25/24 at 3:32 P.M., the Director of Nursing (DON) reviewed Resident #112's care plan and said a care plan had not been developed for his/her use of antipsychotic medication. She said a care plan should have been developed for his/her use of antipsychotic medication that included resident specific targeted behaviors, resident specific interventions, non-pharmacological approaches, and measurable goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #19 was admitted to the facility in January 2024 with diagnoses including peripheral vascular disease, end stage renal disease (ESRD) and diabetes mellitus. Review of the MDS assessment, dated 7/3/24, indicated Resident #19 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of Resident #19's current Physician's Orders indicated but was not limited to: - Arterial wound of the left shin Wash W (with) NS (normal saline) pat dry, apply calcium alginate (a dressing used to treat wounds because it absorbs drainage and forms a gel that helps promote healing), cover w (with) gauze island. Apply skin to periwound area. Every evening shift AND as needed (dated 8/30/2024) Review of Resident #19's September TAR indicated his/her lower extremity treatments had been completed per physician's orders. Review of Resident #19's Wound Evaluation Management and Summary Report, dated 9/11/24, indicated the recommended treatment included but were not limited to: -Arterial wound of the left shin: xeroform gauze, followed by gauze island dressing once daily. Treatment to the peri wound: skin prep once daily. Review of Resident #19's Wound Evaluation Management and Summary Report, dated 9/18/24, indicated the recommended treatment included but were not limited to: -Arterial wound of the left shin: xeroform gauze, followed by gauze island dressing once daily. Treatment to the periwound: skin prep once daily. During an interview on 9/24/24 at 8:58 A.M., Nursing Supervisor #6 said the Wound Consultant would come in on Wednesdays and would complete wound rounds with the DON or designee. Nursing Supervisor #6 said the DON would then receive the recommendations from the Wound consultant and would follow-up with the physician. During an interview with record review on 9/24/24 at 3:32 P.M., the DON and surveyor reviewed Resident #19's current physician orders and recommendations form the Wound Consultant date 9/11/24 and 9/18/24. The DON said the recommendations from the Wound Consultant should have been reviewed with the Physician and been implemented. During a telephonic interview on 9/25/24 at 3:18 P.M., Wound Consultant #1 said his expectation was for his recommendations to be implemented. 4. Resident #73 was admitted to the facility in May 2021 with diagnoses including cellulitis of the left lower limb and peripheral venous insufficiency. Review of the MDS assessment, dated 9/19/24, indicated Resident #73 had moderate cognitive impairment as evidenced by staff assessment for mental status. Review of Resident #73's current Physician's Orders indicated but was not limited to: -Non-Pressure wound of the left, dorsal (back of), first toe: wash with NS (normal saline) pat dry, apply skin prep three times daily, (dated 8/9/24, discontinued on 8/15/24) Review of Resident #73's Wound Evaluation Management and Summary Report, dated 8/4/24, indicated the recommended treatment included but was not limited to: -Skin prep apply Q-shift (every shift) Review of Resident #73's Wound Evaluation Management and Summary Report, dated 8/7/24, indicated the recommended treatment included but was not limited to: -Skin prep apply Q-shift During an interview on 09/24/24 at 12:43 P.M., Nurse #2 said the Wound Consultant would come in weekly on Wednesdays and could be available accessible via phone in between visits if needed. Nurse #2 said the Wound Consultant would do rounds with the DON and me. Nurse #2 said the wound doctor would give a verbal recommendation and then would send the written consultation into the resident's electronic medical record. Nurse #2 said the DON or nurse supervisor will follow up with the doctor and put the order into the resident's medical record. During an interview on 9/24/24 at 3:32 P.M., the DON and surveyor reviewed Resident #73's August physician's orders and recommendations from the Wound Consultant dated 8/4/24 and 8/7/24. The DON said the recommendations from the Wound Consultant should have been reviewed with the Physician and been implemented. During a telephonic interview on 9/25/24 at 3:18 P.M., Wound Consultant #1 said his expectation was for his recommendations to be implemented. 5. Resident #85 was admitted to the facility in July 2022 with the following diagnoses ESRD, dependence on renal dialysis, and diabetes mellitus. Review of Resident #85's MDS assessments, dated 4/18/24 and 6/28/24, indicated he/she was discharged to the hospital with return anticipated. Review of Resident #85's Nursing Progress Note, dated 4/18/24, indicated he/she was transferred to the emergency department. Review of Resident #85's Nursing Progress Note, dated 6/28/24, indicated he/she was transferred to the hospital. Review of Resident #85's Order Listing Report for 4/1/24 through 9/25/24 failed to indicate an order to transfer him/her to the hospital on 4/18/24 or 6/28/24. During an interview on 9/25/24 at 11:48 A.M., Nurse #1 said when a resident is sent out to the hospital, the nurse would call the Physician/NP and obtain an order to send the resident to the hospital and then put the order into the resident's medical record. During an interview on 9/25/24 at 3:32 P.M., the DON reviewed Resident # 85's medical record and physician's orders and said there was no order to transfer Resident #85 to the hospital on 4/18/24 or 6/28/24. The DON said a physician's order should be obtained when a Resident is transferred to the hospital. [NAME], [NAME] R. 6. Review of the facility's policy titled Change in a Resident's Condition or Status, dated as revised February 2021, indicated but was not limited to the following: -Policy Statement: our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (for example, changes in level of care, billing/payments, resident rights, etc.). -The nurse will notify the resident's attending physician or physician on call when there has been a: i. specific instruction to notify the physician of changes in the resident's condition. Resident #76 was admitted to the facility in April 2023 with diagnoses that included Type 2 Diabetes Mellitus (a condition in which the body does not produce enough insulin and has trouble controlling blood sugar levels) with unspecified diabetic retinopathy, diabetic neuropathy, End Stage Renal Disease, and dependence on renal dialysis. Review of Resident #76's MDS assessment, dated 6/18/24, indicated Resident #76 received insulin injections. Review of Resident #76's active Physician's Orders included but were not limited to the following: -Insulin Glargine Subcutaneous Solution Pen-injector 100 units/milliliter (mL). Inject 7 units subcutaneously every 12 hours related to Type 2 diabetes mellitus (T2DM) with unspecified diabetic retinopathy without macular edema; Active 9/9/24. -Insulin Lispro Injection Solution 100 units/mL. Inject 3 units subcutaneously two times a day every Monday, Wednesday, Friday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/16/24. Insulin Lispro Injection Solution 100 units/mL. Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451 - 999 = 12 units Call Medical Doctor (MD) if blood sugar (BS) is greater than 450, subcutaneously two times a day every Monday, Wednesday, Friday related to T2DM with unspecified diabetic retinopathy without macular edema and Inject 3 units subcutaneously two times a day every Monday, Wednesday, Friday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/16/24. Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/mL - Inject 3 units subcutaneously with meals every Tuesday, Thursday, Saturday, Sunday related to T2DM with unspecified diabetic retinopathy without macular edema and Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ = 12 units; 451 and higher administer 12 units and call MD; subcutaneously with meals every Tuesday, Thursday, Saturday, Sunday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/17/24. Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 units/mL. Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ = 12 units; 451 and higher administer 12 units and call MD; subcutaneously with meals every Tuesday, Thursday, Saturday, Sunday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/17/24. May perform finger stick to obtain blood for blood sugar before meals and at bedtime; Active 9/16/24. Insulin Lispro Injection Solution. Inject 6 units subcutaneously every 6 hours as needed for hyperglycemia 400 and above. Notify MD; Active 10/9/23. Insulin Lispro Injection Solution. Inject 6 units subcutaneously one time only related to T2DM with unspecified diabetic retinopathy without macular edema until 9/23/24 23:59. Administer 6 units subcutaneously one time only for elevated blood sugar; Active 9/23/24. Further review of Resident #76's past Physician's orders included but were not limited to the following: -Active 8/25/24-9/16/24: Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/mL Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ = 12 units; 451 and higher administer 12 units and call MD, subcutaneously with meals related to T2DM with unspecified diabetic retinopathy without macular edema. Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/mL. Inject 3 units subcutaneously with meals related to T2DM with unspecified diabetic retinopathy without macular edema. -Active 8/25/24-9/8/24: Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/mL. Inject 5 units subcutaneously every 12 hours related to T2DM with unspecified diabetic retinopathy without macular edema. -Active 7/13/24-8/25/24: Insulin Lispro Injection Solution 100 UNIT/mL. Inject as per sliding scale if: 150 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; call MD if BS is greater than 400; Subcutaneously with meals related to T2DM without complications. Insulin Lispro Injection Solution 100 UNIT/mL. Inject 3 units subcutaneously with meals related to Type 1 Diabetes Mellitus with hypoglycemia without coma. -Active 7/12/24-8/25/24: Insulin Glargine Subcutaneous Solution 100 UNIT/mL. Inject 5 units subcutaneously every 12 hours related to T2DM without complications. Insulin Lispro Injection Solution 100 UNIT/mL. Inject as per sliding scale if: 200 - 250 = 1 unit; 251 - 300 = 2 units; 301 - 350 = 3 units; 351 - 400 = 4 units; call MD if blood sugar (BS) is greater than 400; Subcutaneously at bedtime related to T2DM without complications. -Active 4/8/23-9/16/24: May perform finger stick to obtain blood for blood sugar before meals and at bedtime. Review of Resident #76's Medication Administration Record (MAR) for July 2024, August 2024, and September 2024 indicated the following blood sugar values: 9/16/24 at 6:00 A.M., BS = 460; 8/29/24 at 4:30 P.M., BS = 451; 8/25/24 at 12:00 P.M., BS = 500; 8/5/24 at 11:30 A.M., BS = 450; 7/1/24 at 9:00 P.M., BS = 594; 7/1/24 at 4:30 P.M., BS = 445. Further review of Resident #76's medical record did not indicate there was documentation that the Physician was notified of the elevated BS value. During an interview on 9/24/24 at 10:30 A.M., Nurse #3 and Nurse #10 said when a resident's blood sugar values are above the threshold indicated in the physician's order, they notify the Physician and document the notification in the Nursing Progress notes. During an interview on 9/25/24 at 2:57 P.M., the DON said she could not find documentation in Resident #76's medical record that the Physician was notified of elevated blood sugars for the dates above, but she expects nurses to document that the Physician was notified. 7. Resident #92 was admitted to the facility in April 2023 with diagnoses that included cerebral infarction, dysphagia (difficulty swallowing), and gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach for feeding or drainage) status. Review of Resident #92's MDS assessment, dated 9/2/24, indicated Resident #92 had a feeding tube. Review of Resident #92's active Physician's Orders included but were not limited to the following: -Enteral Feed, every shift, Jevity 1.5 calorie formula to run at 50 milliliters (mL) per hour continuous; Active 5/12/24. -Enteral: Check Residual every 4 hours, if residual is greater than or equal to 100 hold feed and call MD; Active 4/16/2024. Review of Resident #92's MAR indicated but was not limited to the following: 9/14/24 at 4:00 P.M., gastric residuals (GR) = 100; 9/05/24 at 4:00 P.M., GR = 100; 9/02/24 at 4:00 P.M., GR = 240; 8/31/24 at 8:00 P.M., GR = 100; 8/25/24 at 8:00 P.M., GR = 100; 8/14/24 at 4:00 P.M., GR = 100; 8/13/24 at 4:00 P.M., GR = 240; 7/29/24 at 8:00 P.M., GR = 100; 7/14/24 at 8:00 P.M., GR = 100. Review of Resident #92's medical record failed to indicate there was documentation that the Physician was notified of gastric residuals at or above 100. During an interview on 9/24/24 at 9:40 A.M., Nurse #9 said if Resident #92's gastric residuals were over 100, then the tube feeding is held and the Physician is notified. Nurse #9 said a Nursing Progress note is then written to document the Physician notification. During an interview on 9/25/24 at 4:30 P.M., the DON said she reviewed Resident #92's medical record and did not see Nursing Progress notes or documentation indicating the Physician was notified of gastric residuals at or above 100 from July 2024 through September 2024. The DON said she expects nursing to document they notified the Physician. 2. Resident #68 was admitted to the facility in March 2020 with the following diagnoses: dementia, venous insufficiency, and chronic wounds to lower extremities. Review of the Minimum Data Set (MDS) assessment, dated 7/29/24, indicated Resident #68 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Review of Resident #68's Physician's Orders indicated but were not limited to: -Left lower extremity vascular wound: wash with normal saline, pat dry, apply xeroform (sterile wound dressing that is non-adherent), cover with ABD pad (an absorbent pad) and wrap with kerlix (bandage roll), every day shift, dated 9/17/24 and discontinued 9/19/24 -Lymphademic (sic) wound (wound related to chronic lymphedema, also known as lymphoedema and lymphatic edema, a condition of localized swelling caused by a compromised lymphatic system) of the right shin: wash with normal saline, apply xeroform, cover with ABD pad and wrap with kerlix, every day shift, dated 9/20/24 -Lymphademic wound of the left shin: wash with normal saline, apply xeroform, cover with ABD pad and wrap with kerlix, every day shift, dated 9/20/24 Review of Resident #68's September Treatment Administration Record (TAR) indicated his/her lower extremity treatments had been completed per physician orders. Review of Resident #68's Wound Evaluation and Management Summary Report, dated 9/16/24, indicated the recommended treatment included but were not limited to: -Lymphademic wound of the left shin: skin prep (liquid that when applied to the skin forms a protective film or barrier) apply every shift -Lymphademic wound of the right shin: xeroform gauze apply once daily, followed by an ABD pad apply once daily, gauze roll (kerlix) daily and an ACE bandage once daily. Treatment to the periwound (skin surrounding the wound): skin prep apply once daily. Review of Resident #68's Wound Evaluation and Management Summary Report, dated 9/18/24, indicated the recommended treatment included but were not limited to: -Lymphademic wound of the left shin: xeroform gauze apply once daily, followed by an ABD pad apply once daily, gauze roll (kerlix) daily and an ACE bandage once daily. Treatment to the periwound: skin prep apply once daily. During an interview on 9/23/24 at 3:38 P.M., Nurse #5 said the Wound Consultant saw residents weekly on Wednesdays and the Director of Nurses (DON) or another facility nurse completed wound visits with him. Nurse #5 said if there were new recommendations they were verbalized during wound rounds and documented on the wound evaluation and management summary report. Nurse #5 said the nurse conducting wound rounds followed up with Wound Consultant recommendations. During an interview on 9/24/24 at 1:00 P.M., Unit Manager #2 said Resident #68 was followed by the Wound Consultant due to his/her chronic lower extremity wounds. Unit Manager #2 said the DON or another nurse conducted wound rounds with the Wound Consultant and followed through with his/her wound recommendations. Unit Manager #2 reviewed Resident #68's Wound Evaluation and Management Summary Reports, dated 9/16/24 and 9/18/24, and compared them to the current physician's orders. Unit Manager #2 said not all the recommended components had been implemented. During an interview on 9/24/24 at 1:35 P.M., the DON said wound rounds were conducted weekly with the Wound Consultant. The DON said the Wound Consultant verbally makes recommendations but also provides a Wound Evaluation and Management Summary Report which included his assessment and recommendations. The DON reviewed the 9/16/24 and 9/18/24 Wound Evaluation and Management a Summary Reports and the DON said she was not sure why all the recommended components were not implemented when the new orders were transcribed and she must have missed parts of it. Based on observation, interview, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for seven Residents (#5, #68, #19, #73, #85, #76 and #92), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Residents #5, medication reconciliation process was conducted thoroughly and included all medications approved by the physician upon readmission to the facility, and as needed (PRN) interventions implemented according to physician's orders to potentially prevent hospital intervention to treat constipation, and failed to consistently monitor the Resident's response to interventions to prevent constipation; 2. For Resident #68, all components of wound recommendations were implemented; 3. For Resident #19, implement recommendations from the Wound Consultant; 4. For Resident #73, implement recommendations from the Wound Consultant; 5. For Resident #85, obtain a physician's order for transfer to the hospital; 6. For Resident #76, to notify the Physician when the Resident's blood sugar reading was greater than 400 or 451; and 7. For Resident #92, to notify the Physician when the Resident's gastric residual (a volume of fluid remaining in the stomach at a point in time during enteral feeding) reading was greater than or equal to 100. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Pursuant to Massachusetts General Law (M.G.L.), 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 (CMR) 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. 1. Review of the facility's policy titled Bowel (lower gastrointestinal tract) disorders-clinical protocol, last revised September 2017, indicated but was not limited to: -Treatment/Management: The physician will identify and order pertinent cause-specific and symptomatic interventions; for example, institute a regimen to prevent constipation. -Monitoring and Follow-Up: the staff and physician will monitor the individual's response to interventions and overall progress for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc. Review of the facility's policy titled Reconciliation of Medications on Admission, dated 2001, indicated but was not limited to: -The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. -Preparation: Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form b. Discharge summary from referring facility. c. admission order sheet d. All prescription and supplement information obtained from the resident/family during the medication history; and e. Most recent medication administration record (MAR), if this is a readmission. General Guidelines: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. -Medication reconciliation helps to ensure that all medications, routes, and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. -Medication reconciliation helps to ensure that medications, routes, and dosages have been accurately communicated to the Attending Physician and care team. Resident #5 was admitted to the facility in May 2021 with diagnoses including gastroesophageal reflux disease (GERD- chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach). Review of the medical record indicated Resident #5 was sent to the hospital on three occasions within an eight-month period of time and was treated for constipation in the hospital: -On 1/10/24, Resident #5 was admitted to the hospital with nausea, coffee ground emesis (vomit that appears like coffee grounds due to presence of old, coagulated blood in the gastrointestinal tract), and abdominal pain. Review of the hospital documentation including the patient visit information and discharge summary indicated Resident #5 had an abdominal and pelvic computed tomography scan (CT scan-a medical imaging procedure that uses a combination of X-rays and computer technology to produce detailed images of the inside of your body) for evaluation of abdominal pain and vomiting. The results revealed a mild distal esophageal wall thickening, and likely a small epiphrenic esophageal diverticulum (an outpouching or pocket that develops on the inside of your esophagus) as well as moderate to large amount of solid colonic stool without gastrointestinal obstruction. The Resident was treated for constipation and discharged back to the facility on 1/11/24 with new orders including, but not limited to Polyethylene glycol (laxative used to treat constipation by softening hard stools or stimulating the bowels) 17 grams (gm) daily. Review of January 2024 Physician's Orders indicated but was not limited to: -Polyethylene glycol 17 gm/scoop daily, give one scoop one time a day for constipation (1/12/24) Review of the January 2024 Medication Administration Record (MAR) indicated the Polyethylene glycol was administered as ordered by the physician. Review of January 2024 bowel and bladder documentation (every shift) failed to indicate staff documented the Resident's bowel movements in monitoring his/her response to laxative treatment for 38 out of 93 shifts. -On 7/1/24, Resident #5 was admitted to the hospital with vomiting dark colored vomit. The hospital after visit summary indicated an endoscopy (involves passing a tiny lighted camera down the throat, through the esophagus and into the stomach) was performed and found no signs of bleeding in the esophagus or stomach. The imaging revealed a food bezoar (large ball of undigested food in the stomach), and it was removed. The summary indicated a concern that the Resident's bowels may not be moving very well, causing constipation. The Resident was given medication to help him/her have a bowel movement and was discharged back to the facility on 7/5/24. Discharge medications included but were not limited to the following laxatives: bisacodyl 10 milligram (mg) suppository daily as needed; lactulose 10 gm packet, one packet three times a day as needed (if no bowel movement (BM) for greater than 1 day); Senna 8.6 mg take two tablets two times a day, and Polyethylene glycol 17 gm, take 17 gm daily. Instructions listed on the discharge paperwork indicated the Resident should have at least one soft bowel movement every day. Review of a Nursing Progress Note, dated 7/5/24 and written by Unit Supervisor #6, indicated Resident #5 returned from the hospital, medications were reviewed, confirmed, and approved with Nurse Practitioner #1 who was on-call for the Resident's attending Physician. Review of July 2024 Physician's Orders indicated but was not limited to: -Polyethylene glycol 17 gm/scoop daily, give one scoop one time a day for constipation (1/12/24) -Bisacodyl Rectal Suppository 10 mg, insert 10 mg rectally as needed for constipation daily (7/5/24) -Lactulose Oral Solution 10 gm/15 milliliters (ml), give 15 ml by mouth every 8 hours as needed for constipation, no BM >1 a day (7/5/24) The physician's orders failed to include Senna 8.6 mg, two tablets two times a day and failed to include the correct dosage identified on the hospital's discharge medication list: lactulose 10 gm packet, one packet three times a day as needed. Review of the July 2024 MAR indicated the Polyethylene glycol was administered as ordered by the physician. Review of July 2024 bowel and bladder documentation and July 2024 MAR indicated Resident #5: -had no BM for six consecutive days (from 7/6/24 to 1/12/24) and was not administered PRN laxative medication according to physician's orders -had no BM for three consecutive days (from 7/12/24 to 1/15/24) and was not administered PRN laxative medication according to physician's orders -had no BM for three consecutive days (from 7/28/24 to 7/30/24) and was not administered PRN laxative medication according to physician's orders Further review of the July 2024 bowel and bladder documentation failed to indicate staff documented the Resident's bowel movements in monitoring his/her response to laxative treatment for 26 out of 78 shifts. On 8/13/24, a new order was initiated for Bisacodyl (stool softener) Oral Tablet Delayed Release 5 mg, give one tablet by mouth at bedtime every other day for constipation. Review of the August MAR indicated the Polyethylene glycol and Bisacodyl every other day was administered as ordered by the physician. Review of August 2024 bowel and bladder documentation and August 2024 MAR indicated Resident #5: -had no BM for two consecutive days (from 8/15/24 and 8/16/24) and was not administered PRN laxative medication according to physician's orders -had no BM on 8/18/24 and was administered PRN lactulose on 8/19/24 -On 8/20/24, Resident #5 was transferred to emergency department for evaluation of nausea and vomiting. Review of the hospital patient visit information indicated a CT scan was performed and the Resident was found to be constipated and was treated. The Resident returned to the facility the same day with discharge instructions for Resident #5 to increase the frequency of administration of Polyethylene glycol 17 gm to twice daily. Review of August 2024 physician's orders indicated, but was not limited to: -Polyethylene glycol 17 gm/scoop daily, give one scoop two times a day for constipation (8/6/24) -Bisacodyl Rectal Suppository 10 mg, insert 10 mg rectally as needed for constipation daily (7/5/24) -Lactulose Oral Solution 10 gm/15 ml, give 15 ml by mouth every 8 hours as needed for constipation, no BM >1 a day (7/5/24) Review of the August 2024 MAR indicated Polyethylene glycol 17 gm twice daily was administered as orderd by the physician. Review of August 2024 bowel and bladder documentation indicated Resident #5: -had no BM for two consecutive days (from 8/21/24 and 8/22/24) and was not administered PRN laxative medication according to physician's orders On 8/23/24, the physician order for Bisacodyl Delayed Release 5 MG was changed to be administered daily. Further review of the August 2024 bowel and bladder documentation indicated Resident #5: -had no BM for four consecutive days (from 8/27/24 and 8/30/24) and was not administered PRN laxative medication according to physician's orders. Further review of the August 2024 bowel and bladder documentation failed to indicate staff documented the Resident's bowel movements in monitoring his/her response to laxative treatment for 28 out of 93 shifts. During interviews on 9/19/24 at 1:04 P.M. and 9/24/24 at 1:28 P.M., Unit Supervisor #6 said the process for medication reconciliation is that the receiving nurse calls the on-call Nurse Practitioner (NP) and reviews all medications listed on the discharge paperwork. He reviewed Resident #5's medical record and said he was the nurse that did the medication reconciliation when he/she was readmitted from the hospital. He said he reviewed all of the medications and instructions on the discharge paperwork with the NP over the phone and she approved it. He said he entered the orders into the computer. However, he said he entered the lactulose order inaccurately, missed entering the order for Senna and did not enter instructions that Resident #5 should have at least one soft bowel movement every day. Unit Supervisor #6 said that Resident #5 should have received the PRN laxative medication every time he/she did [TRUNCATED]

Based on observation and interviews, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents residing on one Unit (3A), out of four units in the facility. Specifically, the facility failed to ensure residents were involved in activities. Findings include: Review of the facility's policy titled Activity Programs, last revised June 2018, indicated but was not limited to: -The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities -Activities are considered any endeavor, other than routine activities of daily living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance, physical, cognitive or emotional health -Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting cleanup and critique of the programs -Activities are not necessarily limited to formal activities being provided only by activities staff On the following days of survey, the surveyor made the following observations of the 3A Unit Resident Lounge (activity/dining room): -9/17/24 at 10:20 A.M., 15 residents with one staff member present who was sitting in the corner of the room not engaging with the residents, the television was on but none of the residents were looking in the direction of the television, with no evidence of meaningful activity -9/17/24 at 11:12 A.M., 16 residents with one staff member present who was sitting in the corner of the room not engaging with the residents, the television was on but none of the residents were looking in the direction of the television, with no evidence of meaningful activity -9/17/24 at 2:46 P.M., 10 residents with two staff members present in the room not engaging with the residents, the television was on, with no evidence of meaningful activity -9/17/24 at 4:46 P.M., nine residents with two staff members present in the room not engaging with the residents, the television was on with no evidence of meaningful activity -9/18/24 at 11:23 A.M.,16 residents with two staff members in room, 4 of 16 residents were eating/drinking cookies and coffee, the television was on, staff not engaging with the residents, with no evidence of meaningful activity -9/18/24 at 3:29 P.M.,12 residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television, with no evidence of meaningful activity -9/19/24 at 8:20 A.M., six residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television, with no evidence of meaningful activity -9/19/24 at 1:55 P.M., seven residents with two staff members present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television with no staff engagement and no evidence of meaningful activity -9/23/24 at 10:06 A.M.,11 residents with one staff member present in the room not engaging with the residents, the television was on, 2 of 11 residents were independently completing their weekly menu, 9 of 11 residents with no evidence of meaningful activity -9/23/24 at 3:36 P.M., 11 residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television; 1 of 11 residents was repeatedly banging on the table in front of him/her, with no evidence of meaningful activity -9/23/24 at 4:25 P.M., 14 residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television, with no evidence of meaningful activity -9/24/24 at 12:33 P.M., seven residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television; and 1 of 7 residents repeatedly rubbing circles on the table in front of him/her, with no evidence of meaningful activity On the following days of survey, the surveyor made the following observations of the 3A Nurses' Station Hallway/Corridor, not in the Resident Lounge: -9/17/24 at 4:46 P.M., eight residents some of whom were talking amongst themselves with no staff engagement and no evidence of meaningful activity -9/19/24 at 1:55 P.M., six residents with no staff engagement, with no evidence of meaningful activity During an interview on 9/17/24 at 10:14 A.M., Resident #68 said there was not much to do as far as activities go and he/she stayed in bed most of the time. During an interview on 9/17/24 at 10:28 A.M., Resident #273 said he/she did not do much during the day; he/she said the facility had not provided him/her with activities. During an interview on 9/17/24 at 10:37 A.M., Resident #75 said he/she was not offered activities. During an interview on 9/17/24 at 11:07 A.M., Resident #117 said the facility had an activity department but never do what was scheduled. Resident #117 said he/she was not invited to attend activities off the unit. During an interview on 9/17/24 at 3:34 P.M., Resident Representative #1 said Resident #90 was always observed in his/her bed and never in the activity room. Resident Representative #1 said when she visits the facility the residents in the activity room are just sitting and were never involved in an activity. During an interview on 9/23/24 at 10:50 A.M., Certified Nursing Assistant (CNA) #3 said the CNAs rotate in the activity room every 30 minutes to make sure the residents are safe. During an interview on 9/23/24 at 10:53 A.M., CNA #4 said the staff take turns watching the residents in the activity/dining room to make sure they are safe. During an interview on 9/23/24 at 11:06 A.M., Nurse #4 said the 3A Residents receive activities during the coffee social and there will sometimes be music in the room. Nurse #4 said some of the residents leave the unit for activities. Nurse #4 said there was always a CNA in the room to make sure they were safe. During an interview on 9/24/24 at 1:15 P.M., Unit Manager #2 said the 3A unit activities consist of a coffee social in the morning. Unit Manager #2 said the staff tried to encourage residents to attend activities on the 2BC Unit. Unit Manager #2 said the facility could be doing more activities with the residents. During an interview on 9/24/24 at 11:14 A.M., the Activity Director said the activity department consisted of herself, one activity assistant and 2 activity aides. The Activity Director said the role of the activity assistant was mostly paperwork and administrative and the activity aide conducted the activities. The Activity Director said for residents who do not attend activities on other units she tried to visit them at least monthly to offer books or other activities. The Activity Director said the 3A Unit has a monthly game of Shaboom (a musical version of bingo), the coffee social daily, and there is always an activity on Saturdays at 11 A.M. During an interview on 9/24/24 at 2:23 P.M., the Administrator said the Activity Department needed some enhancements and the facility should be offering more than they were.

Based on observations, interviews, and record review, the facility failed to implement nutritional interventions as ordered to maintain acceptable parameters of nutritional status for one Resident (#90), with an unplanned gradual weight loss, in a total sample of 24 residents. Specifically, the facility failed to provide as needed nutritional supplements when his/her meal intake was less than 50% as ordered. Findings include: Resident #90 was admitted to the facility in February 2022 with the following diagnoses: dementia, adult failure to thrive, and moderate protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/26/24, indicated Resident #90 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS indicated Resident #90 was 63 inches, weighted 95 pounds, had experienced weight loss and was not on a prescribed weight loss regimen. Review of Resident #90's medical record indicated he/she had progressive weight loss as evidenced by the following weights: -1/08/24 = 110.4 pounds (sitting) -2/08/24 = 108.4 pounds (sitting) -3/04/24 = 105.2 pounds (sitting) -4/05/24 = 101.6 pounds (sitting) -5/05/24 = 100.4 pounds (sitting) -5/07/24 = 101.2 pounds (sitting) -6/03/24 = 100.1 pounds (sitting) -7/05/24 = 95.9 pounds (sitting) -7/19/24 = 95.2 pounds (sitting) -7/26/24 = 95.0 pounds (sitting) -8/06/24 = 96.6 pounds (sitting) -9/09/24 = 93.6 pounds (both sitting and standing) -9/24/24 = 94.0 pounds (wheelchair) Review of Resident #90's dietary note, dated 8/31/24, indicated but was not limited to: -Resident with varied oral intake consumes 0 to 75% of meals per staff records. Receives a no added salt diet, soft and bite size texture thin liquids, red lip plate, super cereal at breakfast, house shakes offered with poor oral intake. House nutrition supplement eight ounces three times per day. Review of Resident #90's Physician's Orders indicated but were not limited to: -House Supplement every eight hours as needed for poor meal percentage, 120 milliliters (ml) to be provided for meal intake of less than 50% as needed three times per day, dated 2/25/22 Review of the August 2024 Documentation Survey Report indicated Resident #90 consumed 0-25% of his/her meal on 38 occasions. Review of the August 2024 Medication Administration Record (MAR) failed to indicate evidence that the as needed house supplement was provided to Resident #90 on all 38 occasions. Review of the September 2024 Documentation Survey Report indicated Resident #90 consumed 0-25% of his/her meal on 25 occasions. Review of the September 2024 MAR failed to indicate evidence that the as needed house supplement was provided to Resident #90 on all 25 occasions. During an interview on 9/24/24 at 12:21 P.M., Nurse #7 said Resident #90 had a poor appetite and eats his/her meals in the unit dining room so that cueing could be provided. Nurse #7 said Resident #90 gets a house supplement three times per day as ordered and receives additional supplements if he/she asks for them. Nurse #7 said she was not sure about the as needed house supplement order. During an interview on 9/24/24 at 1:06 P.M., Unit Manager #2 said Resident #90 was currently 94 pounds and has been followed by the dietitian due to continued weight loss. Unit Manager #2 reviewed Resident #90's medical record and said he/she has current orders for a house supplement three times per day and an as needed order. Unit Manager #2 said when Resident #90 consumed less than 50% of his/her meal the facility should be offering house supplement and documenting it in the MAR. During an interview on 9/24/24 at 11:52 A.M., the Dietitian said she has been following Resident #90 due to gradual weight loss. The Dietitian said Resident #90 had orders for house supplement eight ounces three times per day and an additional order for house supplement if he/she consumed less than 50% of his/her meal. The dietitian said she would expect the supplements to be provided as ordered but did not monitor the documentation and administration of the as needed supplements. During an interview on 9/25/24 at 9:29 A.M., Physician Assistant (PA) #2 said Resident #90 had documented weight loss despite orders for pharmaceutical aids and nutritional supplements being in place. PA #2 said the expectation was for all nutritional interventions to be implemented as ordered and the facility should follow the current treatment plan. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said the resident has been followed for his/her weight loss for a while. The DON reviewed Resident # 90's medical record and said the Resident has scheduled and as needed orders for a nutritional supplement. The DON said the administration of the as needed house supplement should be provided as ordered and documented in the medical record.

2. Resident #76 was admitted to the facility in April 2023 with diagnoses including ESRD and dependence on renal dialysis. Review of Resident #76's MDS assessment, dated 6/18/24, indicated Resident #76 received dialysis services. Review of the Nursing Home Dialysis Transfer Agreement, dated as revised April 2016, indicated but was not limited to the following: -Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to the Center. This information shall include, but is not limited to, where appropriate, the following: e) treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet or fluid intake. h) any other information that will facilitate the adequate coordination of care as reasonably determined by Center. Resident #76's Dialysis Communication Book contained several Dialysis Communication Records, which are forms filled out by both the facility and the dialysis center as a means to relay clinical information and coordinate care for the Resident. During an interview on 9/24/24 at 9:23 A.M., Nurse #3 and the surveyor reviewed Resident #76's Dialysis Communication Record, dated 9/23/24, together. Nurse #3 said the section titled Facility to Complete Prior to Dialysis was incomplete as 3 out of 14 fields were blank. Nurse #3 said nursing should be completing Facility to Complete Prior to Dialysis or Day of Dialysis (Pre-Dialysis) sections, depending on the communication sheet that was used, and the section should be completed in its entirety. Nurse #3 said this included checking any applicable boxes, the nurse's signature, and the time the Resident left for dialysis. Nurse #3 also said one Dialysis Communication Records sheet was to be completed each time Resident #76 left the facility for dialysis. Review of a sample of the Resident's Dialysis Communication Record sheets, specifically the sections titled Complete Prior to Dialysis or Day of Dialysis (Pre-Dialysis), dated from 8/2/24 through 9/23/24, indicated but was not limited to the following: 8/2/24- 4 of 10 fields not completed; 8/5/24- 14 of 14 fields not completed; 8/7/24- 8 of 14 fields not completed; 8/9/24- 5 of 14 fields not completed; 8/10/24- 14 of 14 fields not completed; 8/12/24- 14 of 14 fields not completed; 8/14/24- Review of two Medication Administration notes, both dated 8/14/24, stated Resident #76 was at dialysis. No Dialysis Communication Record sheet for this date was observed in the Resident's medical record; 8/16/24- 5 of 14 fields not completed; 8/19/24- 14 of 14 fields not completed; 8/21/24- 4 of 14 fields not completed; 8/23/24- 4 of 14 fields not completed; 8/26/24- Review of a Nursing Progress note, dated 8/26/24, stated Resident #76 returned from dialysis that day at 10:30 A.M. No Dialysis Communication Record sheet for this date was observed in the Resident's medical record; 8/28/24- 7 of 10 fields not completed; 8/30/24- 5 of 14 fields not completed; 9/2/24- 10 of 14 fields not completed; 9/4/24- 1 of 10 fields not completed; 9/6/24- 2 of 10 fields not completed; 9/9/24- Review of four Medication Administration notes, all dated 9/9/24, stated Resident #76 was at dialysis; no Dialysis Communication Record sheet for this date was observed in the Resident's medical record; 9/13/24- 1 of 14 fields not completed; 9/16/24- 14 of 14 fields not completed; 9/17/24- 9/21/24- Resident was on Medical Leave of Absence (MLOA) from the facility; 9/23/24- 3 of 14 sections not completed. During an interview on 9/25/24 at 10:36 A.M., the DON and the surveyor reviewed several of Resident #76's Dialysis Communication Records sheets from the month of August. The DON said the section titled Facility to Complete Prior to Dialysis or Day of Dialysis (Pre-Dialysis), depending on which communication form was used, should be entirely completed including all applicable boxes checked, a nurse's signature, and the time the Resident left for dialysis. The DON said the weight field was the only acceptable field to remain empty. The DON said the reviewed Dialysis Communication Record sheets from the month of August were incomplete. The DON also said she expected a communication sheet to be completed fully (minus the weight section) each time Resident #76 left the facility for dialysis. Based on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#19 and #76), out of 24 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Review of the facility's policy titled Care of a Resident with End-Stage Renal Disease, last revised September 2010, indicated but was not limited to: -Policy Statement with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of practice. -Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b) how information will be exchanged between the facilities. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Pursuant to Massachusetts General Law (M.G.L.), 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 (CMR) 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. 1. Resident #19 was admitted to the facility in January 2024 with diagnoses including end stage renal disease (ESRD) and diabetes mellitus. Review of Minimum Data Set (MDS) assessment, dated 7/3/24, indicated Resident #19 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Further review of the MDS indicated Resident #19 had received dialysis. Review of Resident #19's current Physician's Orders indicated but was not limited to: - Dialysis Center T (Tuesday)/TH (Thursday)/SAT (Saturday) one time a day every Tue, Thu, Sat for Dialysis Center- dated 1/30/24 - Sevelamer Carbonate (medication used to lower phosphorus levels in the blood) 800 milligrams (mg), Give 3 tablets with meals- dated 5/10/2024 Review of Resident #19's Dialysis Communication Book indicated a recommendation from the dialysis center Dietitian dated 9/12/24 but was not limited to: - Please hold phosphorus binder Sevelamer due to low phos (phosphorus) 2.3 per MD (medical doctor) Further review of Resident #19's Dialysis Communication Book indicated on 9/10/24 he/she had a phosphorus level of 2.3 mg (milligrams)/dL(deciliter). Review of Resident #19's nurses note, dated 9/12/24 indicated but was not limited to: - Resident returned from dialysis with a request from the MD to hold Sevelamer due to low phos (2.3). No stop date noted. Further Review of Resident #19's medical record failed to indicate the Physician or Physician Extender was notified of the recommendation and review of the Medication Administration Record (MAR) indicated Sevelamer had been administered for 18 extra doses. During an interview on 9/19/24 at 3:05 P.M., Nurse #19 said when a resident returns from dialysis the nurse is responsible for checking his/her dialysis communication book and communicating the recommendations to the Physician/Nurse Practitioner (NP). During an interview on 9/19/24 at 3:06 P.M., Unit Supervisor #6 reviewed Resident #19's dialysis communication book and medical record and said the dialysis recommendations were not reported to the Physician/NP and were not followed-up on. During an interview on 9/19/24 at 3:19 P.M., the Director of Nursing (DON) reviewed Resident #19's dialysis recommendations from 9/12/24 and his/her medical record. The DON said the Physician/NP should have been notified of the recommendations and implemented if ordered by the Physician/NP. During an interview on 9/25/24 at 8:58 A.M., NP #1 said she was not notified of the recommendation from the dialysis center and if she had been then she would have implemented it. During a telephonic interview on 9/25/24 at 12:42 P.M., NP #3 said she was not notified of the recommendations from the dialysis center.

Based on record review and interview, the facility failed to ensure that as needed (prn) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for three Residents (#31, #112, and #173), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #31, that the prn order for Ativan (antianxiety) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; 2. For Resident #112, that the prn order for Valium (hypnotic) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; and 3. For Resident #173, that the prn order for Valium was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use. Findings include: Review of the facility's policies titled Psychotropic Medication Use and Antipsychotic Medication Use, last revised July 2022, indicated but were not limited to: -Residents will not receive prn doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. -The need to continue prn orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the prn order will be indicated in the order. 1. Resident #31 was admitted to the facility in April 2022 with diagnoses including anxiety. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, and received psychotropic medication daily. Review of Physician's Orders indicated but was not limited to: -Ativan 0.5 milligrams (mg) every four hours as needed for anxiety (9/3/24) During an interview on 9/25/24 at 8:58 A.M., Nurse Practitioner #1 said she is aware that prn orders for psychotropic medications must be limited to 14 days but had not been notified by the facility yet that the order was open-ended. She said she would follow up with nursing. 2. Resident #112 was admitted to the facility in January 2024 with diagnoses including dementia with agitation, depression, and anxiety disorder. Review of the MDS assessment, dated 7/3/24, indicated Resident #112 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15, and received psychotropic medication daily. Review of Physician's Orders indicated, but was not limited to: -Valium 5 mg every six hours as needed (6/6/24) Review of the June 2024 through September 2024 MARs indicated Valium was administered: -June 2024: Five times -July 2024: Five times -August 2024: Seven times -September 2024: Eight times Review of the entire medical record failed to indicate the prn orders for Valium from June 2024 through September 2024 were re-evaluated and a clinical rationale for its continued use was documented in the medical record by either the Physician (MD) or Nurse Practitioner (NP). During an interview on 9/23/24 at 2:22 P.M., Unit Supervisor #6 said the prn order for Valium should have a stop date, but it was missed. During an interview on 9/25/24 at 8:58 A.M., Physician Assistant #2 said he is aware of the requirement for prn orders to have a stop date and documented clinical rationale for continued use and Resident #112's order should have a stop date. 3. Resident # 173 was admitted to the facility in July 2024 with diagnoses including anxiety. Review of the MDS assessment, dated 7/17/24, indicated Resident #173 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, and received psychotropic medication daily. Review of Physician's Orders indicated but was not limited to: -Diazepam (Valium) 2 mg as needed daily for anxiety (8/9/24) Review of August 2024 and September 2024 MAR indicated Valium was administered: -August: three times -September: four times Review of the entire medical record failed to indicate the prn orders for Valium from August 2024 through September 2024 were re-evaluated and a clinical rationale for its continued use was documented in the medical record by either the Physician (MD) or Nurse Practitioner (NP). During a telephonic interview on 9/27/24 at 12:51 P.M., Physician #2 said he was not aware that prn orders for psychotropic medication are limited to 14 days and a clinical rationale must be documented in the medical record to extend the prn order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, test tray results, and interview, the facility failed to ensure staff served food that was palatable and at an appetizing temperature for 1 out of 2 test trays conducted. Findings include: During the initial resident screening on 9/17/24, the residents expressed the following concerns about the food at the facility: - Food usually comes up cool - Food is always cold - Food usually comes up cool, even the hot foods - The food is cold sometimes. - Food is often cold; the facility has a tough time controlling that - Food is often cold Review of Food Committee Meeting Minutes, dated 8/27/24, indicated but was not limited to: - French fries are cold Review of Food Committee Meeting Minutes, dated 7/31/24, indicated but was not limited to: - Hard boiled eggs are sometimes undercooked Review of Food Committee Meeting Minutes, dated 4/23/24, indicated but was not limited to: - Food Temps (temperatures) inconsistent On 9/19/24 at 11:53 A.M., the surveyor requested a lunch test tray to the 2A Unit. The food truck left the kitchen at 11:55 A.M., and arrived at the unit at 11:57 A.M. The test tray was conducted with the Food Service Director (FSD) at 12:12 P.M. with the following results in degrees Fahrenheit (F): - Pasta [NAME]: 134 F lukewarm to taste - Broccoli: 132.6 F cold to taste - Garlic Bread: 113 F cold to taste - Cranberry Juice: 53 F cold to taste/touch During an interview on 9/19/24 at 12:20 P.M., the FSD said the temperatures were not within the appropriate ranges, and the hot items should have been hotter for the residents. The FSD said that they have been having a hard time keeping hot foods hot. The FSD said he conducts a test tray maybe monthly.

Based on observations, interviews, and policy review, 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 maintain the ice machine in a clean and sanitary manner in three out of four kitchenettes. Findings include: Review of the facility's policy titled Ice Machines and Ice Storage Chests, undated, indicated but was not limited to: - Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. - Policy Interpretation and Implementation: - Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to manufacturer's instructions. The infection preventionist (or designee) maintains a copy of these procedures. On 9/17/24 at 10:37 A.M., the surveyor observed the following in the 2A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. - Ice Maker Cleaning Schedule posted indicated the months of January, February, March, April, May, June, July, August, and September were blank. On 9/17/24 at 10:57 A.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. - Ice Maker Cleaning Schedule was not posted. On 9/17/24 at 12:26 P.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/17/24 at 12:36 P.M., the surveyor observed the following in the 2A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/17/24 at 12:39 P.M., the surveyor observed the following in the 1A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. - Ice Maker Cleaning Schedule posted last signed off January 2024. The months of February, March, April, May, June, July, August, and September were blank. On 9/17/24 at 3:14 P.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/18/24 at 7:13 A.M., the surveyor observed the following in the 2A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/18/24 at 7:15 A.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. During an interview on 9/17/24 at 12:40 P.M., Certified Nursing Assistant (CNA) #1 said the ice machine is used for the residents. CNA #1 said the ice was given to the residents in their water or as ice chips. During an interview on 9/17/24 at 3:35 P.M., Nurse #19 said the ice from the ice machine was used for the residents, to give them a cup of ice water, ice chips, or to fill the water pitcher used for medication pass. During an interview with observation on 9/17/24 at 12:45 P.M., the Food Service Director (FSD) said the ice machines were checked monthly but were not cleaned monthly. The FSD said the ice machines on the 1A, 2A, and 2BC units were dirty and not as clean as they should have been. The FSD director said he did not know how to clean the ice machines or who was responsible for cleaning them. During an interview on 9/17/24 at 1:41 P.M., the Director of Operations said the expectation is for the ice machines to have been checked monthly and the Ice Maker Cleaning Schedule log to have been filled out. The Director of Operations said he was not sure who was responsible for cleaning the ice machines, either housekeeping or dietary was responsible. During an interview on 9/24/24 at 3:35 P.M., the Administrator said the facility did not have a procedure for cleaning the ice machines but there should have been one.

E. Resident #19 was admitted to the facility in January 2024 with diagnoses including peripheral vascular disease, end stage renal disease (ESRD), and diabetes mellitus. Review of Resident #19's medical record indicated he/she had an arterial wound to his/her left shin and was followed by the wound consultant. On the following dates of survey, the surveyor did not observe an EBP sign on the Resident 19's bedroom door, or anywhere in the immediate vicinity of the Resident's room, and no PPE was available outside or inside the room for staff to use in the event the Resident should require assistance: - 9/17/24 10:22 A.M. - 9/18/24 12:04 P.M. - 9/19/24 12:54 P.M. - 9/19/24 2:47 P.M. - 9/23/24 11:13 A.M. - 9/24/24 8:42 A.M. - 9/24/24 9:14 A.M. Review of Resident #19's entire medical record failed to indicate an order for EBP for high contact resident care activities. During an interview on 9/24/24 at 9:14 A.M., Nurse #13 said any resident with an open wound should be on EBP but was not. During an interview on 9/25/24 at 3:32 P.M., the DON said she could not speak to EBP because the facility had not implemented them yet in the facility. Refer to 882 Based on observation, interview, and policy review, for five Residents (#68, #173, #112, #31, and #19), of 24 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for the following Residents: A. For Resident #68, who has chronic wounds, putting him/her at increased risk for infection; B. For Resident #173, who has wounds and a gastrostomy tube; C. For Resident #112, who has a gastrostomy tube and a tracheostomy; D. For Resident #31, who has an indwelling urinary catheter; and E. For Resident #19, who has a wound, putting him/her at increased risk for infection. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. -EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing -EBP are indicated for residents with any of the following: a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO -EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, indicated but was not limited to: -EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply a. gloves and gown are applied prior to performing the high contact resident care activity -Examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care -EBP are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization -Signs are posted in the door or wall outside the resident room indicating the type of precaution and PPE required -PPE is available outside of the residents' rooms A.Resident #68 was admitted to the facility in March 2020 with the following diagnoses: venous insufficiency and chronic wounds to lower extremities. Review of Resident #68's medical record indicated he/she had chronic wounds to his/her lower extremities and was followed by the wound consultant. On the following dates of survey, the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room, and no PPE was available outside or inside the room for staff to use in the event the Resident should require assistance: -9/17/24 at 10:14 A.M. -9/17/14 at 2:56 P.M. -9/18/24 at 8:22 A.M. -9/18/24 at 11:22 A.M. -9/19/24 at 1:56 P.M. -9/23/24 at 10:26 A.M. -9/23/24 at 4:08 P.M. -9/24/24 at 8:05 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 positioning Resident #68 in bed. CNA #5 was wearing only gloves as PPE. -9/24/24 at 12:32 P.M. -9/24/24 at 12:55 P.M., the surveyor observed two facility staff members transferring Resident #68 from his/her bed to chair. The staff members were wearing only gloves as PPE. Review of Resident #68's Physician's Orders failed to indicate he/she was on EBP. During an interview on 9/24/24 at 12:21 P.M., Nurse #7 and Nurse #4 said there were no residents on that unit requiring any precautions in addition to standard precautions. Nurse #7 and Nurse # 4 said they did not know what EBP was and did not know when or why they would be required. During an interview on 9/24/24 at 12:57 P.M., Unit Manager #2 said Resident #68 did have chronic wounds but was not on any precautions. Unit Manager #2 said she was not aware of EBP. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said Resident #68 had chronic wounds to his/her bilateral lower extremities and was followed by the wound consultant weekly. The DON said Resident #68 did not require any precautions in addition to standard precautions because he/she was not infected with a MDRO. The DON said the EBP program had not been implemented. B. Resident #173 was admitted to the facility in July 2024 with diagnoses including multiple third degree burns on his/her body, and a gastrostomy tube (feeding tube). Review of the Minimum Data Set (MDS) assessment, dated 7/17/24, indicated Resident #173 had multiple unhealed pressure ulcers, surgical wounds and burns. Review of the medical record indicated Resident #173 was receiving treatment for multiple pressure ulcers, wounds, and gastrostomy tube. Review of the entire medical record failed to indicate an order for EBP for high contact resident care activities. C. Resident #112 was admitted to the facility in January 2024 and had diagnoses including presence of a gastrostomy and a tracheostomy. Review of the MDS assessment, dated 7/3/24, indicated Resident #112 had a gastrostomy and tracheostomy. Review of the medical record indicated Resident #112 was receiving care and treatment for a gastrostomy tube and tracheostomy. Review of the entire medical record failed to indicate an order for EBP for high contact resident care activities. D. Resident #31 was admitted to the facility in August 2017 and had diagnoses including a history of urinary tract infections and urinary retention. Review of the MDS assessment, dated 7/2/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had an indwelling urinary catheter. Review of the medical record indicated Resident #31 was receiving care and treatment for a urinary catheter. Review of the entire medical record failed to indicate an order for EBP for high contact resident care activities. On 9/20/24 at 10:13 A.M., the surveyor observed CNA #6 standing at Resident #31's bedside, the privacy curtain was drawn halfway alongside the bed exposing the Resident's legs. The CNA was observed providing a sponge bath to the Resident's legs while wearing gloves and no gown. The surveyor did not observe an EBP sign on the Residents #173, #112 and #31's bedroom doors, or anywhere in the vicinity of the Residents' rooms, no personal protective equipment was available outside or inside the Residents' rooms for staff to use for high contact resident care activities on the following occasions: -9/18/24 at 9:00 A.M. and 12:00 P.M. -9/19/24 at 1:06 P.M. -9/20/24 at 10:00 A.M. -9/23/24 at 2:10 P.M. -9/24/24 at 7:30 A.M. and 2:00 P.M. -9/25/24 at 10:30 A.M. During an interview on 9/24/24 at 1:57 P.M., Nurse #13 said residents with wounds or indwelling medical devices should be on EBP. She said she doesn't know why Residents #173, #112 and #31 were not placed on EBP. During an interview on 9/24/24 at 10:26 A.M., the Staff Development Coordinator said she is helping with the facility's infection control program until they hire someone to take that role. She said she has not implemented EBP in the facility yet and residents with gastrostomy tubes, catheters and wounds should be on EBP.

Based on document review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. The facility failed to provide the surveyor with their Antibiotic Stewardship Policy for review. The facility failed to provide the surveyor with evidence of antibiotic use protocols and a system to monitor antibiotic use (i.e., infection surveillance and/or a line listing). The facility provided the surveyor with a 3-inch binder labeled Antibiotic Stewardship which contained no information for the past year and contained information dated 2018. During an interview on 9/24/24 at 9:48 A.M., the surveyor met with the Administrator, the Director of Nurses (DON), the Director of Clinical Services, and the Director of Operations. The Director of Clinical Services said the Staff Development Coordinator was responsible for the Infection Control Program and was the Infection Control Nurse. The Director of Clinical Services said the SDC was responsible for the infection surveillance and antibiotic stewardship program. He said what was provided to the surveyor is what the facility was able to provide. During the above noted interview, on 9/24/24 at 9:48 A.M., the Administrator said the facility discussed antibiotics weekly at the risk meeting and kept track of them in an ongoing spreadsheet, but the SDC would be the one to complete the actual surveillance report. During an interview on 9/24/24 at 10:26 A.M., the SDC said she was not the Infection Control Nurse and had never formally agreed to be responsible for the antibiotic stewardship program or infection surveillance. The SDC said the only aspect of infection control she was responsible for was education and helping with the vaccination effort in the facility. The SDC said since she has been employed by the facility, since February of this year, there has never been an infection control nurse and there has never been an antibiotic line listing/surveillance. The facility failed to have a system of monitoring and tracking in place to improve the use of antibiotics within the facility, to protect residents and reduce the threat of antibiotic resistance. As of the end of survey, on 9/25/24, the survey team did not receive any additional information regarding the antibiotic stewardship or infection surveillance. Refer to 882

Based on observations and interviews, the facility failed to ensure it was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to effectively manage and utilize their administrative team and stay up to date with current Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and Massachusetts Department of Public Health (MDPH) guidance. Findings include: During the recertification survey on 9/17/24 through 9/20/24 and 9/23/24 through 9/25/24 the survey team determined: -the activity department was not meeting the needs of all residents and the activity calendar was not being reviewed and monitored as evidenced by lack of meaningful and engaging activities on all units -the business office was located out of state, and activity related to residents' personal needs accounts and residents access to their funds was managed by the Activity Director -the human resources department was located out of state, and 5/5 employee records were incomplete or out of date -the role of the Infection Preventionist was vacant and was not effectively being covered by current facility staff as evidenced by no antibiotic stewardship program, no infection surveillance and failure to implement enhanced barrier precautions (EBP, an infection control measure for residents with chronic wounds and/or indwelling devices putting them at increased risk for infection) During an interview on 9/24/24 at 11:14 A.M., the Activity Director said she was the liaison between the business office in New York and the facility and was responsible for managing and accessing the residents' funds from their Personal Needs Accounts (PNA). The Activity Director said the responsibility of managing the PNA has interfered with her ability to be hands-on in the activity department and the residents could only access their funds when she was working. During an interview on 9/24/24 at 2:23 P.M., the Administrator said the monthly activity calendar was not reviewed by the leadership team but she was aware the activities department could use some enhancements. During an interview on 9/25/24 at 11:19 A.M., the Administrator said the Human Resources department was off-site but the scheduler was taking care of some new-hire credential verification in house. The Administrator said she was aware employee files were missing some things and could be better. During an interview on 9/24/24 at 9:48 A.M., the Director of Clinical Operations said the Staff Development Coordinator (SDC) was also the Infection Control Nurse. The Director of Clinical Operations said the Infection Control Nurse position had been vacant and the SDC had been covering that role since March. He said a job description had not been signed indicating her understanding of this expectation. The Director of Clinical Operations said a monthly infection control report with infection surveillance was not provided by the SDC but a listing of residents on antibiotics was discussed weekly at the risk meeting. During an interview on 9/24/24 at 9:48 A.M., the Director of Nurses said there had not been an actual designated Infection Control Nurse since last year, but the SDC was supposed to be covering the role. During an on 9/24/24 at 9:48 A.M., the Administrator said the SDC was learning and that she and the Director of Clinical Operations had provided the SDC with guidance. The Administrator said the facility was working to find someone who was qualified to be the Infection Control Nurse. During an interview on 9/24/24 at 9:48 A.M., the Director of Operations said the Infection Preventionist job had been posted off and on in 14-30 day increments, and that it was taken down every so often so the same job was not posted for an extended period of time. Review of the facility provided job postings indicated the Infection Control Nurse position had been posted on 7/26/23, 4/2/24, 5/20/24, and 7/12/24. During an interview on 9/24/24 at 10:26 A.M., the SDC said she was hired as the SDC and not an Infection Control Nurse. The SDC said, in March of this year, she told the leadership team she could help with the infection control program until an Infection Control Nurse was hired. The SDC said her job description was never adjusted and her understanding was that she would be responsible for education and helping with the vaccinations. The SDC said she did not complete a line listing or perform an analysis of antibiotics/infections and had never done that for the facility. The SDC said she was not involved in an antibiotic stewardship program. During an interview on 9/24/24 at 2:23 P.M., the Administrator and the DON said they were unaware of how to find new CDC, CMS, and MDPH guidance and how to stay up to date with changes in facility expectations. The Administrator and DON said they were unaware of regulations related to some of the concerns the surveyors had. The DON said she did not receive any memos from CMS of DPH and did not know when guidelines changed. Refer to 882

Based on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to: 1. Ensure active involvement of all required members when conducting the facility assessment; and 2. Implement the identified competency-based training as indicated. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance, dated 6/18/24, indicated but was not limited to: -In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process: a. Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and b. Direct care staff, including but not limited to, Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, Nursing Assistants, and representatives of the direct care staff, if applicable c. The facility must also solicit and consider input received from residents, resident representatives, and family members. Review of the facility's policy titled Facility Assessment, dated as revised October 2018, indicated but was not limited to: -The team responsible for conducting, reviewing and updating the facility assessment includes the following: a. the administrator; b. a representative of the governing body; c. the medical director; d. the director of nursing services; e. the infection preventionist; and f. the director (or designee) from the following departments: environmental services, physical operations, dietary services, social services, activity services, and rehabilitative services 1. Review of the Facility Assessment, dated July 2024, indicated but was not limited to: -Names/Titles of individuals involved in completing the assessment: Administrator, Director of Nurses, Medical Director, Director of Social Services, Director of Clinical Operations and Food Service During an interview on 9/25/24 at 3:32 P.M., the Administrator said the facility assessment was last updated July 2024. The Administrator said the process for updating the facility assessment was to review the previous assessment page by page and make sure no changes had occurred in staffing or resident care needs. The Administrator said the leadership team/department heads were involved in updating and formulating the facility assessment. 2. Review of the Facility Assessment, dated July 2024, indicated but was not limited to: -Competency Based Training: All staff are required to complete a comprehensive orientation upon hire and annually thereafter including but not limited to the following requirements: a. Dementia training: original eight hours and four hours annually Review of the staff education records for Nurses #14, #15, #16, and #18 failed to include mandatory dementia training. During an interview on 9/25/24 at 12:54 P.M. and 1:11 P.M., the Staff Development Coordinator said there are approximately 80 relevant employees at the facility, and she could not find any evidence that the annual four-hour dementia training was completed as required in 2023. She said when she began working at the facility, four months ago, there was no staff education program in place. During an interview on 9/25/24 at 11:35 A.M., the Administrator and the facility Scheduler said there was no formal dementia training in the facility at that time. The Administrator and Scheduler said the dementia training should be conducted prior to the completion of orientation and then annually. Refer to F949

Based on record review and interview, the facility failed to ensure the designated Infection Control Nurse (ICN) adequately assessed, developed, implemented, monitored, and managed the infection prevention and control program. Specifically, the ICN failed to: 1. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were implemented; and 2. Implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: 1. On multiple days of survey, the surveyors observed several residents, who met criteria for EBP, but did not have EBP in place. During an interview on 9/24/24 at 10:26 A.M., the Staff Development Coordinator said she has not implemented EBP in the facility. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said the EBP program had not been implemented. 2. During survey, the facility was unable to provide evidence of infection surveillance and of an Antibiotic Stewardship Program. During an interview on 9/24/24 at 9:48 A.M., the surveyor met with the Administrator, the Director of Nurses (DON), the Director of Clinical Services, and the Director of Operations. The Director of Clinical Services said the Staff Development Coordinator was responsible for the Infection Control Program and was the ICN. The Director of Clinical Services said the SDC was responsible for the infection surveillance and antibiotic stewardship program. He said what was provided to the surveyor is what the facility was able to provide. During an interview on 9/24/24 at 10:26 A.M., the SDC said she was not the ICN and had never formally agreed to be responsible for the antibiotic stewardship program or infection surveillance. The SDC said the only aspect of infection control she was responsible for was education and helping with the vaccination effort in the facility. The SDC said since she has been employed by the facility, since February of this year, there has never been an ICN and there has never been an antibiotic line listing/surveillance.

Based on interviews and staff education records reviewed for five direct care staff employees (Nurse #14, Nurse #15, Nurse #16, Nurse #17 and Nurse #18) of five employees reviewed, the facility failed to ensure that training on behavioral health was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Behavioral Health Services, last revised July 2022, indicated but was not limited to: -Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress; -Staff training regarding behavioral health services includes, but is not limited to: a. recognizing changes in behavior that indicate psychological distress; b. implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his/her needs; c. monitoring care plan interventions and reporting changes in condition; and d. protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma and post-traumatic stress disorder. Review of the staff education records for Nurse #14, Nurse #15, Nurse #16, Nurse #17 and Nurse #18 failed to include mandatory training on care specific to the individual needs of residents that are diagnosed with a mental, psychosocial, or substance use disorder, a history of trauma and/or post-traumatic stress disorder, or other behavioral health condition; and care specific to the individual needs of residents that are diagnosed with dementia. During an interview on 9/25/24 at 12:54 P.M. and 1:11 P.M., the Staff Development Coordinator said she could not find any evidence that Nurse #14, Nurse #15, Nurse #16, Nurse #17, Nurse #18 or any other staff had received required behavioral health training. She said there are approximately 80 relevant employees at the facility, and she could not find any evidence that behavioral health training was completed as required in 2023. She said when she began working at the facility four months ago, there was no staff education program in place. The facility failed to provide the survey team with any additional documentation by the time of the exit conference on 9/25/24.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 12/27/23 Resident #2 reported to a staff member that Resident #1 had acted in a sexually inappropriate manner towards him/her, and although several staff members became aware of the allegation, they did not report the allegation to administration until the following day. Findings include: Review of the Facility's Policy titled Resident Abuse, Neglect, Exploitation, or Misappropriation, dated as revised April 2021, indicated that if resident abuse, neglect, exploitation, or misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of the Facility's Policy titled Resident-to-Resident Altercations, dated as revised September 2022, indicated that facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or staff. Occurrences of such incidents shall be promptly reported to the nurse supervisor, Director of Nursing Services, and the administrator. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/28/23 indicated that on 12/28/23 at 11:45 A.M., it was reported to Administration that an incident occurred on 12/27/23 where Resident #2 threw water at Resident #1 because he/she (Resident #2) saw him/her (Resident #1) acting inappropriately, that he/she was touching him/herself. Resident #2 was admitted to the Facility in March of 2022, diagnoses included cerebrovascular accident (stroke), polyneuropathy (pathological damage to peripheral nerves), and major depressive disorder. Review of Resident #2's Quarterly Minimum Set Data (MDS) Assessment, dated 12/05/23 indicated Resident #2 had severe cognitive impairment and was dependent on staff to meet his/her care needs. Review of an Incident/Accident Report, undated, indicated Nurse #1 reported that on 12/27/23 at 8:30 A.M., Resident #2 told her that while in the dining room, he/she tossed water on another resident (later identified as Resident #1) because he/she acted inappropriately towards him/her (Resident #2). The Report indicated that Resident #1 and Resident #2 were immediately separated. The Surveyor was unable to interview Nurse #1 as she did not respond to the Department of Public Health's telephone call or letter requests for an interview. During an interview on 01/09/24 at 3:00 P.M., and review of her Written Witness Statement, dated 12/2723, Certified Nurse Aide (CNA) #1 said that on 12/27/23, while staff were passing breakfast trays, she heard Resident #1 scream. CNA #1 said she asked him/her what happened, and said Resident #1 told her that Resident #2 threw water at him/her. CNA #1 said she went into the dining room where Resident #2 was seated and asked him/her what happened. CNA #1 said Resident #2 told her that Resident #1 tried to get him/her to touch his/her genitals. CNA #1 said Nurse # 1 and Nurse #2 were both there and were aware of the incident, so she thought one of them reported it. CNA #1 said that, just to be sure, she reported the alleged incident to the Activities Director the next day. During a telephone interview on 01/11/24 at 12:07 P.M., CNA #2 said on 12/27/23, staff were passing breakfast trays and Resident #1 left the dining room screaming and said Resident #2 threw water at him/her. CNA #2 said she talked to Resident #2, and he/she said Resident #1 asked him/her to put his/her mouth on his/her genitals. CNA #2 said she didn't tell Nurse #1 exactly what Resident #2 had told her, but instead, said she told Nurse #1 to ask Resident #2 what happened. Review of Nurse #2's Written Witness Statement, dated 12/27/23, indicated he went to the dining room to assess the nature of Resident #2's complaint, and to hear Resident #2's side of the story. The Statement indicated that Resident #2 told him (Nurse #2) that Resident #1 insulted him/her by asking him/her to do inappropriate things to his/her genitals. During an interview on 01/09/24 at 12:59 P.M., Nurse #2 said all he heard Resident #1 say was that another resident spilled water on him/her. Nurse #2 said he did not hear what Resident #2 said about the alleged incident, and he denied that Resident #2 reported to him that Resident #1 asked him/her to do inappropriate things to his/her genitals (however that contradicted what Nurse #2 provided in his Written Witness Statement). During an interview on 01/09/24 at 12:10 P.M., and review of her Written Witness Statement, undated, the Activities Director said on 12/28/23, CNA #1 told her that Resident #1 did something inappropriate with Resident #2, the previous day (12/27/23) and as a result, Resident #2 threw water in Resident #1's face. The Activities Director said she immediately reported the allegation to the Administrator. During an in person interview on 01/09/24 at 9:30 A.M., and a telephone interview on 01/16/24 at 11:10 A.M., the Administrator said that the Activities Director notified her on 12/28/23 that CNA #1 reported to her that on 12/27/23, Resident #2 threw water at Resident #1. The Administrator said she interviewed CNA #1 immediately and said CNA #1 told her that on 12/27/23, Resident #2 said he/she threw water at Resident #1 because he/she (Resident #1) acted inappropriately toward him/her. The Administrator said staff (including CNAs) must immediately report any suspicion or allegation of abuse to a nurse and then the nurse must immediately report to administration. The Administrator said after CNA #1 reported the allegation of abuse to Nurse #1, she (Nurse #1) should have immediately reported it administration, but she had not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware on 12/28/23 of an allegation of an unwanted sexual advance made by Resident #1 toward Resident #2 that occurred on 12/27/23, that they obtained and maintained evidence that a thorough investigation was completed. Findings include: Review of the Facility's Policy titled, Abuse Reporting and Investigating, dated as revised April 2021, indicated the following: -all reports of resident abuse will be thoroughly investigated by facility management, and -the individual conducting the investigation will interview the person reporting the incident and the resident. Review of the Facility's Policy, titled Abuse and Neglect-Clinical Protocol, dated as revised March 2018, indicated the following: -instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, and -the nurse will assess the individual and document related findings. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/28/23 indicated that on 12/28/23 at 11:45 A.M., it was reported that an incident occurred on 12/27/23 where Resident #2 threw water at Resident #1 because he/she (Resident #2) saw him/her (Resident #1) acting inappropriately, that he/she (Resident #1) was touching him/herself. Review of the Facility's Investigation File, undated, indicated there was no documentation to support that Resident #1 and/or Resident #2 had been interviewed as part of the investigative process. Further review of the File indicated there was no documentation to support any other residents on the unit that had the potential to be affected by Resident #1's sexually inappropriate behavior, had been interviewed. Resident #2 was admitted to the Facility in March of 2022, diagnoses included cerebrovascular accident (stroke), polyneuropathy (pathological damage to peripheral nerves), and major depressive disorder. Review of Resident #2's Quarterly Minimum Set Data (MDS) Assessment, dated 12/05/23 indicated Resident #2 had severe cognitive impairment and was dependent on staff to meet his/her care needs. During an interview on 01/09/24 at 2:58 P.M., the Director of Nurses (DON) said she and the Administrator were notified that Resident #2 threw water at Resident #1 because Resident #1 had acted sexually inappropriate toward Resident #2. The DON said she and the Administrator conducted the investigation. The DON said that they did not interview other residents and said she was unable to provide documentation to support that they had interviewed Resident #1 or Resident #2. During an interview on 01/09/24 at 3:26 P.M., the Administrator said she could not provide any documentation to support Resident #1 or Resident #2 had been interviewed as part of their investigation. The Administrator said she did not interview other residents as potential witnesses or to determine if any other residents had been subjected to Resident #1's alleged inappropriate sexual behavior. The Administrator said she could not substantiate that Resident #1 said or did anything sexually inappropriate to Resident #2 since there was not enough evidence.

Based on record review and interviews, the facility failed to ensure that one Resident (#24), out of a total sample of 40 residents, whose right to be informed of, and participate in his/her treatment plan, was honored, when his/her Health Care Agent, which was not invoked, signed Resident #24's advanced directive form, consent to treatment form, consent for wound services form, consent for bed rails form, and consent to psychotropic medication form. Findings include: Review of the facility's policy titled Advanced Directives, dated January 2017, indicated the facility staff will abide by resident advanced directives. Resident #24 was admitted to the facility in March 2023 with diagnoses including diabetes, heart failure, dysphagia, end stage renal disease, and convulsions. Review of the Minimum Data Set (MDS) assessment, dated 7/3/23, indicated Resident #24 can make self understood and he/she can understand others. The Brief Interview for Mental Status indicated a score of 12 out of a possible 15, and he/she had no behaviors. Further review of the MDS indicated Resident #24 had a health care proxy and the health care proxy was not invoked. Review of the plan of care related to advanced directives, dated 3/15/23, did not indicate Resident #24's health care proxy was invoked. Review of the Physician's Orders, dated 7/12/23, indicated there was no documentation to support Resident #24's health care proxy was invoked. Review of the Health Care Proxy Form, undated, indicated it was blank and not filled out, and therefore, Resident #24's health care proxy was not invoked. Review of Resident #24's medical record indicated the following forms were signed by Resident #24's health care agent: - 3/3/23 Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) (advanced directive) - 3/13/23 Consent for Side Rail Use - 3/14/23 Consent to Treatment and Services - 3/14/23 Consent to Treat- Wound Physician's Group - 3/14/23 Consent for Psychotropic Medication Administration form During an interview on 7/12/23 at 12:59 P.M., Resident #24 said that he/she would like his/her health care proxy involved with his/her care. Resident #24 said he/she wishes to sign his/her own consents. During an interview on 7/13/23 at 8:50 A.M., Nurse #4 said that Resident #24 is his/her own person and he/she should sign his/her own consents. On 7/13/23 at 9:01 A.M., the surveyor and the Assistant Director of Nursing (ADON) reviewed Resident #24's medical record. The ADON said that Resident #24 is his/her own responsible person and he/she should sign his/her consents. The ADON said that if Resident #24 deferred to his/her health care agent to sign the forms, this information should have been included on the consents. During an interview on 7/14/23 at 7:08 A.M., the Social Services Director said that Resident #24 should sign his/her own consents. During an interview on 7/14/23 at 11:46 A.M., the Director of Nursing (DON) said Resident #24 should sign his/her own consents.

NOT CORRECTED Based on observation, record review, policy review, and interview, the facility failed to ensure one Resident (#11) was assessed for the ability to self-administer medications, out of a total sample of 39 residents. Findings include: Review of the facility's policy titled Administering Medications, dated as revised December 2012, indicated medications shall be administered in a safe and timely manner, and as prescribed. Further review indicated that 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. Resident #11 was admitted to the facility in May 2018 with diagnoses including schizophrenia and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 6/16/23, indicated Resident #11 could understand others and he/she could make self-understood. The Brief Interview for Mental Status assessment indicated a score of 11 out of 15, indicating he/she had moderate cognitive impairment. On 8/24/23 at 9:27 A.M., the surveyor and Nurse #1 observed on Resident #11's bedside table the following: - one bottle of Vitamin D3 softgels - one bottle of adult triple immune support multiple vitamin tablets - one bottle of Vitamin C 1000 milligrams (mg) tablets - one bottle of multiple vitamins with minerals tablets During an interview on 8/24/23 at 9:28 A.M., Resident #11 said he/she takes these medications daily. During an interview on 8/24/23 at 9:29 A.M., Nurse #1 said that Resident #11 has been taking the medications that are brought in from home. Nurse #1 said that it is okay for Resident #11 to take the medications at his/her bedside. Review of the Physician's Order, active 8/24/23, failed to include a physician's order for self-administration of medication. Review of the plan of care related, active 8/24/23, failed to include that Resident #11 was assessed for self-administration of medications. On 8/25/23 at 6:45 A.M., the surveyor observed the following at the bedside: - one bottle of Vitamin D3 softgels - one bottle of adult triple immune support multiple vitamin tablets - one bottle of Vitamin C 1000 mg tablets - one bottle of multiple vitamins with minerals tablets On 8/25/23 at 8:56 A.M., the surveyor and Nurse #5, observed: - one bottle of Vitamin D3 softgels - one bottle of adult triple immune support multiple vitamin tablets - one bottle of Vitamin C 1000 mg tablets - one bottle of multiple vitamins with minerals tablets During an interview on 8/25/23 at 8:56 A.M., Nurse #5 said Resident #11's family brought him/her in the medications and the medications are okay to be at the bedside. Nurse #5 said that Resident #11 can self-administer his/her medications. During an interview on 8/25/23 at 9:04 A.M., Unit Manager #1 said that Resident #11 should not be self-administering medications. During an interview on 8/25/23 at 9:30 A.M., the Assistant Director of Nursing said that Resident #11 should not be self-administering medications.

2) Resident #116 was admitted to the facility in July 2023 with diagnoses including anemia. Review of the Minimum Data Set (MDS) assessment, dated 7/7/23, indicated that Resident #116 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. Further review of the MDS indicated Resident #116 requires the extensive assistance of two staff with toileting and assistance of 1 staff with personal hygiene. During an interview on 9/21/23 at 9:25 A.M., Resident #116 said that two or three days ago he/she had a concerning exchange with a certified nursing assistant (CNA). The Resident said he/she had asked the aide to be cleaned after having a bowel movement, however, when the aide arrived, the Resident felt the bowel movement was not complete and asked the aide to wait a few minutes. Resident #116 said this had prompted the aide to warn the Resident to not burn bridges with the CNA's as they will no longer be willing to clean him/her. When the Resident responded that it was the CNA's responsibility to clean him/her and that if the CNA's refused to clean him/her that he/she would report them the CNA responded I have bills to pay, if I lose my job it will not be good for you. Resident #116 said he/she perceived this as a serious threat, and that he had told the Assistant Director of Nursing (ADON) yesterday. During an interview on 9/21/23 at 12:44 P.M., the ADON said that yesterday at 3:30 P.M. she was present in the Resident's room when Resident #116 said he/she wanted to transfer to a different facility because he/she was being threatened by staff. During an interview on 9/21/23 at 12:46 P.M., the Administrator said she would consider the Resident report of a threat by staff an allegation of abuse that required immediate investigation and it should have been reported to the Department of Public Health within 2 hours of when the ADON was made aware of the threat the previous day. The Administrator said she was made aware of the allegation today, and that she would have expected the ADON to have reported the allegation to her immediately when the allegation was made to her the previous day. The Administrator said that there were some staff present during the initial allegation, however, a formal investigation had not been initiated until today and should have been initiated sooner. Review of the Health Care Facility Reporting System (HCFRS) indicated the allegation of staff threats was categorized by the facility as verbal abuse by staff and submitted on 9/21/23 at 12:57 P.M., 22 hours after the allegation was made to the ADON. Based on observations, interviews and policy review, the facility failed to implement their Abuse Investigation and Reporting policy for two Residents (#13 and #116) out of a total sample of 16 residents. Specifically, 1) Resident #13 reported to a Certified Nursing Assistant (CNA) that he/she was not provided with incontinence care over night and the CNA failed to promptly report the allegation to any staff, delaying the initiation of an investigation. 2) Resident #116 reported that staff had threatened him/her to the Assistant Director of Nursing (ADON) who had failed to report the allegation to the Administrator or initiate an investigation. Findings include: The facility policy titled Abuse Investigation and Reporting, dated as revised July 2017 indicated: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. 1) Resident #13 was admitted to the facility in April 2018 and had diagnoses that includes dementia, spinal stenosis and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/28/23, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 11 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 had no behaviors and required extensive two person assist with toileting. On 9/21/23 at 7:43 A.M., the surveyor observed a Certified Nursing Assistant (CNA) #1 enter Resident #13's room to deliver breakfast. The surveyor overheard Resident #13 report to CNA #1 that last night I asked to get changed and they wouldn't get me out of bed and I was all drenched. CNA #1 told Resident #13 to eat his/her breakfast first and exited the room. CNA #1 continued passing breakfast trays to other residents and did not report what Resident #13 had told her to the Nurse or other staff. On 9/21/23 at 7:50 A.M., Resident #13 was observed seated in bed. There was no sheet on the bed and Resident #13 was naked with his/her lower body wrapped in a blanket. Resident #13 confirmed that he/she had informed CNA #1 that he/she was undressed with no sheet on the bed, because the 11-7 staff would not assist him/her with care overnight causing the sheets to became drenched in urine. Resident #13 added that at about 6:30 A.M., that morning, a girl came in to get his/her roommate dressed and that Resident #13 told her that he/she needed help and the girl just walked out. Resident #13's roommate confirmed that this occurred. On 9/21/23 at 8:25 A.M., the surveyor heard Resident #13 tell Nurse #1 that the girl just walked out when I told her I was soaked. Nurse #1 exited the room, instructed a CNA to assist Resident #13 with care and then continued working at her medication cart without notifying staff or administration of what Resident #13 reported to her. During an interview on 9/21/23 at 9:01 A.M., with CNA #1 she said that this morning when she delivered the breakfast tray to Resident #13 she noticed that everything was on the floor, including a wet brief and wet sheets. CNA #1 said that she asked Resident #13 what happened and that Resident #13 told her that last night and this morning staff would not provide him/her with care when he/she requested it. CNA #1 said that she told Resident #13 that she would come back and help him/her after breakfast but had not done so yet. CNA #1 said that she did not report what Resident #13 had told her to anyone. During an interview on 9/21/23 at 9:24 A.M., with Nurse (#1), she said Resident #13 had told her that staff had not given him/her care as requested and that he/she had been soaked in urine, which is why he/she was in bed with no sheets or clothes on. Nurse #1 said that when a resident reports to her that staff are not providing care as requested she reports that to the Nurse Unit Manager when she sees her. Nurse #1 said that she has not yet reported the allegation to the Nurse Unit Manager or Administration, although Resident #13 had reported the concern to her 59 minutes prior. During an interview on 9/21/23 at 9:30 A.M., with the Nurse Unit Manager (#1) she said that CNA #1 should have reported what Resident #13 reported to her to a Nurse immediately because that is something we need to investigate. During an interview on 9/21/23 at 10:09 A.M., the Nursing Home Administrator said that as soon as Resident #13 reported to CNA #1 that staff refused to provide him/her care she should have reported that to the Nurse or someone in Administration so that an investigation could be initiated. As well, she said that as soon as Resident #13 reported to Nurse #1 that staff refused to provide care that the Nurse should have told Nurse Unit Manage #1 or someone in administration and not wait until she sees her.

Based on Interview and policy review the facility failed to report an allegation of verbal abuse to the Department of Public Health within 2 hours of when the allegation was made for 1 Resident (#116) out of a total sample of 16 residents. Findings Include: Review of the facility policy titled Abuse Investigation and Reporting, dated as revised July 2017 indicated the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Resident #116 was admitted to the facility in July 2023 with diagnosis including anemia. Review of the Minimum Data Set (MDS) assessment, dated 7/7/23, indicated that Resident #116 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. Further review of the MDS indicated Resident #116 requires the extensive assistance of two staff with toileting and assistance of 1 staff with personal hygiene. During an interview on 9/21/23 at 9:25 A.M., Resident #116 said that two or three days ago he/she had a concerning exchange with a certified nursing assistant (CNA). The Resident said he/she had asked the aide to be cleaned after having a bowel movement, however, when the aide arrived, the Resident felt the bowel movement was not complete and asked the aide to wait a few minutes. Resident #116 said this had prompted the aide to warn the Resident to not burn bridges with the CNA's as they will no longer be willing to clean him/her. When the Resident responded that it was the CNA's responsibility to clean him/her and that if the CNA's refused to clean him/her that he/she would report them, the CNA responded I have bills to pay, if I lose my job it will not be good for you. Resident #116 said he/she perceived this as a serious threat, and that he had told the Assistant Director of Nursing (ADON) yesterday. During an interview on 9/21/23 at 12:44 P.M., the ADON said that yesterday at 3:30 P.M. she was present in the Resident's room when Resident #116 said he/she wanted to transfer to a different facility because he/she was being threatened by staff. During an interview on 9/21/23 at 12:46 P.M., the Administrator said she would consider the Resident report of a threat by staff an allegation of abuse that required immediate investigation and it should have been reported to the Department of Public Health within 2 hours of when the ADON was made aware of the threat the previous day. The Administrator said she was made aware of the allegation today, and that she would have expected the ADON to have reported the allegation to her immediately when the allegation was made to her the previous day. The Administrator said the ADON is currently the acting Director of Nursing (DON) as the current DON is on medical leave. Review of the Health Care Facility Reporting System (HCFRS) indicated the allegation of staff threats was categorized by the facility as verbal abuse by staff and submitted on 9/21/23 at 12:57 P.M., 22 hours after the allegation was made to the ADON.

2. Review of the facility's policy titled Catheter Care, Urinary, dated as revised September 2014, indicated the purpose of this procedure is to prevent catheter associated urinary tract infections. -Preparation 1. Review the resident's care plan to assess for any special needs A urinary catheter is a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag. Urinary catheters come in many sizes and types. -French or Fr is the size in French units is roughly equal to the circumference of the catheter in millimeters. -French sizes only apply to intermittent and indwelling catheters. External catheters ' sizes are measured in millimeters (mm), depending on the diameter of the condom-shaped receptacle. -The average catheter size used by adult men range from 14Fr to 16Fr, and most men use 14Fr catheters. -The average catheter size used by adult women range from 10Fr to 12Fr, and most women use 12Fr catheters. *Catheters are color-coded based on their french sizes -Size 10 French: black -Size 12 French: white -Size 14 French: green -Size 16 French: orange -Size 18 French: red Resident #142 was admitted to the facility in March 2023 with diagnoses including dementia, urinary retention, hearing loss, and sepsis. Review of the Minimum Data Set (MDS) assessment, dated 6/2/23, indicated Resident #142 required an indwelling catheter. Review of the plan of care related to indwelling catheter, dated 3/31/23, indicated: -CATHETER: The resident has (SPECIFY Size) 14Fr 10cc balloon foley (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. Review of the Physician's Orders indicated: -4/14/23 Catheter: Foley catheter 18Fr and 10cc balloon size) 2/2 (secondary) to (diagnosis) Urinary retention every shift. -4/14/23 Order Summary: Foley catheter 18Fr 10cc balloon every shift. -4/14/23 Change Foley catheter every 4 weeks every evening shift starting on the 14th and ending on the 14th every month. On 7/14/23 at 7:02 A.M., the surveyor, accompanied by Nurse #5, went to Resident #142's room. The surveyor observed an indwelling urinary catheter size 18 French 10cc balloon and not a 14 French 10 cc balloon as indicated in the plan of care. During an interview on 7/14/23 at 9:13 A.M., the ADON said the care plan for the indwelling catheter size and the physician's order should be the same. During an interview on 07/14/23 at 11:31 A.M., the DON said the care plan for the indwelling catheter size and the physician's order should match and that nursing should have revised the care plan. Based on record review and interviews, the facility failed to update and revise care plans for two Residents (#19 and #142), out of a sample of 40 residents. Specifically, the facility failed: 1. For Resident #19, to update a behavior care plan after he/she was involved in two physical altercations with other residents; and 2. For Resident #142, to revise a care plan related to the size of an indwelling catheter. Findings include: 1. Review of the care plan policy titled 'Behavior management/Trauma informed Care', with no revision date, indicated the following: *It is the policy of this facility to provide an interdisciplinary approach for the care of residents who have a diagnosis of a mental disorder. Residents demonstrating changes in behavior and mood shall be evaluated to ensure appropriate interventions. *Diagnosis with resulting behavioral symptoms and approaches shall be placed in the resident specific plan of care and communicated to the care staff and other departments as appropriate. Resident #19 was admitted to the facility in October 2022 with diagnoses including dementia and bipolar disorder. Review of the most recent Minimum Data Set (MDS) assessment, completed on 6/2/23, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. Review of Resident #19's medical record indicated two incident reports, dated 11/27/22 and 4/3/23. The incident reports indicated that Resident #19 was involved in two physical altercations with other residents. Review of Resident #19's behavior care plan did not indicate that it was revised to indicate that Resident #19 is physically abusive towards other residents. During an interview on 7/12/23 at 12:16 P.M., the Social Worker said behavior care plans and interventions should be revised and updated after residents have incidents with other residents. During an interview on 7/12/23 at 12:50 P.M., the Assistant Director of Nurses (ADON) said behavior care plans should be revised and personalized after incidents occur. During an interview on 7/12/23 at 2:01 P.M., the Director of Nurses (DON) said that behavior care plans should be updated after incidents happen to reflect new interventions.

2B. Resident #45 was admitted to the facility in March 2016 with diagnoses including traumatic brain injury (TBI). Review of the MDS assessment, dated 5/5/23, indicated that Resident #45 was unable to complete a BIMS. Review of a Nursing Progress Note, dated 6/22/23, indicated Resident #45 received intravenous (IV) rehydration on 6/22/23. Review of Resident #45's electronic medical record failed to indicate a physician's order for IV fluid, or for a peripheral line insertion, was entered. Review of Resident #45's physical chart failed to indicate a physician's order for IV fluids or peripheral line insertion. Review of Resident #45's Medication Administration Record for the month of June 2023 failed to indicate that an order for IV fluids or peripheral line insertion was transcribed or signed off as completed by a nurse. During an interview on 7/17/23 at 1:42 P.M., Unit Manager (UM) #1 said a telephone order was received for the IV fluids. UM #1 was able to produce a telephone order for IV fluids and the insertion of a peripheral line, which was stored in a binder separate from Resident #45's chart. The telephone order, dated 6/22/23, was not signed by a physician. UM #1 said telephone orders should be transcribed and signed by the physician. UM #1 said she had forgotten to flag it, so it was never signed by the physician. During an interview on 7/17/23 at 2:00 P.M., the Director of Nursing said she would expect all physician's orders to be in the resident's chart, and all telephone orders should be signed by the physician on the date of their next visit to the facility. The DON said the telephone order from 6/22/23 should have been signed. During an interview on 7/17/23 at 12:47 P.M., the Physician said he had been present in the facility on three occasions (6/28, 7/6, and 7/12) since the telephone order was recorded. 3. Resident #13 was admitted to the facility in April 2018 and had diagnoses that included dementia and chronic kidney disease stage 3. Review of the most recent MDS assessment, dated 5/19/23, indicated Resident #13 had a BIMS score of 8 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 requires extensive one person physical assistance with eating. On 7/11/23 at 8:18 A.M., the surveyor observed Resident #13 lying in bed. His/her Bilateral Lower Extremities (BLE) appeared fragile. Review of the current Physician's Orders indicated: -ACE wraps to BLE, on in AM, off in PM, dated as started 1/13/23 On 7/11/23 at 9:56 A.M., the surveyor observed Resident #13 in bed and there were no ace wraps on his/her BLE. On 7/11/23 at 10:59 A.M., the surveyor observed Resident #13 dressed and seated at the nurses' station. There were no ace wraps on his/her BLE. On 7/11/23 at 2:18 P.M., the surveyor observed Resident #13 seated in a wheelchair in his/her room. There were no ace wraps on his/her BLE. On 7/12/23 at 8:11 A.M., the surveyor observed Resident #13 in bed and there were no ace wraps on his/her BLE. On 7/12/23 at 12:00 P.M., the surveyor observed Resident #13 in bed and there were no ace wraps on his/her BLE. On 7/13/23 at 8:27 A.M., the surveyor observed Resident #13 in bed and there were no ace wraps on his/her BLE. Review of the July 2023 Treatment Administration Record (TAR) indicated that nursing documented on July 11, 12 and 13th, 2023 that Resident #13 had ace wraps applied to his/her BLE. During an interview on 7/13/23 at 11:08 A.M., Resident #13's Nurse (#12) said she wasn't aware that Resident #13 wears ace wraps and that it might be an old order. Nurse #12 said she doesn't know how to discontinue an order and just checks off that the ace wraps are in place because she doesn't know what else to do. During an interview on 7/17/23 at 8:56 A.M., the Director of Nursing (DON) said that Resident #13 should be wearing ace wraps as ordered by the physician. Based on record review, policy review, and staff interviews, the facility failed to: 1. Implement the facility's policy to obtain a physician's order to administer COVID-19 vaccine for five Residents (#37, #19, #95, #84, and #5); 2. Ensure that a physician's telephone order for a medication was transcribed by the nurse according to professional standards of practice to include the name of the medication being ordered for two Residents (#124 and #45); and 3. Implement a physician's order for an ace wrap for one Resident (#13), out of a total sample of 40 residents. Findings include: 1. Review of the facility's policy titled medication and treatment orders, dated July 2016, indicated the following: -Medications shall be administered only upon written order of a person duly licensed and authorized to prescribe such medication in this state. -Drug and biological orders must be recorded on the Physician's order sheet in the resident chart. -Orders for medications must include. *Name and strength of drug *Number of doses, start and stop date, and/or specific duration of therapy *Dosage and frequency of administration *Route of administration A. Resident #37 was admitted to the facility in May 2020. Review of the clinical record indicated that the facility administered bivalent COVID-19 booster on 6/29/23. Further review of the medical record indicated there were no physician's orders to administer the vaccine. B. Resident #19 was admitted to the facility in October 2022. Review of the clinical record indicated that the facility administered bivalent COVID-19 booster on 6/29/23. Further review of the medical record indicated there were no physician's orders to administer the vaccine. C. Resident #95 was admitted to the facility in April 2022. Review of the clinical record indicated that the facility administered bivalent COVID-19 booster on 6/29/23. Further review of the medical record indicated there were no physician's orders to administer the vaccine. D. Resident #84 was admitted to the facility in December 2022. Review of the clinical record indicated that the facility administered bivalent COVID-19 booster on 6/29/23. Further review of the medical record indicated there were no physician's order to administer the vaccine. E. Resident #5 was admitted to the facility in October 2022. Review of the clinical record indicated that the facility administered bivalent COVID-19 booster on 6/29/23. Further review of the medical record indicated there were no physician's orders to administer the vaccine. During an interview on 7/17/23 at 12:20 P.M., the Director of Nursing (DON) said that the facility had a vaccine clinic for bivalent COVID-19 boosters on 6/29/23. She said that an outside pharmacy administers the vaccine to the residents that were qualified and consented. She said that she was not aware that there were no physician's orders written. The facility staff could not provide the surveyor any further documented evidence of any physician's order to administer the vaccines to the residents, as required. 2A. Resident #124 was admitted to the facility in April 2023 with diagnoses including type 2 diabetes mellitus and hemiplegia (paralysis of one side of the body) following cerebral infarction affecting the left non-dominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/23/23, indicated that Resident #124 scored a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating moderate cognitive impairment. Review of the Massachusetts Board of Registration in Nursing, Accepting, Verifying, Transcribing and Implementing Prescriber Orders (last revised 4/11/2018) indicated the following: -Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. -The minimum elements required for inclusion in a complete medication order include patient's full name; name of medication; dose and route of the medication; frequency of the medication administration; valid medication order date; specific directions for administration; signature of the duly authorized prescriber; and signature of the individual accepting/verifying the order. Review of the facility's policy titled medication and treatment orders, dated July 2016, indicated the following: *Drug and biological order must be recorded on the Physician's order sheet in the resident chart. *Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, date and time of the order. *Orders for medications must include: -name and strength of drug -number of doses, start and stop date, and/or specific duration of therapy. -dosage and frequency of administration. -route of administration. -clinical condition or symptoms for which the medication is prescribed. -any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, etc.) On 7/11/23 at 10:01 A.M., the surveyor observed Resident #124 sleeping in bed with a Peripheral Inserted Central Catheter (PICC- a long thin tube that is advanced into the vein of the upper arm and the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart) on his/her right arm. The surveyor also observed an intravenous (IV) pump machine (a medical device that delivers fluids, medications, into a patient's body in controlled amount). During an interview on 7/11/23 at 10:05 A.M., Nurse #7 said that Resident #124's morning dose of IV Vancomycin (a medication used to treat infections caused by bacteria) is on hold because the phlebotomist (a person that primarily draws blood) that is scheduled to draw the blood for the Vancomycin trough (a test to measure drug levels during treatment) is late. Review of Resident #124's Physician's Order, dated 6/26/23, indicated: -Vancomycin 750 milligrams (mg) intravenously twice a day at 10:00 A.M. and 10:00 P.M. for osteomyelitis (an infection in a bone) on left heel. Review of Resident #124's Nurse Progress notes, dated 7/10/23, indicated that the Vancomycin trough level was 17.2 and the Physician Assistant (PA) was notified and ordered to continue with IV Vancomycin 750 mg twice a day, and to repeat Vancomycin trough on 7/11/23 before the 10:00 P.M. dose. Review of the July 2023 Electronic Medication Administration Record (EMAR) indicated that IV Vancomycin was not given on 7/11/23 at 10:00 A.M. and 10:00 P.M. as ordered. During an interview on 7/13/23 at 9:42 A.M., Nurse #4 said that on 7/10/23 she notified the PA of the Vancomycin level results. She said that the PA gave a telephone order to give the scheduled IV Vancomycin 750 mg on 7/11/23 at 10:00 A.M. and repeat the Vancomycin trough before the 10:00 P.M. dose. She reviewed Resident #124's medical record (including physician's orders) and said that she did not write the telephone orders by the PA to give the scheduled IV Vancomycin 750 milligrams (mg) on 7/11/23 at 10:00 A.M., and to repeat the Vancomycin trough on 7/11/23 before the evening dose. She said that she cannot recall reporting the telephone order to give the scheduled IV Vancomycin 750 mg on 7/11/23 at 10:00 A.M., and to repeat the Vancomycin trough on 7/11/23 before the evening dose of IV Vancomycin on 7/11/23 to the evening shift 3:00 P.M.-11:00 P.M. nurse. Further review of Resident #124's medical record (including physician's orders) failed to indicate the telephone order on 7/10/23 to give scheduled IV Vancomycin 750 mg and to repeat Vancomycin trough on 7/11/23 before the 10:00 P.M. dose. During an interview via telephone on 7/13/23 at 10:08 A.M., the physician said that the nurse called him on the afternoon of 7/11/23 and let him know that the 10:00 A.M. dose of IV Vancomycin was not given and that the Vancomycin trough was not done in the morning because the lab tech was late and did not collect the blood sample until 1:00 P.M., and that the result was still pending. He said that he was not aware that the Vancomycin trough was scheduled before the evening dose on 7/11/23. He said that the nurse should have given the scheduled morning dose of IV Vancomycin on 7/11/23. He told the surveyor that he gave a telephone order to the nurse to give IV Vancomycin 750 mg now and to notify him once the Vancomycin trough result was available. During an interview on 7/13/23 at 11:00 A.M., Nurse #7 said that he called the physician on 7/11/23 at 5:00 P.M. and let him know that the morning dose of IV Vancomycin was not given and that the Vancomycin trough was not drawn until 1:00 P.M., and that the results were still pending. He said that the physician gave a telephone order to give IV Vancomycin 750 mg now and to notify him once Vancomycin level results are available. Nurse #7 told the surveyor that he did not write the telephone order to give IV Vancomycin 750 mg. Both the surveyor and Nurse #7 reviewed the EMAR/ETAR and nurse progress notes and were unable to locate any evidence that IV Vancomycin 750 mg was given to Resident #124 as ordered. The facility staff failed to write and transcribe a telephone order resulting in Resident #124 missing IV Vancomycin as ordered.

Based on observations, interviews, and record review, the facility failed to provide a language manual to assist staff in communicating with one Resident (#140), out of a sample of 40 residents. Findings include: Review of the facility's policy titled 'Foreign Language', with no revision date, indicated the following: *The facility will maintain an up-to-date language manual for use by staff. *Staff will utilize the manual to assist in communicating with Residents in their dominant language of understanding. Resident #140 was admitted to the facility in March 2023 with diagnoses including dementia with behaviors. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/16/23, did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely understood and rarely interviewable. On 7/11/23 at 9:35 A.M., the surveyor observed Certified Nurse's Assistant (CNA) #1 assisting the Resident with breakfast. CNA #1 was struggling to cue and communicate with the Resident in English. No communication book was observed in the room. Review of Resident #140's Communication Care Plan, initiated 3/15/23, indicated that the Resident is Cantonese speaking only. On 7/12/23 at 9:22 A.M., the surveyor observed CNA #1 assisting Resident #140 with breakfast. CNA#1 was cueing the Resident in English repeatedly; the Resident was having a hard time following the verbal cueing. No communication book was observed in the room. On 7/12/23 at 1:03 P.M., the surveyor observed CNA #1 assisting Resident #140 with lunch. CNA #1 was having a hard time cueing and communicating with the Resident in English. No communication book was observed in the room. During an interview on 7/13/23 at 7:22 A.M., CNA #1 said she does not speak Cantonese, and has a hard time providing care for the Resident because of the language barrier. She said she makes up ways to communicate hoping the Resident will understand. She has never seen a communication book in the room. CNA #1 said it would be beneficial to have a communication book in the room with basic statements such as Hello, eat, drink, swallow, sleep, bathroom, are you all right, in Cantonese so she can communicate clearly to the Resident. During an interview on 7/13/23 at 7:37 A.M., the Social Worker said there should be a communication book in the Resident's room; even with a diagnosis of Dementia, the Resident is able to understand basic statements in Cantonese. During an interview on 7/12/23 at 8:31 A.M., the Director of Nurses said there should be a communication book in the Resident's room to help staff communicate with the Resident while providing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to two dependent Residents (#13 and #23), out of a total sample of 40 residents. Specifically, the facility failed to provide assistance with bed mobility and eating. Findings include: 1. Resident #13 was admitted to the facility in April 2018 and had diagnoses that included dementia and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/19/23, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 8 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 requires extensive two person physical assistance with bed mobility and one person physical assistance with eating. On 7/11/23 at 8:18 A.M., the surveyor observed Resident #13 lying in bed, with the head of the bed nearly flat. There was a tray table directly in front of Resident #13 with a breakfast tray placed on it. The tray was not set up, covers were on the food, and the container of juice was unopened. Resident #13 was attempting to drink from a container of milk, but due to the position of the head of the bed, the milk was spilling down Resident #13's cheeks. At 8:26 A.M., the surveyor observed Resident #13 use a butter knife to open the juice. During an interview and observation on 7/11/23 at 8:29 A.M., Resident #13 said, Sometimes I can't open things, and get all flustered then, and can't eat. The surveyor observed Resident #13 had eggs and muffin all over his/her chest. Review of the [NAME] (resident specific care instructions) indicated Resident #13 requires the following: * EATING: Resident #13 is able to feed self with 1 assist for fatigue or increased confusion. Requires increased assistance in evenings; * BED MOBILITY: Resident #13 needs 1 assist for bed mobility to be repositioned every 2 hours and as needed. On 7/12/23 at 8:02 A.M., the surveyor observed a Certified Nursing Assistant (CNA) deliver breakfast to Resident #13 who was seated in bed. The CNA placed the breakfast tray on a tray table beside the bed and exited the room, leaving Resident #13 not positioned properly to reach the food and without assistance for eating. The surveyor continued to make the following observations: * At 8:07 A.M., Resident #13 remained without assistance and had made no attempts to reach the food or eat. * By 8:28 A.M., no staff had entered the room to properly position Resident #13 or to assist with the meal since the CNA delivered the meal 26 minutes earlier. * At 8:29 A.M., Resident #13's roommate could be heard from the hallway instructing Resident #13 to Sit up, you will feel a little better if you get some food in you, please Resident #13, sit up, hold onto the bar and try to pull yourself up and eat. On 07/12/23 at 12:02 P.M., a CNA delivered lunch to Resident #13 in his/her room, set up the tray on a tray table in front of Resident #13 and exited the room. The surveyor continued to make the following observations: * By 12:28 P.M., no staff have entered the room to supervise or offer assistance to Resident #13 since the meal was initially provided 26 minutes earlier and the food remained untouched. On 7/13/23 at 7:54 A.M., a CNA delivered a breakfast tray to Resident #13 and exited the room, leaving Resident #13 unsupervised and unassisted. The milk, juice and cereal containers were all unopened and a tray cover was left atop the plate of food. The surveyor continued to make the following observations: * At 8:19 A.M., Resident #13 remained unsupervised and unassisted. He/she was observed taking a sip of juice than began profusely coughing for approximately 30 seconds. No staff were observed in the vicinity or responded to the coughing. * At 8:21 A.M., Resident #13's roommate could be overheard from the hallway pleading with the Resident to eat something on the tray, just the cereal. Resident #13 responded, I can't open it. During an interview on 7/13/23 at 10:29 A.M., Resident #13's CNA (#2) said it is only her second day working on the floor and that she knows she can read the [NAME] for instructions on Resident #13's care needs, but to be honest I never looked at his/hers. CNA #2 said Resident #13 can tell you exactly what he/she wants and needs and eats by him/herself, although admitted ly said that the Resident refused to talk to her that day. During an interview on 7/13/23 at 11:08 A.M., Resident #13's Nurse (#2) said that she had never seen a [NAME] and did not know what it was. Nurse #2 said that she thinks Resident #13 can feed him/herself and if he/she asks us to open things or chop things up we will. During an interview on 7/17/23 at 1:11 P.M., the Director of Nursing (DON) said feeding assistance should be provided for Resident #13. 2. Resident #23 was admitted to the facility in December 2014 and had diagnoses that included epilepsy and dysphagia (difficulty chewing and swallowing). Review of the most recent MDS assessment, dated 6/9/23, indicated that on the BIMS exam Resident #23 scored a 9 out of 15, indicating moderately impaired cognition. The MDS further indicated Resident #23 had no behaviors and required one person physical assistance with eating and extensive physical assistance with bed mobility. The MDS indicated an active diagnosis of dysphagia. Review of the current [NAME] indicated: * Monitor/document/report PRN any s/sx (symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. * EATING: The resident is totally dependent on 1 staff for eating. Participation encouraged to maximize independence. * BED MOBILITY: Resident #23 requires assistance by 1-2 staff to turn and reposition in bed every 2 hours and as necessary. Review of the current Activity of Daily Living (ADL) care plan for Resident #23 indicated the following interventions: * EATING: The resident is totally dependent on 1 staff for eating. Participation encouraged to maximize independence. * BED MOBILITY: Resident #23 requires assistance by 1-2 staff to turn and reposition in bed every 2 hours and as necessary. Review of the most recent Licensed Nursing Summary, dated 6/23/23, indicated Resident #23 was totally dependent for eating and needed assist of 1 for positioning. On 7/11/23 at 8:42 A.M., the surveyor observed Resident #23 in bed. Breakfast was placed on a tray table directly in front of him/her and no staff were present to supervise or assist with the meal. On 7/12/23 at 8:04 A.M., the surveyor observed Resident #23 in the unit dining room, attempting to feed self breakfast. No staff were present in the room to supervise or assist the Resident. On 7/14/23 at 8:01 A.M., the surveyor observed Nurse (#9) deliver breakfast to Resident #23 who was in bed. Nurse #9 placed the tray on a tray table directly in front of Resident #23 and exited the room leaving Resident #23 with no staff present to supervise or assist with the meal. The surveyor continued to make the following observations: * At 8:03 A.M., the head of the bed was at a 45-degree angle and Resident #23 appeared to be having difficulty reaching the food. * At 8:13 A.M., Resident #23 was staring off into space and the food was untouched. * At 8:25 A.M., Resident #23 was with his/her head resting on the pillow and the food remained untouched. No staff have supervised or assisted Resident #23 since the tray was served 24 minutes earlier. During an interview on 7/14/23 at 9:10 A.M., Resident #23's Certified Nursing Assistant (CNA) #7 said Resident #23 requires full assistance with care and is a feeder. CNA #7 said when she feeds Resident #23 he/she eats 100%. CNA #7 reported Resident #23 ate well that day, contrary to the surveyor's direct observations of him/her without assistance and not eating the meal. During an interview on 7/17/23 at 7:29 A.M., Resident #23's Nurse (#8) said that if the Resident's care plan and [NAME] indicate that the Resident is dependent on staff for positioning and eating then the staff should be positioning Resident #23 and should be with Resident #23 through the meal providing the feeding assistance. During an interview on 7/17/23 at 8:46 A.M., the Director of Nursing (DON) said that if a Resident's [NAME] and care plan indicate they require assistance with eating, then the staff should be providing assistance throughout the meal.

Based on observations, record review, and interviews, the facility failed to provide appropriate activities for one Resident (#140), out of a sample of 40 residents. Specifically, the facility failed to provide age-appropriate activities in the Resident's dominant language. Findings include: Review of the facility's policy titled 'Activity Programs', with no revision date, indicated the following: *Activity programs are designed to meet the needs of each resident and are available on a daily basis. *Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. *Social activities are scheduled to increase self-esteem, to stimulate interest and friendships and to provide fun and enjoyment. Resident #140 was admitted to the facility in March 2023 with diagnoses including dementia with behaviors. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/16/23, did not indicate a Brief Interview for Mental Status score because the Resident is rarely understood and rarely interviewable. On 7/11/23 at 9:35 A.M., the surveyor observed Resident #140 watching children's cartoons playing in English in his/her room during breakfast. Review of the Communication Care Plan, initiated on 3/15/23, indicated that Resident #140 is Cantonese speaking only. Further review of the Activity Care Plan, initiated on 4/11/23, did not indicate that Resident #140 preferred to watch cartoons in English. On 7/12/23 at 9:11 A.M. and 12:28 P.M., the surveyor observed Resident #140 in bed watching children's cartoons in English while eating breakfast and lunch, respectively. During an interview on 7/13/23 at 8:22 A.M., the Activities Director said children's cartoons in English are not age-appropriate activities for the Resident. She said there are other appropriate activities in Cantonese that can be provided for the Resident since he/she still has his/her long-term memory. During an interview on 7/13/23 at 8:28 A.M., the Director of Nurses said children's cartoons should not be an alternative for an activity for Residents unless it is the Resident's preference. She also said Residents who don't speak English as their first language should be provided activities that they understand.

2. For Resident #142, the facility failed to develop and implement an individualized plan of care for hearing and communication when Resident #142 required a cochlear implant device (cochlear implant is an electronic device that improves hearing) to maintain his/her hearing. Nursing did not consistently implement the device. Review of the facility's policy titled, Care of Hearing Aid, dated as revised October 2010, indicated: *Purpose -The purpose of caring for a hearing aid is to maintain the resident's hearing at the highest attainable level. *Preparation -Review the resident's care plan to assess for any special needs of the resident. *Storage of the Hearing Aid: 3. Be sure that the hearing container is clearly labeled with the resident's name and room number. *Documentation The following information should be recorded in the resident's medical record: 1. The date and time the hearing aid was checked and/or battery was replaced. 3. If the resident refused the procedure, the reason(s) why and the intervention taken. *Reporting 1. Notify the supervisor if hearing aid is damaged or needs to be sent to the dealer for cleaning. 2. Notify the supervisor if the resident complains of problems related to hearing and/or the hearing aid or has a wax build up in the ear. 3. Report other information in accordance with facility policy and professional standards of practice. Resident #142 was admitted to the facility in March 2023 with diagnoses including dementia, urinary retention, hearing loss, and sepsis. Review of the MDS assessment, dated 6/2/23, indicated Resident #142 had moderate difficulty with hearing and did not use a hearing appliance during the assessment. The MDS indicated Resident #142 had no behaviors and did not refuse care. The MDS indicated he/she required extensive assistance of two for dressing and his/her health care proxy had been activated. Review of the plan of care related to hearing, dated 4/21/23, indicated: - Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. - Discuss with resident/family concerns or feelings regarding communication difficulty - Report to Nurse changes in: Ability to communicate, Possible factors which cause/make worse/make better any communication problems. Further review of the plan of care failed to indicate the use of a cochlear implant. On 7/11/23 at 8:57 A.M., the surveyor observed Resident #142 in his/her room eating alone. The surveyor attempted to speak to Resident #142 but he/she was hard of hearing. The surveyor observed a hearing device on Resident #142's windowsill that was not applied. On 7/11/23 at 9:46 A.M. and 7/11/23 at 11:09 A.M., the surveyor observed Resident #142 dressed and in bed yelling out. The surveyor was unable to communicate with Resident #142. During an interview on 7/11/23 at 2:20 P.M., Resident #142's Health Care Agent said that Resident #142 used to have two cochlear implants. The Health Care Agent said that one of the cochlear implants was lost and said she was told the cochlear hearing aid went down to the kitchen and was thrown out. The Health Care Agent said that Resident #142 was able to hear better with two cochlear implants. On 7/11/23 at 2:20 P.M., the surveyor observed Resident #142 wearing his/her cochlear implant. The Resident could communicate with the surveyor. On 7/12/23 at 10:00 A.M., the surveyor observed Resident #142 in bed and dressed for the day; the Resident was not wearing his/her cochlear implant. The cochlear implant was on the windowsill. On 7/13/23 at 8:44 A.M., the surveyor observed Resident #142 in bed and dressed for the day; the Resident was not wearing his/her cochlear implant. The cochlear implant was on the windowsill. Resident #142 was unable to communicate with the surveyor. During an interview on 7/13/23 at 10:00 A.M., CNA #5 said Resident #142 is dependent on staff for care. CNA #5 said that Resident #142 has bad hearing and will need to shout to communicate with Resident #142 during care, and the nurses will put on the hearing device. On 7/13/23 at 1:03 P.M., the surveyor observed Resident #142 in bed awake and not wearing his/her cochlear implant. The cochlear implant was on the windowsill. Resident #142 was unable to communicate with the surveyor. During an interview on 7/13/23 at 1:47 P.M., Nurse #4 said that Resident #142 is hard of hearing and the nurse will apply the cochlear implant for communication. Nurse #4 said that Resident #142 put one of his/her cochlear implants on his/her meal tray one day and it went missing. Nurse #4 said that staff are afraid to give Resident #142 his/her cochlear implant because they don't want to lose it. On 7/14/23 at 7:02 A.M., the surveyor, accompanied by Nurse #5, went into Resident #142's room. Resident #142 was hard of hearing. Nurse #5 did not utilize Resident #142's cochlear implant to communicate with Resident #142. During an interview on 7/14/23 at 9:13 A.M., the Assistant Director of Nursing (ADON) said Resident #142 lost one cochlear implant at the facility. The ADON said that nursing should apply the cochlear implant to communicate with Resident #142. During an interview on 7/14/23 at 10:14 A.M., the Director of Social Services said she thought that Resident #142's cochlear implant was found and was not aware it was still missing. During an interview on 07/14/23 at 11:36 A.M., the DON said Resident #142 lost one of his/her cochlear devices at the facility. The DON said that Resident #142's plan of care for communication should include the use of a cochlear implant with individualized interventions. Based on record reviews, policy review, and interviews, the facility failed to: 1. Follow the recommendations of the eye doctor and schedule an appointment with a retina specialist for one Resident (#79); and 2. Develop and implement a plan of care for hearing and communication for one Resident (#142) who required a cochlear implant to maintain his/her hearing and communication, out of a total sample of 40 residents. Findings include: 1. For Resident #79, the facility failed to ensure an appointment with a Retina Specialist was rescheduled after the Resident missed the appointment in December 2022. During that time Resident #79 reports significant deterioration in vision affecting his/her day-to-day life. Review of the facility's policy titled Visually Impaired Resident, Care of, dated as revised March 2021, indicated the following: * While it is not required that our facility provide devices to assist with vision, it is our responsibility to assist the resident and representatives in locating available resources (e.g., Medicare, Medicaid or local organizations), scheduling appointments and arranging transportation to obtain needed services. Resident #79 was admitted to the facility in August 2022 and had diagnoses that included Type II diabetes mellitus with unspecified diabetic retinopathy without macular edema and unspecified cataracts. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/12/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #79 scored a 15 out of 15, indicating intact cognition. The MDS further indicated Resident #79 has impaired vision and an active diagnosis of Cataracts, Glaucoma or Macular Degeneration. During an interview on 7/11/23 at 9:00 A.M., Resident #79 said that he/she had been asking the head nurse for at least five months to make him/her an appointment to see the eye doctor, and that the head nurse did nothing. Resident #79 said, Nothing is being done and it (his/her vision) has been getting worse and worse and now I can only see shadows. Resident #79 added, I'm going blind and no one cares to help me. Review of the entire appointment book for the year 2023 indicates first and only eye appointment scheduled for November 21, 2023. Review of the current Impaired Vision care plan for Resident #79 indicated the following interventions: * Refer to optometrist/ophthalmologist as needed and ordered. Review of the Psychology notes for Resident #79 indicated the following: * A Psychology Session Note, dated 4/25/23, indicated: STRESSORS/CHANGES IN MENTAL STATUS: (Stressors, or changes in mental status that may affect functioning): Eye issues need cataract surgery; it's affecting his/her quality of life. Summary of the session included The patient said that emotionally he/she was feeling good but waiting on the surgery for cataracts. He/she had a conflicting appointment, so the surgery needed to be rescheduled. However, he/she hasn't received a new date for cataract surgery. * A Psychology Session Note, dated 4/18/23, indicated Multiple frustrations related to medical and eye concerns. They are supposed to be checking for cataracts and something else. Last time pt had an appt was in December. I talk to everyone I can here about it. Pt frustrated with waiting. * A Psychology Session Note, dated 3/21/23, indicated: STRESSORS/CHANGES IN MENTAL STATUS: (Stressors, or changes in mental status that may affect functioning) Eye issues need cataract surgery; it's affecting his/her quality of life. * A Psychology Session Note, dated 2/14/23, indicated: STRESSORS/CHANGES IN MENTAL STATUS: (Stressors, or changes in mental status that may affect functioning) Eye issues need cataract surgery; it's affecting his/her quality of life. * A Psychology Session Note, dated 2/7/23, indicated: STRESSORS/CHANGES IN MENTAL STATUS: (Stressors, or changes in mental status that may affect functioning) Eye issues need cataract surgery; it's affecting his/her quality of life. * A Psychology Session Note, dated 1/31/23, indicated: STRESSORS/CHANGES IN MENTAL STATUS: (Stressors, or changes in mental status that may affect functioning) Eye issues need cataract surgery; it's affecting his/her quality of life. * A Psychology Session Note, dated 1/24/23, indicated: STRESSORS/CHANGES IN MENTAL STATUS: (Stressors, or changes in mental status that may affect functioning) Eye issues need cataract surgery; it's affecting his/her quality of life. * A Psychology Session Note, dated 12/27/22, indicated: STRESSORS/CHANGES IN MENTAL STATUS: (Stressors, or changes in mental status that may affect functioning) Eye issues. Notes from the session included: Writer encouraged the patient to participate in activities at the facility to thwart social isolation and emotional withdrawal. The patient said he/she would feel more comfortable participating in activities after eye treatment. During an interview on 7/17/23 at 10:00 A.M., Certified Nursing Assistant (CNA) #8 said she has been Resident #79's CNA for the past two months. CNA #8 said that Resident #79 complains about his/her vision and doesn't see well and that it is itchy. He/she told me that he/she is waiting for an appointment for cataract surgery. CNA #8 added, He/she complains that vision is getting worse and worse and that he/she can't see things anymore. During an interview on 7/17/23 at 10:09 A.M., the ophthalmology clinic Representative said that Resident #79 had an annual Optometrist appointment in November 2022 and that the recommendation by the Optometrist at that appointment was for Resident #79 to see a Retina Specialist. She said that it was scheduled for 12/8/22 but Resident #79 never showed up and the facility did not reschedule. The only appointment that is presently scheduled is Resident #79's yearly visit with the optometrist on 11/21/23. Review of the Nurse's Notes failed to indicate attempts had been made to reschedule the Retina Specialist appointment when it was missed in December 2022. Review of the record indicated Resident #79 was hospitalized for 10 days in December 2022, however, has been in the facility without any hospitalizations since March 2023. During an interview on 7/17/23 at 1:07 P.M., with the Director of Nursing (DON) and the Assistant DON, the DON said that the Nurse Unit Manager on Resident #79's unit abruptly quit and they continue to find out of things she didn't do, and about appointments that were missed and not rescheduled. The DON said that the Retina Specialist appointment should have been rescheduled when it was missed in December 2022.

Based on observation, interview, and record review, the facility failed to provide proper foot care for one Resident (#83), out of a total sample of 40 residents. Findings include: Resident #83 was admitted to the facility in May 2021 with diagnoses including traumatic brain injury (TBI). Review of the Minimum Data Set (MDS) assessment, dated 5/19/23, indicated that Resident #83 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. Further review of the MDS indicated Resident #83 requires one person physical assist with grooming. On 7/11/23 at 9:30 A.M., the surveyor observed that Resident #83's toenails were elongated, protruding around half an inch past the toe. On 7/12/23 at 9:47 A.M., the surveyor observed that Resident #83's toenails were elongated, protruding around half an inch past the toe. On 7/12/23 at 12:17 P.M., the surveyor observed that Resident #83's toenails were elongated, protruding around half an inch past the toe. During an interview on 7/11/23 at 9:30 A.M., Resident #83 said his/her toenails are too long and that he/she would like to have them cut. During an interview on 7/12/23 at 12:09 P.M., Certified Nursing Assistant (CNA) #9 said the CNAs do not cut toenails, if long toenails are observed the CNA will notify the nurse. During an interview on 7/12/23 at 12:14 P.M., Nurse #3 said if a resident's nails are too long a podiatry appointment will be made by the Unit Manager. Nurse #3 said she is unaware of Resident #83's elongated toenails. During an interview on 7/12/23 at 12:21 P.M., Unit Manager #1 said podiatry services typically come once a month, were last in the facility on July 5th, and are returning to the facility on July 26th. UM #1 said nurses will check toenails when completing their skin checks, and will alert the UM of any residents in need of podiatry services; she also said that if there is a more urgent need for the resident to be seen for foot care the wound doctor will be consulted. UM #1 does not recall being made aware of Resident #83's elongated toenails, and that the Resident is not on the podiatry list to be seen. UM #1 said she would have expected staff to have notified her of the Resident's toenails when the Resident's last skin check was completed, on 7/10/23, and that any refusals for skin checks should be documented. During an observation of Resident #83's toenails UM #1 said the Resident's nails are elongated and need to be cut. Review of Resident #83's electronic medical record failed to indicate the Resident had refused any recent skin-checks. Review of Resident #83's chart indicated a signed consent to be seen by podiatry services, dated 5/27/21. During an interview on 7/12/23 at 1:54 P.M., the Wound Doctor said he has not been consulted to see Resident #83, and that Resident #83 was not on his list to be seen.

Based on observation, record review, policy review, and interview, the facility failed for one Resident (#108), out of a total sample of 40 residents, to maintain professional standards in the managing and care for urinary catheter devices. Specifically, the facility failed to maintain Resident #108's urinary catheter in a manner to prevent the possibility of infection. Findings include: Review of the facility's policy titled Catheter Care, Urinary, dated as revised September 2014, indicated the purpose of this procedure is to prevent catheter associated urinary tract infections. -Preparation 1. Review the resident's care plan to assess for any special needs -Infection Control b. Be sure the catheter tubing and drainage bag are kept off the floor Resident #108 was admitted to the facility in May 2023 with diagnoses including anxiety, depression, dysphagia, diabetes, atrial fibrillation, and convulsions. Review of the Minimum Data Set (MDS) assessment, dated 6/20/23, indicated Resident #108 did not have behaviors and did not refuse care. The MDS indicated he/she required extensive assistance of two staff members for toilet use which included the use of the catheter and Resident #108 required an indwelling catheter. Review of the plan of care related to activities of daily living, dated 5/24/23, indicated: -TOILET USE: The resident requires assistance by (1-2) staff for toileting. May be dependent. Incontinent of bowel. Foley catheter managed by nursing staff. On 7/11/23 at 7:56 A.M., 7/11/23 at 10:11 A.M., 7/11/23 at 2:19 P.M., 7/12/23 at 6:44 A.M., 7/12/23 at 7:21 A.M., and on 7/13/23 at 6:41 A.M., the surveyor observed Resident #108's urinary catheter bag directly on the floor. During an interview on 7/13/23 at 10:08 A.M., Certified Nurse Assistant (CNA) #5 said that urinary drainage bags should be stored off the floor. During an interview on 7/13/23 at 11:52 A.M., CNA #6 said that urinary drainage bags should be stored off the floor. During an interview on 7/13/23 at 1:35 P.M., Nurse #4 said that urinary drainage bags should be stored off the floor. During an interview on 7/14/23 at 11:30 A.M., the Director of Nursing (DON) said that urinary drainage bags should be stored off the floor.

Based on observation, record review, and interview, the facility failed to address significant weight changes for one Resident (#45), out of a total sample of 40 residents. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, revised September 2008, indicated the following: *Weights will be recorded in each unit's Weight Record Chart or notebook and in the individual's medical record. *Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. *The Dietitian will respond within 24 hours if receipt of notification. *The Dietitian will review the Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. *The threshold for significant unplanned weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant, greater than 5% is severe b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe c. 6 months - 10% weight loss is significant; greater than 10% is severe Resident #45 was admitted to the facility in March 2016 with diagnoses including Traumatic Brain Injury (TBI). Review of the Minimum Data Set (MDS) assessment, dated 5/5/23, indicated that Resident #45 was unable to complete a Brief Interview for Mental Status (BIMS). Review of Resident #45's care plans indicated the Resident is at risk for nutritional decline secondary to a diagnosis of dysphagia/ NPO (nothing by mouth) status and requires nutritional support via enteral nutrition support (nutrition formula administered directly into the stomach or intestine) and that Body Mass Index (BMI) indicates overweight status. Review of Resident #45's Physician's Orders indicated the following orders: *NPO diet *Jevity 1.5 (an enteral nutrition formula) at 65 mL/hr (milliliters per hour) for 20 hours daily. Review of Resident #45's Weight Report indicated the following weights: -1/5/23: 172 pounds (lbs.) obtained via mechanical lift -2/6/23: 173 lbs. obtained via mechanical lift -3/7/23: 172.5 lbs. obtained via mechanical lift -4/6/23: 182.6 lbs. -4/14/23: 190.2 lbs. obtained via mechanical lift -5/5/23: 183 lbs. obtained via mechanical lift -6/13/23: 184.5 lbs. obtained via mechanical lift -7/3/23: 186.4 lbs. obtained via mechanical lift Review of the weight report indicated Resident #45 had experienced a clinically significant weight gain of 10.1 lbs. (5.9% total body weight) between 3/7/23 and 4/6/23. Review of the progress notes indicated the weight gain had not been assessed until 4/27/23, 3 weeks after the significant weight gain had been identified. During an interview on 7/13/23 at 1:33 P.M., the Registered Dietitian (RD) said any weight changes of 5 lbs., loss or gain, warrant a reweigh to confirm the weight change; her expectation is the reweigh occur within 48 hours. Once the significant weight change is confirmed she would expect nursing to notify her of the change, and would expect to assess the resident within a week. The RD said nursing did not notify her of the weight change, and that the reweigh should have occurred sooner. The RD said that weight maintenance is the goal for Resident #45, and that any weight gain is undesirable due to the Resident's elevated BMI.

Based on observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) was provided in accordance of professional standards of practice and his/her physician's orders for one Resident (#112), out of a total sample of 40 residents. Specifically, Resident #112's physician ordered tube feed was ordered as continuous and did not account for a dialysis schedule and a meal schedule. Findings include: Review of the facility's policy titled, Enteral Feedings- Safety Precautions, dated as revised May 2014, indicated the facility will remain current in and follow accepted best practice in enteral nutrition. Resident #112 was admitted to the facility in February 2023 with diagnoses including cerebral infraction, dysphagia, end stage renal disease, atrial fibrillation, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 5/14/23, indicated Resident #112 required total dependence of one staff member for eating and required a feeding tube. The MDS indicated he/she required dialysis. Review of the Physician's Orders indicated: - 2/9/23 Hemodialysis (Tuesday/Thursday/Saturday) - 4/25/23 Nepro at 40 ml/hr (milliliters/ hour) via G-tube - Hold for a residual greater than 100 ml every shift - 5/20/23 Enteral feed every shift Nepro to run at 40 ml/hr - 6/3/23 Consistent Carbohydrate Diet-Renal diet, Pureed texture, Thin Liquids consistency Review of the plan of care related to activities of daily living, dated 2/7/23, indicated: - EATING: The resident is totally dependent on staff for eating. Tube fed Review of the Dietary Note, dated 6/30/23, indicated current diet order on hold d/t [due to] hospitalization. CCHO, renal diet, puree consistency, thin liquids. SLP [speech language pathologist] to evaluate resident for appropriate consistency. Nepro at 40 ml/hr with estimated run time of 22 hours provides 880 ml Nepro, 1584 kcal, 71 gm protein, 640 ml free water, 200 ml free water flushes plus water flushes with meds. Review of the Speech Therapy Treatment Encounter Notes, dated 7/2/23, 7/3/23, 7/4/23, 7/7/23, 7/11/23, and 7/12/23, indicated Resident #112 was participating with speech therapy and tolerating meals. During an interview on 7/13/23 at 11:46 A.M., Certified Nurse Assistant #6 said Resident #112 eats meals. During an interview on 7/12/23 at 12:42 P.M., Nurse #4 said that Resident #112's tube feeding order is not accurate. Nurse #4 said that the order does not indicate when the feeding should be stopped for dialysis. Nurse #4 said that she does not have an order to resume the tube feeding after Resident #112 returns from dialysis. Nurse #4 said Resident #112 returns between 10:00 A.M. and 11:00 A.M., from dialysis 3 days a week. Nurse #4 said she needs to shut off the tube feeding at least 1 hour prior to Resident #112 receiving his/her oral meals. During an interview on 7/14/23 at 8:37 A.M., Nurse #5 (who works the 11:00 P.M. to 7:00 A.M. shift) said she shuts off Resident #112's tube feeding around 4:30 A.M. on days that Resident #112 is picked up for dialysis. Nurse #5 said she does not have a physician's order to shut off the tube feeding. During an interview on 7/13/23 at 1:11 P.M., the Dietitian said that the physician's order indicates a continuous tube feed for Resident #112. The Dietitian said her calculations for estimated run time of 22 hours does not take into consideration the 3 days a week Resident #112 receives dialysis. The Dietitian said she was not aware that Resident #112 was eating and would need to review the orders for tube feeding. During an interview on 7/14/23 at 9:33 A.M., the Assistant Director of Nursing said that Resident #112's physician's order for tube feeding should include start and stop times that include dialysis days and meals. During an interview on 7/14/23 at 11:53 A.M., the Director of Nursing (DON) said Resident #112's physician's order should include start and stop times to include dialysis days and meals.

Based on observation, interview, and policy review, the facility failed to ensure medications once opened were dated as required on 2 of 4 sampled medication carts. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised April 2007, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. a. On 7/12/23 at 6:52 A.M., the surveyor observed the following on the 2A Medication Cart 2 with Nurse #6: - one bottle of Dorzolamide, Hydrochloride and Timolol Maleate Ophthalmic Solution (eye drops), opened and undated - one bottle of Brimonidine Tartrate Solution 0.2% Ophthalmic Solution, opened and undated - one bottle Pro-Stat liquid protein, opened and undated. Review of manufacturer's guidelines indicated to discard 3 months after opening. During an interview at 7/12/23 at 6:58 A.M., Nurse #6 said that Pro-stat liquid protein and eye drops should be dated when opened. b. On 7/12/23 at 7:19 A.M., the surveyor observed the following on 1A Medication Cart 1 with Nurse #7: - one bottle Pro-Stat liquid protein, opened and undated. Review of manufacturer's guidelines indicated to discard 3 months after opening. - three Anoro Ellipta (umeclidinium and vilanterol inhalation powder) inhalers, opened and undated. Review of manufacturer's guidelines indicated good for 6 weeks once opened. During an interview on 7/12/23 at 7:22 A.M., Nurse #7 said Pro-Stat liquid protein and the three Anoro Ellipta inhalers should be dated when opened. During an interview on 7/14/23 at 12:03 P.M., the Director of Nursing (DON) said medications should be dated when opened.

3. Review of the facility's policy titled Documentation of Medication Administration, dated as revised April 2007, indicated the facility shall maintain a medication administration record to document all medications administered. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral) Resident #4 was admitted to the facility in December 2022 with diagnoses including traumatic brain injury, paraplegia, bipolar disorder, insomnia, neuromuscular dysfunction of the bladder, and suicidal ideations. Review of the Physician's Order, dated 2/14/23, indicated: -Prostat (medication used to promote wound healing) one time a day for wound healing. Further review of the physician's order indicated there was no dose as required. During an interview on 7/13/23 at 1:45 P.M., Nurse #4 said Resident #4's Prostat order was incomplete and required a dose. During an interview on 7/14/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said Resident #4's Prostat order was incomplete and required a dose. During an interview on 07/14/23 at 12:17 P.M., the DON said Resident #4's Prostat order was incomplete and required a dose. 4. Review of the facility's policy titled Documentation of Medication Administration, dated as revised April 2007, indicated the facility shall maintain a medication administration record to document all medications administered. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral) Resident #112 was admitted to the facility in February 2023 with diagnoses including cerebral infraction, dysphagia, end stage renal disease, atrial fibrillation, and diabetes. Review of the MDS assessment, dated 5/14/23, indicated Resident #112 required total dependence of one staff member for eating and required a feeding tube (G-tube). Review of the Physician's Order, dated 3/27/23, indicated: - Apixaban (blood thinning medication) Oral Tablet 2.5 milligrams (mg), Give 1 tablet by mouth two times a day for blood thinning During an interview on 7/12/23 at 12:42 P.M., Nurse #4 said that Resident #112 takes medications via g-tube. Nurse #4 said the physician's order should say by G-tube and Resident #112 does not take the medication by mouth. During an interview on 7/14/23 at 9:36 A.M., the ADON said Resident #112 takes medications via g-tube. The ADON said the physician's order should say by G-tube and Resident #112 does not take the medication by mouth. During an interview on 07/14/23 at 11:53 A.M., the DON said that Resident #112 takes medications via g-tube. The DON said the physician's order should say by G-tube and Resident #112 does not take the medication by mouth. Based on observation, record review, and interview, the facility failed to maintain an accurate medical record for four Residents (#13, #23, #4, and #112), out of a total sample of 40 residents. Specifically, 1. For Resident #13, the nurses documented in the Treatment Administration Record (TAR) that they had applied ace wraps to the Resident's legs, when they had not; 2. For Resident #23, the nurses documented in the TAR that the Resident was wearing a boot, when he/she was not; 3. For Resident #4, the facility failed to maintain an accurate record for a medication's dose as required; and 4. For Resident #112, the facility failed to ensure nursing maintained an accurate medical record related to the route of administration of a medication. Findings include: 1. Resident #13 was admitted to the facility in April 2018 and had diagnoses that included dementia and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/19/23, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 8 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 requires extensive one person physical assistance with dressing. On 7/11/23 at 8:18 A.M., the surveyor observed Resident #13 lying in bed. His/her Bilateral Lower Extremities (BLE) appeared fragile. Review of the current Physician's Orders indicated an order, dated as started 1/13/23, for ACE wraps to BLE, on in AM, off in PM. On 7/11/23 at 9:56 A.M., the surveyor observed Resident #13 in bed and there were no ace wraps on his/her BLE. On 7/11/23 at 10:59 A.M., the surveyor observed Resident #13 dressed and seated at the nurses' station. There were no ace wraps on his/her BLE. On 7/11/23 at 2:18 P.M., the surveyor observed Resident #13 seated in a wheelchair in his/her room. There were no ace wraps on his/her BLE. On 7/12/23 at 8:11 A.M. and 12:00 P.M., the surveyor observed Resident #13 in bed and there were no ace wraps on his/her BLE. On 7/13/23 at 8:27 A.M., the surveyor observed Resident #13 in bed and there were no ace wraps on his/her BLE. Review of the July 2023 TAR indicated that nursing documented on July 11th, 12th and 13th, 2023 that Resident #13 had ace wraps applied to his/her BLE. Review of the record failed to indicate Resident #13 refused to wear the ace wraps. During an interview on 7/13/23 at 11:08 A.M., Resident #13's Nurse (#12) said she isn't aware that Resident #13 wears ace wraps and that it might be an old order. Nurse #12 said she doesn't know how to discontinue an order and just checks off that the ace wraps are in place because she doesn't know what else to do. During an interview on 7/17/23 at 8:56 A.M., the Director of Nursing (DON) said that the TAR should not indicate Resident #13 has had the ace wraps applied if the nurse has not applied them. 2. Resident #23 was admitted to the facility in December 2014 and had diagnoses that included epilepsy and fracture of upper and lower end of right fibula. Review of the most recent MDS assessment, dated 6/9/23, indicated that on the BIMS exam Resident #23 scored a 9 out of 15, indicating moderately impaired cognition. The MDS further indicated Resident #23 had no behaviors and required one person physical assistance with dressing. Review of the current Physician's Orders indicated the following order: * May remove ortho boot at bedtime, every night shift, with a start date 4/29/23 * WBAT (weight bear as tolerated) in cast boot to right lower extremity On 7/11/23 at 8:42 A.M., the surveyor observed Resident #23 in bed. He/she was not wearing a boot as ordered by the physician. During an observation and interview on 7/11/23 at 10:09 A.M., the surveyor observed Resident #23 in his/her bed and he/she was not wearing a boot as ordered by the physician. Resident #23 said that he/she is supposed to have a boot on, but that he/she doesn't know where it went. On 7/14/23 at 8:01 A.M., the surveyor observed Resident #23 dressed and in bed. He/she was not wearing a boot as ordered by the physician. On 7/14/23 at 9:00 A.M., the surveyor observed Resident #23 seated in a wheelchair in the hallway with his/her nurse. Resident #23 was not wearing a boot. On 07/14/23 at 11:26 A.M., the surveyor observed Resident #23 using his feet to peddle his wheelchair forward. Resident #23 was not wearing a boot. Review of the July 2023 TAR indicated that nursing documented on July 11th and 14th, 2023 that Resident #23 was wearing a boot, contrary to direct observation that he/she was not. Review of the record failed to indicate Resident #23 refused to wear the boot. During an interview on 7/14/23 at 9:10 A.M., Resident #23's Certified Nursing Assistant (CNA) #7 said that Resident #23 requires full assistance with care and that she was not aware that Resident #23 is supposed to wear a boot. During an interview on 7/17/23 at 7:29 A.M., Resident #23's Nurse (#8) said that she called that morning to get the boot order discontinued, as when she was going to do his/her treatments she did not see a boot in the room. Nurse #8 said that nurses should not be documenting that the Resident is wearing the boot if he/she is not. During an interview on 7/17/23 at 8:46 A.M., the DON said that Nursing should not be signing off that the boot is applied if there was not a boot.

Based on observations, policy review, and interview, the facility failed to ensure staff disinfected reusable resident care equipment (a blood pressure cuff) between residents. Findings include: Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated as revised July 2014, indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standards. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. On 7/12/23 at 9:40 A.M., the surveyor observed Nurse #3 obtain a Resident's blood pressure using a reusable blood pressure cuff. The cuff directly touched the Resident's bare skin. Nurse #3 did not clean the blood pressure cuff after use. The surveyor continued to observe Nurse #3. On 7/12/23 at 9:55 A.M., Nurse #3 obtained a different Resident's blood pressure using the same reusable blood pressure cuff, which had not been disinfected and directly touched this Resident's bare skin. During an interview on 7/12/23 at 9:58 A.M., Nurse #3 said she cleans the blood pressure cuff at the beginning of her shift and at the end of her shift. Nurse #3 said she does not clean the blood pressure cuff between residents. During an interview on 7/14/23 at 11:49 A.M., the Director of Nursing (DON) said that nursing should disinfect the blood pressure cuff between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure a smoke detector in a resident bedroom, located on the second floor, was free of obstruction and functioned properly. Findings include: On 9/21/23 at 9:07 A.M., the surveyor observed a smoke detector, located on the ceiling in room [ROOM NUMBER], and approximately four feet from the entry door. A clear yellow piece of thin plastic covered the smoke detector, preventing the device from sensing potential smoke in the bedroom. During an interview with Certified Nurse Aide (CNA) #2 on 9/21/23 at 9:10 A.M., she observed the plastic covering the smoke detector in room [ROOM NUMBER]. CNA #2 said she had been unaware the smoke detector had been covered. During an interview with Nurse #1 on 9/21/23 at 9:15 A.M., she observed the plastic covering the smoke detector in room [ROOM NUMBER]. Nurse #1 said she had been unaware the smoke detector had been covered. During interviews with both residents who occupied room [ROOM NUMBER] on 9/21/23 at 9:15 A.M., they said they were unaware the smoke detector was covered with plastic. During an interview with Maintenance Staff on 9/21/23 at 9:20 A.M., he observed the plastic covering the smoke detector in room [ROOM NUMBER]. The Maintenance Staff said he had been sanding plaster in room [ROOM NUMBER] approximately one week ago and had covered the smoke detector with this plastic to prevent dust from entering the device. The Maintenance Staff said he had forgotten to remove the plastic after completing the work and that no one had informed him the plastic remained covering the device.

3. The facility failed to provide a dignified dining experience on 2 of 5 units. During an observation on 7/11/23 at 9:01 A.M., the surveyor heard two different staff members refer to residents as feeders three separate times while passing out breakfast trays on the 3A unit in a common area within earshot of a resident. During an observation on 7/12/23 at 1:09 P.M., the surveyor heard a staff member refer to a resident as a feeder while distributing lunch trays on the 3A unit in a common area within earshot of a resident. During an observation on 7/14/23 at 8:40 A.M., the surveyor heard Unit Manager (UM) #1 referred to six different residents as feeders while distributing lunch trays on the 1A unit in a common area within earshot of a resident. For two of the six residents, UM #1 identified the residents by their full names before referring to them as feeders. During an interview on 7/14/23 at 9:24 A.M., the DON said staff should use the phrase requiring assistance when referring to residents who require assistance with meals, as referring to residents as feeders is not dignified. 2A. Review of the facility's policy titled Catheter Care, Urinary, dated as revised September 2014, indicated the purpose of this procedure is to prevent catheter associated urinary tract infections. -Preparation 1. Review the resident's care plan to assess for any special needs Resident #4 was admitted to the facility in December 2022 with diagnoses including traumatic brain injury, paraplegia, and neuromuscular dysfunction of the bladder. Review of the MDS assessment, dated 6/30/23, indicated Resident #4 can make self understood and he/she can understand others. The MDS indicated Resident #4 required staff assistance for toilet use including managing the catheter and utilizing an indwelling catheter. Review of the plan of care related to suprapubic catheter, dated 12/30/23, indicated: -CATHETER: The resident has suprapubic catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. On 7/11/23 at 7:57 A.M., 7/11/23 at 9:40 A.M., 7/11/23 at 11:31 A.M., 7/12/23 at 6:41 A.M., 7/12/23 at 11:49 A.M., 7/13/23 at 6:37 A.M., 7/13/23 at 7:55 A.M., and on 7/13/23 at 10:00 A.M., the surveyor observed Resident #4 in his/her bed with his/her urinary catheter drainage hanging from the bed which was visible from the entrance room door, without a privacy bag covering it. During an interview on 7/11/23 at 2:14 P.M., Resident #4 said he/she would like a privacy bag for his/her urinary drainage bag. During an interview on 7/13/23 at 10:05 A.M., CNA #5 said urinary catheter drainage bags require a privacy bag. During an interview on 7/13/23 at 1:35 P.M., Nurse #4 said urinary catheter drainage bags require a privacy bag. During an interview on 07/14/23 12:17 PM at 11:40 A.M., the DON said urinary catheter drainage bags require a privacy bag. B. Resident #108 was admitted to the facility in May 2023 with diagnoses including anxiety, depression, dysphagia, diabetes, atrial fibrillation, and convulsions. Review of the MDS assessment, dated 6/20/23, indicated Resident #108 had a BIMS score of 8 out of 15 indicating moderate cognitive impairment. Resident #108 did not have behaviors and did not refuse care. The MDS indicated he/she required extensive assistance of two staff members for toilet use which included the use of catheter and Resident #108 utilized an indwelling catheter. On 7/11/23 at 7:56 A.M., 7/11/23 at 10:11 A.M., 7/11/23 at 2:19 P.M., 7/12/23 at 6:44 A.M., 7/12/23 at 7:21 A.M., 7/13/23 at 6:41 A.M., the surveyor observed Resident #108's urinary catheter bag without a privacy bag. During an interview on 7/13/23 at 10:08 A.M., CNA #5 said that urinary catheter drainage bags should be stored in a privacy bag. During an interview on 7/13/23 at 11:52 A.M., CNA #6 said that urinary catheter drainage bags should be stored in a privacy bag. During an interview on 7/13/23 at 1:35 P.M., Nurse #4 said that urinary catheter drainage bags should be stored in a privacy bag. During an interview on 7/14/23 at 11:30 A.M., the DON said that urinary catheter drainage bags should be stored in a privacy bag. C. Resident #142 was admitted to the facility in March 2023 with diagnoses including dementia, urinary retention, hearing loss and sepsis. Review of the MDS assessment, dated 6/2/23, indicated Resident #142 utilized an indwelling catheter; and his/her health care proxy had been activated. Review of the plan of care related to indwelling catheter, dated 3/31/23, indicated: -CATHETER: The resident has (SPECIFY Size) 14fr (French) 10cc (cubic centimeters) balloon Foley (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. On 7/11/23 at 7:59 A.M., 7/11/23 at 9:46 A.M., 7/11/23 at 2:20 P.M., 7/12/23 at 6:44 A.M., and 7/12/23 at 10:00 A.M., the surveyor observed Resident #142 in bed with his/her indwelling urinary catheter bag visible from the entrance room door, without a privacy bag covering it. During an interview on 7/13/23 at 10:08 A.M., CNA #5 said that urinary catheter drainage bags should be stored in a privacy bag. During an interview on 7/13/23 at 11:52 A.M., CNA #6 said that urinary catheter drainage bags should be stored in a privacy bag. During an interview on 7/13/23 at 1:35 P.M., Nurse #4 said that urinary catheter drainage bags should be stored in a privacy bag. During an interview on 7/14/23 at 11:30 A.M., the DON said that urinary catheter drainage bags should be stored in a privacy bag. Based on observations, interviews, policy review, and record review, the facility failed to provide dignified experiences for four Residents (#140, #4, #108, #142), out of a sample of 40 residents. The facility also failed to provide a dignified dining experience on 2 out of 5 units. Specifically, the facility failed: 1. For Resident #140, to provide a dignified dining experience and dignified age-appropriate activities; 2. For Residents #4, #108, and #142, to ensure a catheter bag was covered for privacy; and 3. To address residents requiring assistance in a dignified manner on 2 out of 5 units. Findings include: Review of the facility's policy titled Quality of Life-Dignity, revised August 2009, indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Resident #140 was admitted to the facility in March 2023 with diagnoses including dementia with behaviors. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/16/23, indicated a Brief Interview for Mental Status (BIMS) exam was not completed because the Resident is rarely understood and rarely interviewable. On 7/11/23 at 9:35 A.M., the surveyor observed Resident #140 propped up in bed getting assistance with breakfast from Certified Nurse's Assistant (CNA) #1 while watching children's cartoons playing in English on television. CNA #1 was standing while feeding the Resident. On 7/12/23 at 9:22 A.M., the surveyor observed Resident #140 propped up in bed getting assistance with breakfast from CNA #1 while watching children's cartoons playing in English. CNA #1 was standing while feeding the Resident. On 7/12/23 at 1:03 P.M., the surveyor observed Resident #140 propped up in bed getting assistance with lunch from CNA #1 while he/she watched children's cartoons playing in English on television. CNA #1 was standing while feeding the Resident. Review of the medical record did not indicate cartoon programs as a preferred activity for the Resident. Further review of the medical record indicated a communication care plan dated 3/15/23 indicating Resident #140 is Cantonese speaking only. During an interview at 1:30 P.M., CNA #1 said she should be seated at eye level while assisting Resident #140 with meals. She also said she turns the cartoon channel on for the Resident while he/she is eating. She was not sure if that was his/her preferred activity. During an interview on 7/13/23 at 7:55 A.M., the Social Worker said it is undignified to assist the Resident with meals while standing. She also said it is undignified to play children's cartoons in English for a Resident who does not speak English as a first language and not able to verbalize his/her activity preference. During an interview on 7/13/23 at 8:28 A.M., the Director of Nurses (DON) said CNAs should be seated at eye level while assisting Residents with meals. She also said children's cartoons in English should not be played for non-English speaking Residents who are not able to communicate their activity preferences.

Based on observations, record review, policy review, and interviews, the facility failed to ensure for two Residents (#24 and #112), who required dialysis received such services consistent with professional standards of practice and the comprehensive person-centered care plan, out of 40 sampled residents. Specifically, the facility failed: 1. For Resident #24, to ensure nursing implemented a physician's order and plan of care related to blood pressure checks; and 2. For Resident #112, to ensure nursing implemented a physician's order and plan of care related to blood pressure checks. Findings include: Review of the facility's policy titled Dialysis Management, dated as revised January 2019, indicated the facility has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents/patients regardless if the procedure is performed at the dialysis center or at the facility. 16. Assure plan of care indicates which limb contains the vascular access. Blood pressures and draws should not be done on the access arm. 1. Resident #24 was admitted to the facility in March 2023 with diagnoses including end stage renal disease and convulsions. Review of the Minimum Data Set (MDS) assessment, dated 7/3/23, indicated Resident #24 required dialysis. Review of the Physician's Orders indicated: - 3/13/23 Hemodialysis- Assess site (specify) Right IJ (central venous catheter access point located in the internal jugular) for bruising / bleeding / ballooning / symptoms of infection. Notify MD for new onset, every shift - 3/16/23 No Bps (blood pressures) in left an[d] right arm every shift for blood pressure Review of the plan of care related to dialysis, dated 3/13/23, indicated: - do not draw blood or take B/P (blood pressure) in arm with graft. On 7/11/23 at 10:36 A.M., Resident #24 showed the surveyor his/her dialysis site on the right clavicle (IJ) area and showed the surveyor his/her A/V fistula (a connection that's made between an artery and a vein for dialysis access) on his/her left arm. Review of Resident #24's blood pressure records indicated nursing obtained his/her blood pressure in the left arm or right arm on: July: 7/1/23-7/13/23 June: 6/27/23-6/30/23, 6/22/23-6/24/23, 6/1/23-6/10/23 May: 5/1/23-5/31/23 On 7/13/23 at 1:40 P.M., the surveyor and Nurse #4 reviewed the physician's order for blood pressures. Nurse #4 said that nursing should not obtain blood pressure from Resident #24's left or right arms and should use his/her lower extremities. On 7/14/23 at 9:31 A.M., the surveyor and the Assistant Director of Nursing (ADON) reviewed the physician's order for blood pressures and the blood pressures that were obtained and documented in the medical record. The ADON said that nursing should not obtain blood pressure from Resident #24's left or right arm and should use his/her lower extremities. The ADON said nursing should have implemented the physician's order and should have obtained blood pressures from the lower extremities. During an interview on 7/14/23 at 11:48 AM, the Director of Nursing (DON) said nursing should not have obtained Resident #24's blood pressure in his/her arms. 2. Resident #112 was admitted to the facility in February 2023 with diagnoses including cerebral infraction, dysphagia, end stage renal disease, atrial fibrillation, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 5/14/23, indicated Resident #112 required dialysis. Review of the plan of care related to dialysis, dated 2/6/23, indicated: -Do not draw blood or take B/P in arm with graft. Left arm Review of the Physician's order dated, 2/22/23, indicated: - NO BP OR BLOOD TO BE DRAWN IN LEFT ARM every shift related to END STAGE RENAL DISEASE Review of Resident #112's Blood Pressure documentation indicated nursing obtained a blood pressure from Resident #112's left arm on the following dates: - June: 6/13/23 - May: 5/1/23, 5/3/23 - April: 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/19/23, 4/21/23, 4/23/23, 4/23/24, 4/25/23, 4/27/23, and 4/30/23 During an interview on 7/12/23 at 12:42 P.M., Nurse #4 said that nursing should only obtain Resident #112's blood pressure from his/her right arm. During an interview on 07/14/23 at 11:53 A.M., the Director of Nursing (DON) said that nursing should implement the physician's order and care plan and not obtain blood pressures from Resident #112's left arm. The DON said that using the left arm could compromise Resident #112's dialysis and A/V fistula.

Based on observation, interviews and record review, the facility failed to provide behavioral health services, for one Resident (# 95), out of a sample of 40 residents and 31 residents out of the facility census of 149 residents. Specifically, the facility failed to provide substance abuse counseling services for residents with a history of substance abuse. Findings include: Review of the facility's policy titled 'Providing care to residents experiencing addiction or substance abuse disorder', with no revision date, indicted the following: *Educate residents on how to make better lifestyle choices and enjoy their recovery. This includes providing residents with access to programs and resources that can structure the process for a greater potential for success. Resources include mental health providers and therapists, crisis hotlines, pain management practices and inpatient substance abuse treatment options. Resident #95 was admitted to the facility in July 2018 with diagnoses including a history of alcohol abuse. Review of the Minimum Data Set (MDS) assessment, initiated 6/23/23, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. On 7/11/23 at 10:59 A.M., the surveyor observed Resident #95 in his/her room with a bottle of whiskey containing alcohol on his/her bedside table. During an interview on 7/14/23 at 7:54 A.M., Resident #95 said that he/she has a history of drinking alcohol, and he/she would like to attend Alcoholics Anonymous (AA) meetings if offered. The Resident said he/she feels the support from a substance abuse counselor and being around others with the same daily urges to drink alcohol would be very helpful to him/her. Further review of the medical record indicated that 31 other residents in the facility have a history of substance abuse and have not been offered any substance abuse counseling services. During an interview on 7/13/23 at 10:40 A.M., the Social Worker said there is currently no substance abuse counselor in the facility. She said having a substance abuse counselor offering AA and Narcotics Anonymous (NA) meetings is needed for a facility with residents with a history of substance abuse. During an interview with on 7/14/23 at 8:16 A.M., the Director of Nurses said that substance abuse counseling services should be provided to the residents in the facility with a history of substance abuse.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 4 nurses observed made 3 errors out of 30 opportunities resulting in a medication error rate of 10%. Those errors impacted 2 Residents (#25 and #64), out of 4 residents observed. Findings include: Review of the facility's policy titled Documentation of Medication Administration, dated as revised April 2007, indicated the facility shall maintain a medication administration record to document all medications administered. 2. Administration of medication must be documented immediately after it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g. oral) Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner, and as prescribed. 7. Medications are administered within one hour of their prescribed time. 10. The individual administering medications checks the label three times to verify the right medication, right dose, right time, and right method before administering the medication. 1. For Resident #25, Nurse #1 administered the incorrect form of aspirin and the incorrect dose of Calcium Carbonate with Vitamin D. On 7/12/23 at 8:51 A.M., Nurse #1 prepared the following medications for Resident #25: -aspirin 325 milligrams (mg) enteric coated (EC), 1 tablet -Calcium Carbonate 600 mg/ Vitamin D 200 units, 1 tablet Review of the Physician's Order included: - 2/9/18 Calcium Carbonate-Vitamin D3 Tablet 600-400 mg-unit (Calcium Carb-Cholecalciferol), Give 1 tablet by mouth one time a day for supplement - 2/27/22 Aspirin Tablet 325 MG, Give 1 tablet by mouth one time a day for DVT (deep vein thrombosis) During an interview on 7/12/23 at 9:00 A.M., Nurse #1 said that he is required to check the right medication and right dose of medications. 2. For Resident #64, Nurse #2 administered medications one hour and 19 minutes after their scheduled time. On 7/12/23 at 9:19 A.M., Nurse #2 prepared and administered the following medications for Resident #64: -Primidone 50 mg, 2 tablets, administered one hour and 19 minutes late Review of the Physician's Order, dated 6/20/22, indicated for nursing to administer: Primidone Tablet 50 milligrams, Give 2 tablets by mouth four times a day for tremors. Further review indicated the medications were scheduled daily at 800, 1400, 1700, and 2100. During an interview on 7/12/23 at 9:21 A.M., Nurse #2 said she was late administering medications because of breakfast trays. Nurse #2 said she is required to pass medications within one hour of their scheduled time. During an interview on 7/14/23 at 12:00 P.M., the Director of Nursing (DON) said that nursing should have administered the correct aspirin, Calcium with Vitamin D. The DON said medications should be administered within one hour of the scheduled time.

Based on interview and record review, the facility failed to take into consideration the dietary preferences of each resident. Specifically, the facility failed to accommodate residents' preferences for eating pork. Findings include: During the Resident Group Meeting on 7/12/23 at 10:20 A.M., 17 of 21 residents in attendance said they have been told they are not allowed to have pork because the facility is Jewish owned. The Resident Group said that turkey bacon is not an acceptable alternative and that they want real bacon, real ham and real pork products offered and provided. Resident #116 was admitted to the facility in July 2022 with diagnoses including Anemia. Review of the Minimum Data Set (MDS) assessment, dated 4/18/23, indicated that Resident #116 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. During an interview on 7/14/23 at 12:34 P.M., Resident #116 said he/she has asked for pork but was told that he/she could not have pork because this is a Jewish facility and because the owners of the facility are Jewish. Resident #116 said he/she does not understand why he/she is not allowed to have pork as he/she is not Jewish and would like pork. Resident #101 was admitted to the facility in February 2019 with diagnoses including cancer. Review of the Minimum Data Set (MDS) assessment, dated 5/26/23, indicated that Resident #101 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. During an interview on 7/17/23 at 7:30 A.M., Resident #101 said he/she has been told he/she is not allowed to eat pork because this is a Jewish facility. Resident added that he/she dislikes the pork alternatives. Resident #132 was admitted to the facility in August 2022 with diagnoses including diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 5/19/23, indicated that Resident #132 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. During an interview on 7/17/23 at 9:02 A.M., Resident #132 said he/she dislikes the pork alternatives. During the initial walk-through of the kitchen on 7/11/23 at 7:09 A.M., no pork containing items were observed in the food storage areas. Review of the facility menus failed to indicate any pork containing options. Review of the resident council minutes for August 2022 indicated the resident council had requested an option for ham. Review of the Dislike Tally Report indicated that only one Resident out of the 149 current residents had a potential pork product (sausage) listed as a dislike. During an interview on 7/14/23 at 11:05 A.M., the Registered Dietitian (RD) said she is unaware of anyone having ever received pork at the facility, and that out of the 149 current residents there are no residents that follow a kosher diet. The RD said the residents should have the right to eat pork. During an interview on 7/14/23 at 11:09 A.M., the Food Service Director (FSD) said the kitchen is not Kosher certified, however, the owner of the facility prefers to impose certain aspects of a Kosher diet, specifically by not allowing pork. The FSD said that residents have asked him for pork but have been told that the facility does not provide pork. The FSD said that resident input is taken into consideration for menu development and that items frequently requested will be added to the menu; the FSD said that this does not apply to pork, as it is not allowed on the menu by ownership. The FSD said that throughout his 5 years working at the facility, pork has never been on the menu. Review of the facility admission packet failed to indicate the facility notifies the residents of, or requests a consent for, following a pork restricted diet. Review of the facility website fails to indicate the facility is a pork-free facility. During an interview on 7/17/23 at 8:17 A.M., the Director of Nursing said the owners do not allow the facility to purchase pork, but if residents ask for pork, the facility should provide it to them. During an interview on 7/17/23 at 10:23 A.M., the facility Administrator said the residents do not consent to a pork restriction when admitting to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure bedroom furniture and was in good working condition on one of three resident floors. Findings include: 2nd floor Unit 2A On 9/21/23 between 8:25 A.M., to 9:40 A.M., the surveyor observed the following: room [ROOM NUMBER]: Two broken bureau drawers. room [ROOM NUMBER]: Rusted bathroom trash can with missing lid. room [ROOM NUMBER]: Nightstand drawer unable to be opened. room [ROOM NUMBER]: Nightstand drawer has a broken handle. 2nd floor Unit 2B On 9/21/23 between 9:00 A.M. to 11:40 A.M., the surveyor observed the following: room [ROOM NUMBER]: Window screen missing from middle window. Missing closet door handle. During an interview with the Administrator and Maintenance Director on 9/21/23 at 1:42 P.M., they said they were aware the second floor resident rooms needed repairs. The Administrator and Maintenance Director said they were in the process of replacing broken furniture, but that there had not been sufficient time to complete the large amount of work required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on three of three units (Unit 1 A, Unit 2 ABC, and Unit 3). Specifically, the survey team observed: environmental cleanliness concerns in resident rooms, resident showers and hallways which included dirty wall surfaces, wall surfaces in disrepair, missing tiles, floors in need of washing, mouse droppings, dead mice, ants and black flies. Findings include: The surveyor observed the following in room [ROOM NUMBER]: -On 7/11/23 at 8:22 A.M., mouse droppings located in the corner of the room and behind the resident's dresser. Dust and debris were observed on the floors. -On 7/17/23 at 10:03 A.M., mouse droppings were in the corner of the room, beside the resident's dresser and under the heating vent. The surveyor observed the following in room [ROOM NUMBER]: -On 7/13/23 at 9:19 A.M., a dead mouse in the corner of the room on a sticky board. Mouse droppings were observed under the heating vent and behind the resident's bedside table. -On 7/17/23 at 12:49 P.M., the dead mouse and mouse droppings were observed in room [ROOM NUMBER]. The Resident was observed sitting on the side of the bed eating his/her lunch just feet away from the dead rodent. On 7/17/23 at 10:10 A.M., the surveyor observed the main dining room area located on the first floor. A smell, similar to that of a cleaning product, was present when entering the room and the floor was visibly wet with wet floor signs. Mouse dropping were observed in two corners of the rooms. The area behind the code cart was observed with dust and debris. The baseboard was visibly dirty. On 7/17/23 beginning at 8:05 A.M., the surveyor conducted environmental rounds throughout the facility and made the following observations: 2B Unit began at 8:05 A.M.: - Room B 205: Cracked and missing tiles between the resident room and bathroom. A broken heater vent below the resident window. Door trim and baseboards scuffed, dirty in appearance with peeling paint. A strong smell of urine was present. - Room B 207: Peeling wallpaper in various areas of the room. The walls were shredded with holes observed behind residents' beds. Pieces of the shredded wall were observed under the beds. The floor was sticky with a brown substance located on the floor between the beds. - Room B 209: Peeling wallpaper, scuffed areas, and peeling paint in various walls of the room. The floor had a brown/black substance located beside the resident's bed. The resident bathroom had several areas of plastered holes around the soap dispenser and behind the toilet. - Room B 203: Peeling wallpaper around the heating vent, including a discolored area of the wall to the left of the heating vent. The floor was dirty with food product and in need of washing. - Room B 202: [NAME] scratch marks observed on the wall to the left of the resident's bed. A white plastered area was observed behind the resident's bed. The baseboards around the closet area were covered in a brown substance and a black build-up was observed in the corners of the room. - The hallway across from room [ROOM NUMBER] had lifting floor tiles. The floor was in need of cleaning with a black sticky substance observed to the left of the hallway. The door frames were scuffed with a black substance observed at the base of the doorframe. The handrails had wrappers, dust and debris tucked between the handrail and walls. - Room B 201: The baseboards were chipped, scuffed and with dusty debris. Chipped paint was observed on the walls in multiple corners of the room. - Room B 210: Broken tile observed in the corner of the door. A black build-up was observed on the doorframes and baseboards. The bathroom door had areas with chipped paint. - The Shower Room to the right of the ramp between Unit 2B and 2 C: A rust-colored substance was observed at the base of the doorway. Floor tiles were observed to be missing. C Unit began at 8:50 A.M.: - The unit hallway entrance was observed to have scuffed, chipped walls. Specifically, the corners of the walls had paint and plaster chipped away exposing metal. The walls were dirty and in disrepair. A large stain was observed on the carpet as you enter the unit. The stain was observed to look wet but was dry to the touch and old in appearance. - Room C 202: The walls, doorframes and baseboards were visibly scuffed, and chipped. The floor tiles had a black substance swept across the tile floors in front of the resident's dresser. The heating vent was chipped with a black scuff mark across the panel. - Room C 208: The baseboards and doors were visibly scuffed and chipped. One side of the wall had several holes observed. The corner walls were observed with peeling paint. - Room C 203: The tile floor was cracked in the doorway of the room. Wallpaper was peeling from the walls near the heater vent. The walls and baseboards were scuffed and in need of cleaning. - Room C 207: The walls were peeling and visibly dirty along the heater with a black substance. The floor was visibly dirty with debris, dried material and food product observed. Several ants, too numerous to count, were observed surrounding two cooked elbow pastas beside the heating vent. - Room C 205: The heating vent was scuffed and in disrepair with two panels disconnected from one another. The paint on the walls was chipped in various areas. Wires were observed hanging from the walls and outlets. Trash, including a bottle of maple syrup, was observed behind the resident's bedside table. The wall located behind the bedside table was shredded with a hole present. Unit 1 A began at 9:20 A.M.: - room [ROOM NUMBER]: The walls and door frames were scuffed with peeling paint, and visibly dirty. The heating vent located in the resident bathroom was in disrepair and observed with a broken metal piece on the floor next to the vent. - room [ROOM NUMBER]: The walls were scuffed with visible holes, and peeling paint, specifically behind the resident's bed. Dirt and debris were observed under the heating vent, including an opened milk container, a styrofoam cup, various wrappers and food debris. Resident products including clothing, personal items, plastic and paper bags were observed piled up behind the resident's dresser. Black flies were visible throughout the room. - The hallway floor tiles, across from the shower room were lifting, cracked and in need of repair. - The shower room had an exposed drain with no cover protecting the hole. A shower chair was present with ripped material on the seat cover. The ceiling was cracked with exposed plaster and paint hanging from the ceiling. The women's bathroom across from the shower room had multiple missing wall tiles under the sink. The broken tiles were observed laying on the floor next to the toilet. - room [ROOM NUMBER]: Exposed wires, including extension cords, were observed in the corner of the room. Resident belongings, personal beverages and equipment were observed piled in the corner of the room. Trash was scattered on the floor including tissues and bottle caps. - room [ROOM NUMBER]: Multiple black flies were observed in the room. Trash, including used tissues, napkins and a blood soiled alcohol prep pad were observed scattered on the floor. - room [ROOM NUMBER]: Mouse droppings were observed on the floor behind the resident's dresser and under the heating vent. The floors were dirty with crumbs and dried food product stuck to the floor. The bathroom heating vent was observed with rust-colored areas. - room [ROOM NUMBER]: A hole in the wall was observed at the baseboard behind the bathroom door. The bathroom door was observed to not fully close without the use of force. The floor was sticky with a brown/black substance observed on the floor between the beds. The walls were scuffed and in disrepair. - room [ROOM NUMBER]: The walls were scuffed with a hole observed at the baseboard next to the resident's dresser. A fan was observed in the room, broken with the face of the fan resting on the floor, leaving the fan blades exposed. The fan had dust collecting on the blades. - The hallway floors outside of rooms 108 -110 were observed with dirt build-up along the walls. Floor tiles were observed to be cracked and lifting at the doorframe. - room [ROOM NUMBER]: Mouse droppings were identified in the corner of the room beside the resident's dresser and under the heating vent. The walls were scuffed, dirty in appearance and in disrepair. - room [ROOM NUMBER]: Multiple black flies were observed in the room. The bathroom floor had missing tiles in the doorway to the bedroom. Unit Three (Third Floor) began at 11:15 A.M., - room [ROOM NUMBER]: Multiple resident items were observed piled behind the resident's dresser and on top of a heating vent. Items included a winter jacket hood, multiple papers, and a woven basket. The wall under the air conditioner unit was peeling, cracked and in disrepair. Additional walls in the room were observed with scuffs and cracks at the base of the wall. The bathroom heater vent was observed with a rust-colored scrape across the panel. The bathroom wall tiles were cracked and missing. - room [ROOM NUMBER]: The floor was visibly dirty with black dirt and debris in the corner of the room. The walls were scuffed with peeling paint. The plastic baseboard was pulled away from the wall. - The men's bathroom (between room [ROOM NUMBER] and 318) was visibly dirty around the base of the toilet and wall. Floor and wall tiles behind the toilet were cracked. - room [ROOM NUMBER]: A strong smell of urine was present when entering the room. Multiple wires were observed hanging from a television fixed to the wall. The wires stretched across the heating vent and air conditioner unit to an additional TV on a dresser. Mouse droppings were observed behind the resident's dresser. - room [ROOM NUMBER]: Mouse droppings were present in multiple areas in the room including under the heating vent and behind a resident's dresser. Dust and debris were observed under the heater vents and in the corners of the room. - room [ROOM NUMBER]: The walls were scuffed with chipping paint and in disrepair. The plastic baseboard was pulling away from the wall in two separate areas in the room. - room [ROOM NUMBER]: The threshold flooring between the resident room and bathroom was missing. - room [ROOM NUMBER]: Black flies were present in the room. The walls were scuffed with chipping paint. The bathroom commode was observed with rust-colored areas on the legs and below the seat. - room [ROOM NUMBER]: A strong smell of urine was present when entering the room. The walls were scuffed and dirty. The heating vent was observed with a dried brown and black substance that covered the vent, dirty in appearance. A cracked outlet plate cover was observed on the wall. - room [ROOM NUMBER]: A black residue build-up was observed on the floor in various areas of the room, including between in resident's beds and in front of the dresser. The walls were scuffed and stained with liquid drip marks. - The tub room door was scuffed with chipped paint across the door and around the handle. Unit 2 A began at 11:58 A.M. - Black flies were observed in the unit kitchenette. Wires were observed hanging from the wall. - Cracked tiles were observed in the hallway in front of the unit elevator. - room [ROOM NUMBER]: Black flies were observed in the room. The walls were scuffed with chipped paint. - room [ROOM NUMBER]: Resident belongings were observed piled against the walls and in the corner of the room. Resident belongings included food products, beverages, personal hygiene products, multiple bags, clothing, and stacks of papers. Mouse droppings were identified behind the resident's dresser and in the corner of the room where the resident belongings were piled. - The men's bathroom (between rooms 217-218) had missing wall tiles. - room [ROOM NUMBER]: The walls were scuffed with missing baseboards and closet trim. The bathroom commode was observed with rust-colored areas below the seat. The tiles between the resident bathroom and bedroom were cracked and missing. - The resident lounge area was observed with the door open. The door had chipped missing paint in the center with scuff marks observed. The walls had areas of chipped paint. - The tiled floor between the resident lounge and tub room was cracked. - The shower room and tub room doors were scuffed with chipped paint. - room [ROOM NUMBER]: Mouse droppings were observed in the corners of the room and behind the bedside tables. - room [ROOM NUMBER]: A dead mouse was observed on a mouse trap in the corner of the room under the heating vent. - room [ROOM NUMBER]: Black flies were observed throughout the room. During an interview on 7/17/23 at 1:33 P.M., the Administrator said it is expected that housekeeping is cleaning all common areas and resident rooms every day. She said resident rooms have a room of the day where a deeper cleaning is completed in the room. During an interview on 7/17/23 at 1:42 P.M., the Maintenance Director, Director of Housekeeping, Administrator, and the surveyor walked throughout different areas in the facility and reviewed the observations. The Director of Housekeeping said we should be cleaning every room every day to which the Administrator said the staff needs to be reeducated on this. During an interview on 7/17/23 at 2:15 P.M., the surveyor reviewed the environmental concerns and observations with the Administrator. The Administrator said the facility needs to have a better system in place between housekeeping and maintenance. She said the facility needs to communicate when mouse droppings are found so we can correct the problem.

Based on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: Review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised October 2008, indicated the following: *Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of the facility's policy titled Preventing Foodborne Illness - Food Handling, revised July 2014, indicated the following: *The facility recognizes that the critical factors implicated in foodborne illness are: -Poor personal hygiene of food service employees; -Inadequate cooking and improper holding temperatures -Contaminated equipment Review of the current United States Department of Agriculture (USDA) food safety guidelines indicate that undercooked or raw unpasteurized eggs should not be consumed as they pose a significant risk for Salmonella (a potentially serious bacterial food-borne infection), especially for those who are elderly and/or immuno-compromised (those with a weakened immune systems). The USDA food safety guidelines also indicate that leftover prepared food should not be kept for more than 4 days in the refrigerator. On 7/11/23 at 7:09 A.M., the surveyor made the following observations during the initial walkthrough of the kitchen: *Three staff members in the food preparation area were without hair restraints *A putrid smell permeating with the walk-in refrigerator *A dark, wispy substance lining the shelves in the walk-in refrigerator *Artichokes with significant signs of decomposition, including the presence of a white, wispy growth in the walk-in refrigerator *Bell peppers with significant signs of decomposition, including the presence of a white, wispy growth in the walk-in refrigerator *Lettuce in a container labeled 3/30/23, with significant signs of decomposition in the walk-in refrigerator *Four food containers stacked on top of each other in the walk-in refrigerator so that the bottom of each pan was in direct contact with food in the container below it *A container of cooked carrots in the walk-in refrigerator unlabeled and undated *An open bag of mozzarella cheese in the walk-in refrigerator undated *An open bag of cheddar cheese in the walk-in refrigerator undated *A container of an unknown food substance in the walk-in refrigerator unlabeled and undated *A large container of frozen chicken in the freezer undated, unlabeled and loosely covered in tinfoil exposing the chicken to air During an interview on 7/11/23 at 7:49 A.M., the Food Service Director (FSD) said all food items should be covered, labeled, dated, and discarded after three days. The FSD also said that food containers should not be stacked on top of each other as a method for covering the containers, and that the shelves with black wispy substances need to be cleaned. On 7/12/23 at 7:40 A.M. through 8:00 A.M., the surveyor made the following observations of the tray line during breakfast service: *The cook contaminated her gloves by touching the handles of serving spoons, tongs, the bottom of plates, and scoops, and then with the same contaminated gloves directly grabbed ready to eat food including waffles and toast placing the food items on six different residents' trays. *The cook contaminated her gloves by touching the handles of serving spoons, tongs, the bottom of plates, and scoops, and then with the same contaminated gloves directly placed a loaf of bread through a bread toaster. Using the same contaminated gloves, the cook grabbed the ready to eat toast and placed each piece in a pan to be served, contaminating every piece of toast. *The cook was asked to prepare over-easy eggs (eggs which are undercooked), the cook prepared over easy eggs placed them on the resident's plate to be served despite not knowing whether the eggs have been pasteurized. During an interview on 7/12/23 at 8:00 A.M., the FSD confirmed that the eggs were cooked over-easy/undercooked and said he is not sure if the eggs are pasteurized as there is no indication on any of the eggs packaging currently in storage that the eggs are pasteurized. The FSD said eggs should not be undercooked/served over-easy unless the eggs are known to be pasteurized as this would place the residents at risk for foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on three of three units. Findings include: During the Resident Group meeting on 7/12/23 at 10:20 A.M., 21 residents were in attendance. Twenty-one out of twenty-one residents in the group indicated that there are rodents on all floors in the building. They said that pest service company comes in but changes nothing. When you report the concerns to maintenance, nothing gets done. They said there are little black bugs everywhere in the building. The group expressed frustration that the facility is fixing everything but the rooms. They said they are upset the facility put in a golf course that nobody uses, and redesigned the lobbies, the pub, and new trees all around perimeter, however; it seems housekeeping is barely working and does not wash floors or the toilets. During an interview on 7/17/23 at 12:51 P.M., the Maintenance Director said the facility has been utilizing a pest control company for some time due to a concern with black flies and mice. He said the pest control company comes to the facility weekly to service the facility. Review of the Commercial Pest Control Service Agreement, signed 8/25/14, indicated the following: -Inspection and treatment is to uncover and eliminate infestation, prevent influx of pests, and to maintain pest-free conditions. Areas to be serviced included: patient rooms, common areas, hallways, closets, offices, storage areas, utility and mechanical/boiler room, food service, dining, trash handling, dock and exterior perimeter. On 7/11/23 at 8:22 A.M., the surveyor observed the following: -room [ROOM NUMBER]: Mouse droppings located in the corner of the room and behind the resident's dresser. Dust and debris were observed on the floors. -On 7/17/23 at 10:03 A.M., mouse droppings located in the corner of the room, beside the resident's dresser and under the heating vent. On 7/13/23 at 9:19 A.M. the surveyor observed the following: -106: A dead mouse in the corner of the room on a sticky board. Mouse droppings were observed under the heating vent and behind the resident's bedside table. -On 7/17/23 at 12:49 P.M., the dead mouse and mouse droppings were again observed in room [ROOM NUMBER]. Resident #24 was observed sitting on the side of the bed eating his/her lunch just feet away from the dead rodent. During an interview on 7/17/23 at 12:49 P.M., Resident #24 said he/she sees mice often, they crawl along the walls at night. On 7/17/23 beginning at 8:05 A.M., the surveyor conducted environmental rounds throughout the facility and made the following observations: - Room C 207: The floor was visibly dirty with debris, dried material and food product observed. Several ants, too numerous to count, were observed surrounding two cooked elbow pastas beside the heating vent. - room [ROOM NUMBER]: Black flies were visible throughout the room. - room [ROOM NUMBER]: Multiple black flies were observed in the room. - room [ROOM NUMBER]: Mouse droppings were observed on the floor behind the resident's dresser and under the heating vent. The floors were dirty with crumbs and dried food product stuck to the floor. - room [ROOM NUMBER]: Mouse droppings were identified in the corner of the room beside the resident's dresser and under the heating vent. - room [ROOM NUMBER]: Multiple black flies were observed in the room. - room [ROOM NUMBER]: Mouse droppings were observed behind the resident's dresser. - room [ROOM NUMBER]: Mouse droppings were present in multiple areas in the room including under the heating vent and behind a resident's dresser. - room [ROOM NUMBER]: Black flies were present in the room. - Black flies were observed in the 2A unit kitchenette. - room [ROOM NUMBER]: Black flies were observed in the room. - room [ROOM NUMBER]: Resident belongings were observed piled against the walls and in the corner of the room. Resident belongings included food products, beverages, personal hygiene products, multiple bags, clothing, and stacks of papers. Mouse droppings were identified behind the resident's dresser and in the corner of the room where the resident's belongings were piled. - room [ROOM NUMBER]: Mouse droppings were observed in the corners of the room and behind the bedside tables. - room [ROOM NUMBER]: A dead mouse was observed on a mouse trap in the corner of the room under the heating vent. The Resident was observed in bed eating lunch and in close proximity to the dead rodent. - room [ROOM NUMBER]: Black flies were observed throughout the room. During an interview on 7/17/23 at 8:21 A.M., Resident #77 said he/she sees mice often in their room and about a month ago one was dead in the white box so he asked the staff to remove it. During an interview on 7/17/23 at 8:25 A.M., Resident #101 and #103, who share a room, both said they see mice often. Resident #101 said he/she went to the store to purchase their own mouse traps since the traps being used were ineffective. Resident #101 showed the surveyor multiple mouse traps, including one set up in the bedroom closet. Resident #103 said they reported the sightings to the staff, but it doesn't seem to be helping. During an interview on 7/13/23 at 11:08 A.M., Nurse #2 said the black bugs are all over the building all the time. She isn't sure if anything is being done to try to get rid of them. During an interview on 7/17/23 at 9:08 A.M., the Pest Control Specialist was present in the building. He said he comes to the building weekly and checks the Pest Control Service Request Logs on the units. He further said the building has identified a concern with mice and black flies in the building. Review of the Pest Control Service Request log for Unit 2 failed to indicate any documented reports of pest or rodent concerns since 2022 despite multiple observations on the unit by the survey team. During an interview on 7/17/23, the Maintenance Director said the master list for the Pest Control Service Logs is kept at the front desk, which should be checked by the Pest Control Specialist. The surveyor reviewed the log at the front desk which indicated only one occurrence in July, one in June, four in May, three in April, one in March and two in February, despite the multiple observations throughout the facility by the survey team and resident complaints. During an interview on 7/17/23 at 1:42 P.M., the Administrator said as housekeeping is cleaning rooms, they should be communicating with maintenance when flies or mouse droppings are identified. She said we have a pest control company, but we need a better system within the building for communicating when mouse activity and flies are identified so we can report it to the pest company and correct the issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure the dignity of Residents (#264 and #12) was maintained, and the rights of Resident (#35) was protected and promoted, out of a total sample of 23 residents. Specifically, the facility 1. Failed to provide a privacy bag for the Foley catheters of Residents #264 and #12; and 2. Suspended Resident #35's smoking privileges. Findings include: 1A. Resident #264 was admitted to the facility July 2021 with diagnoses of urinary retention and urinary tract infection. On 08/26/21 at 11:23 A.M., the surveyor observed Resident #264 walking on Unit One with a rolling walker and the Foley catheter bag, hanging on the right side of the walker, was filled with urine. On 08/27/21 at 02:20 P.M., the surveyor observed Resident #264 returning to Unit One, escorted by contracted Transportation Specialist #1. Resident #264 was walking with a rolling walker and the Foley catheter bag, hanging on the right side of the walker, was full of urine. During an interview on 08/27/21 at 02:20 P.M., Transportation Specialist #1 said he brought Resident #264 to a Physician's appointment and is now returning Resident #264 to the facility. Transportation Specialist #1 said when he picked up Resident #264 for the appointment, the Foley catheter was not in a privacy bag. During an interview on 08/31/21 at 01:52 P.M., Unit Manager #1 said normally, when Resident #264 goes out for an appointment, she switches the catheter bag to a leg bag for privacy. Unit Manager #1 said, the nurse who sent Resident #264 out to his/her appointment on 8/27/21 should have switched the catheter bag to a leg bag or put the catheter bag in a privacy bag. B. Resident #12 was admitted to the facility in August 2019 with a diagnosis of paraplegia. Review of the Minimum Data Set (MDS), dated [DATE], indicated the Resident had a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder). On 9/1/21 at 12:40 P.M., the surveyor observed Resident #12 entering the elevator to leave the unit. At 1:02 P.M., the Resident returned to the unit and was sitting in the hallway in his/her wheelchair with the catheter bag attached underneath the chair. There was no privacy bag covering the catheter bag. During an interview on 9/1/21 at 1:30 P.M., Resident #12 said they [facility staff] do not have a privacy bag for his/her urinary catheter bag. 2. Review of the COVID-19 Smoking Policy, revised 5/6/20, included but is not limited to: -The smoking area has had seating arranged to allow only four persons at one time on the smoking deck. Seats are greater than six feet apart. All smokers were provided the changed information with social distancing education. Review of the Smoking Policy and Procedure, revised 10/26/20, included but is not limited to: -All persons who desire to smoke will be accompanied from and to their units by a staff member to ensure proper social distancing and facial covering. -Resident will be educated that until all COVID-19 restrictions are lifted, no residents will be allowed independent smoking privileges. All smokers will be escorted to and from designated areas to ensure proper social distancing and infection control. Resident #35 was admitted to the facility in November 2019 with diagnoses that included Peripheral Vascular Disease and anxiety. Review of Resident #35's MDS assessment, dated 6/2/21, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident is cognitively intact. Review of the medical record indicated Resident #35 had his/her smoking privileges suspended for 14 days due to noncompliance on 12/3/20 as evidenced by a disciplinary action form signed by the Resident and the Director of Nurses (DON) for a first offense of smoking outside the facility. During an interview on 9/1/21 at 11:30 A.M., Resident #35 said he/she had their smoking privileges taken away because he/she went outside in the evening hours with other residents and a Certified Nursing Assistant (CNA) to smoke. The Resident did not think this was an issue because he/she went out with a CNA. Resident #35 said he/she was told his/her privileges were suspended because residents are supposed to be six feet apart and only two residents are allowed in the elevator at a time. Resident #35 said he/she did not remember being told they couldn't go out with a staff member at night. He/she said that it had been going on for a while so he/she thought it was okay. Resident #35 said that when their smoking privileges were suspended he/she, Felt like I was being treated like a kid. Review of the smoking policy, revised 10/26/20, was signed by the Resident and indicated the COVID-19 adaptations, which states that the residents must be escorted to and from designated areas by a staff member. During an interview on 9/1/21 at 2:00 P.M., the Administrator and the Director of Nurses said that during the time Resident #35's smoking privileges were suspended they were following the COVID-19 smoking policy. They said all residents, including Resident #35, signed a contract, stating they would comply with the policy. The Administrator and DON said if residents don't comply then privileges are suspended.

Based on policy review, record review, and interview, the facility failed to ensure an allegation of abuse, specifically a resident to resident altercation, was reported to the Department of Public Health within two hours in accordance with federal guidelines and facility policy for two Residents (#73 and #94), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled Abuse and Neglect Clinical Protocol, last revised 3/18/19, indicated, but was not limited to the following: - All alleged incidents involving abuse, neglect, exploitation, misappropriation or mistreatment will be immediately reported but no later than two hours after the allegation is made to regulatory agencies. - All incidents that do not involve allegations of abuse or serious bodily harm will be reported no later than twenty-four hours from the time of event. - Results of investigations will be reported to the Administrator and/or designee and to other officials/agencies in accordance with state law and no later than five working days. Review of the facility's policy titled Resident to Resident Altercations, last revised 4/1/19, indicated, but was not limited to the following: - All altercations, including those that occur between residents which may represent abuse, will be investigated and reported to a member of administration. - Report the incident, findings, and corrective measures to the appropriate agencies. Review of the facility's policy titled Brush Hill Care Center Accident and Incident - Investigating and Reporting, last revised 6/6/18, indicated, but was not limited to the following: - All alleged incidents involving abuse, neglect, exploitation, misappropriation, or mistreatment will be reported immediately but no later than two hours after the allegation is made. - All incidents that do not involve allegation of abuse or serious bodily injury will be reported no later than twenty-four hours of event. - Results of investigations will be reported to the administrator and/or designee and to other officials/ agency in accordance with state law and no later than five working days. Resident #94 was admitted to the facility in July 2019 with diagnoses which included vascular dementia with behavioral disturbances and psychosis. Resident #73 was admitted to the facility in November 2008 with diagnoses which included schizophrenia and violent behavior. Review of Resident #73's progress note, dated 2/13/21, indicated the following: - At approximately 13:55 (1:55 P.M.), Resident #73 screamed for assistance to his/her room. The nurse rushed to the room and noted the Resident was agitated and asked to remove his/her roommate from the bed. Noted his/her roommate was covering his/her left eye and stated that Resident #73 had punched him/her. Resident #73 was removed from the room and also stated that he/she felt threatened by his/her roommate. Review of Resident #94's progress note, dated 2/13/21, indicated the following: - At approximately 13:55 (1:55 P.M.), Resident #94's roommate screamed for assistance to his/her room. Noted Resident #94 lying on his/her bed covering his/her left eye. The Resident also stated his/her roommate punched him/her in the left eye. Noted blood and a small laceration under the left eye of Resident #94. During an interview on 8/30/21 at 12:42 P.M., the Director of Nurses (DON) said she did not report the resident to resident altercation between Resident #94 and Resident #73 because both residents were cognitively impaired so there was no intent. Review of the Health Care Facility Reporting System (HCFRS), on 8/30/21 at 4:18 P.M., which is the reporting system utilized by the Department of Public Health, indicated the facility did not report the allegation of abuse, alleged to occur on 2/13/21, to the Department of Public Health.

Based on policy review, interview, and record review, the facility failed to thoroughly investigate an allegation of abuse, specifically a resident to resident altercation, for two Residents (#73, #94), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled Resident to Resident Altercations, last revised 4/1/19, indicated, but was not limited to, the following: - All altercations, including those that occur between residents which may represent abuse, will be investigated and reported to a member of administration. - Complete Incident & Accident report, document the incident, document the incident findings, document corrective measures put into place. - Report the incident, findings and corrective measures to the appropriate agencies. Review of the facility's policy titled Abuse and Neglect Clinical Protocol, last revised 3/18/19, indicated, but was not limited to, the following: - Results of investigations will be reported to the Administrator and/or designee and to other officials/agencies in accordance with state law and no later than five working days. - Resident history will be reviewed to determine history of abuse/neglect. - Investigating person (s) will attempt to identify risk factors for abuse within the facility (staffing, behaviors, family dynamics). Review of the facility's policy titled Brush Hill Care Center Accident and Incident - Investigating and Reporting, last revised 6/6/18, indicated, but was not limited to, the following: - The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. - The following data, as applicable, shall be included in the documentation and investigation: - The date and time the accident or incident took place - The nature of the injury/illness (e.g., bruise, fall, nausea, etc.) - The circumstances surrounding the accident or incident - Where the accident or incident took place - The names of witnesses and their accounts of the accident or incident - The injured person's account of what took place - The condition of the injured person, including his/her vital signs - The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work etc.) - Results of investigations will be reported to the administrator and/or designee and to other officials/ agency in accordance with state law and no later than five working days. Resident #94 was admitted to the facility in July 2019 with diagnoses which included vascular dementia with behavioral disturbances and psychosis. Resident #73 was admitted to the facility in November 2008 with diagnoses of schizophrenia and violent behavior. Review of Resident #73's progress note, dated 2/13/21, indicated the following: - At approximately 13:55 (1:55 P.M.), Resident #73 screamed for assistance to his/her room. The nurse rushed to the room and noted the Resident was agitated and asked to remove his/her roommate from the bed. Noted his/her roommate was covering his/her left eye and stated that Resident #73 had punched him/her. Resident #73 was removed from the room and also stated that he/she felt threatened by his/her roommate. Review of Resident #94's progress note, dated 2/13/21, indicated the following: - At approximately 13:55 (1:55 P.M.), Resident #94's roommate screamed for assistance to his/her room. Noted Resident #94 lying on his/her bed covering his/her left eye. The Resident also stated his/her roommate punched him/her in the left eye. Noted blood and a small laceration under the left eye of Resident #94. During an interview on 8/20/21 at 2:29 P.M., Unit Manager #2 said that Resident #73 punched Resident #94 in the left eye which resulted in a large bruise and laceration to his/her face. Unit Manager #2 said she could not recall if an investigation was conducted, but at the time of the incident both residents were sent to the hospital. Unit Manager #2 further said both residents still reside on the same unit, but no longer share a room. During an interview on 8/30/21 at 12:42 P.M., the Director of Nurses (DON) said she did not report or investigate the resident to resident altercation between Resident #94 and Resident #73, because both residents were cognitively impaired so there was no intent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff reviewed and revised the Comprehensive Care Plan for Fall Prevention for one (#13) sampled Resident, out of a total of 23 residents. Specifically, the facility failed to review and revise the care plan for falls after the Resident fell out of bed. Findings include: Resident #13 was admitted to the facility in November 2020 with diagnoses that included cerebral infarction with hemiplegia (paralysis on one side of the body) and a left above the knee amputation. In November 2021, a new diagnosis of a right above the knee amputation was added. Review of the Minimum Data Set, dated [DATE], indicated Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. The MDS also indicated that Resident #13 was dependent for transfers and had impaired function range of motion on one side for the upper body and on both sides for the lower part of the body. During an interview on 8/30/21 at 9:20 A.M., Resident #13 said he/she fell out of bed a few weeks ago. The Resident said it happened early in the morning and he/she had to wake up his/her roommate to get help. Review of Resident #13's medical record and Falls Incident Report indicated on 8/12/21 at 4:30 A.M., the Resident's roommate came to the nurse's station and said that his/her roommate needed help. Upon reaching the room, the nurse observed Resident #13 on the floor next to the bed. The Resident said he/she was trying to reposition him/herself to have a bowel movement and slipped off the bed. The Resident did not sustain any injuries and was transferred back to bed. Review of the Risk Management Meeting Minutes indicated Resident #13's fall was discussed and the new intervention was to have the Resident screened by Physical Therapy (PT) with potential for adaptive equipment and to provide education about bedpan use. Review of Resident #13's care plans indicated a care plan was initiated on 11/21/19, addressing falls related to deconditioning, incontinence of bowel, left AKA (above the knee amputation), right sided weakness and (11/19/21) right AKA amputation. The approaches dated 11/21/19 included: -call light within reach and encourage the resident to use -safe environment: floors free from spills and/or clutter, adequate light, a working and reachable call light, personal items within reach -PT and treat as ordered, or PRN (as needed) During an interview on 8/30/21 at 2:00 P.M., the Occupational Therapist said there was no request for a Physical Therapy screen for Resident #13 on or after 8/12/21. During an interview on 8/30/21 at 3:30 P.M., the Director of Nurses (DON) said she sent a request to PT via the computer. During a follow up interview on 8/31/21 at 10:17 A.M., the DON said there was no Rehab screen completed by the Physical Therapist. Therefore, there were no interventions or changes made to the Falls Care Plan to prevent further falls out of bed for Resident #13.

Based on observation, policy review, and staff interview, the facility failed to ensure that services provided met professional standards of quality. Specifically, the facility 1. Failed to ensure two Nurses (#5 and #4) did not pre-pour medications for residents and store them, unlabeled, in the top drawer of their assigned medication carts; and 2. Failed to document in the medical record information pertaining to the death of a Resident (#115) and obtain a Physician's Order for a Registered Nurse (RN) pronouncement of death. Findings include: 1 A. On 8/31/21 at 10:21 A.M., the surveyor and Nurse #5 inspected the Side 1 Medication Cart on Unit 3A. Nurse #5 was responsible for administering medications to the residents on Side 1. The surveyor and Nurse #5 observed the top drawer of the medication cart to have three plastic medication cups with a number of unidentified medications in each cup placed inside the drawer. The only information noted on the medication cup was the name of the resident written in black ink on each of the three medication cups. During an interview on 8/31/21 at 10:25 A.M., Nurse #5 said he should not have pre-poured the three residents' medications and said, It's on me, and acknowledged that it was against the facility policy to pre-pour medications for residents. B. On 8/31/21 at 11:07 A.M., the surveyor and Nurse #4 inspected the Side 1 Medication Cart on Unit 2A. Nurse #4 was responsible for administering medications to the Side 1 residents. The surveyor observed the top drawer of the medication cart to have one plastic medication cup with multiple unidentified medications inside. The medication cup contained only the resident's first name, and no other information regarding the resident or the medications in the cup. During an interview on 8/31/21 at 11:10 A.M., the surveyor asked Nurse #4 what the facility policy was with regard to pouring medications in advance. Nurse #4 said, You don't pre-pour. During an interview on 8/31/21 at 11:30 A.M., the Director of Nursing (DON) said the facility medication administration policy prohibits nurses from pre-pouring medications. Review of the facility's policy titled Storage of Medications, dated 6/14/21, indicated but was not limited to the following: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transfer such items shall not be left unattended if opened or otherwise potentially available to others. 2. Resident #115 was admitted to the facility in January 2020 with diagnoses that included metabolic encephalopathy and dementia without behavioral disturbances. Review of the facility's policy titled Death of a Resident, Documenting, revised July 2017, indicated the following: -Appropriate documentation shall be made in the clinical record concerning the death of a resident -All information pertaining to a resident's death (i.e. date, time of death, the name and title of the individual pronouncing the resident dead, etc.) must be recorded in the nurse's notes. - A resident may be declared dead by a Licensed Physician or Registered Nurse with Physician authorization in accordance with state law. Review of the Nurse's Progress Note, dated 8/10/21, indicated Resident #115's body was released to the funeral home with family present. The Nurse's Note did not indicate any information pertaining to the death of the Resident including date, time of death, and name and title of individual pronouncing the Resident's death. Review of Resident #115's Physician's Orders indicated no documented evidence that an order for an RN pronouncement of death was obtained. During an interview on 9/1/21 at 4:50 P.M., the Director of Nurses acknowledged the lack of information in the medical record pertaining to the death of Resident #115.

Resident #45 was admitted to the facility in April 2020 with diagnoses that include anoxic brain damage resulting in a persistent vegetative state, gastrostomy tube placement (feeding tube), and tracheostomy. Review of the Resident's current Physician's Orders indicated an order for bilateral hand pillows/rolls daily for management/prevention of contractures, monitor skin integrity and positioning management every shift. May remove for care, skin checks, and/or patient discomfort, dated 4/16/20. The surveyor observed the following: - 08/26/21 at 9:30 A.M.: Resident in bed at this time. Bilateral hands observed to be resting on a small pillow on the Resident's chest. No hand rolls were observed in both the right and left hand per the Physician's Order. 08/30/21 at 01:37 P.M.: Resident in bed at this time. Bilateral hands observed to be resting on a small pillow on the Resident's chest. No hand rolls were observed in both the right and left hand per the Physician's Order. 08/31/21 at 11:20 A.M. Resident in bed at this time. Bilateral hands observed to be resting on a small pillow on the Resident's chest. No hand rolls were observed in both the right and left hand per the Physician's Order. During an interview on 8/31/21 at 11:30 A.M., Nurse #1 said for Resident #45 the staff should be performing passive range of motion and applying hand rolls to prevent contractures. He further said the Resident's hand rolls were not in the room and currently not in use. Nurse #1 said he would call therapy to find out what Resident #45 should be using to prevent contractures in both hands. Review of the Occupational Therapy Evaluation and Plan of Treatment, dated 8/31/21, indicated Resident #45 was referred to Occupational Therapy by nursing for splinting evaluation after a noted worsening of contractures in bilateral hands; Nursing reported being unable to locate splints that were issued over two years ago. During an interview on 8/31/21 at 1:46 P.M., Nurse #1 said therapy came up to screen Resident #45 since she did not have hand rolls available. Nurse #1 said if there was a Physician's Order for hand rolls, then the Resident should have them in place. Based on record review, observations, and staff interviews, the facility failed to ensure that a resident with limited range of motion and contractures (shortening and hardening of tissues leading to rigidity of joints) received the appropriate equipment and services to prevent a further decrease in range of motion for one Resident (#45), out of a total sample of 23 residents. Specifically the facility failed to apply bilateral hand rolls to Resident #45 to prevent further worsening of hand contractures. Findings include:

Based record review and interviews, the facility failed to ensure the staff maintained the nutritional status of one Resident (#94), out of a total sample of 23 residents. Specifically, the facility failed to maintain acceptable parameters of nutrition status and implement interventions to prevent further weight loss. Findings include: Resident #94 was admitted to the facility in July 2019 with diagnoses of vascular dementia with behavioral disturbances, psychosis, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 5/7/21, indicated Resident #94 scored a 99 on the Brief Interview for Mental Status assessment, indicating the Resident was unable to complete the interview. The MDS also indicated that the Resident had moderately impaired cognitive skills for daily decision making according to staff. Furthermore, the MDS indicated that Resident #94 was 66 inches tall and weighed 149 pounds. Review of the weekly weights for Resident #94 indicated the following: -5/04/21: 149.0 lbs. -5/11/21: 147.2 lbs. -5/18/21: 149.2 lbs. -6/01/21: 150.2 lbs. -6/07/21: 151.4 lbs. -6/08/21: 152.0 lbs. -6/15/21: 153.4 lbs. -6/22/21: 153.0 lbs. -6/28/21: 154.2 lbs. -6/29/21: 152.0 lbs. -7/05/21: 152.2 lbs. -7/13/21: 153.6 lbs. -7/20/21: 140.2 lbs. -7/27/21: 139.6 lbs. -7/28/21: 131.2 lbs. -8/03/21: 131.0 lbs. -8/17/21: 130.8 lbs. -8/24/21: 129.6 lbs. -8/31/21: 131.6 lbs. Review of the Dietary Progress Notes, dated 5/4/21, indicated that Resident #94 had a current weight of 149.2 lbs. (4/28/21). Estimated nutritional needs: 1756 calories, 68 grams of protein (1.0/kg), 1695-2035ml (25-30ml/kg). A CCD (consistent carbohydrate diet) secondary to DM (Diabetes Mellitus). Intakes average 70% at meals. Speech Therapy was evaluating the Resident. No significant weight changes. Plan: Prescribed diet; monitor weight; labs; oral intake and skin. Goal: see care plan which was reviewed and updated. At the time of the dietary assessment, Resident #94 had Physician's Orders for Med Pass (dietary supplement) 120 ml two times per day between meals and house supplements as needed for poor nutritional intake (give 120 ml for meal intake of <50%), which had been in place since June 2020. Review of Resident #94's care plans indicated the facility identified: A nutritional problem or potential nutritional problem related to therapeutic diet altered texture (initiated 8/7/19, revised 4/27/21). The goal was to maintain adequate nutritional status as evidenced by maintaining weight, no s/s of malnutrition, and consuming at least 75% of meals daily through review date (Revision date 7/28/20). The interventions included: -Administer medications as ordered. Monitor/Document for side effects and effectiveness (8/7/19) -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated (8/7/19) -Provide, serve diet as ordered. Monitor intake and record each meal. CCD, mechanical soft, thin liquids, dislikes fish (tuna ok). (5/3/21) -Weight per facility protocol (8/7/19). There was no indication in Resident #94's care plan that revisions and updates were made as indicated by the Dietary Progress Note on 5/4/21. On 05/04/2021, Resident #94 weighed 149 lbs. On 08/03/2021, the Resident weighed 131 pounds which is a -12.08 % loss in two months. Review of the quarterly Dietary Progress Notes, dated 7/30/21, indicated Resident #94 had a current weight of 131.2 lbs. (7/28/21) with a reweight pending. Prior weight was 139.6 lbs. which is an 8% loss over one month but stable vs three and six months with no s/s (signs and symptoms) of malnutrition. The plan was to continue prescribed diet; monitor weights, labs, oral intake and skin. The goal was see care plan which was reviewed and updated. During an interview on 9/1/21 at 9:13 A.M. (via telephone), the facility Dietitian said she completed an assessment on Resident #94 on 7/30/21. She said, she did a visual assessment on the Resident and did not see signs and symptoms of malnutrition and did not put additional interventions in place to prevent weight loss. The Dietitian further said, weight loss should trigger in the computer system and alert the staff to significant weight changes. This information is then brought to the facility's at risk meetings so interventions can be put into place and monitored. Review of the medical record indicated a weight warning was triggered for Resident #94 on 7/21/21, 7/29/21, 8/4/21, 8/18/21 and 8/24/21. During a subsequent telephonic interview on 9/1/21 at 12:35 P.M., the facility Dietitian said Resident #94 was not discussed at the weekly risk meetings. She further said we need to do what we can to prevent further weight loss for this Resident; Resident #94 needs to be discussed weekly and monitored closely for a further decline.

Based on observation and staff interview, the facility failed to ensure that its medication error rate was not 5% or greater. Findings include: On 8/31/21 and 9/1/21, the surveyor conducted a Medication Administration Observation. The surveyor observed 2 errors out of 25 opportunities for error during the observation. The surveyor calculated the facility's medication error rate to be 8%. 1. On 8/31/21 at 8:50 A.M., the surveyor observed Nurse #2 preparing medications for Resident #51, including Seroquel, an antipsychotic medication. The Physician's Order indicated, give Seroquel, 25 milligrams (mg) give 2 tablets TID (three times a day). The surveyor observed Nurse #2 pour one Seroquel, 25 mg tablet, and said to the surveyor that she was prepared to administer all of the medications to the Resident. The surveyor requested that Nurse #2 re-check the Seroquel order. Nurse #2 re-checked the Physician's Order and said that she had not prepared the correct dose of Seroquel, and had to pour an additional 25 mg tablet to equal the total amount of Seroquel (50 mg) ordered by the physician. 2. On 08/31/21 at 11:20 A.M., the surveyor observed Nurse #4 preparing and administering morning medications to Resident #84. One of the Resident's morning medications was Vitamin B-12, 500 micrograms (mcgs), give 2 tablets daily. Nurse #4 poured four other medications first, reviewed the Physician's Order for Vitamin B-12, 500 mcg, give 2 tablets daily, secured the medication bottle from the medication cart, and poured 5, 100 mcg tablets into the medication cup (total dose of 500 mcg). Nurse #4 said to the surveyor that she was ready to administer the medications to the Resident. The surveyor stopped Nurse #4 immediately prior to her leaving the medication cart and requested that she re-check the order for Vitamin B-12, as the order indicated that 500 mcg, 2 tablets (1000 mcg total dose) were to be administered. The nurse re-checked the order and said that she had made an error by only pouring 500 mcg of Vitamin B-12 (100 mcg x 5 tablets=500 mcg). Nurse #4 said that she should have poured an additional 5, 100 mcg tablets to equal a total dose of 2, Vitamin B-12, 500 mcg tablets. During an interview on 8/31/21at 11:25 A.M., the Director of Nursing (DON), who was present on the nursing unit at the time, said that Nurse #4 had prepared an incorrect dose of Vitamin B-12, and acknowledged that the Physician's Order was for Vitamin B-12, 500 mcg, 2 tablets daily, and that Nurse #4 had poured only one tablet of Vitamin B-12, 500 mcg (100 mcg x 5 tablets). The surveyor informed the DON of Nurse #2 and Nurse #4's two medication errors from a total of 25 opportunities for error. The survey staff informed the facility at the exit interview on 9/2/21 of the resulting Medication Error Rate of 8%.

Based on interview and record review, the facility failed to maintain complete, systematically organized and readily accessible medical records in accordance with professional standards and practices, for 4 Residents (#94, #45, #13, and #9), out of a total sample of 23 residents. Findings include: Review of 244 CMR: Board of Registration in Nursing: Standards of Conduct indicated: -A nurse licensed by the Board shall make complete, accurate, and legible entries in all records required by federal and state laws and regulations and accepted standards of nursing practice. On all documentation requiring a nurse's signature, the nurse shall sign his or her name as it appears on his or her license. 1. Resident #94 was admitted to the facility in July 2019 with diagnoses of vascular dementia with behavioral disturbances, Diabetes Mellitus, and psychosis. Review of Resident #94's medical record failed to indicate Physician's or Nurse Practitioner (NP)'s Progress notes from January 2021 through August 2021 were readily available for review. The last available Physician's note located in the medical record was from November 2020. During an interview on 9/1/21 at 8:21 A.M., the Director of Nurses, with the Administrator present, said the facility does not have a system that allows physicians or NPs the ability to upload their progress notes into our electronic medical record. She further said whenever we need to review a progress note we have to call and get the documents faxed over to the facility. Further review of the medical record indicated Resident #94 was seen a total of 16 times from the attending physician or NP from January 2021 through August 2021 without documentation of the visits readily available in the medical record. 2. Resident #45 was admitted to the facility in April 2020 with diagnoses that included anoxic brain damage resulting in a persistent vegetative state, gastrostomy tube placement, and tracheostomy. Review of Resident #45's current Physician's Orders indicated the Resident required skilled nursing care every shift for the care and treatment of a gastrostomy tube, a tracheostomy, and a respiratory assessment every shift to evaluate for signs and symptoms of COVID-19. Review of the August 2021 Treatment Administration Record (TAR) failed to indicate treatment orders were documented and signed consistently throughout the month indicating the care and treatment was provided. Further review of the TAR indicated a total of 20 entries were missing for the care and treatment (specifically the monitoring and placement of the gastrostomy tube by auscultation (listening) and aspiration) of Resident #45's gastrostomy tube between 8/1/21 and 8/30/21. The TAR also indicated a total of 21 missing entries for a respiratory assessment to evaluate the Resident for signs and symptoms of COVID-19 between 8/1/21 and 8/30/21. Additionally, the missing entries failed to indicate vital signs including blood pressure, oxygen levels, respirations, pulse and a nurse's initials/signature. During an interview on 8/30/21 at 2:24 P.M., Unit Manager #2 could not provide the surveyor with an answer as to why the medical record has missing and incomplete documentation. She said nurses should be documenting the care they provide every shift. 3. Resident #9 was admitted to the facility in November 2020 with diagnoses which included dementia. Review of Resident #9's medical record indicated that Psychiatry Assessments were conducted on 4/19/21 and 4/26/21. The assessments listed the name of the psychiatry service, the Psychiatry Board Certification number, State License number and a cell phone number. However, the assessments did not include the name of the psychiatrist conducting the assessments. Additionally, the psychiatrist's assessments did not include a legible signature for the provider conducting the assessments. During an interview on 8/27/21 at 2:15 P.M., Nurse #6 said she could not identify who the psychiatrist was that conducted the assessments on 4/19/21 and 4/26/21, as there was no name listed. Nurse #6 also said she could not identify who the psychiatrist was because of the scribbled signature. 3. Resident #13 was admitted to the facility in November 2020 with diagnoses that included cerebral infarction with hemiplegia (paralysis on one side of the body) and a left above the knee amputation. In November 2021, a new diagnosis of a right above the knee amputation was added. Review of the Resident's medical record indicated that there were only two documented physician's progress notes dated 7/15/21 and 6/24/21. During an interview on 8/31/21 at 11:00 A.M., Unit Manager #3 said the physicians and nurse practitioners do not write in the computer through the Point Click Care software, but rather send their notes via fax machine and then the resident's notes are placed in the medical record. On 8/31/21 at 4:00 P.M. Unit Manager #3 provided the surveyor with 13 Physician's Progress Notes dated from 1/7/21 to 7/13/21. Unit Manager #3 said they were faxed over to the facility that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #67 was readmitted to the facility in August 2021 with a newly diagnosed shear wound to the right buttock. A shear wound is defined as a wound that develops from the combination of downward pressure and friction. It occurs at the deeper layers of tissue and can result in cell deformation and cell death. Review of the most recent MDS assessment, dated 8/12/21, indicated that the Resident was non-ambulatory and required an extensive assist with bed mobility and transfers. Review of the initial Consultant Wound Evaluation and Management Summary, dated 8/18/21, indicated that Resident #67 had a full thickness shear wound of the right buttock with a surface area of 7.00 centimeters squared. The treatment plan was for Silver Sulfadiazine to be applied to the area every shift (three times per day) for 30 days. Additionally, it was recommended to off-load (distribute the load to other areas which are not susceptible to pressure) the wound and reposition the resident per the facility's policy. Review of the Consultant Wound Evaluation and Management Summary, dated 8/25/21, indicated the Resident should continue with the same treatment, Silver Sulfadiazine to be applied to the area every shift (three times per day) for 30 days and to off-load the wound and reposition the resident per the facility's policy. Review of Resident #67's current Physician's Orders failed to indicate an order for Silver Sulfadiazine to the right buttock shear wound every shift per the Wound Physician's recommendations. Review of Resident #67's Treatment Administration Record for August 2021, failed to indicate that Silver Sulfadiazine was applied to the Resident's shear wound on the right buttock per the Consultant Wound Physician's recommendations. During an interview on 9/1/21 at 3:46 P.M., Nurse #2 said she was caring for Resident #67 and just received report from the previous nurse. Nurse #2 could not tell the surveyor if the Resident had any skin areas that required treatment. Nurse #2 looked through the electronic medical record and said Resident #67 has intact skin and we should only be applying barrier cream as a preventative measure for skin breakdown. Review of Resident #67's care plan failed to indicate that a care plan had been developed for the newly identified shear wound on the right buttock. During an interview on 9/1/21 at 3:34 P.M., Unit Manager #1 said Resident #67 had an open area, present on return from the hospital. She further said we should be following the Consultant Wound Physician's recommendations and applying the Silvadene (Silver Sulfadiazine). Unit Manager #1 said she was unable to locate a Physician's Order or Care Plan in the electronic medical record for the care and treatment of Resident #67's shear wound to the right buttock. During an interview on 9/1/21 at 3:55 P.M., the Assistant Director of Nurses said Resident #67 should be receiving Silvadene every shift and that an order and care plan should be in place.Based on record review and staff interviews, the facility failed to ensure staff developed and implemented a comprehensive, person centered care plan for 4 Residents (#26, #12, #112, and #67), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #26, develop a comprehensive care plan for the application and use of bilateral resting hand splints; 2. For Resident #12, develop a comprehensive care plan for the care and treatment of skin wounds to the Resident's left hip, buttocks, and [genitalia]; 3. For Resident #112, develop a comprehensive care plan for the care and treatment of Clostridioides Difficile (C-diff) infection (a bacterium that causes severe diarrhea and inflammation of the colon); and 4. For Resident #67, develop and implement a comprehensive care plan for the development of skin issues including shearing. Findings include: 1. Resident #26 was admitted to the facility in December 2020 with diagnoses that included cerebral infarct of the left anterior artery, anoxic brain damage, and cardiac arrest, all resulting in a persistent vegetative state. The most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was in a persistent vegetative state, was dependent for all activities of daily living, and had functional limitations on both sides of the Resident's upper and lower extremities. The MDS also indicated that the Resident had received services from Occupational and Physical Therapy in the last quarter. Review of the Occupational Therapy Discharge summary, dated [DATE], indicated Resident #26 should wear bilateral hand splints at least eight hours a day. In-service training had been provided to staff that included splint care including: how to don/doff (put on/take off) splints, proper eight hour wearing schedule, and the importance of performing frequent skin checks. Review of Resident #26's Physician's Orders (interim), dated 7/2/21, indicated the Resident had been discharged from skilled Occupational Therapy Services. The Occupational Therapist recommended caregivers apply bilateral resting hand splints eight hours a day to Resident #26 and perform frequent skin checks. The order was initiated on 7/16/21. Review of the Treatment Administration Record (TAR) for August 2021 indicated staff were to don bilateral hand splints eight hours a day starting at 9:00 A.M. daily and perform frequent skin checks. Further review of the TAR indicated the nurse checked off that the Resident's splints were applied daily except for 8/6/21, 8/8/21, and 8/17/21. The surveyor observed Resident #26 without bilateral hand splints on the following days: -On 8/26/21 at 9:30 A.M. and 3:30 P.M., the Resident was lying in bed without bilateral hand splints applied. -On 8/31/21 at 9:30 A.M. and 3:45 P.M., the Resident was lying in bed without bilateral hand splints applied. -On 9/1/21 at 11:20 A.M., the Resident was lying in bed without bilateral hand splints applied. During an interview on 9/1/21 at 11:30 A.M., Unit Manager #3 said there was an order to apply the splints. The surveyor and Unit Manager #3 went to Resident #26's room and observed the Resident lying in bed. Unit Manager #3 said that the Resident had a support pillow under his/her arm, however the bilateral splints were observed on the Resident's side table. Unit Manager #3 said, I should have put those (splints) on him/her. Review of Resident #26's Interdisciplinary Care Plans indicated there was no documented evidence that the facility developed care plans that addressed the application and use of bilateral hand splints. 2. Resident #12 was admitted to the facility in August 2019 with a diagnosis of paraplegia. Review of the MDS assessment, dated 5/26/21, indicated Resident #12 had a Stage IV pressure area. Review of the medical record indicated Resident #12 had Physician's Orders for the treatment and care of wounds to the buttocks, [genitalia], and left hip. Review of the Wound Physician's Progress Notes, dated 8/4/21, indicated the Resident was being evaluated and managed weekly for the treatment and care of wounds to the buttocks, [genitalia], and left hip. Review of Resident #12's Interdisciplinary Care Plans indicated there was no documented evidence that the facility developed care plans that addressed the care and treatment of the Resident's buttocks, [genitalia], or left hip wounds. 3. Resident #112 was admitted in April 2021 with diagnoses that included C-diff, pneumonia, and acute respiratory failure. Review of the medical record indicated Resident #112 had a Physician's order, dated 7/6/21, for the treatment and care of Enterocolitis due to Clostridium Difficile with Vancomycin (antibiotic), for a total of six weeks. During an interview on 8/30/21 at 9:45 A.M., Nurse #3 said the Resident was being treated for an infection. She said the Plan of Care was for antibiotics for six weeks. Review of Resident #112's Interdisciplinary Care Plans indicated there was no documented evidence that the facility developed a care plan that addressed the care and treatment of the C-diff infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility failed to store all drugs and biologicals in locked compartments, and permit only authorized personnel to have access for 2 out of 2 medication carts located on the 2A Unit. On [DATE] at 9:28 A.M., the surveyor observed Medication Cart #1 on the 2A Unit to be unlocked and unattended for a total of four minutes while the nurse entered a resident room. During that time, the medication cart was observed to be at the nurse's station where staff and residents were observed in the area. During an interview on [DATE] at 9:32 A.M., Unit Manager #2 identified the unlocked medication cart and said medication carts should be locked at all times when unattended and not in use. On [DATE] at 11:42 A.M., the surveyor observed Medication Cart #2 on the 2A Unit to be unlocked and unattended for a total of ten minutes during the passing of afternoon lunch meals. The medication cart was observed to be at the nurse's station where staff and residents were observed preparing for lunch. During an interview on [DATE] at 11:52 A.M., the surveyor observed Nurse #1 exiting a resident's room. He said he was responsible for the unlocked medication cart and should lock the medication cart when not in use so nobody runs away with the medications. Based on observation and staff interview, the facility failed to ensure that all medications were properly labeled, stored, and secured, to ensure safe administration, in accordance with the facility's policy. Additionally, the facility failed to ensure that medications were stored in a clean, sanitary environment, including medication rooms and medication carts. Findings include: Review of the facility's policy titled Storage of Medications, dated [DATE], indicated but was not limited to the following: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be destroyed. - Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transfer such items shall not be left unattended if opened or otherwise potentially available to others. - Medications/Biologicals are reviewed weekly for expired products which are removed. 1. On [DATE] at 10:21 A.M., the surveyor and Nurse #5 inspected the Side 1 Medication Cart on Unit 3A. Nurse #5 was responsible for administering medications to the residents on Side 1. The surveyor observed the top drawer of the medication cart to have three plastic medication cups with a number of unidentified medications in each cup placed inside the drawer. The only information noted on the medication cup was the name of the resident written in black ink on each of the three medication cups. Nurse #5 said that he should not have pre-poured the three residents' medications and said, It's on me, and acknowledged that it was against the facility's policy to pre-pour medications for residents. The surveyor observed an undated bottle of Natural Tears in the Side 1 medication cart. Nurse #5 said he did not know when the bottle of eye drops was opened or when they should be discarded. According to a medically-reviewed journal article in Insider Health, dated [DATE], once your eye drops are opened, you should throw them away after three months of use, as there is a greater risk of contamination. Additionally, the surveyor observed the top drawer of the medication cart to have a moderate amount of dirt, dust, and, debris inside. The outer right side of the medication cart near the trash receptacle and along the bottom edge of the cart, were observed to have a large amount of dried, brown stains visible. Nurse #5 said that the medication carts were not on a regular cleaning schedule. The surveyor observed the medication room to have the following medications and medical supplies resting on the floor: -A cardboard box with multiple bottles of Lactulose inside it. -A cardboard box with multiple plastic med cups. -A box with multiple chemical cold packs inside it. 2. On [DATE] at 10:35 A.M., the surveyor inspected the Side 2 Medication Cart for unit 3A with Nurse #6. Nurse #6 is responsible for administering medications to Side 2 residents. The surveyor observed the medication cart to have the following: -Two bottles of Artificial tears opened and not dated. -A bottle of acidophilus opened and in the second drawer. The medication was clearly labeled refrigerate after opening. Nurse #6 was not aware that the acidophilus required refrigeration. Nurse #6 acknowledged that eye drops should be dated when opened. She acknowledged that without a labeled date of opening, it was unclear when the eye drops should be discarded due to the potential for contamination. 3. On [DATE], at 11:07 A.M., the surveyor inspected the Unit 2A, Side 1 Medication Cart with Nurse #4 present. Nurse #4 is responsible for administering medications to the Side 1 residents. The surveyor observed Nurse #4 open the top drawer of the medication cart and remove a plastic medication cup with multiple unidentified medications inside. The medication cup contained only the resident's first name, and no other information regarding the resident or the medications in the cup. The surveyor asked Nurse #4 what the facility policy was in regards to pouring medications in advance. Nurse #4 said, You don't pre-pour. 4. On [DATE] at 3:15 P.M., the surveyor inspected the Unit 1A medication room with Nurse #7. The surveyor observed the top shelf of the medication refrigerator to have a large amount of a dried, white, chalky-looking substance coating it. The white material nearly covered the entire glass shelf. Nurse #7 said that it was unacceptable for whoever spilled the white substance not to have cleaned it.

Based on observation, staff interview, and record review, the facility failed to ensure that staff stored food in unit nourishment rooms in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Findings include: 1. On 8/31/21 at 11:05 A.M., the surveyor observed all nourishment kitchens and noted that 3 out of 4 were not maintained per professional standards as follows: Unit 3 A Nourishment Kitchen: -The sink was removed; the open wall was exposing pipes. -A cabinet located above the refrigerator, had one carton of warm milk. The Food Manager said the sink has been gone about two weeks because it was leaking. Unit 2 A Nourishment Kitchen: -No thermometer located in the freezer, and no documented temperatures for the freezer for the prior two days. Unit 2 BC Nourishment Kitchen: -Microwave enamel burned off. Unit 2 B nursing station refrigerator: -Resident food including five cartons of milk that had expired on 8/27/21. -No thermometer -Refrigerator had juice spills. The Food Manager said that the dietary staff do not stock or clean this small refrigerator. During an interview on 8/31/21 at 11:45 A.M., the Administrator said the sink was removed due to a leak, but was not sure when it would be replaced. The Administrator acknowledged the unsanitary condition of the nourishment rooms.

Based on interviews, the facility failed to ensure residents had access to their personal funds, per Centers for Medicare and Medicaid Services (CMS) regulations. Specifically, the facility 1. Failed to make funds available for same day requests for cash amounts less than $100.00 ($50.00 for Medicaid residents); 2. Failed to make funds available in three banking days for requests in the amount of $100.00 or more ($50.00 for Medicaid residents); and 3. Restricted requests for petty cash to one business day a week for all residents residing in the facility. Findings include: During a meeting with the surveyor on 8/27/21 at 10:00 A.M., four residents made the following comments about their personal funds being restricted or limited by the facility staff: -They will only give you money one day a week and it is limited to $50.00 cash. If you want more than $50.00 cash, you have to fill out a form and you have to tell them why you want the money. -A Resident deposited $250.00 into their account and he/she had a difficult time getting access to the money. -You are limited to $50.00 cash and can only get the money on Wednesdays. The Activity Director comes around on Tuesdays and asked you if you want money and then he delivers it to you on Wednesday. - You can't get any money on Fridays. During an interview on 08/27/21 at 11:00 A.M., the Administrator said that due to COVID-19 he changed how residents could access their personal funds, and residents could no longer come to the front receptionist desk and request money on a daily basis. The Administrator said on Tuesday of each week, the residents that have personal fund accounts can request up to $50.00 cash through the Activity Director. The Administrator said, he then goes to the bank and all the funds requested are delivered to the residents the following day on Wednesday. The Administrator said he limits all residents to $50.00, because he needs to make sure he has enough money for all the resident requests. The Administrator said even with multiple days' notice, if any resident wants more than $50.00, the resident is required to fill out a request form and he issues them a check. He said due to a large volume of cash requests, he has to limit the cash requests to $50.00 or he would end up making multiple trips to the bank every week. The Administrator said residents cannot get money over the weekends, he is the only facility staff that handles the money requests and the banking hours are Monday through Friday.

Based on observation, record review, and interviews, the facility failed to ensure staff served food that is palatable and at an appetizing temperature. Findings include: During an interview on 8/26/21 at 3:09 P.M., Resident #35 said that the food is not appetizing. The Resident said the food is often difficult to chew and feels like rubber. During a meeting with the surveyor on 8/27/21 at 10:00 A.M., five residents made the following comments about the food served and the dining experience at the facility including: -The food is either undercooked or overcooked. When it is overcooked, it is like shoe leather. -Sometimes the food is raw, like the potatoes, and the food is cold. -The dishes are dirty, especially the glasses and silverware. -Two residents said the food is cold. During an interview on 8/30/21 at 2:33 P.M., Resident #35 said the food does not taste good. The Resident said most days the food is overcooked, burnt, and dry. He/she said sometimes the chicken is still pink when it is served. Resident #35 said a friend brings him/her to the grocery store to buy food such as cold cuts and pre-made meals that he/she can heat up in the unit microwave because the food is not good. During an interview on 9/1/21 at 8:03 A.M., Resident #111 said the meats are like leather and difficult to chew. During an interview on 9/1/21 at 2:29 P.M., Resident #44 said the food is terrible; it is either undercooked or overcooked. Resident #44 said today we had stuffed peppers and the pepper was not cooked all the way. He/she said the other day we had chicken that was overcooked and hard to swallow and the green beans were overcooked. On 8/30/21 at 12:30 P.M., the surveyor entered the facility kitchen to observe the noon meal service. At 12:35 P.M. the surveyor requested a test tray for Unit 3 A. The food truck left the kitchen at 12:40 P.M. and arrived on the unit at 12:42 P.M. The surveyor observed meal distribution until 12:50 P.M. when the staff completed serving the trays to the residents. The surveyor, with the Food Manager present, conducted the test tray with the following results: -Baked tilapia (fish) registered 110 degrees Fahrenheit (F). The fish was overcooked and very dry; -The hash brown potatoes registered 111 degrees F and had a burnt texture; -The green beans registered 110 degrees F and were tepid (lukewarm) to temperature; -The coffee registered 145 degrees F and was bitter and tepid in temperature; -The milk registered 48 degrees F and was acceptable; and -The grilled cheese sandwich was soggy in texture and cold to taste. The surveyor and the Food Manager both tasted the meal and identified that the plate was cool to the touch. All food and beverages were unpalatable. On 8/31/21 at 5:35 P.M. the surveyor entered the kitchen to observe the supper meal service. The surveyor asked for a test tray to be sent on the 2 BC truck. At 5:40 P.M. the food truck left the kitchen and arrived on the unit at 5:43 P.M. Two nurses began to pass the meals to the residents and completed the meal pass at 5:50 P.M. at which time the surveyor conducted a test tray with the following results: -The pureed meat and vegetable registered 144 degrees F. The meat was thick in consistency; -The mashed potatoes registered 142 degrees F and were adequate in flavor; and -The coffee registered 135 degrees F and the tea water registered 136 degrees F, both were tepid. Although the pureed food temperatures were acceptable, the hot beverages were not. During an interview on 8/31/21 at 6:15 P.M., the Food Manager said test trays were conducted two times a week and completed by herself or another dietary staff member. Review of the facility test trays for three months did not indicate any unacceptable meal service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to implement infection prevention and control measures recommended by the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) to minimize the potential transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1. Implement Transmission Based Precautions for a new admission, not fully vaccinated; 2. Post signage and make appropriate personal protective equipment (PPE) available to staff for a resident on contact precautions; and 3. Wear eye protection with direct resident care. Findings include: Review of CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated March 29, 2021 indicated but is not limited to the following: -In general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Review of CDC guidance titled Transmission-Based Precautions, dated 1/7/16, indicated staff should implement the following: -Place signage outside the resident's room such as the door or on the wall next to the doorway identifying the CDC category of transmission-based precautions (e.g. contact, droplet, or airborne), instructions for use of PPE, and/or instructions to see the nurse before entering; -Make PPE readily available near the entrance to the resident's room; -Don appropriate PPE upon entry into the room 1. Resident #265 was admitted to the facility in August 2021 (within the last 14 days) with a diagnosis of dementia. Review of the facility's bed board indicated Resident #265 was not fully vaccinated for COVID-19. On 08/26/21 at 12:08 P.M., the surveyor observed Resident #265 wearing a surgical mask below his/her nose and mouth, self-propelling on Unit #1 down to the nurse's station and around the corner to the elevator. The surveyor observed Resident #256's room and there was no precaution signage posted outside the room and no available PPE outside the room. During an interview on 08/26/21 at 11:10 A.M., Unit Manager #1 said there is only one resident on Unit #1 that is currently on precautions and that resident is in room [ROOM NUMBER]. On 08/31/21 at 01:49 P.M., the surveyor observed Resident #265 lying in his/her bed, and observed new signage posted outside his/her room, indicating the Resident was on Quarantine and Droplet/Contact precautions. The surveyor also observed a new plastic cart outside the room that contained PPE. During an interview on 08/31/21 at 01:50 P.M., Unit Manger #1 said Resident #265 was put on 14-day quarantine when he/she was admitted last week, because Resident #265 was not fully vaccinated. Unit Manager #1 said she could not remember when the precautions signs were posted, she thinks maybe Thursday (8/26) or Friday (8/27). Unit Manger #1 said she does not know why there was no precaution signage or available PPE outside room [ROOM NUMBER] for Resident #265 when the surveyor observed the room on 8/26/21. During an interview on 08/31/21 at 05:36 P.M., Infection Control Nurse said if a new admission is not fully vaccinated for COVID-19, then the resident is placed on 14-day quarantine. The Infection Control Nurse reviewed the facility bed board and said Resident #265 is not fully vaccinated and should have been placed on 14 day quarantine with signage posted outside the room and PPE available at the entrance to the room upon admission. The Infection Control Nurse was not working when Resident #265 was admitted and said the precaution signage was posted and PPE made available outside the room on 8/27/21. 2. Resident #81 was admitted to the facility with diagnosis of urinary tract infection, positive for Extended Spectrum beta-lactamase (ESBL) (an enzyme made by some bacteria that prevents certain antibiotics from being able to kill the bacteria. The bacteria then become resistant to the antibiotics) infection. At the time of admission Resident #81 did not have a Foley catheter. On 08/26/21 11:25 A.M., the surveyor observed Resident #81's room (#103) to have sign posted Stop-Please see nurse Before entering. There was no available PPE outside room [ROOM NUMBER]. On 08/27/21 02:08 P.M., the surveyor observed Resident #81's room and still had the sign on the door to Stop see nursing before entering and no PPE available outside the door. During an interview on 08/27/21 at 02:33 P.M., Unit Manager #1 said Resident #81 returned from the hospital with an ESBL infection in the urine and remains on contact precautions. Unit Manager #1 said there is a sign on the Resident #81 to stop and see nurse before entering, the PPE gowns are kept around the corner by the elevator and gloves are kept in the bathroom. Unit Manager #1 said she expects staff to wear gown and gloves if the staff expects to come in contact with the resident's urine. During an interview on 08/31/21 at 05:36 P.M., Infection Control Nurse said Resident #81 is on contact precautions for ESBL in the urine and should have Contact Precaution signage posted outside the resident's room and available PPE at the entrance to the room. 3. During the Medication Pass Observation on 08/31/21 at 08:50 AM, Nurse #2 was observed standing at the medication cart preparing medications without wearing goggles or eye protection. The surveyor commented on this. Nurse #2 said that she cannot see properly when wearing goggles. She said knew that the facility policy was to wear eye protection when on the nursing unit and when administering medication. The nursing supervisor approached the medication cart at that time and reminded Nurse#2 that she should be wearing eye protection. On 9/01/21 at 07:49 A.M. on Unit 3A, the surveyor observed Nurse #6 without eye protection while preparing medications for a resident. Nurse #6 finished pouring the resident's medications and brought them to the resident's room and administered them to the resident. During an interview on 9/1/21 at 7:55 A.M., Nurse #6 said she should have worn goggles and knew that it was the facility's policy to do so when in a resident's room. Review of CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 3/29/21, indicated eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters.

Based on interviews and document review, the facility failed to ensure staff followed the Centers for Medicare and Medicaid Services (CMS) published final rule, updated 4/27/21, for Long Term Care (LTC) Testing and Reporting Requirements for Residents and staff during the COVID-19 pandemic. Specifically, the facility failed to notify residents, resident representatives and families of a positive COVID-19 case (staff or resident) by 5:00 P.M. the following day as required. Findings include: Review of the infection control testing data indicated the facility identified an employee (non-healthcare department) as being positive for COVID-19 on 8/18/21, during routine testing. The facility could provide no documentation of having communicated to the residents of the COVID-19 positive staff member by 5:00 P.M. the following day. On 8/27/21 at 10:00 A.M, the surveyor held a Resident Group Meeting, with 16 residents in attendance. The residents were asked if they had been informed of the positive COVID-19 case identified in the facility in August 2021. All residents said they were not informed or made aware of the most recent COVID-19 case identified. During an interview on 8/27/21 at 1:48 P.M., the Administrator said all Unit Managers should have told the residents about the positive case during outbreak testing, but could provide no documentation in the medical record that residents were informed of the positive COVID-19 case by 5 P.M. the following day. The Administrator further said previously he had sent out letters to families and text-blasts when positive cases were identified, but did not do that for this most recent case since the staff member was only in the front offices and not on the units. During an interview on 9/1/21 at 10:41 A.M., the Administrator said the facility website had been updated to notify resident representatives and/or families of the one new confirmed case. The Administrator provided the surveyors a printed copy of the facility website (undated), indicating a COVID-19 positive case was identified. The printed copy failed to indicate the date of the newly confirmed case. The Administrator could provide no additional documentation, aside from the undated website, that the COVID-19 positive case identified on 8/18/21 was communicated to residents, resident representatives, or family members.