**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure advanced directives were followed, resulting in one Resident (#24) being transferred to the hospital, out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Advanced Care Planning, dated [DATE], indicated the following: -Individuals will have the opportunity to discuss preferences for care and treatment upon admission and to establish written directives, preferences, and choices for care and treatment in the event that the individual becomes unable to continue to express his or her wishes at a later time. -Known as an Advanced Care Plan, these preferences, directives, and choices will guide care and treatment for individuals who can no longer express their goals for care or make treatment choices. -Advanced Care Planning is a process enabling a patient to express wishes about his or her future health care in consultation with health care providers, family members and other important people in their lives. Based on the ethical principle of patient autonomy and the legal doctrine of patient consent, advanced care planning helps to ensure that the concept of consent is respected if the patient becomes incapable of participating in treatment decisions. -Health Care Proxy (HCP) sometimes called the durable power of attorney or power of attorney for health care, the health care proxy is a type of advanced directive appointing a decision maker to make medical decisions if an individual is no longer able to make those decisions. The HCP is only activated if the individual is incapable to make medical decisions and must be activated by the physician. The HCP deals with all medical decisions not just end of life. The Proxy must make decisions based on the resident's wishes not on the Proxy's opinion the DHCP is legal in 48 states. -New or revised documents and orders may be needed to implement revised or new treatment choices. Updating should be done within a time frame that is relevant to changes in an individual's prognosis, condition, and wishes. Resident #24 was admitted to the facility in [DATE] with diagnoses including Alzheimer's Disease, mild protein-calorie malnutrition, and dysphagia. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #24 was dependent on staff for all daily care tasks. Review of Resident #24's admission paperwork indicated the Resident was originally admitted to the facility for respite care and the hospital had an electronic copy of the Health Care Proxy available. The medical record failed to include a copy of the health care proxy form and there were no notes to indicate the facility attempted to obtain a copy of the form. The hospital discharge instructions listed the following under the advanced directives section: -Intubation (a tube used to support breathing) : no - Intravenous Fluid and Support : yes -CPR (cardio pulmonary resuscitation): no -Life Support : no -MOLST(Medical Orders for Life Sustaining Treatment) form: yes -Health Care Proxy (a person assigned to make medical decisions for a patient who is unable): yes Review of Resident #24's medical record indicated the following: -The Resident's spouse was listed as his/her health care proxy on his/her face sheet (a form listing pertinent information regarding a resident's identifying information, payer information, care providers and contact information). -The admission social service note listed the Resident's spouse as his/her health care proxy. -Resident #24's spouse was listed as his/her guardian (an individual assigned by the court to make decisions on behalf of the resident) as of [DATE]. -Upon admission, the Nurse Practitioner invoked Resident #24's health care proxy which indicated the Resident was unable to make his/her own decisions. -Upon admission, the physician initiated an order for the Resident to be DNR (Do not Resuscitate)/DNI (Do not Intubate and Ventilate)/DNH (Do not Hospitalize). Further review of the medical record failed to indicate the Resident's Massachusetts Health Care Proxy Form. When asked to provide a copy of the health care proxy form, the facility was unable to do so. Review of the MOLST form dated [DATE] indicated the following: -Resident #24's spouse signed the form as the Resident's guardian and patient's representative. -Resident #24's spouse indicated Resident #24's goals of care were -Do not Resuscitate -Do not Intubate and Ventilate -Use Non-Invasive Ventilation -Do not Transfer to Hospital (unless needed for comfort) -No Dialysis -Use artificial nutrition, but short term only -Use artificial hydration, but short term only Review of Resident #24's active advanced directives care plan indicated the following: Focus: Advance Directives as follows: HX (history) Guardianship MOLST: DNR/DNI, Use non- invasive Ventilation, DNH, No dialysis, Use artificial nutrition but short term and Use artificial hydration but short term only. On [DATE] at 7:39 A.M., Resident #24 was observed lying in bed with a significant amount of thick, greenish/brown mucous build-up on his/her lips, sealing his/her lips approximately 75% closed. Unit Manager #1 entered the room with surveyor and observed the Resident's mouth. Unit Manager #1 said mouth care had been provided the evening prior and said the Resident has been declining recently and the facility had discussed placing the Resident on hospice services. Review of the social service note dated [DATE] indicated Resident #24's spouse passed away in [DATE]. All further social service notes indicated the facility referred the Resident for alternate guardianship after his/her spouse passed away. The notes failed, however, to indicate the facility sought guidance regarding the Resident's advanced directives and continued to maintain the physician order of DNR/DNI/DNH. Review of the social service note dated [DATE] indicated the following: -MOLST DNR/DNI/DNH Review of the Physician note dated [DATE] indicated Resident #24 was at the end of life and referred to his/her spouse as the health care proxy. Review of Resident #24's comprehensive Minimum Data Set assessment dated [DATE] at Section S, indicated Resident #24 was coded as having a guardian, coded as a Do Not Resuscitate, Do Not Hospitalize, Do Not Intubate, Feeding Restrictions, Other treatment Restrictions. Review of the Nurse Practitioner note dated [DATE], two months after the Resident's spouse passed away, indicated the following: -I confirm today that the patient's Advance Care Plan is documented in the medical record either by discussing and documenting the patient's Advance Care Plan, confirming that the patient surrogate decision maker is documented in the medical record, or confirming that the patient's Advanced Care Plan is presently documented. -advanced directives: DNR/DNI (noninvasive intubation OK), no HD (hemodialysis), short term art (artificial) nutrition and IVF (intravenous fluids) OK. Resident #24 was sent out to the hospital on [DATE]. Review of the physician orders indicated Resident #24's orders changed from DNR/DNI/DNH to Full Code on [DATE] just prior to the Resident being sent to the hospital on [DATE]. During an interview on [DATE] at 1:59 P.M., the Social Worker (SW) said all residents' advance directives are determined upon admission and if needed, the medical team will activate the heath care proxy of a resident if they are not able to make their own decisions. The SW said that if a MOLST is in place, there is never a circumstance when the MOLST is not followed, and the facility should always follow the orders for a resident's advanced directives. The SW said that Resident #24's spouse had been making all medical decisions up until he/she passed away and the facility had never questioned his/her decisions and felt he/she was making them in the best interest of the Resident. The SW said the facility made a referral to a law office to obtain a new guardian for Resident #24 when his/her spouse passed away and the facility is waiting for a court date. The SW said she consulted the attorney being used by the facility to obtain a new guardian for the Resident and this attorney told the facility to make the Resident a full code now that the spouse has passed away. The SW said the conversation regarding changing the Resident's code status occurred on [DATE] when the facility wanted to send Resident #24 out to the hospital. During an interview on [DATE] at 3:12 P.M., Attorney #1 said the authority of Resident #24's spouse to make advance directive decisions became invalid once he/she passed away. When asked how Resident #24's advanced directives will be determined, the Attorney said the firm will apply for new guardianship, one piece of evidence that will be used will be the MOLST form previously filled out by the spouse. During an interview on [DATE] at 10:45 A.M., Nurse #1 said Resident #24 had always been a DNR since admission. Nurse #1 said Resident #24 had been declining and as soon as Unit Manager #1 saw the Resident on [DATE], she had made the decision that Resident #24 needed to be sent to the hospital. During an interview on [DATE] at 11:26 A.M., Unit Manager #1 said once she saw Resident #24 with the surveyor on the morning of [DATE], she realized the Resident's condition was critical and had the NP order labs, a chest x-ray and oxygen. Unit Manager #1 said the facility then made the decision to send the Resident to the hospital. Unit Manager #1 said the facility had not looked into the Resident's advanced directives prior to [DATE] because there was no clinical need to. During an interview on [DATE] at 8:13 A.M., the Nurse Practitioner (NP) said Resident #24 was admitted to the facility with advanced dementia and the Resident's spouse had been making the Resident's healthcare decisions for him/her. The NP said she received a call from the facility stating that a lawyer told the facility the Resident needed to be made a full code and that superseded what she thought clinically, and the Resident was sent out to the hospital. The NP said she is very frustrated by this decision as Resident #24's health has been declining. The NP said she felt this decision was not right and that the Resident's wishes were not being followed. The NP said she feels the MOLST form should be 100% valid because it was the decision made when the spouse was alive. The NP said the Resident should be comfort care only and that this creates suffering at end of life. The NP said there is no reason to put Resident #24 through this ordeal due to his/her recent decline and now when he/she actually needs the comfort care he/she is not able to get it. The NP said this is not dying with dignity and because the code changed the Resident will most likely be sent back and forth to the hospital until the hospital does the right thing and admits him/her to hospice care. The NP said people should not have to suffer at the end of life. During a follow-up interview on [DATE] at 9:52 A.M., the SW said although the law firm had been contacted to obtain a new guardian for the Resident, there had been no discussion about changing his/her advanced directives until she had contacted the law firm on [DATE]. The SW said she contacted the attorney about changing the residents code status on [DATE] because she wanted to let them know she was being sent to the hospital and did not want the Resident to be alone in the hospital. The SW could not confirm whether she made the call before or after the facility made the choice to send the Resident to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure one Resident (#1) was free from neglect, out of a total sample of 20 residents. Specifically, the facility failed to implement an established care plan for incontinence care resulting in incontinence care not being provided in a timely manner. Findings include: Review of the facility's policy titled Resident Abuse/Mistreatment/Neglect/Exploitation Misappropriation of Property Policy, not dated indicated the following: It is the policy of the facility that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property. Further, each resident at the facility will be treated with respect and dignity at all times. Definitions Neglect: failure to provide goods and services necessary to avoid physical harm mental anguish or mental illness. In determining whether or not neglect has occurred the following standards shall apply: 1 A resident has been mistreated a) an individual has failed to provide appropriate care, treatment, or service to the resident and b The individual's failure to provide the treatment, care or service to the resident is either intentional or the result of carelessness. Resident #1 was admitted to the facility in February 2011 and has diagnoses that include unspecified dementia with agitation, schizophrenia and epilepsy and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the staff assessment for mental status indicated Resident #1 as severely cognitively impaired, is dependent on staff for bathing, dressing, toileting, personal hygiene and eating. Further the MDS indicated Resident #1 as always incontinent of bladder and bowel, at risk for developing pressure ulcers and had dulsions and behaviors verbal and other behaviors. On 8/13/24 Resident #1 was out of bed and in his/her Broda chair at 7:45 A.M. From 8:29 A.M. through 10:19 A.M., Resident #1 was observed sitting in a Broda chair (a specialized chair that can recline) in the dining room. At no time during the observation did staff check on Resident #1 to assess if incontinence had occurred or provide incontinence care. Resident #1 was not provided incontinence care after the breakfast meal. On 8/13/24 from 12:07 P.M. through 2:50 P.M., the following was observed sitting in his/her Broda chair in the dining room. At no time did staff check to see on Resident #1 to see if incontinence occurred or remove from the room to provide incontinence care. Resident #1 was not provided incontinence care after the lunch meal. On 8/14/24 from 7:32 A.M. through approximately 11:50 P.M., Resident #1 was observed sitting in his/her Broda chair in the dining room. At no time during the observation did staff check on Resident #1 to assess for the need for incontinence care or remove from the room to provide incontinence care. Resident #1 was not provided incontinence care after the breakfast meal. Review of Resident #1's care plans indicated the following: -Resident has functional bowel and bladder incontinence r/t (related to) confusion, Dementia, Impaired Mobility, Inability to communicate needs, Medication Side Effects, Combative and resistive to care dated as reviewed 6/18/24 with a target date of 9/6/2024. Interventions not dated included: Incontinent care, check as needed for incontinence. Wash rinse and dry perineum. Incontinent care with dependent x 2 every 2 hours and prn for toilet hygiene dated as created 4/17/23 observe skin after each incontinent episode and notify the nurse if skin breakdown. -Resident has potential for skin breakdown r/t (related to) decreased mobility, COPD (chronic obstructive pulmonary disease), CHF, incontinent of urine and bowel, anemia and PVD (peripheral vascular disease), dated as reviewed 6/18/2024 with a target date of 9/6/2024 and interventions that include: Bed mobility and positioning every 2 hours and prn (as needed) with dependent x 2 rolling left to right and right to left, [NAME] (sic) to sit and sit to [NAME] (sic) with mechanical lift. Review of the [NAME] (a document that summarizes a resident's care requirements) indicated the following: Ambulation: did not occur, Toileting Total dependence of 2/Hoyer (a mechanical lift used to transfer a resident from bed to chair). Bladder: incontinent Bowel: incontinent. During an interview on 8/14/24 at 11:29 A.M., Certified Nursing Assistant (CNA) #3 said he is trained on abuse prevention at least once a year. CNA #3 said neglect is when a resident needs something that they do not get. CNA # 3 said with incontinence care you have to keep checking a resident to see if they need to be changed. If a resident cannot tell you then you have to check. CNA #3 said Resident #1 gets his/her morning care before breakfast and then will do incontinent care after lunch. During an interview on 8/14/24 at 11:36 A.M., Certified Nursing Assistant #2 said if a resident is incontinent, they check to see if a change is needed by taking the resident into their room and checking the brief and will change if needed. CNA #2 said incontinent care is provided in the morning and then residents are checked. CNA #2 said she is taking care of Resident #1 today and that Resident #1 requires a two person assist and requires a Hoyer lift. CNA #2 said she got Resident #1 up before breakfast and has not provided incontinence care to Resident #1 since then. On 8/14/24 at approximately 11:50 A.M., after the surveyor brought it to the attention of staff that Resident #1 was brought to his/her room for incontinence care. Resident #1's incontinence brief was observed to be wet with urine requiring a change. During an interview on 8/14/24 at 11:45 A.M., Nurse #1 said every person with incontinence has a care plan with a toileting schedule. Nurse #1 said Resident #1 needs to be checked or changed every two to three hours. Nurse #1 said Resident #1 is at risk for skin breakdown due to incontinence. Nurse #1 said neglect can be not providing the care a person requires. Nurse #1 said Resident #1 should be checked or changed at least every three hours. Nurse #1 said she noted that residents were not being changed timely yesterday. During an interview on 8/14/24 at 12:26 P.M., the Unit Manger said she would expect the incontinence care plan to be followed for Resident #1. On 8/14/24 at 1:36 P.M., the Director of Nurses (DON) said residents who are incontinent should be checked for odor, changed as needed, and changed after lunch. The DON said staff should be aware of the plan of care and provide the care as required and if it is not provided that would be a neglect concern. Ref. F677

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to complete a restraint assessment for one Resident (#36) out of a total sample of 20 residents. Specifically, the facility failed to complete a bed safety assessment prior to adding a bolster pillow in the Resident's bed. Findings include: A review of the facility policy titled 'Restraints' with no revision date indicated the following: -Definitions-Physical restraint-any manual or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Goal-To provide a systematic method of evaluating and monitoring restraint use to assure utilization of the least restrictive method and medical necessity. -It is the facility policy that the resident has the right to be free from any physical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptom. When it is determined a restraint is necessary based on an interdisciplinary evaluation, the least restrictive method will be utilized. -A written physician's order is necessary when utilizing a restraint. The physician's order must be specific to the type of restraint, the time it will be used and the medical necessity for use. Resident #36 was admitted to the facility in June 2023 with diagnoses including Dementia. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 indicating moderate cognitive impairment. On 8/13/24 at 7:43 A.M., the surveyor observed Resident #36 sleeping in a low positioned bed. The Resident's bed had a bolster pillow tucked in under the bedsheets on the edge of the Resident's bed. The bolster pillow appeared as a raised border on the edge of the Resident's bed. On 8/14/24 at 7:11 A.M., the surveyor observed Resident #36 sleeping in a bed placed in a low position. The Resident's bed had a bolster pillow tucked in under the bed sheets on the edge of the Resident's bed. The bolster pillow appeared as a raised border on the edge of the Resident's bed. A review of Resident #36's August physician's orders failed to indicate the necessity of a bolster pillow in the Resident's bed. A review of Resident #36's care plan with a revision date of 3/11/24 indicated the following: -Bed mobility with positioning with dependent x 2-rolling left to right and right to left, sit to [NAME] and [NAME] to sit with dependent x 2 with mechanical lift. [sic] A review of the bed safety assessments dated 3/4/24 and 5/23/24 indicated the following: -Cognitive-unaware of safety needs. -Fall history-history of rolling out of bed. -Safety device needed-low bed, fall mat on left side. -Safety device listed above recommended at this time. Further review of the bed safety assessments failed to indicate a bolster pillow as a safety device. During an observation and interview on 8/14/24 at 7:34 A.M., Certified Nurse's Assistant (CNA) #1 and the surveyor observed the Resident in bed. There was a bolster pillow tucked in the bed sheets on the edge of the Resident's bed. CNA #1 said she was not sure why there was a bolster pillow in the Resident's bed. She said the physician's orders would indicate if the bolster pillow should be in the Resident's bed, if it did not, then the bolster pillow should not be in the Resident's bed. During an interview on 8/14/24 at 7:37 A.M., Resident #36 said he/she did not know why he/she has a bolster pillow in his/her bed. He/she said he/she felt that the bolster pillow on the edge of his/her bed has a blocking effect on him/her while he/she is in bed. During an observation and interview on 8/14/24 at 7:44 A.M., Nurse #2 and the surveyor observed the Resident in bed. There was a bolster pillow tucked in the bed sheets on the edge of the Resident's bed. Nurse #2 said any equipment added in the Resident's bed should be assessed before being placed in the Resident's bed. Nurse #2 said if there is no bed safety assessment that includes the bolster pillow, one wasn't done and should have been done before the bolster pillow was added to the Resident's bed. During an interview on 8/14/24 at 7:51 A.M., the Clinical Corporate Nurse said she expects the staff to complete a bed safety assessment before placing any equipment in the Resident's bed even if the Resident or the responsible party prefers the equipment in the bed. She said a bed safety assessment should have been completed before adding a bolster pillow in the Resident's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to follow the plan of care for three Residents (#25, #26 and #41) out of a total sample of 20 residents. Specifically, the facility 1) Failed to follow a physician's order to provide an air mattress for Resident #25. 2) Failed to offload Resident #26's heels as written in his/her care plan. 3) Failed to offload Resident #41's right heel as ordered by the physician. Findings include: 1. Resident #25 was admitted to the facility in April 2018 with diagnoses including diabetes. Review of Resident #25's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #25 is dependent on staff for bed mobility tasks. Review of Resident #25's physician orders indicated the following order initiated on 4/27/23: - Air Mattress - check function and settings #130 (pounds) every shift for positioning. On 8/13/24 at 7:35 A.M., 8:41 A.M., 11:19 A.M., and 1:26 A.M., Resident #25's bed was observed with a facility pressure relieving mattress, not an air mattress. During an interview on 8/13/24 at 1:24 P.M., Unit Manager #1 reviewed Resident #25's physician orders and confirmed the order for the air mattress was an active order. Unit Manager #1 said all physician orders should be followed as ordered. 2. Resident #26 was admitted to the facility in September 2023 with diagnoses including stroke, left hemiplegia and muscle weakness. Review of Resident #26's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated Resident #26 is dependent on staff for bed mobility tasks. Review of Resident #26's skin integrity care plan, last revised on 7/1/24, indicated the following intervention: -Off load heels when in bed. On 8/13/24 at 7:54 A.M. and 10:30 A.M., Resident #26 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. On 8/14/24 at 7:20 A.M., and 8:39 A.M., Resident #26 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. Review of Resident #26's medical record failed to indicate Resident #26 refused to offload his/her heels. During an interview on 8/14/24 at 9:00 A.M., Certified Nursing Assistant (CNA) #2 said the CNAs should ask the nursing staff if residents require any special care or equipment. CNA #2 said Resident #26 did not have any orders or care plan to have any special equipment while lying in bed. During an interview on 8/14/24 at 9:06 A.M., Nurse #1 said Resident #26 should have his/her heels offloaded while in bed. Nurse #1 was unaware Resident #26's heels were not offloaded while lying in bed. During an interview on 8/14/24 at 8/14/24 9:42 A.M., Unit Manager #1 said she would expect all care plans and orders to be followed as written. 3. Resident #41 was admitted to the facility in July 2024 with diagnoses including stroke, right side hemiplegia and muscle weakness. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief interview for Mental Status (BIMS) assessment and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #41 is dependent on staff for bed mobility tasks. Review of Resident #41's physician orders indicated the following order initiates on 7/10/24: - elevate right heel off of bed for pressure relief, every shift for pressure relief, On 8/13/24 at 9:22 A.M., Resident #41 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. On 8/14/24 at 7:17 A.M., Resident #41 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. During an interview on 8/14/24 at 7:26 A.M., Certified Nursing Assistant (CNA) #2 said she was unaware if Resident #41 had any skin concerns or if he/she had any special equipment when lying in bed. Review of Resident #41's nursing notes failed to indicate Resident #41 refused to elevate his/her right heel on 8/13/24 or 8/14/24. During an interview on 8/14/24 at 7:39 A.M., Nurse #1 said Resident #41's heels should be offloaded when in bed. Nurse #1 said Resident #41 may refuse to offload his/her heels, but if he/she does refuse, nursing would have to write a note indicating the Resident refused. At this time, Nurse #1 entered Resident #41's room and observed his/her heels directly on the bed. Nurse #1 spoke to the Resident in his/her native language and the Resident told Nurse #1 that staff did not offload his/her heels on the prior night. During an interview on 8/14/24 at 9:42 A.M., Unit Manager #1 said all physician orders should be followed as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to ensure a physician's order was implemented as ordered for one Resident (#25) out of a total sample of 20 residents. Specifically, the facility failed to obtain blood pressure parameters as ordered. Findings include: Resident #25 was admitted to the facility in April 2028 with diagnoses including cardiomyopathy. Review of Resident #25's Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During a medication observation pass on 8/13/24 at 9:15 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #25 including metoprolol 12.5 mg (milligram). Review of Resident #25's physician orders for the month of August 2024 indicated the following order: -Metoprolol succinate tab 25 mg (milligram) extended release. Give 12.5 mg orally one time a day related to cardiomyopathy. Hold for systolic blood pressure less than 110 and heart rate less than 60. Review of the Medication Administration Record (MAR) for the month of August 2024 failed to indicate that blood pressure parameters were obtained and documented. During an interview on 8/13/24 at 2:00 P.M., Nurse #1 said the blood pressure was done by the night shift nurse. When asked where it was documented, Nurse #1 said it should be documented in the MAR. During an interview on 8/14/24 at 1:36 P.M., the Director of Nursing said physician orders should be followed as ordered and the nurses should document parameters in the medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #32 was admitted to the facility in November 2023 with diagnoses including congestive heart failure, cerebral infarction, failure to thrive and type 2 diabetes mellitus. Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #32 is at risk of developing pressure ulcers. Review of Resident #32's physician's order dated 2/7/23 indicated the following: - Weekly Skin Assessment on Tuesday 7-3 every day shift every Tue (Tuesday) Review of Resident #32's Norton Scale for Predicting Risk of Pressure Ulcer dated 6/14/24, indicated that Resident #32 was a high risk for pressure ulcer development. Review of Resident #32's Potential for Skin Breakdown Care Plan revised and dated 6/24/24 indicated the following interventions: - Norton Plus Assessment every 90 days - Skin protocol per house policy Review of Resident #32's weekly skin checks indicated the skin checks ordered for 7/30/24 and 8/13/24 were not completed. During an interview on 8/15/24 at 8:51 A.M., Nurse #2 said skin checks are done weekly by nursing and are documented only in the electronic medical record. Nurse #2 said a resident with congestive heart failure and at risk for pressure ulcers has potential for skin issues. Nurse #2 said Resident #32 should have weekly skin checks and the nurse must have forgotten to complete them on 7/30/24 and 8/13/24. During an interview on 8/15/24 at 11:15 A.M., the Director of Nursing (DON) and Unit Manager #1 said skin checks should be done weekly, and all physician's orders should be followed. Unit Manager #1 said the skin checks must have been missed. Based on observations, record review and interview, the facility failed to implement the medical plan of care for two Residents (#28, #32) who are assessed as high risk for developing pressure ulcers, out of a total sample of 20 residents. Specifically, the weekly skin assessments for both residents were not completed in accordance with the physician's orders. Findings include: 1) Resident #28 was admitted to the facility in 9/2023 with diagnoses that include but are not limited to unspecified dementia, Parkinson's disease, congested heart failure, and anemia. Review of Resident #28's Minimum Data Set assessment dated [DATE] indicated Resident #28 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderate cognition, is dependent on staff for bathing, toileting, dressing and is at risk for developing pressure ulcers. Review of Resident #28's medical record indicated the following: -The Norton Scale for Predicating Risk of Developing Pressure Ulcers dated 12/2/23 with a score of 6, 2/22/24 with a score of 7, and 5/25/24 with a score of 5, (a score of 10 or less is high risk) assessed Resident #28 as high risk for developing pressure ulcers. Review of Resident #28's physicians orders indicated the following: -Weekly skin assessment on Mon (Monday) 7-3 shift in the morning every Mon for skin checks. Order date 1/17/24. .Record review indicated the following: -A documented weekly skin check dated 6/27/24. The medical record failed to have any further documented skin checks for the next four weeks until 7/29/24. During an interview on 8/14/24 at 9:45 A.M., Unit Manger #1 said all residents have weekly skin checks. UM#1 said she was not sure of Resident #28's Norton Scale Score and therefore could not say if Resident #28 was at risk for developing pressure ulcers and would need to review it. UM #1 reviewed the medical record with the surveyor which revealed the weekly skin checks were not completed for four weeks between 6/27/24 and 7/29/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement the use of a hand splint in accordance with the rehabilitation plan of care for one Resident (#38), out of a total sample of 20 residents. Findings include: Review of the facility policy titled Therapy Screen Policy, dated January 2017, indicted the following: - Therapy will screen residents for appropriateness of therapy intervention. This will include quarterly, annual or as needed screens or referrals from other clinical team members. Resident #38 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side and contracture of the right hand. Review of Resident #38's most recent Minimum Data Set assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Score of 7 out of a possible 15 indicating he/she has moderate cognitive impairment. Further review of Resident #38's MDS indicated that he/she is dependent on staff for Activities of Daily Living and has a right hand contracture. The surveyor made the following observations: - On 8/13/24 at 7:40 A.M., Resident #38's was laying in his/her bed. Resident #38 said he/she had just woken up and was not dressed or bathed for the day yet. Resident #38's fingers on his/her right hand were observed to be slightly curled into a fist position. Resident #38 had to use his/her left hand to extend the fingers on the right hand. Resident #38 was not wearing a hand splint on his/her right hand. No hand splint was visible in Resident #38's room. - On 8/14/24 at 7:05 A.M., Resident #38's was laying in his/her bed. Resident #38 said he/she had just woken up and was not dressed or bathed for the day yet. Resident #38 was observed not wearing a hand splint on his/her right hand. No hand splint was visible in Resident #38's room. The surveyor observed the second floor's Activities of Daily Living book on 8/14/24 at 7:31 A.M., Resident #38 was not documented as receiving AM care yet. Review of Resident #38's physician's order dated 12/6/23 indicated the following order: - Right resting hand splint: apply after PM (nighttime) care and remove before AM (morning) care. Check skin integrity when donning and doffing. Every day and evening shift for support. Review of Resident #38's ADL self-care performance deficit related to right hemiparesis and right hand contracture care plan, revised and dated 7/28/24 indicated the following interventions: - PT/OT/SP (physical therapy/occupational therapy/speech pathology) evaluation and treatment as per MD (medical doctor) orders - Right resting hand splint: Right resting hand splint: apply after PM care and remove before AM care. Check skin integrity when donning and doffing. Review of Resident #38's document titled Occupational Therapy Certification dated from 11/14/23 through 12/11/23 indicted the following: - Range of motion: R (right) digits impaired Review of Resident #38's document titled Occupational Therapy Discharge Summary dated from 11/14/23 through 12/11/23 indicted the following: - Pt (patient) was issued a right resting hand splint to wear overnight in order to reduce risk of further contracture development and skin breakdown. Staff have vocalized 100% carryover with no questions/concerns regarding splint use/wear/donning techniques. The Occupational Therapy Discharge Summary failed to document the current range of motion values for Resident #38's right hand. During an interview on 8/14/24 at 10:11 A.M., the Certified Occupational Therapy Assistant (COTA) said if staff sees something relating to a resident's range of motion they can send a referral slip to therapy. The COTA said Resident #38 does not wear devices for his/her hands and she does not remember if he/she had a hand splint ordered. The COTA continued to say a Resident would wear a hand splint for contracture management so the contracture would not get worse and she would expect all physician's orders to be followed. The COTA said if no measurements were documented we cannot monitor if the contracture has gotten worse. The COTA said she would have the facilities Occupational Therapist evaluate Resident #38. During an interview on 8/14/24 at 2:32 P.M., the Occupational Therapist (OT) said Resident #38's should be wearing his/her hand splint at night time if that is what the current physician's order says. The OT continued to say that the device is for contracture management so the hand contracture does not get worse. Review of Resident #38's document titled Occupational Therapy Certification, dated 8/14/24 through 9/10/24 indicated the following: - Patient/Caregiver Goal: Pt was educated on purpose of OT evaluation to assess current right UE (upper extremity) and ROM (range of motion), function and need for orthotic. - Goals: Right hand resting splint and schedule is still appropriate for pt. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) said all physician's orders should be followed and Resident #38 should be wearing a hand splint at bed time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to complete an investigation of a fall for one Resident (#12) out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Accident and Incident Reports, undated, indicated the following: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Resident #12 was admitted to the facility in January 2017 with diagnoses including respiratory failure and heart failure. Review of resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status of 14 out of 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #12 required substantial assistance from staff for mobility tasks. During an interview on 8/13/24 at 7:42 A.M., Resident #12 said he/she sustained a fall within the last year and he/she has felt weaker since this fall. Review of the form titled, Referral for Rehabilitation Services dated 9/15/24 indicated the following: -Reason for therapy referral: Fall -Resident #12 rolled out of bed approx. (approximately) 2 p.m. - as reported. -The form was signed by the Director of Rehabilitation (DOR) Rehabilitation screen dated 9/19/23 Pt (patient) had an unwitnessed fall 9/15 and was found next to (his/her) bed. Nursing evaluated pt and implemented a HR (handrail) on the bed. Pt currently on PT (Physical Therapy) services, plan to continue and to focus on safety awareness and balance. Review of the nursing notes for 9/15/22 to 9/19/23 failed to indicate any nursing notes regarding Resident #12's fall. The facility was unable to provide an incident report with investigation of Resident #12's self-reported fall. During an interview on 8/14/24 at 11:13 A.M., the DOR said she had made the referral to therapy after Resident #12 had reported to her that he/she had fallen. The DOR said it would be the expectation of the facility to report the fall to the nursing staff, however, she could not remember if she had. The DOR said nursing would have to complete an investigation of the fall. The DOR reviewed the therapy screen and said the screen confirmed the report of the Resident's fall. During an interview on 8/14/24 at 12:06 P.M., the Corporate Nurse said the therapy staff should have reported the fall to the nursing staff. The Corporate Nurse said Resident #12 sometimes says things have occurred that haven't, but regardless, the facility would still need to complete a fall investigation to conclude whether the fall occurred. The Corporate Nurse said she would expect an investigation with this incident and there is not one.

Based on observations, policy review and interviews, the facility failed to ensure medications with short expirations dates were dated when opened, expired medications were removed from supply, medications were securely stored and medication carts were locked when unattended. Findings include: Review of the facility policy titled 'Medication Storage In The Facility', dated 2017, indicated the following but not limited to: -Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. 1. During an inspection of the first-floor medication cart on 8/14/24 at 6:52 A.M., the following medications were available for administration: -Ocuflox eye drops open and undated. -Earwax removal solution expired 7/2024 -Artificial tears with an expiration date of 3/2024 During an interview on 8/14/24 at 7:00 A.M., Nurse # 3 said the nurses are responsible to ensure medications are dated when opened and expired items are removed and destroyed. 2. During a medication pass observation on 8/13/24 at 10:54 A.M., Nurse #2 prepared medications to administer. Nurse #2 then walked away from his medication cart in the hallway and into the dining room. On the medication cart were multiple bottles of over the counter medications that were left unsecured. There was a resident who was walking in the hallway. During an interview on 8/13/24 at 10:56 A.M., Nurse #2 said medications should be secured in the medication cart. During an interview on 8/14/24 at 1:36 P.M., the Director of Nursing said medications with short expiration dates should be dated when opened and that the nurses and the pharmacist are responsible of ensuring expired medications are removed and discarded. 3. During an observation on 8/13/24 at 12:20 P.M., the medication cart was left open and unattended on the second-floor unit. The surveyor was able to pull the drawer open. No nursing staff was visible in the hallway where the cart was located. A resident walked by the cart while it was open. During an interview on 8/13/24 at 12:24 P.M., Nurse #2 said the cart should have been locked when he was not with it. During an observation on 8/14/24 at 9:01 A.M., the medication cart was left open and unattended on the second-floor unit. The surveyor was able to pull the drawer open, multiple Certified Nursing Assistant walked by the open medication cart. During an interview on 8/14/24 at 9:09 A.M., the surveyor asked Nurse #2 if the medication cart should be left open while unattended, Nurse #2 said it should be locked at all times when he is not with it. During an interview on 8/14/24 at 1:34 P.M., the Director of Nursing said medications carts should be locked when not in use or when they are out of sight of the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the correct diet texture was implemented for one Resident (#38) out of a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #10 received a minced textured diet as ordered by the physician. Findings include: Resident #38 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side and contracture of the right hand. Review of Resident #38's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental score of 7 out of a possible 15 indicating he/she has moderate cognitive impairment. Further review of Resident #38's MDS indicated that he/she is dependent on staff for Activities of Daily Living. The surveyor made the following observations: - On 8/13/24 at 12:27 P.M., Resident #38 was observed eating lunch in the second-floor dining room. On Resident #38's lunch plate was a whole cutlet of chicken roughly five inches in length. The chicken was not cut up in any way. - On 8/13/24 at 12:30 P.M., Resident #38's meal card that was on his/her lunch tray indicated that the Resident is on a regular diet. The meal card failed to indicate that he/she was on a minced texture diet as well. - On 8/14/24 at 8:38 A.M., Resident #38 was observed eating breakfast in the second-floor dining room. On Resident #38's breakfast plate was a whole sausage with a casing on it that was not cut up in any way. Review of Resident #38's physician's order dated 8/9/24 indicated the following: - Regular diet, minced texture, mechanically altered, easy to chew During an interview on 8/14/24 at 1:00 P.M., Nurse #2 said a minced diet means the food should be cut up into small pieces. Nurse #2 said there has been some confusion among the nurses with what minced means. The surveyor showed Nurse #2 photos of Resident #38's meals and he said the sausage and chicken should have been cut up into small pieces. During an interview on 8/14/24 at 1:23 P.M., the Food Service Director (SD) said she gets diet slips from nursing that state the type of diet and texture each resident needs and the kitchen staff will make meal cards from that information. The FSD said she received a diet slip from nursing on 8/8/24 that said Resident #38 was on a regular diet and regular texture. The FSD said the Registered Dietitian has a binder that states which foods need to be altered depending on what textured diet a resident in on. The FSD continued to say when a resident is on a minced texture the kitchen staff will alter the food texture in the kitchen. The FSD said if the nursing slip said Resident #38 was on a minced diet she would have made sure the sausage and chicken were cut up. The surveyor showed the FSD photos of the sausage and chicken that Resident #38 received, and she said it was not minced. Review of the document titled Diet Orders that was hanging on the wall in the kitchen indicated that Resident #38 was on a minced, textured diet. Review of the Diet Binder in the kitchen indicated that a Resident who is on a minced diet texture should have sausages that are ground and chicken that is ground. During a telephone interview on 8/15/24 at 9:03 A.M., the Registered Dietitian (RD) said staff must have missed that Resident #38 was on a minced textured diet and it should have been on his/her meal card. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said there was miscommunication among staff for Resident #38's diet texture and his/her meal card should have said he/she was on a minced diet texture. The DON and Unit Manager #1 said all physician's orders should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to maintain an accurate medical record for one Resident (#25) out of a total sample of 20 residents. Findings include: Resident #25 was admitted to the facility in April 2018 with diagnoses including diabetes. Review of Resident #25's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #25 is dependent on staff for bed mobility tasks. Review of Resident #25's physician orders indicated the following order initiated on 4/27/23: - Air Mattress - check function and settings #130 (pounds) every shift, every shift for positioning. On 8/13/24 at 7:35 A.M., 8:41 A.M., 11:19 A.M., and 1:26 A.M., Resident #25's bed was observed with a facility pressure relieving mattress, not an air mattress. Review of the Medication Treatment Record indicated the Nursing staff had documented the presence of the air mattress on 8/13/24. During an interview on 8/13/24 at 1:24 P.M., Unit Manager #1 said Resident #25 has not had an air mattress for at least two weeks. Unit Manager #1 said Nurses should not check off an order as complete if not actually completed.

Based on observations, record review, and interviews, the facility failed to implement the infection prevention and control program. Specifically: the facility failed to ensure nursing implemented infection control standards for blood glucose meter cleaning. Review of the facility policy, infection control, undated indicated the following but not limited to: -Equipment if disinfecting is not possible, clean and disinfect equipment using the same guidelines as for environmental cleaning, after contact with the resident and prior to using the equipment on another resident. -All equipment must be cleaned with PDI sani-cloth germicidal disposable cloth. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 gather supplies to obtain a Resident's blood sugar. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 obtain Resident #2's blood sugar. Nurse #2 exited the room with the contaminated glucometer and placed it in the carrier case where there were more lancets (devices used to obtain blood for testing blood sugar levels) test strips and alcohol wipes. Nurse #2 did not disinfect the blood glucose meter. During an interview on 8/13/24 at 2:20 P.M., Nurse #2 said the blood glucose meter should be sanitized after each use. Nurse #2 said they use the sani-cloth wipe to disinfect the glucose meter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #12 was admitted to the facility in January 2017 with diagnoses including respiratory failure and heart failure. Review of resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status of 14 out of 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #12 required substantial assistance from staff for bathing tasks. During an interview on 8/13/24 at 7:42 A.M., Resident #12 was observed to have a brown stain in his/her face surrounding his/her mouth. Resident #12 said he/she had not been given a shower in 3-4 weeks and would like to be assisted with a shower. Review of the weekly shower schedule indicated Resident #12 was scheduled to have showers on Mondays and Thursdays on the 3-11 shift. During an interview on 8/15/24 at 9:38 A.M., Certified Nursing Assistant (CNA #3) said he did not give Resident #12 a shower on Monday 3-11. He said the Resident refused as the Resident has a preference of not receiving showers from male care givers. When asked if CNA #3 reported to the nurse of the refusal he said he did not. During an interview on 8/15/24 at 9:39 A.M., Nurse #1 said she was unaware Resident #12 had not been provided his/her weekly shower and staff should be reporting any refusals of care to the nurse. 2a) Resident #2 was admitted the facility in November 2023 with diagnoses including dysphagia, unspecified dementia and type 2 diabetes mellitus. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 3 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated that Resident #2 requires supervision or touching assistance with eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 8/13/24 at 8:44 A.M., Resident #2 was laying in his/her bed eating breakfast with no staff members in the room providing supervision. Resident #2 was eating pancakes with his/her hands and was observed pulling pieces of pancakes out of his/her mouth. At 8:54 A.M., Resident #2 was heard coughing by the surveyor while in the hallway. No staff members checked in on Resident #2. - On 8/14/24 at 8:50 A.M., Resident #2 was laying in his/her bed eating breakfast with no staff members in the room providing supervision with the door shut. Resident #2 could not be seen from the hallway. Review of Resident #2's [NAME] (a form describing the type of care a resident needs) indicated the following under the Eating section: Continual Supervision (1:8). Review of Resident #2's ADL Self Care Performance Deficit care plan, revised and dated 7/23/24 indicated the following intervention: Eat with supervision. Review of a nursing progress note dated 8/1/24 indicated the following: - Resident is alert and confused as per baseline. Continues to feel weaker than usual. Lack of appetite, difficulty to swallow. Will continue to monitor. During an interview on 8/15/24 at 10:42 A.M., Certified Nursing Assistant (CNA) #4 said she uses the Resident's [NAME] form to know the type of care each resident needs. CNA #4 said continuous supervision means residents need to be watched at all times while they are eating until they are finished. During an interview on 8/15/24 at 11:01 A.M., CNA #5 and CNA #6 said they use the Resident's [NAME] form to know the type of care they need. CNA #5 and CNA #6 continued to say continuous supervision for meals means residents need to be watched at all times while they are eating. During an interview on 8/15/24 at 11:11 A.M., Nurse #2 said continuous supervision means a staff member should always be watching a resident while they are eating. Nurse #2 said a resident might be on continuous supervision if they have trouble chewing food or swallowing or if they need encouragement. Nurse #2 said anyone could choke or have trouble swallowing in a moment's notice. The surveyor and Nurse #2 reviewed the [NAME] and Nurse #2 said Continuous supervision (1:8) means someone can check on the resident and come back, the surveyor asked Nurse #2 how someone could be continuously watching the resident if they left the resident, and he said the [NAME] is up to interpretation. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said continuous supervision means you can watch a resident eat and leave and come back and check on them. When asked if they thought that was continuous and always watching a resident eat the DON and Unit Manager #1 said that's how they interpret it. When asked if a resident had trouble with swallowing could they choke in a moment's notice and the DON said there is no time limit for choking and it could happen in a moments notice. 2b) Resident #32 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, failure to thrive and type 2 diabetes mellitus. Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #32 requires supervision or touching assistance with eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 8/14/24 at 8:58 A.M., Resident #32 was observed laying in his bed eating breakfast with no staff supervision in the room. Resident #32's door to his/her room was shut and the Resident could not be seen from the hallway. - On 8/15/24 at 8:53 A.M., a Certified Nursing Assistant (CNA) was observed setting up Resident #32's breakfast tray while he/she was laying in bed. The CNA then left Resident #32's room and he/she was observed eating without continuous supervision. Review of Resident #32's [NAME] (a form describing the type of care a resident needs) indicated the following under the Eating section: Continual Supervision (1:8). Review of Resident #32's ADL Self Care Performance Deficit care plan, revised and dated 6/24/24 indicated the following intervention: Eat with supervision. During an interview on 8/15/24 at 10:42 A.M., Certified Nursing Assistant (CNA) #4 said she uses the Resident's [NAME] form to know the type of care each resident needs. CNA #4 said continuous supervision means residents need to be watched at all times while they are eating until they are finished. During an interview on 8/15/24 at 11:01 A.M., CNA #5 and CNA #6 said they use the Resident's [NAME] form to know the type of care they need. CNA #5 and CNA #6 continued to say continuous supervision for meals means residents need to be watched at all times while they are eating. During an interview on 8/15/24 at 11:11 A.M., Nurse #2 said continuous supervision means a staff member should always be watching a resident while they are eating. Nurse #2 said a resident might be on continuous supervision if they have trouble chewing food or swallowing or if they need encouragement. Nurse #2 said anyone could choke or have trouble swallowing in a moment's notice. The surveyor and Nurse #2 reviewed the [NAME] and Nurse #2 said Continuous supervision (1:8) means someone can check on the resident and come back, the surveyor asked Nurse #2 how someone could be continuously watching the resident if they left the resident, and he said the [NAME] is up to interpretation. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said continuous supervision means you can watch a resident eat and leave and come back and check on them. When asked if they thought that was continuous and always watching a resident eat the DON and Unit Manager #1 said that's how they interpret it. The DON said staff would not be able to see a Resident from the hallway if his/her door was closed. When asked if a resident had trouble with swallowing could they choke in a moment's notice and the DON said there is no time limit for choking and it could happen in a moment's notice. 2c) Resident #19 was admitted to the facility in October 2015 with diagnoses including unspecified dementia, anxiety disorder and unspecified protein calorie malnutrition. Review of Resident #19's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident was unable to complete the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review of the MDS indicated that Resident #19 requires supervision or touching assistance with eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 8/13/24 at 12:30 P.M., a Certified Nursing Assistant (CNA) set up Resident #19's lunch tray while he/she was sitting on his/her bed. The CNA then left the room and left Resident #19 unsupervised with his/her lunch. The surveyor observed Resident #19 not receive any supervision with his/her meal until 12:49 P.M. - On 8/14/24 at 9:01 A.M., a CNA set up Resident #19's breakfast tray while he/she was sitting on his/her bed. The CNA then left the room and left Resident #19 unsupervised with his/her breakfast. - On 8/15/24 at 8:37 A.M., a CNA set up Resident #19's breakfast tray while he/she was sitting on his/her bed. The CNA then left the room and left Resident #19 unsupervised with his/her breakfast. Review of Resident #19's [NAME] (a form describing the type of care a resident needs) indicated the following under the Eating section: Totally Dependent Review of Resident #19's ADL Self Care Performance Deficit care plan, revised and dated 6/24/24 indicated the following intervention: Eat with supervision. During an interview on 8/15/24 at 10:42 A.M., Certified Nursing Assistant (CNA) #4 said she uses the Resident's [NAME] form to know the type of care each resident needs. CNA #4 said continuous supervision means residents need to be watched at all times while they are eating until they are finished. During an interview on 8/15/24 at 11:01 A.M., CNA #5 and CNA #6 said they use the Resident's [NAME] form to know the type of care they need. CNA #5 and CNA #6 continued to say continuous supervision for meals means residents need to be watched at all times while they are eating. During an interview on 8/15/24 at 11:11 A.M., Nurse #2 said continuous supervision means a staff member should always be watching a resident while they are eating. Nurse #2 said a resident might be on continuous supervision if they have trouble chewing food or swallowing or if they need encouragement. Nurse #2 said anyone could choke or have trouble swallowing in a moment's notice. The surveyor and Nurse #2 reviewed the [NAME] and Nurse #2 said Continuous supervision (1:8) means someone can check on the resident and come back, the surveyor asked Nurse #2 how someone could be continuously watching the resident if they left the resident, and he said the [NAME] is up to interpretation. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said continuous supervision means you can watch a resident eat and leave and come back and check on them. When asked if they thought that was continuous and always watching a resident eat the DON and Unit Manager #1 said that's how they interpret it. When asked if a resident had trouble with swallowing could they choke in a moment's notice and the DON said there is no time limit for choking and it could happen in a moment's notice. Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for five dependent Residents (#1, #2, #38, #19, #12) out of a total sample of 20 Residents. Specifically, the facility failed to: 1) Provide incontinence care timely and in accordance with the plan of care for Resident #1. 2) Provide supervision while eating for three Residents (#2, #38, #19). 3) Provide showers as ordered for Resident #12. Findings include: Review of the facility's policy titled Activities of Daily Living, effective date 01/01/2015 indicated the following: A program of activities of daily living (ADL) is provided to residents by the following method: The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or member of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Educations is provided to resident and family. Process: 1. Hygiene/Grooming: 2. Dressing: 3. Feeding: 4. Elimination: 5. Ambulation: 1) Review of the facility's policy titled Bladder Incontinence Management, with a revision date of 10/1/05 indicated: Fundamental Information: Based on Bladder Incontinence Assessment, the interdisciplinary team will determine the most appropriate course of action to assist the resident to either: re-establish continence, or: Manage incontinence in a dignified, healthy manner. Documentation: The resident care plan will reflect the current management plan. Resident #1 was admitted to the facility in February 2011 and has diagnoses that include unspecified dementia with agitation, schizophrenia and epilepsy and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the staff assessment for mental status indicated Resident #1 as severely cognitively impaired, is dependent on staff for bathing, dressing, toileting, personal hygiene and eating. Further the MDS indicated Resident #1 as always incontinent of bladder and bowel, is not on a urinary or bowel toileting program, and at risk for developing pressure ulcers. Review of Resident #1's care plan indicated the following: -Resident has functional bowel and bladder incontinence r/t (related to) confusion, Dementia, Impaired Mobility, Inability to communicate needs, Medication Side Effects, Combative and resistive to care dated as reviewed 6/18/24 with a target date of 9/6/2024. Interventions not dated included: Incontinent care, check as needed for incontinence. Wash rinse and dry perineum. Incontinent care with dependent x 2 every 2 hours and prn for toilet hygiene dated as created 4/17/23. -Resident has potential for skin breakdown r/t (related to) decreased mobility, COPD (chronic obstructive pulmonary disease), CHF, incontinent of urine and bowel, anemia and PVD (peripheral vascular disease), dated as reviewed 6/18/2024 with a target date of 9/6/2024 and interventions that include: Bed mobility and positioning every 2 hours and prn (as needed) with dependent x 2 rolling left to right and right to left, [NAME] (sic) to sit and sit to [NAME] (sic) with mechanical lift. On 8/13/24 at 7:45 A.M., Resident 31 was not in his/her room. The Unit Manger said Resident #1 gets up early and is in the sitting (dining) room waiting for breakfast. On 8/13/24 at 8:29 A.M., Resident #1 was observed in a Broda chair (a specialized chair that can recline) in the dining room alone. Resident #1 had his/her eyes closed and was leaning on his/her left side and his/her clothes were bunched up. On 8/13/24 the following observations were made: -At 8:41 A.M., Resident #1 was in the dining room in a Broda chair leaning on his/her left side. His/her eyes were closed. Staff were distributing the breakfast meals. -At 8:51 A.M., Resident #1 was in the dining room, sitting in a Broda chair leaning on his/her left side. -At 9:02 A.M., Resident #1 had his/her hand on his/her chin and other hand in his/her lap. -At 8:59 A.M., Resident #1 was alone in the dining room sitting in the Broda Chair. -At 9:05 A.M., A Certified Nursing Assistant (CNA) approached Resident #1 with a clothing cover and said softly 'wake up' and placed the clothing cover on the Resident. -At 9:07 A.M. a nurse and CNA assisted Resident #1 to be sitting upright in the chair. -At 9:12 A.M., Resident #1 was fed his/her breakfast by a CNA. -At 9:34 A.M., Resident #1 remained sitting in the dining room. -At 10:00 A.M., Resident #1 was sitting in his/her chair which was slightly reclined and holding a baby doll. Resident #1's eyes were closed. -At 10:19 A.M., Resident #1 was in the dining room sitting in his/her Broda chair. At no time during the observation did staff check for or provide incontinence care. During the observation on 8/13/24 which began at 12:07 P.M., and concluded at 2:50 P.M., the following was observed: -At 12:07 P.M., Resident #1 was sitting in the dining room in a Broda Chair. Staff was feeding Resident #1. -At 12:50 P.M., 1:12 P.M., 1:33 P.M., 2: 02 P.M., Resident #1 was seated in his/her Broda chair in the same location in the dining room. -At 2:19 P.M., music was on in the room. Resident #1 was in his/her Broda chair leaning on his/her left arm. His/her eyes were opened, and a doll was on his/her lap. -At 2:24 P.M., Resident #1 was sitting in his/her Broda chair. -At 2:50 P.M., Resident #1 remained in the dining room in his/her Broda chair. At no time is the two hours and 50 minutes was Resident #1 checked for or provided incontinence care. On 8/14/24 at 7:32 A.M., Resident #1 was observed in his/her room with a Hoyer (a pad used with a mechanical lift) pad underneath him/her. During observation on 8/14/24 from 7:46 A.M., through 11:30 P.M., the following was observed: -At 7:46 A.M., Resident #1 was sitting in his/her Broda chair in the dining room. -At 7:59 A.M., 8:17 A.M., Resident #1 was sitting in his/her Broda chair leaning toward his/her left side. in dining room in broda chair. -At 9:01 A.M., 9:18 A.M., Resident #1 was sitting in his/her Broda chair in the dining room. -At 9:20 A.M., Resident #1 was looking around, his/her eyes were wide open, he/she reached out a hand and his/her other hand was picking at His/her shirt. -At 10:07 A.M., Resident #1 was in the dining room with music playing and activity staff present. -At 10:11 A.M., 10:55 A.M., Resident #1 remained in the dining room during a sing a-long activity, holding a baby doll. -At 11:02 A.M., Resident #1 was in the dining room and shortly after the Activities Assistant moved Resident #1 to his/her room. During an interview on 8/14/24 at 11:36 A.M., Certified Nursing Assistant #2 said if a resident is incontinent, they check to see if a change is needed by taking the resident into their room and checking the brief and will change if needed. CNA #2 said incontinent care is provided in the morning and then residents are checked. CNA #2 said she is taking care of Resident #1 today and that Resident #1 requires a two person assist. CNA #2 said she got Resident #1 up before breakfast and has not provided incontinence care to Resident #1 since then. On 8/14/24 at approximately 11:50 A.M., Resident #1 was brought to his/her room for incontinence care. Resident #1's incontinence brief was observed to be wet with urine requiring a change. Resident #1 was not provided incontinence care for over three hours, and it was not until the surveyor brought it to the attention of staff was then Resident #1 brought back to his/her room and provided care. On 8/14/24 at 11:45 A.M., Nurse #1 said every person with incontinence has a care plan with a toileting schedule. Nurse #1 said Resident #1 needs to be checked or changed every two to three hours. Nurse #1 said Resident #1 is at risk for skin breakdown due to incontinence. During an interview on 8/14/24 at 12:26 P.M., the Unit Manger said she would expect the incontinence care plan to be followed for Resident #1. On 8/14/24 at 1:36 P.M., the Director of Nurses (DON) said residents who are incontinent should be checked for odor, changed as needed, and changed after lunch. The DON said staff should be aware of the plan of care and provide the care as required. The DON said Resident #1 should be provided incontinence care timely.

Based on observations, policy review and interviews, the facility failed to provide a dignified dining experience to the residents on the first floor. Findings include: Review of the facility policy titled, Dignity and Respect, dated 8/1/22, indicated the following: *Promoting independence & dignity and dining: facility and staff should avoid: staff standing over residents while assisting them to eat and staff interacting/conversing only with each other rather than with residents while assisting residents. The following was observed in the first floor dining room during the breakfast meal on 6/20/23 at 8:33 A.M.: * Two Certified Nursing Assistants (CNAs) were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them. Throughout the meal, the CNAs spoke to each other in Spanish, however, never conversed with the residents. The following was observed in the first floor dining room during the lunch meal on 6/20/23 at 12:35 P.M.: * Two CNAs were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them. Throughout the meal, the CNAs spoke to each other in Spanish, however, never conversed with the residents. The following was observed in the first floor dining room during the breakfast meal on 6/21/23 at 8:10 A.M.: * An Activities Assistance was observed feeding a resident while standing, not at the eye level of the resident. * Two CNAs were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them. Throughout the meal, the CNAs spoke to each other, however, never conversed with the residents. During an interview on 6/21/23 at 8:31 A.M., Unit Manager #1 said staff should be conversing with residents as they are assisting them with their meals. Unit Manger #1 said staff should be speaking in the language of the residents and not to each other in a foreign language and that is something that has been an issue in the building. Unit Manager #1 said if staff are assisting residents with their meals, they should be sitting, not standing over them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to accommodate one Resident (#8)'s needs by having the bed remote within reach, out of a total sample of 15 residents. Findings include: Resident #8 was re-admitted to the facility in May 2023 with diagnoses including pneumonia and stroke. Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) exam of 6 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #8 is dependent on staff for all functional daily tasks. During an interview on 6/20/23 a 9:34 A.M., Resident #8 was observed lying in bed with the head of the bed elevated to approximately 75 degrees and the bed remote behind the head of the bed, out of his/her reach. Resident #8 said he/she would like to change the position of his/her bed, however, cannot reach the remote. On 6/20/23 at 12:08 P.M., Resident #8 was observed lying in bed with the head of the bed elevated to approximately 75 degrees and the bed remote behind the head of the bed, out of his/her reach. On 6/20/23 at 2:08 P.M., Resident #8 was observed lying in bed with the head of the bed elevated to approximately 75 degrees and the bed remote behind the head of the bed, out of his/her reach. On 6/21/23 at 8:05 A.M., Resident #8 was observed lying in bed with the head of the bed elevated to approximately 75 degrees and the bed remote behind the head of the bed, out of his/her reach. During an interview on 6/21/23 at 8:09 A.M., Certified Nursing Assistant (#2) said Resident #8 can speak and move when he/she wants to and would be able to use a bed remote if it were within reach. CNA #2 said he did not know why the bed remote was kept behind the head of the bed. During an interview on 6/21/23 at 9:25 A.M., the Director of Nursing said Resident #8 would be able to use the bed remote and it should be within reach.

Based on observations and interviews, the facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on one of two nursing units. Findings include: During an observation on 6/21/23 at 9:30 A.M., during a medication pass, Nurse #3 had an Electronic Health Record (EHR) located on a medication cart on the 2nd floor hallway. The screen was open, unattended and the screen of residents' PHI was visible to anyone who passed by. During an observation on 6/21/23 at 9:36 A.M., during a medication pass, Nurse #3 left the EHR computer screen open, revealing PHI to anyone who passed by. During an observation on 6/21/23 at 9:43 A.M., during a medication pass, Nurse #3 left the EHR computer screen open, revealing PHI to anyone who passed by. During an interview on 6/21/23 at 9:50 A.M., Nurse #3 said the computer screen should be closed out of view anytime she is not near it. During an interview on 6/21/23 at 2:30 P.M., the Director of Nursing said anytime a nurse moves away from the computer screen they are expected to put a privacy screen up to protect PHI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide a dietary supplement as ordered for one Resident (#6) out of a total sample of 15 residents. Findings Include: Resident #6 was admitted to the facility in May 2016 with diagnosis including abnormal weight loss, dementia, and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 was unable to complete a Brief Interview for Mental Status (BIMS) due to being rarely or never understood. Further review of the MDS indicated Resident #6 is totally dependent on staff to assist with eating. Review of Resident #6's diet orders indicated the following: *Magic cup (a high calorie, nutrient fortified ice-cream) all meals for meals On 6/20/23 at 8:44 A.M., the surveyor observed a card on Resident #6's breakfast tray indicating Magic Cup three times a day with meals. There was no magic cup on the Resident's meal tray. On 6/21/23 at 8:33 A.M., the surveyor observed a card on Resident #6's breakfast tray indicating Magic Cup three times a day with meals. There was no magic cup on the Resident's meal tray. Review of the Nutritional Assessment, dated 5/23/23, indicated the following: *1 magic cup Q (each/every) meal *(Resident #6) Enjoys magic cups *Body Mass Index (BMI) of 16.21, indicating the Resident is underweight Review of a nutrition progress note, dated 3/11/23, indicated Resident #6 had previously experienced a significant weight loss which was attributed to the unavailability of Magic Cups, and that Magic Cup alternatives were not accepted by the Resident. During an interview on 06/21/23 at 01:00 P.M., the Registered Dietitian (RD) said she would expect Resident #6's Magic Cups to be served on the Resident's meal tray as ordered. The RD also said that not providing the Magic Cups would put the Resident at risk for weight loss, especially because Resident #6 expends a lot of calories by walking around all day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#4) was provided with services and/or materials to maintain communication in his/her own language, out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Communication Translation, indicated the following: *Should a non-English speaking or deaf resident be admitted , a resident rights and facility responsibilities will be translated into the appropriate foreign or sign language that is understood by the resident. It will be accessible for all staff to communicate with the resident and care planned as a communication tool. *The facility has developed an interpreter service policy to assure adequate and effective communication between residents and staff. Employees of the facility will be utilized whenever possible to interpret for non-English speaking or hearing-impaired persons of a staff member is not available, the facility will contract with (an interpreter service) and for services for the speech and hearing impaired. The facility will assume all costs involved in providing sufficient interpreter services to meet the needs of the resident. Resident #4 was admitted to the facility in July 2022 with diagnoses including stroke. Review of Resident #4's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #4 was dependent on staff for all activities of daily living. On 6/20/23 at 8:30 A.M., Resident #4 was observed sitting in the dining room waiting for breakfast. The Surveyor was unable to interview the Resident secondary to he/she is Russian speaking only. Throughout the day on 6/20/23, Resident #4 was observed sitting in the dining room. All activities were in English, and the Resident was provided with a magazine in English. There were no Russian materials observed. On 6/20/22 at 2:22 P.M., Resident #4 was observed in his/her room with Certified Nursing Assistant (CNA) #1. CNA #1 said she was going to assist the Resident back to bed for an afternoon nap. When asked how CNA #1 communicates with the Resident, CNA #1 said she cannot because she does not speak Russian. CNA #1 said she just provides care without explaining what she is doing. CNA #1 said she is unable to understand Resident #4's basic needs including if the Resident is thirsty, hungry, or in pain. CNA #1 said Resident #4's daughter can translate for him/her but is only in the building 3 days a week. CNA #1 said there is a therapist in the building that speaks Russian, but the therapist is not always available to translate if needed. CNA #1 said Resident #4 does not have a communication board and has never had one. CNA #1 was unaware of an interpreter service. On 6/21/22 at 8:21 A.M., Resident #4 was observed eating breakfast. An Activity Assistant was assisting the Resident with his/her meal. Throughout the meal, Resident #4 was shaking his/her head no and saying words in Russian. The Activity Assistant did not respond and made no attempt to use a translator. When asked, the Activity Assistant said she did not understand what Resident #4 was saying and added more sugar to the cereal assuming that is what he/she wanted. The Activity Assistant said she cannot communicate with the Resident and just continued to assist him/her because he/she needed to eat. Observations of Resident #4's bedroom failed to have any signs in Russian or a communication board for the Resident to use if needed. There was a sign on the closet door explaining the preferences of the Resident and how to care for him/her and the sign was in English only. Observation of the nursing unit and nurses station failed to provide information regarding an interpreter service. Review of Resident #4's impaired cognition care plan, last revised 4/6/23, indicated the following intervention: *Russian communication card or books as needed. Review of Resident #4's activities of daily living care plan, last revised 4/9/23, indicated the following intervention: *Explain each task in simple terms. During an interview on 6/20/23 at 2:26 P.M., Nurse #1 said the building does not have a translator service and there are no staff in the building that can speak Russian and translate for Resident #4. Nurse #1 said she would be able to tell if Resident #4 has pain if he/she grimaces, but other than that, she has no way of communicating with the Resident. Nurse #1 said she is unable to explain medication to Resident #4 and the Resident often spit his/her medication out. Nurse #1 said when the Resident's daughter is in the building, she can explain the medications to Resident #4 and the Resident will take them. Nurse #1 said she cannot understand anything the Resident says and cannot communicate with him/her. During an interview on 6/21/23 at 9:25 A.M., the Administrator and Director of Nursing said staff are to use their personal phones to utilize translation applications if needed to translate for a resident. Neither mentioned a translator service. The Director of Nursing said a communication book should be on the nursing unit and did not know there was not a communication board in the Resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure physician wound recommendations were addressed for a resident with a coccyx pressure ulcer for 1 Resident (#19) and failed to ensure that an air mattress was at the ordered setting and heel protective booties were applied for 1 Resident (#8) with a pressure ulcer out of a total of 15 sampled Residents. Findings include: Review of Facility policy titled, Wound Policy dated 6/16/19 included the following: -Wound rounds will be done weekly by the wound team which will consist of the ADNS, UM, and rehab. These rounds are done the same day every week. Wound measurements are done at this time in treatment response and progress of the wound is discussed After rounds are completed a descriptive note will be written on the weekly pressure/non pressure documentation tool. The MD/NP should also document in their progress notes. 1. Resident #19 was admitted to the facility in March 2022 with diagnoses including type 2 diabetes, pressure ulcer of sacral region stage 4 and dementia. Review of the most recent Minimum Data Set Assessment (MDS) dated , 5/17/23 indicated a Brief Interview for Mental Status score of 10 out of possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated Resident #19 had a stage 4 pressure ulcer, received pressure ulcer care including non-surgical dressings with applications of ointments or medications. Review of Resident #19's medical record included the following: -A wound care progress note dated 3/2/23, indicated Resident #19 had a stage 3 coccyx pressure ulcer with dimensions including 4.5 x 1.5 x 0.4 cm that was identified as deteriorating. Treatment recommendations included cleanse with normal saline, apply Opticell Ag (Antimicrobial silver gelling fiber wound dressing) cover with bordered foam dressing daily and as needed. -Wound progress notes dated, 3/9/23 and 3/16/23 also indicated wound treatment recommendations for cleanse with normal saline, apply Opticel Ag cover with bordered foam dressing daily and as needed. -Active Physician Orders with a start date of 2/22/23 and an end date of 3/22/23 indicated wash sacral wound with normal saline followed by santyl (an ointment that debrides necrotic tissue) and calcium alginate (dressing that absorbs drainage and turns into a gel) daily. -A wound care progress noted dated 3/23/23, indicated Resident #19 had a stage 3 coccyx pressure ulcer with dimensions including 4 x 1.2 x 0.4 cm and had no change since previous assessment. Treatment recommendations indicated to cleanse with normal saline, apply hydrofera blue with silver (wound dressing uses foam technology with organic pigments to provide antibacterial healing effects) , moistened with sterile saline before application, cover with bordered foam dressing daily and as needed. -Wound progress notes dated, 3/30/23, 4/6/23, 4/13/23, and 4/17/23 also indicated wound treatment recommendations for cleans with normal saline, apply hydrofera blue with silver (moistened with sterile saline before application), cover with bordered foam dressing daily and as needed. -Active physician orders with a start date of 3/22/23 and an end date of 4/11/23 indicated wound orders to wash sacral wound with normal saline followed by santyl, polysporin and calcium alginate daily. -Active physician orders with a start date of 4/12/23 and an end date of 5/16/23 indicated wound orders to, wash sacral wound with normal saline followed by medihoney and DCD (dry clean dressing) [sic] daily. -A wound progress note dated 4/27/23, indicated Resident #19 had a stage 3 coccyx pressure ulcer with dimensions including 4 x 1.4 x 0.5 cm that had no change since previous assessment. Treatment recommendations included cleanse with normal saline, apply medihoney (a gel that has antibacterial and bacteria resistant properties), cover with bordered foam and DPD (dry pressure dressing) daily and as needed. -Wound progress notes dated, 5/4/23, 5/11/23, 5/18/23, and 5/25/23 indicating wound treatment recommendations to cleanse with normal saline, apply medihoney, cover with bordered foam and DPD daily and as needed. -A wound progress note dated 6/1/23, indicated Resident #19 had a stage 3 coccyx pressure ulcer with dimensions of 4 x 1 x 0.4 cm. Treatment recommendations indicated to cleanse with normal saline, apply Hydrofera Blue (moistened with Sterile Saline), and cover with bordered foam DPD daily and as needed. The plan of care indicated it was discussed with facility staff. -Wound progress notes dated, 6/8/23 and 6/15/23 also indicating wound treatment recommendations to apply Hydrofera Blue (moistened with Sterile Saline), and cover with bordered foam DPD daily and as needed. -Active physician orders dated 5/18/23, to wash sacral wound with normal saline followed by hydrogel/wound gel and a DPD. Review of Resident #19's Physician/Nurse Practitioner progress noted indicated the following: -A progress note dated 3/22/23, indicated resident was seen and examined. Further review indicated that sacral wound is managed by wound care provider and is healing slowly. Pressure ulcer of sacral region stage 3 is followed by wound care provider. -A progress note dated 4/26/23, indicated resident was seen an examined today (4/26/23). Further review indicated sacral wound is managed by wound care provider, healing slowly and has no complaints of pain. The exam revealed sacral wound measured 1.5 x 3 x 0.5 cm with a clean pale bed. Note also indicated pressure ulcer on sacral region, stage 3 was followed by wound care provider. -A progress note dated 5/3/23 indicated Resident #19 had a sacral wound that is managed by wound care provider and is healing slowly. Further review indicated Resident #19 has a pressure ulcer of the sacral region stage 3 that was present on admission and is followed by the wound care provider. Resident #19's medical record failed to indicate the Wound Nurse Practitioner notes were reviewed on multiple by Resident #19's attending Physician and/or attending Nurse Practitioner for treatment recommendations. The Nurse Practitioner notes indicated the Wound Nurse Practitioner was managing Resident #19's wound. During an interview on 6/21/23 at 12:43 P.M., Nurse #2 said Resident #19 is seen by the wound care provider weekly and the unit manager receives the treatment recommendations. Nurse #2 walked the surveyor through the dressing change for Resident #19. Nurse #2 said the treatment included cleansing the wound, applying collagen hydrogel and covering with a dressing. During an interview on 6/21/23 at 1:56 P.M., Unit Manager #1 said she does the wound rounds with the Wound Nurse Practitioner. Unit Manager #1 said the Wound Nurse Practitioner writes out the recommendations and then types up the recommendations for Unit Manager #1 to review with the Physician. When Unit Manager #1 was asked how the surveyor could see the physician is reviewing the wound Nurse Practitioners recommendations Unit Manager #1 said, because I am telling you. Unit Manager #1 said there is no documentation to show the wound nurse practitioners' recommendations were reviewed with the physician. During a follow up interview with the Wound Nurse Practitioner on 6/23/23 at 1:19 P.M., she said that she goes to the facility weekly to do wound rounds and will make recommendations on treatments. The Wound Nurse Practitioner said that she has not had communication with resident's attending Physician or Nurse Practitioner and it is facility's staff responsibility to relay her recommendations. The Wound Nurse Practitioner said that she has not been notified of an attending Physician or Nurse Practitioner disagreeing with any of her recommendations for wound care. 2. Resident #8 was re-admitted to the facility in May 2023 with diagnoses including multiple pressure ulcers. Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) exam of 6 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #8 is dependent on staff for all functional daily tasks. On 6/20/23 at 9:34 A.M., Resident #8 was observed lying in bed. He/she was lying on an air mattress and the mattress was set to 80 pounds. Both of Resident #8's heels were lying directly on the mattress. On 6/20/23 at 12:08 P.M., Resident #8 was observed lying in bed. He/she was lying on an air mattress and the mattress was set to 80 pounds. Both of Resident #8's heels were lying directly on the mattress. On 6/20/23 at 2:08 P.M., Resident #8 was observed lying in bed. He/she was lying on an air mattress and the mattress was set to 80 pounds. Both of Resident #8's heels were lying directly on the mattress. On 6/21/23 at 8:05 A.M., Resident #8 was observed lying in bed. He/she was lying on an air mattress and the mattress was set to 80 pounds. Review of Resident #8's physician orders indicated the following: *Air Mattress - check function and settings every shift #150 (150 pounds) every shift for ar mattress, initiated on 5/10/23. Review of Resident #8's skin integrity care plan last revised on 4/16/23, indicated the following intervention: *Air Mattress - check setting #150 and function every shift. Review of Resident #8's weight log indicated the Resident weighed 158.4 pounds. Review of the weekly wound note dated 6/1/23 indicated Resident #8 has a right lateral deep tissue pressure injury with the recommendation to offload extremities and may utilize pressure relief boots to manage pressure. Review of the weekly wound not dated 6/8/23 indicated Resident #8's right lateral deep tissue injury had opened and was now a stage 2 pressure ulcer. The treatment recommendation was to elevate heels and again may utilize pressure relief boots to manage pressure. Review of Resident #8's medical record failed to indicate documentation that the facility Nurse Practitioner (NP) had reviewed the recommendations from the wound NP or had implemented these recommendations as physician orders or as part of the skin integrity care plan. During an interview on 6/21/23 at 8:09 A.M., Certified Nursing Assistant (CNA) #2 said Resident #8 uses and air mattress on his/her bed because he/she has wounds. CNA #2 said the air mattress should be set to the Resident's weight, which is about 150 pounds, but that the nursing ensures the air mattress is set to the right settings, not him. CNA #2 said Resident #8 also uses booties on both feet to offload pressure from his/her heels when in bed and he could not say why the booties were not in place yesterday. During an interview on 6/21/23 at 9:25 A.M., the Director of Nursing (DON) said Resident #8 has multiple wounds. The DON said Resident #8 uses an air mattress and the mattress should be set to the Resident's weight. The DON said all wound recommendations are reviewed by the NP and if she agrees with the recommendation, it would be added to the physician orders and/or care plan. The DON said Resident #8 has bilateral heel booties to offload his/her heels and should be used when the Resident is in bed.

Based on observation, record review and interview, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of two nurses observed made three errors in 28 opportunities resulting in a medication error rate of 10.71%. These errors impacted 2 Residents (#17 and #11) out of 4 residents observed. Findings include: Review of the facility policy titled, Medication Administration Policy and Procedures undated included the following: -Administration of the correct dosage, form and route -Dosage, route of administration and drug form (tablets, suppository's, liquid) are only ordered by the physician. On 6/21/23 at 8:20 A.M., the surveyor observed a medication pass on the 1st floor nursing unit. Nurse #2 prepared and administered the following medications for Resident #17: -Two docusate sodium 100 milligram (mg) tablets. Review of Resident #17's medical record indicated the following: - A physician order dated 10/5/21 for Docusate Sodium Cap 100 mg, give two capsules orally in the morning. During an interview on 6/21/23 at 11:29 A.M., Nurse #2 said the order was for a capsule and should follow physician's orders. On 6/21/23 at 9:43 A.M., the surveyor observed a medication pass on the 2nd floor unit. Nurse #3 prepared and administered the following medications for Resident #11: - Acetaminophen 325 mg 2 tablets. - Aspirin 81 mg enteric coated one tablet. - Memantine 5 mg one tablet. -Doxycycline 100 mg one capsule. -Saline nasal spray 1 spray in nostril. - Combivent RSP 20-100 1 puff inhalation. - Loratadine 10 mg one tablet. During an interview on 6/21/23 at 9:47 A.M., Nurse #3 said she was going to administer the following medications that were scheduled after Resident #11 had his/her shower: - Breo Ellipta 100-25 mcg 1 puff orally - Erythromycin ophthalmic ointment 5 mg/GM 1 ribbon in left eye. - Easivent MIS 1 device by mouth. The Surveyor asked Nurse #3 twice to confirm the medications that were to be administered after Resident #11's shower and repeated the above medications. Review of Resident #11's medical record indicated the following: - A physician order dated, 4/21/23 for one Aspirin 81 mg oral tablet chewable. - A physician order dated, 3/15/23 for guaifenesin oral tablet 400 mg one tablet by mouth twice daily. During an interview on 6/21/23 at 1:52 P.M., Nurse #3 said she gave the enteric coated Aspirin and did not administer the guaifenesin 400 mg tablet. Nurse #3 said the expectation is to follow physicians' orders. During an interview on 6/21/23 at 2:30 P.M., the Director of Nursing said nurses are expected to follow physicians' orders and follow the five rights of medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure medications were appropriately stored per policy for one Resident (#25) out of a total of 15 sampled Residents. Findings include: Review of the Facility's Medication Storage policy, dated 2017, indicated the following: *Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Review of the Facility's Medication Administration Policy, undated, indicated the following: *Observe patient to ensure that medication is swallowed. Do not leave medications with a patient even if you feel a patient is competent. Resident #25 was admitted to the facility in May 2016 with diagnoses including stroke, and hypoxic respiratory arrest requiring intubation. Review of Resident #25's Minimum Data Set assessment dated [DATE] indicated he/she scored 9 out of a possible 15 on the Brief interview for Mental Status Exam indicating Resident #25 is moderately cognitively impaired. On 6/20/23 at 7:44 A.M. the surveyor observed a small cup of two pill halves on Resident #25's dresser. On 6/20/23 at 12:00 P.M., the surveyor observed the cup of two pill halves were still on Resident #25's dresser. Resident #25 said he/she didn't know what those medications were or who they were for. Review of Resident #25's clinical record indicated: *His/Her healthcare proxy was activated on 5/25/16 due to dementia. *A self administration of medication consent and medication dated 5/10/16, indicated that Resident #25 cannot safely self medicate During an interview with Unit Manager #1 on 6/20/23 12:22 P.M., she said that Resident's are assessed upon admission for self-administration of medication and is re-assessed if there is a change of status or if a Resident requests to self-administer. She said that Resident #25 has not been re-assessed and was unable to administer his/her own medications. The surveyor informed Unit Manager #1 of the observations of medication on Resident #25's dresser and Unit Manager #1 said she had to go remove it as it is not safe as wandering Residents may enter the room. On 6/20/23 at 12:29 P.M., Unit Manager #1 said that the medications on Resident #25's dresser were his/her prescribed medications which were synthroid (a medication used to treat hypothyroidism) and metroprolol (a medication used to treat blood pressure) from the previous shift.

Based on observations and interviews, the facility failed to properly handle food to prevent the spread of food borne illnesses during mealtimes on the first floor. Findings include: The following was observed in the first floor dining room during the breakfast meal on 6/20/23 at 8:33 A.M.: * 4 staff members were observed putting on gloves without washing or sanitizing their hands. The staff then proceeded to open containers and touch packaging on the food, potentially contaminating their gloves. Without changing their gloves, one staff member then touched the head of the spoon that holds the resident's food. Another staff member opened two juice cartons by sticking her finger in the carton to expand the spout. A third staff member was cutting a resident's food and while doing so, her glove on her index finger was in the resident's eggs. The following was observed in the first floor dining room during the breakfast meal on 6/21/23 at 8:10 A.M.: *3 staff members were observes putting on gloves without washing or sanitizing their hands. The staff then proceeded to open containers and touch packaging on the food, potentially contaminating their gloves. Without changing their gloves, all 3 staff members touched the English muffins that had been served and began to butter the muffins. *The Director of Nursing (DON) was observed wearing gloves while setting up a breakfast tray. The DON opened containers and packaging on the food, potentially contaminating their gloves. The DON then put her finger in the juice carton to expand the spout. She then touched an English muffin to spread butter on it. During an interview on 6/21/23 at 8:31 A.M., Unit Manager #1 said the facility expects staff to wear gloves while passing out trays. Unit Manager #1 was unaware that when wearing gloves, if you touch other surfaces prior to touching food, the gloves may be contaminated, and food should not be touched with those gloves. During an interview on 6/21/23 at 9:35 A.M., the Director of Nursing said the facility expects staff to wear gloves while passing out trays. The DIrector of Nursing was unaware that when wearing gloves, if you touch other surfaces prior to touching food, the gloves may be contaminated, and food should not be touched with those gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #6 was admitted to the facility in May 2016 with diagnoses including abnormal weight loss, dementia, and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 was unable to complete a Brief Interview for Mental Status (BIMS) due to being rarely or never understood. Further review of the MDS indicated Resident #6 is totally dependent on staff to assist with eating. On 6/20/23 at 8:44 A.M., the Surveyor observed Resident #6 eating scrambled eggs using his/her hands alone in his/her room. On 6/21/23 at 8:37 A.M., the Surveyor observed Resident #6 eating in common area without the assistance of staff. On 6/21/23 at 12:33 P.M., the Surveyor observed Resident #6 eating in common area without the assistance of staff. The Resident was spilling drinks on to himself/herself, and attempting, unsuccessfully, to use his/her fork to pick up food that had fallen on to the table. Resident #6 was then observed attempting to, unsuccessfully, open his/her closed Magic Cup (a high calorie, nutrient fortified ice-cream prescribed to prevent weight loss). Review of Resident #6's Activities of Daily Living (ADL) care plan indicated the following intervention: *Dependent x1 for eating, updated 6/19/23 Review of Resident #6's care card, undated, indicated Resident #6 is totally dependent for eating Review of the Activities of Daily Living Functional Coding guidelines reference page indicated the following: *Totally Dependent - the resident is fed by nursing staff During an interview on 6/21/23 at 12:51 P.M., the Director of Rehab Services said the expectation would be for staff to assist Resident #6 if they see the Resident struggling with her meal. During an interview on 6/21/23 at 1:56 P.M. Certified Nursing Assistant (CNA) #4 said residents should be provided the level of care outlined on their care cards. CAN #4 said Resident #6 requires assistance with eating, and that a staff member should be sitting and assisting the Resident throughout the entirety of the meal. During an interview on 6/21/23 at 2:08 P.M., the Unit Manager #1 said that for Resident's with care plans indicating they need supervision or assistance with meals, staff should be following the plan of and care. Based on observations, policy review, record review and interviews, the facility failed to provide assistance for meals for 4 Residents (#31, #23, #5, and #6) out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 1/1/2015, indicated the following: *A program of activities of daily living (ADL) is provided to residents by the following method: The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or member of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Education is provided to resident and family. *Feeding: Meals are planned considering needs and desires of residents. 1. Resident #31 was admitted to the facility in May 2018 with diagnoses including stroke and left sided hemiplegia (paralysis). Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicates Resident #31 requires supervision for self-feeding tasks. On 6/20/23 at 9:16 A.M., Resident #31 was observed eating breakfast while lying in bed without staff present to supervise or assist if needed. The Resident was unable to be seen from the hallway. On 6/20/23 at 12:36 P.M., Resident #31 was observed eating lunch in his/her room while sitting in the wheelchair. There were no staff present to supervise or assist if needed. The Resident had his/her back to the door and could not be viewed from the hallway. On 6/21/23 at 8:30 A.M., Resident #31 was observed eating breakfast while lying in bed without staff present to supervise or assist if needed. The Resident was unable to be seen from the hallway. Review of Resident #31's activity of daily living care plan last revised 5/19/23, indicated the following intervention: *Eating with continual supervision with 1:8 ratio. Review of Resident #31's Care Card (a form indicating the level of assist each resident needs) indicated the Resident requires continual supervision with meals. During an interview on 6/21/23 at 8:41 A.M. Certified Nursing Assistant (CNA) #1 said the Care Card explains the level of assistance a resident requires with activities of daily living. CNA #1 said Resident #31 requires supervision with meals. During an interview on 6/21/23 at 9:25 A.M., the Administrator and Director of Nursing said they expect staff to look at the Care Cards and provide the level of care written. The Director of Nursing said continuous supervision means supervision throughout the meal and if a resident was alone in their room for any portion of the meal, they were not receiving continuous supervision. 2. Resident #23 was admitted to the facility in December of 2018 with diagnosis including dysphagia, dehydration, and osteoarthritis. Review of Resident #23 most recent Minimum Data Set (MDS) dated , 3/29/23, indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicates Resident #23 requires supervision with self-feeding tasks. On 6/20/23 at 10:24 A.M., Resident #23 was observed eating breakfast in bed, alone in his/her room. The Resident was not visible from the hallway and there were not staff present to provide assistance or supervision if needed. On 6/21/23 at 8:28 A.M., Resident #23 was observed eating breakfast in bed, alone in his/her room. The Resident was not visible from the hallway and there were not staff present to provide assistance or supervision if needed. Review of Resident #23's activity of daily living care plan last revised 1/18/23, indicates Resident requires eating with continuous supervision 1:8 ratio. Review of Resident #23's care card (form indicating level of assistance each Resident needs) indicates the Resident requires continual supervision 1:8 while eating. During an interview on 6/21/23 at 8:42 A.M., Certified Nursing Assistant (CNA) #1 said staff are to follow the care card form for providing care to all Residents. CNA #1 said Resident #1 requires supervision during meals. During an interview on 6/21/23 at 8:36 A.M., Unit Manager #1 said staff should provide the level of care listed on the care card and care plan. 3. Resident #5 was admitted to the facility in March 2020 with diagnoses including dementia and chronic pulmonary disease. Review of Resident #5's Minimum Data Set assessment dated [DATE] indicated he/she scored 7 out of a possible 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. On 6/20/23 at 12:34 P.M. and 12:44 P.M. the surveyor observed Resident #5 in his/her room with with his/her lunch meal untouched in front of him/her. There were no staff present providing supervision, assistance, or encouragement. Resident #5 presented as thin and confused. Resident #5 said I'm not hungry but I'll eat it but made no attempts to feed himself/herself. On 6/20/23 at 1:01 P.M. the surveyor observed Resident #5's lunch tray on the food truck. The tray had 100% of his/her meal remaining. Review of Resident #5's Activities of Daily Living (ADL) care plan dated 2/16/23, indicated the following intervention: Eating with continual supervision with 1:8 ratio. Ask Resident what time he/she prefers to get up. Review of Resident #5's care card, undated, indicated Resident #5 requires continual supervision 1:8 with eating. Review of Resident #5's Nutrition care plan indicated Resident #5 had a significant weight loss of 11% of his/her total body weight in February 2023 and 14.5% in April 2023. Interventions implemented effective 2/22/23 included: Assist at meals, allow adequate time to eat, offer alternative meals. Review of Resident #5's clinical record included notes from the Dietitian dated 2/22/23 and 4/29/23 indicating staff will continue to provide encouragement and assistance with Resident #5 during meals. On 6/21/23 at 9:04 A.M., the surveyor observed Physical Therapy Aide (PTA) #1 preparing Resident #5's tray for breakfast. PTA said he was not sure what kind of assistance Resident #5 requires with eating and was helping the Resident with breakfast because he was asked to. During an interview with Certified Nurses Aide (CNA) #3 on 6/21/23 9:26 A.M., she said that Resident #5 eats alone in his/her room and does not need any assistance. On 6/21/23 at 12:34 P.M. the surveyor observed a CNA deliver Resident #5's lunch meal and leave the room. Resident #5 was observed eating alone in his/her room without supervision, assistance, or staff encouragement per the plan of care. During an interview on 6/21/23 at 9:25 A.M., the Director of Nursing said continuous supervision means supervision throughout the meal and if a resident was alone in their room for any portion of the meal, they were not receiving continuous supervision. During an interview with Unit Manager #1 on 6/21/23 at 2:08 P.M., she said that for Resident's with care plans indicating they need supervision or assistance with meals, staff should be following the plan of care. Unit Manager #1 said that Resident #5 would refuse physical assistance with meals, but said she understood that Resident #5's care plan indicated he/she required encouragement with meals and continuous supervision. Unit Manager #1 said that CNA #3 may have reported the information to the surveyor incorrectly due to a language barrier. CNA #3 then joined the interview and said that Resident #5 does not need supervision or encouragement during meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #21 was admitted in May 2019 with diagnoses including Alzheimer's and depression. According to the most recent Minimum Data Set (MDS), dated [DATE], Resident #21 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS). During an observation on 10/7/21 at 9:15 A.M., Resident #21 was sitting in a wheelchair holding a blanket with only a brief on and a shirt. Resident #21 was exposed from the waist down and did not have any pants on. There were two other residents in the room and one of the residents told the surveyor that he/she asked Resident #21 if they were cold. There was no staff in the dining room to assist Resident #21. During an interview on 10/7/21 at 9:18 A.M., Nurse #1 said that Resident #21 does not usually sit in the dining room without pants on and was in a surgical gown in the morning. Nurse #1 said that a Certified Nursing Aide must have lifted Resident #21 with a hoyer lift into the chair and did not put pants on Resident #21 before placing him/her in the chair. Based on observation, record review and interview, the facility failed to ensure residents were treated with respect and provided a dignified existence for 2 Residents (#35 and #21) out of a total of 13 sampled residents. Findings include: 1. Resident #35 was admitted to the facility in March 2021 with diagnoses including vascular dementia and interstitial lunch disease. Review of Resident #35's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with bathing dressing and toileting. Review of Resident #35's clinical record indicated the following nursing progress note dated 6/7/21: 11:00 P.M., Resident #35 was not able to stand, needed two assist for transfer. Resident #35 was able to void in the bathroom, but I told him/her that he/she needed to have a Depends (a type of adult brief) for the night and would not be transferred out of bed; he/she was too weak. During a follow up interview with the Administrator on 10/8/21 at 10:20 A.M., he said that residents should be offered a bed pan or a bedside commode instead of being told to urinate in a brief.

Based on observation, interview, and record review, the facility failed to follow the plan of care for 1 Resident (#21) out of a total sample of 13 residents. Findings include: Resident #21 was admitted in May 2019 with diagnoses including Alzheimer's and depression. Review of the current Physician orders indicated that Resident #21 had a treatment order for a soft cervical collar to be worn daily in the morning and to remove it during care. During an observation on 10/6/21 at 9:00 A.M., Resident #21 was lying in bed without a surgical collar on. There was no surgical collar observed in the room. During an observation on 10/7/21 at 9:05 A.M., Resident #21 was sitting in the dayroom with no surgical collar on. During an interview on 10/7/21 at 9:12 A.M., Nurse #1 said she was unaware of the situation regarding Resident #21's surgical collar, but that she would look into it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assess 1 Resident's skin (#15) out of a total of 13 sampled residents. Findings include: Resident #15 was admitted to the facility in January 2017 with diagnoses including chronic obstructive pulmonary disease, schizophrenia, and osteoporosis. Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated he/she is cognitively intact and required assistance with bathing and dressing. Review of a grievance dated 6/28/21, included an email from a family member on behalf of Resident #15 to Social Worker #1. The email indicated: I visited Resident #15 yesterday (6/27/21). Nurse #3 was on duty and I spoke with her. I also just called to try to speak with Nurse #1 but she is not there today. Resident #15 has been complaining about the oxygen tubing hurting his/her left ear. I think the doctor needs to look at it. There has to be some other way to protect his/her ear. It looks red and is starting to get infected. During an interview with Resident #15 on 10/7/21, at 8:15 A.M., the surveyor observed Resident #15 with a bandage on his/her left ear. Resident #15 said that he/she had to squawk about it for a day or two to the nursing staff to get some attention. Resident #15 said that his/her ear has gotten better since. Review of the facility's Skin Management Program: Skin Assessment and Surveillance indicated: *Certified nursing assistants (CNAs) will inspect the skin of each resident during daily care and whenever skin care is provided and report to the Licensed Nurse of the following changes in skin condition: *redness that does not disappear after pressure is relieved and skin management is provided to red area, inflammation, skin breaks, cracks, blisters, etc., discoloration, pain or tenderness. *Licensed Nurses will respond to reports of skin problems and assess the resident's skin as soon as possible. Review of the facility's Skin Care Protocol for All Residents, undated, indicated: *Complete description and measurement of all wounds will be documented on admission or at onset and at weekly intervals to assist in tracking the effectiveness of treatment. Review of Resident #15's clinical record failed to indicate any skin assessments were completed on 6/27/21; the date the grievance indicates nursing was notified of the new area on Resident #15's ear. Review of Resident #15's weekly skin assessment dated [DATE], indicated that his/her skin was intact. Review of a nursing progress note dated 6/30/21; (3 days after the grievance indicated that nursing was notified of the area on Resident's #15's ear) indicated; Seen by Nurse Practioner (NP). New area on back of left ear. New order for DuoDerm to left ear. Review of the NP note dated 6/30/21, indicated: Left ear abrasion secondary to chronic oxygen (O2) use. Review of Resident #15 Treatment Administration Records for July 2021 through September 2021 indicated that Resident #15 received DuoDerm treatment to his/her left ear every three days as ordered by the nurse practitioner. Review of Resident #15's Weekly Skin Assessments from July 2021 through September 2021 indicated that Resident #15's skin was intact and failed to indicate he/she had an area being treated on his/her left ear. During an interview with Nurse #1 on 10/7/21, at 7:56 A.M., she said that Resident #15 had brought his/her area behind his/her ear to the nurses attention. Nurse #1 said that measurements should have been taken but could not say why they were not documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents identified as high risk for falls received adequate supervision and revision of care plan interventions as needed to prevent falls for 1 Resident (#35) out of a total of 13 sampled residents. Findings include: Review of the facility's Fall Protocol policy, undated, indicated the following: *Assess resident *Ask the resident what they thought caused the fall *Completely fill out the 'Event/Incident Report *The section 'steps taken to avoid reoccurrence' must be completed *Update the care plan with new interventions *All falls/incidents will be brought to the weekly at risk meeting to ensure interventions are working Resident #35 was admitted to the facility in March 2021 with diagnoses including vascular dementia and interstitial lunch disease. Review of Resident #35's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with bathing dressing and toileting. Review of Resident #35's clinical record indicated he/she had an activated health care proxy due to memory loss. Review of Resident #35's Fall Care Plan, indicated the following: Potential for Falls: Initiated 3/22/21 Approaches: Monitor adjustment to facility. Reminders of room location as needed. Proper footwear to be worn at all times. Keep room well lit and free from clutter. Call light accessible at all times and resident to be aware of location of light while in room. Keep all items within reach of resident. Anticipate resident needs as needed. Advise/remind resident to call for assistance if able. The above approaches were pre-populated and not individualized to Resident #35. Additions to Resident #35's fall care plan's were hand written interventions which indicated: 4/1/21: Educated for proper footwear 5/22/21: call bell given 5/24/21: pt re-educated re: call light/bell 6/7/21: PT (physical therapy) screen 6/9/21: walker re-evaluation No date: commode at bedside. Review of Resident #35's progress notes and fall investigation reports indicated that he/she had 16 falls since his/her admission: Fall 4/28/21: Resident #35 found on the floor in bathroom at 9:00 A.M. Resident stated he/she was trying to wash his/her feet when he/she lost his/her balance. Interventions implemented to prevent recurrence: instructed to use call light. Fall 5/22/21: Resident #35 found on floor 9:00 A.M., call light on, sitting on buttocks. Resident #35 was carrying tray to the chair. Interventions implemented to prevent recurrence: Asked him/her to wait for someone to get his/her tray. (Review of Resident #35's care plans indicated Resident #35 was also given a handbell in addition to his/her call light) Fall 5/24/21: Resident #35 was found at 12:30 A.M., on buttocks on floor. Resident stated 'I went to the bathroom, came back and lost my balance. Interventions implemented to prevent recurrence: Remind Resident #35 to use call light for help when getting out of bed. (An intervention already in place and not effective due to his/her dementia.) Fall 6/7/21: Staff heard yelling; help me help me, CNA found resident on floor at 9:30 P.M. Interventions implemented to prevent recurrence: [NAME] evaluated for safety/PT screen. (Review of Resident #35's clinical record indicated Resident #35 was screened on 6/9/21 to use a wheelchair) Fall 6/8/21: Staff found Resident #35 on the floor of his/her room at 6:30 P.M. Resident #35 said he/she got up to tidy the room and fell. No interventions were implemented to prevent recurrence. Fall 6/9/21: Staff found Resident #35 on floor with walker brought in by a friend at 10:30 P.M. Interventions implemented to prevent recurrence: Remove new walker from room. Remind Resident #35 to please use his/her call light. (An intervention already in place and not effective due to his/her dementia.) Fall 6/16/21: Staff found Resident #35 on the floor close to the bathroom at 2:30 P.M. Resident #35 sustained a skin tear to the left knee and complained of neck pain. No new interventions were implemented to prevent recurrence. Fall 7/1/21: Resident #35 found on the floor in the hallway at 1:35 P.M., and was saying he/she was trying to get dressed. Resident #35 was dressed at the time. Interventions implemented to prevent recurrence: 1:1 supervision for 1 hour. (An intervention that would not be effective on an ongoing basis.) Fall 7/8/21: Resident #35 found at 3:05 P.M., sitting on the floor between the bed and chair. Resident #35 stated he/she slid to the floor from the chair. Intervention implemented to prevent recurrence: Room reassessed. Fall 8/15/21: Resident #35 found on floor at 5:45 P.M., said he/she slipped. Seat cushions from wheel chair also on floor. Interventions implemented to prevent recurrence: re-addressed need to ask for assistance. (An intervention in place and not effective due to his/her dementia.) Fall 9/8/21: Staff heard loud noise and help me help me Resident #35 found on the floor of the resident's room at 4:20 P.M. Resident #35 said he/she was trying to go to the bathroom. Interventions implemented to prevent recurrence: Orient Resident #35 to use call light, check on Resident frequently. (The clinical record and care plan failed to indicate any increase in supervision Resident #35 received in response to his/her fall. There was no schedule documented and no updates to his/her care plan regarding increased check ins. Re-orienting Resident #35 to his/her call light was an intervention in place and not effective due to his/her dementia.) Fall 9/16/21: Staff heard Help help from roommate. Resident #35 was found on the floor after trying to self transfer from wheelchair to bed and slipped to the floor. Interventions implemented to prevent recurrence: Remind Resident #35 to use call bell, check on Resident #35 every 15-30 minutes. (The clinical record and care plan failed to indicate any schedule and duration of 15-30 minute checks Resident #35 received in response to his/her fall. There was no schedule documented and no updates to his/her care plan regarding increased check ins. Re-orienting Resident #35 to his/her call light was an intervention in place and not effective due to his/her dementia.) Fall 9/23/21: Resident #35 was found on the floor of the bathroom at 9:00 A.M. Interventions implemented to prevent recurrence: Resident #35 was re-educated to use call light. (An intervention in place and not effective due to his/her dementia.) Fall 9/23/21: Resident #35 was found on floor by foot of bed by staff at 7:15 P.M. after he/she was trying to transfer from the bed to the chair. There was no fall investigation provided to the surveyor regarding this fall. The progress notes in the medical record indicated that Resident #35 was reminded to not transfer himself/herself without assistance. (An intervention in place and not effective due to his/her dementia.) Fall 9/30/21: Resident #35 was found on the floor of his/her room after slipping from his/her wheelchair at 10:15 A.M. Interventions implemented to prevent recurrence: Resident #35 was educated to use call light when he/she needs help. (An intervention in place and not effective due to his/her dementia.) Fall 9/30/21: Resident was found laying on his/her back on the floor of his/her room after trying to get up out of bed at 10:50 P.M., Interventions implemented to prevent recurrence: Reinforce teaching with the resident to use call bell to call for help and staff educated to check on resident more often. (The clinical record failed to indicate any increase in supervision Resident #35 received in response to his/her fall. There was no schedule documented and no updates to his/her care plan regarding increased check ins or education provided to staff. Re-educating Resident #35 to his/her call light was an intervention in place and not effective due to his/her dementia.) During an interview with Occupational Therapist (OT) #1 on 10/7/21, at 10:24 A.M., she said that Resident #35 was screened by rehab after every fall. OT #1 said that due to Resident #35 being on hospice he/she was never picked up by rehab and re-education was always provided to Resident #35 to call for assistance. During an interview with Social Worker (SW) #1 on 10/7/21, at 9:10 A.M., she said that Resident #35 knows he/she is supposed to call for help but does not. SW #1 then acknowledged that Resident #35 has dementia and an activated healthcare proxy. SW #1 said that the facility did offer Resident #35 a room change which he/she declined. SW #1 could not identify other interventions attempted to prevent or reduce Resident #35's falls with the exception of education. During an interview with the Director of Nursing (DON) on 10/7/21, at 9:21 A.M., he/she said that Resident #35 falls frequently. The DON said that staff have attempted re-education and a room change which Resident #35 declined in response to his/her falls. The DON could not identify other interventions attempted to prevent or reduce Resident #35's falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents received oxygen within professional standards of practice and in accordance with physicians orders for 1 Resident (#35) out of a total of 13 sampled residents. Findings include: Resident #35 was admitted to the facility in March 2021 with diagnoses including vascular dementia and interstitial lung disease. Review of Resident #35's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with bathing dressing and toileting. On 10/6/21 at 8:52 A.M., the surveyor observed Resident #35 laying in bed. Resident #35 was receiving 5 liters of continuous oxygen via nasal cannula. There was nothing on the tubing or oxygen concentrator to indicate when the tubing was last changed. Review of Resident #35's clinical record indicated the following: Supplemental oxygen (O2) as needed if 02 saturation is less than 02% on room air. There was no date indicating when the order originated. There were no other orders regarding Resident #35's use of oxygen or the care and maintenance of the concentrator or tubing. On 10/07/21 at 7:47 A.M., the surveyor observed Resident #35 asleep in bed. Resident #35 was on 5 liters of continuous oxygen. There was nothing on the tubing or oxygen concentrator to indicate when the tubing was last changed. During an interview with Nurse #2 on 10/7/21 at 7:51 A.M., she said that Resident #35 had been on continuous oxygen since his/her admission to the facility. Nurse #2 said that the overnight shift is expected to change the tubing weekly and label the tubing with the date and document it in the treatment record. Nurse #2 said she was not sure if Resident #35 had orders for changing his/her oxygen equipment. During an interview with Nurse #1 on 10/7/21 at 7:45 A.M. she said that Resident #35 should have orders for continuous oxygen and orders for his/her oxygen tubing to be changed weekly.

Based on document review and interview, the facility failed to ensure staff used the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days per week on 9 out of 16 weekend days. Findings include: Review of the nursing schedule for the following weekend days indicated no RN was in the building for 8 consecutive hours: 8/7/21, 8/8/21, 8/28/21, 9/4/21, 9/11/21, 9/12/21, 9/18/21, 9/1921, and 9/25/21. During an interview on 10/06/21, at 4:23 P.M. the Director of Nursing said that it is very difficult to get nurses since Covid-19. Review of the facility policy titled RN Coverage 7 days a week for 8 Consecutive Hours and not dated indicated that the facility would have an RN in the building for 8 consecutive hours a day, 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was admitted to the facility in January 2017 with diagnoses including chronic obstructive pulmonary disease, schizophrenia, and osteoporosis. Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is cognitively intact and requires assistance with bathing and dressing. Review of a grievance dated 6/28/21 included an email from a family member on behalf of Resident #15 to Social Worker #1. The email indicated: Resident #15 has been complaining about the oxygen tubing hurting his/her left ear. I think the doctor needs to look at it. There has to be some other way to protect his/her ear. It looks red and is starting to get infected. Review of Resident #15's weekly skin assessment dated [DATE] indicated that his/her skin was intact. Review of a nursing progress note dated 6/30/21; (3 days after the grievance indicated that nursing was notified of the area on Resident's #15's ear) indicated; Seen by Nurse Practioner (NP). New area on back of left ear. New order for Duoderm to left ear. Review of the NP note dated 6/30/21 indicated: Left ear abrasion chronic oxygen (O2) use. Review of Resident #15 Treatment Administration Records for July 2021 through September 2021 indicated that Resident #15 received DuoDerm treatment to his/her left ear every three days as ordered by the nurse practitioner. Review of Resident #15's Weekly Skin Assessments from July 2021 through September 2021 indicated that Resident #15's skin was intact, despite him/her being treated for an area behind his/her left ear. Based on observations, interviews and record reviews, the facility failed to maintain complete and/or accurate clinical records for 2 sampled Residents (#15 and #39) out of a total of 13 sampled residents. Findings include: 1. Resident #39 was admitted to the facility in [DATE] with diagnoses including dementia, anxiety and hypertension. Review of the Medication Administration Record (MAR) dated 9/8/21 indicated an order for Seroquel (an antipsychotic) 25 milligrams (mg) as needed (PRN) at bedtime. Further review indicated the order had been discontinued on 9/13/21. Review of the doctor's orders dated 9/13/21, indicated an order to discontinue the Seroquel PRN order. Review of the doctor's orders from 9/13/21 to 10/6/21, failed to indicate an order to reinstate the Seroquel PRN. Review of the MAR dated 10/1/21, indicated an order for Seroquel PRN. The facility failed to produce a policy upon request by the surveyor for the editing of monthly doctor's orders. During an interview on 10/06/21, at 4:23 P.M. the Director of Nursing said that the order for Seroquel was not edited off during the monthly turn over of the MAR's.

Based on observation and staff interview, the Facility failed to ensure that food is distributed in accordance with professional standards for food safety and sanitation to prevent the spread of pathogens which could result in food borne illness. Findings include: On 10/06/21, at 8:30 A.M., the surveyor observed Certified Nurse's Aid (CNA) #1 in the dining room peeling an egg with her bare hands, contaminating the egg, and serve it to a resident. On 10/06/21, at 8:37 A.M. the surveyor observed CNA #1 open a juice carton by sticking her finger into the spout to pull it open, contaminating the carton, and then exit the room without performing hand hygiene (HH). On 10/06/21, at 8:42 A.M. the surveyor observed CNA #1 enter another resident's room with a breakfast tray. She opened the juice and milk cartons by sticking her finger into the spout to pulled them open, contaminating both cartons. During an interview on 10/06/21, at 8:45 A.M. CNA #1 said that she did not know she had to wear gloves when touching food and didn't realize she was sticking her finger into the milk and juice cartons. On 10/06/21, at 12:41 P.M. the surveyor observed CNA #2 open chocolate milk carton by sticking her finger into the spout to pull it open, contaminating the carton. On 10/06/21, at 12:28 P.M. the surveyor observed CNA #3 open 2 juice containers by sticking her thumb in to pull the spouts out, contaminating both cartons. On 10/07/21, at 8:15 A.M. the surveyor observed CNA #4 in a resident's room serving a resident breakfast. CNA #4 opened a carton of milk and a carton of orange juice by sticking her finger into the spouts to pull them open, contaminating both cartons. CNA #4 then held a slice of toast with her bare hands while buttering it contaminating the toast. On 10/07/21, at 8:21 A.M. the surveyor observed CNA #4 open a carton of milk and a carton of orange juice by sticking her finger into the spouts to pull them open, contaminating both cartons. CNA #4 then held a slice of toast with her bare hands while buttering it, contaminating the toast. During an interview on 10/07/21, at 8:23 A.M. CNA #4 said that she should have worn gloves to prevent contaminating the food. Review of the facility policy titled Preventing Foodborne Illness-Food Handling and not dated indicated that food will be handled and served so that the risk of foodborne illness is minimized.