Based on observations, and interviews, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the facility failed to ensure that resident food was prepared and distributed appropriately to prevent the potential for cross contamination by staff in the main kitchen when: -Dietary Staff #1 was observed handling food items and food trays and walked around other areas of the main kitchen touching surfaces using the same gloves. Dietary Staff #1 was also handling dirty trays and resident food items on the food service line and did not change gloves or perform appropriate hand hygiene. -Dietary Staff #2 did not change gloves or perform appropriate hand hygiene between working on the resident food service line, moving around other areas of the kitchen and returning to the serving line. Findings include: Review of the facility policy for Glove Use in the Dining Services Department, last revised 4/1/25, indicated: -plastic gloves will be worn when handling food that will not be cooked further to ensure that bacteria are not transferred from the food handler's hands to the food product being served. -if used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. -hands are to be washed when entering the kitchen and before putting plastic gloves on. -wash hands after removing gloves. Review of the facility policy for Food Services- Hand Hygiene last revised 4/1/25, indicated that hands should be washed with soap and water at the following times: -before each shift -before putting on (donning) gloves -between handling raw and cooked foods -after handling soiled silverware/utensils -after handling garbage -after removing gloves -after any activity that may contaminate hands On 6/23/25 the surveyor observed the following during the breakfast meal service in the facility main kitchen: -At 8:29 A.M., the surveyor and the Food Service Director (FSD) observed Dietary Staff #1 step away from the serving line with gloved hands to walk to the corner of the kitchen to grab a tray of muffins. Dietary Staff #1 placed the tray on a table closer to the food she was serving, took a muffin off the tray with her gloved hand and placed it on a resident's tray. Dietary Staff #1 then proceeded to continue to serve food on the resident trays with the same gloved hands. The surveyor observed the FSD instructing Dietary Staff #1 to remove her gloves and wash her hands. During an interview at the time, the FSD said that Dietary Staff #1 should have changed her gloves and washed her hands as soon as she stepped away from the serving line and she did not. -At 8:34 A.M., the surveyor observed Dietary Staff #1 step away from the serving line to take a dirty metal tray to the dirty dish area of the kitchen. Dietary Staff #1 did not remove her gloves, wash her hands or don a new pair of gloves prior to returning to the serving line and proceeding to serve breakfast with the same gloved hands. -At 8:36 A.M., the surveyor observed Dietary Staff #2 step away from the serving line to retrieve a serving utensil from another area of the kitchen. Dietary Staff #2 did not remove her gloves, wash her hands or don a new pair of gloves prior to returning to the serving line and proceeding to serve breakfast with the same gloved hands. The surveyor then observed the FSD instructing both Dietary Staff #1 and Dietary Staff #2 to remove their gloves and wash their hands prior to returning to the serving line. During an interview at the time, the FSD said that Dietary Staff #1 and Dietary Staff #2 should have removed their gloves and washed their hands after stepping away from the food serving line and they did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #10 was admitted to the facility in July 2020 with diagnoses including open wound of the abdominal wall and atherosclerosis of native arteries of left leg with ulceration of heel and midfoot. Review of Resident #10's Physician's order for June 2025, indicated: -Enhanced Barrier Precautions (EBP) related to lower leg wounds. >Special Instructions: Gown/Glove Use for High Contact Care: dressing, bathing/showering, transferring, providing hygiene, changing linens. On 6/20/25 at 8:01 A.M., the surveyor observed CNA #2 remove soiled linen from Resident #10's bed and place the linen in a bag on the floor next to the Resident's bed in his/her room. CNA #2 was observed wearing gloves but not wearing a gown. CNA #2 was further observed to exit Resident #10's room with the soiled gloves still in place, and proceed into the hallway and remove clean linen from a linen cart in the hallway. The surveyor observed CNA #2 go back into Resident #10's room with the clean linen and make the Resident's bed with the soiled gloves still in place. When CNA #2 finished making the bed, she doffed the dirty gloves and sanitized her hands. During an interview on 6/20/25 at 8:10 A.M., CNA #2 said she was aware Resident #10 was on EBP related to leg wounds. CNA #2 said she did not don a gown because she was not providing high contact care to Resident #10. The surveyor and CNA #2 reviewed the EBP sign at the Resident's door and CNA #2 said she should have worn a gown while changing Resident #10's bed, but she did not. CNA #2 further said she should have removed her gloves and sanitized her hands before exiting the Resident's room to obtain clean linen, but she did not. During an interview on 6/20/25 at 8:14 A.M., Unit Manager (UM) #1 said she was unsure whether the CNAs are expected to wear gowns or gloves when changing linens on the bed for residents on EBP and would get back to the surveyor. During an interview on 6/20/25 at 8:42 A.M., UM #1 said that CNAs were expected to wear gowns and gloves when changing linens for residents on EBP. UM #1 said that CNA #2 should have worn a gown when making Resident #10's bed but she did not. During an interview on 6/20/25 at 10:17 A.M., the Chief Nursing Officer (CNO) said that CNA #2 should have worn gloves and a gown when she made Resident #10's bed, but she did not. Based on observation, and interview, the facility failed to adhere to infection control standards of practice, increasing the risk of contamination and spread of infections on one unit ([NAME] Unit) out of two units, and for one Resident (#10) out of a total sample of 18 residents. Specifically, the facility failed to: 1. ensure that the staff on the [NAME] Unit wore the indicated personal protective equipment (PPE-items such as gowns and gloves worn by staff to decrease the spread of infections) when providing high contact care for residents on Enhanced Barrier Precautions (EBP-measures using protective barrier gowns and gloves as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDRO) during high contact resident care) when a Certified Nurses Aide (CNA) provided denture hygiene care for a unit resident. 2. For Resident #10, ensure that staff followed the EBP ordered by the Physician when removing the Resident's dirty bed linens and performed appropriate hand hygiene and glove use when applying clean bed linens. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), dated 4/6/23, indicated: -Enhanced Barrier Precautions expands the use of PPE and refer to the use of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing -MDRO's may be indirectly transferred from resident to resident during these high contact care activities -The use of gown and gloves for high contact resident care activities is indicated when contact precautions do not otherwise apply for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. -Examples of high-contact resident care requiring gown and glove for use of enhanced barrier precautions include: >dressing >bathing/showering >transferring >providing hygiene >changing linens >changing briefs or assistance with toileting 1. On 6/18/25 at 8:22 A.M., the surveyor observed the following: -Certified Nurses Aide (CNA) #1 enter a room on the [NAME] unit with posted signs for EBP which indicated: >Everyone must clean their hands, including before entering and when leaving the room >providers and staff must also: -wear gloves and a gown for the following high contact resident care activities: >dressing >bathing/showering >transferring >changing linens >providing hygiene >changing briefs or assisting with toileting >device care or use: central line, urinary catheter, feeding tube, tracheostomy >wound care: any skin opening requiring a dressing -CNA #1 was observed donning gloves but no gown, and entering the EBP room. -CNA #1 was observed to take a denture cup from the resident and then bring the denture cup into the resident's bathroom. -CNA #1 returned from the resident's bathroom with the dentures on a paper towel and handed the dentures to the resident. -CNA #1 doffed her gloves, performed hand hygiene and exited the room. During an interview on 6/18/25 at 8:26 A.M., CNA #1 said she was washing the resident's dentures in the bathroom. CNA #1 said she did not know why the resident was on precautions because she does not normally work on the [NAME] Unit. CNA #1 said she did not think she needed a gown because she had gloves on and was only cleaning the resident's dentures. During an interview on 6/23/25 at 12:20 P.M., the Director of Nursing (DON) said the resident on the [NAME] Unit observed by the surveyor was on EBP because the resident had a Peripherally Inserted Central Catheter (PICC line). The DON said that CNA #1 should have been wearing a gown when completing denture care for the resident because denture care is considered high contact care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure that patient care equipment was maintained in safe operating condition for one Resident (#47) out of a total sample of 18 residents. Specifically, for Resident #47, the facility failed to ensure that an air mattress ordered by the Physician was appropriately functioning as required when the air mattress was plugged into a non-functioning electrical outlet and the Resident was not receiving the pressure relieving benefit of the air mattress. Findings include: Review of the Medline Supra CXC User Manual, undated, indicated: -Troubleshooting >power is not on. Solution: check if the plug is connected to the mains, check if there is any blown fuse. >patient is bottoming out. Solution: pressure setting might be inadequate for the patient. Adjust pressure to a higher level and wait a few minutes. Resident #47 was admitted to the facility in July 2024 with diagnoses including Dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #47: -was unable to complete the Brief Interview for Mental Status exam because they are rarely or never understood -was significantly cognitively impaired -was dependent on staff for all Activities of Daily Living (ADLs) -was at risk for developing pressure ulcers and utilized a pressure relieving device for bed and chair -was receiving Hospice services Review of Resident #47's Care Plan for Skin Breakdown, last revised 5/2/25, indicated: -the Resident is at risk for skin breakdown due to incontinence and decreased mobility -an intervention for an air mattress to bed Review of Resident #47's June 2025 Physician's orders indicated: -order for an air mattress with bolsters applied to the bed -monitor mattress for comfort setting per resident preference every shift, start date 4/28/25. On 6/17/25 at 8:45 A.M., the surveyor observed Resident #47 asleep in bed on an air mattress which had been plugged into a red electrical outlet (electrical outlet connected to emergency backup power). The surveyor observed the power to the Resident's mattress was not on and the mattress was deflated when the surveyor touched it. On 6/17/25 at 4:27 P.M., the surveyor observed Resident #47's lying in bed with an air mattress in place and plugged into a red outlet. The surveyor observed that the power to the air mattress was not on and the mattress was deflated upon examination. On 6/18/25 at 7:48 A.M., the surveyor observed Resident #47 asleep in bed on an air mattress that was plugged into a red outlet, but the power was not turned on and the air mattress was deflated on examination. Review of the Resident #47's June 2025 Medication Administration Record (MAR) indicated that the Resident's air mattress had been checked daily every shift for comfort. During an interview on 6/18/25 at 8:40 A.M., the surveyor and Nurse #1 observed Resident #47 asleep in the bed with an air mattress in place. Nurse #1 said that the red outlet did not appear to be working, that nursing staff should have been checking the air mattress every shift, according to the Physician's orders and they had not been. During an interview on 6/18/25 at 8:41 A.M., the Director of Nurses (DON) said that Resident #47's air mattress should have been working, but it had not been and that she intended to notify the maintenance department.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff implemented and followed their abuse policy, when on 7/22/24 an Activity Aide (AA) witnessed another staff member interact with and handle Resident #1 in a potentially abusive manner, however the AA did not immediately report the incident as required, and Administrative staff did not become aware of the incident until the following day (7/23/24) when a visitor, who was also present during the incident reported it to the facility. Findings include: Review of the Facility Policy titled Abuse Prevention and Prohibition, dated as revised 04/01/2019, indicated the Facility assured an environment free of abuse, neglect, mistreatment, and misappropriation of resident property. The Policy indicated that staff who witness or have knowledge of abuse, mistreatment, neglect, misappropriation of resident property or exploitation are required to report it immediately to the nursing supervisor. Resident #1 was admitted to the Facility in August 2023, diagnoses included Neurocognitive Disorder, Lewy Bodies Dementia, and Parkinson's disease. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/15/24, indicated he/she scored a 3 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact. Further review of the MDS Assessment, indicated Resident #1 required substantial to maximal assistance of one staff member for transfers and ambulation. Review of Resident #1's Activites of Daily Living (ADL) Care Plan, reviewed and renewed with his/her May 2024 Quarterly MDS Assessment, indicated he/she required partial to moderate assistance of one staff member for sit to stand and required reminders to stay seated in the activity room. Review of Resident #1's Cognitive Loss/Dementia Care Plan, reviewed and renewed with his/her May 2024 Quarterly MDS Assessment, indicated staff would anticipate and meet his/her needs when he/she was unable to communicate them. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) dated as submitted on 7/23/24 indicated that on 07/22/24 at approximately 4:30 P.M., a Family Member of another Resident witnessed CNA #1 in the activity room being rough with Resident #1 and said the Activity Aide also witnessed the event. Per the Report, the Family Member reported the incident the following day on 7/23/24. Further review of the Report indicated the Activity Aide witnessed Resident #1 in the activity room, attempting to stand and that CNA#1 pushed down on his/her shoulders in a rough manner. The Report indicated that an investigation was initiated on 7/23/24 as soon as it was reported, CNA #1 was interviewed, denied the allegations, and was suspended pending further investigation and ultimately terminated. During an interview on 08/29/24 at 1:25 P.M., the Activity Aide said on 7/22/24 at approximately 4:30 P.M., she witnessed CNA# 1 push Resident # 1 on his/her bilateral shoulders down onto the chair in a rough manner when he/she stood up in the activity room. The Activity Aide said she did not report the incident until 7/23/24, but said she should have reported it immediately to a nursing supervisor. During an interview on 08/29/24 at 1:01 P.M., the Director of Nurses (DON) said that on 7/23/24 at approximately 2:30 P.M., a Family Member attending the care plan meeting of another Resident reported she witnessed a CNA being rough with Resident #1 and that an Activity Aide was also present and witnessed the event. The DON said that on 07/23/24, after the Family Member report, she began an investigation into the allegation of abuse and reported the allegation of abuse to the Department of Public Health (DPH) as required. The DON said that the allegation of abuse should have been reported by the Activity Aide immediately to Administration on 7/22/24 and that education on the abuse policy and timely reporting had been conducted with all staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for two Residents (#27 and #28) out of a total sample of 19 residents. Specifically, the facility failed to: 1. For Resident #27, ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #27's invoked (made active by a Physician) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so). 2. For Resident #28, ensure that the MOLST form was valid and reflected the signature of the Resident's appointed/invoked HCP. Findings include: Review of the facility policy titled Advanced Directives and Massachusetts Health Care Proxy, last revised 2/25/24, indicated the following: -On admission determine if the patient has a validly executed MOLST form or copy of the form. -The Admissions Director or Social Worker will determine if the form has been validly executed and contains the signature of the Resident and the signature of the Physician, Nurse Practitioner (NP) or Physician Assistant (PA). -At the time of the Quarterly Care planning, the Advanced Directives will be reviewed with the patient, or health care agent to determine if they remain valid. 1. Resident #27 was admitted to the facility in May 2023, with diagnoses including vascular Dementia (problems with reasoning, planning, memory, judgement, and other thought processes caused by brain damage from impaired blood flow to the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #27 was unable to complete the Brief Interview for Mental Status (BIMS) exam and was cognitively impaired. Review of the clinical record revealed a MOLST form that was signed by someone other than the Resident, or Resident #27's appointed HCP on 10/31/14. Review of the Massachusetts Health Care Proxy Designation Form indicated Resident #27 had appointed a HCP on 2/11/16. Review of the clinical record indicated that the Physician had invoked Resident #27's Health Care Proxy (HCP) on 5/17/23. During an interview on 5/8/24 at 12:02 P.M., the Director of Nurses (DON) said the facility did not have evidence that Resident #27's HCP had been activated prior to the date the MOLST form was signed on 10/31/14. The DON also said that a new MOLST form should have been completed on the Resident's admission to the facility and that the MOLST form that was currently on file was not valid. 2. Resident #28 was admitted to the facility in December 2023 with a diagnosis of Malignant Neoplasm (Cancer). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #28 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment of 14 out of a total possible score of 15. Review of the Massachusetts Health Care Proxy Designation Form indicated Resident #28 had appointed a HCP on 9/5/13. Review of the HCP Invocation Form for Resident #28 indicated that the Resident's HCP had been invoked on 2/7/24. Review of the MOLST form for Resident #28 indicated that the MOLST form was signed by someone other than the Resident or appointed HCP and was dated 12/15/23. During an interview on 5/8/24 at 12:09 P.M., the DON said that the Resident's MOLST form was invalid because it had been signed by verbal authorization of a person who was not Resident #28's HCP on 12/15/23. The DON said a new MOLST form should have been signed by Resident #28's designated HCP when the Resident was admitted to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review, the facility failed to provide privacy and confidentiality for one Resident (#27) out of 19 sampled residents. Specifically, for Resident #27, the facility staff failed to ensure that personal privacy of the Resident's own body was provided when he/she was observed to be naked and attempting to get dressed in their bedroom. Findings include: Review of the facility policy titled Resident's Rights, last revised 9/19/23, indicated that Federal and state law guarantee certain basic rights to all residents of this facility including: -a dignified existence -privacy and confidentiality Resident #27 was admitted to the facility in May 2023, with diagnoses including vascular Dementia (problems with reasoning, planning, memory, judgement, and other thought processes caused by brain damage from impaired blood flow to the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #27 was unable to complete the Brief Interview for Mental Status (BIMS) exam and was cognitively impaired. On 5/7/24 at 8:03 A.M., the surveyor observed from the Resident's bedroom doorway that Resident #27 was located in his/her bedroom, was naked, and attempting to dress him/herself while sitting in his/her wheelchair. On 5/7/24 at 8:11 A.M., the surveyor asked Nurse #1, who was in the vicinity of the Resident's doorway, if Resident #27 required assistance with dressing. The surveyor observed that Nurse #1 looked into the room at Resident #27 and said that he/she did not require any assistance with dressing. The surveyor further observed that Nurse #1 continued with the task she was doing and did not attempt to enter the Resident's room to draw the Resident's privacy curtain, close the door, or cover the Resident's body. On 5/7/24 at 8:18 A.M., the surveyor observed Certified Nurses Aide (CNA) #2 enter Resident #27's room to obtain an item for the Resident's roommate. The surveyor observed that the Resident was still naked and sitting in his/her wheelchair. The surveyor observed CNA #2 exiting the room without covering the Resident's body or drawing the privacy curtain and leaving the Resident naked, where he/she could still be seen from the doorway by anyone looking into the bedroom. During an interview on 5/8/24 at 8:15 A.M., Nurse #1 said that Resident #27 should have been covered or a privacy curtain should have been drawn and that was not done. During an interview on 5/8/24 at 8:17 A.M., CNA #1 (who also worked on the Resident's unit) said if she saw a Resident naked from the hallway, she would go and help them by covering them with a sheet, when the surveyor asked what she would do in this situation. During an interview on 5/8/24 at 12:18 P.M., Unit Manager (UM) #1 said that the staff should have covered Resident #27 when he/she was exposed. During an interview on 5/9/24 at 10:01 A.M., CNA #2 said that he saw Resident #27 naked in his/her room. CNA #2 also said that he told the CNA on the Resident's assignment what he had seen, but did not cover the Resident's body or draw the curtain for privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to ensure that two Residents (#54 and #61), out of a total sample of 20 residents were provided with necessary assistance during dining service to decrease the risk of reduced nutritional intake. Specifically, the facility staff failed to: 1. For Resident #54, offer to provide physical assistance to set up meal trays by opening opening containers and placing meal items in an accessible manner that would enable the Resident to consume his/her meals. 2. For Resident #61, assist the Resident in setting up their meal tray for ease with dining by cutting up food items as needed and ensuring meal items were accessible. Findings include: Review of the facility's Dining Program Policy, undated, indicated the following: -It was the facility's policy to provide an enhancing resident-centered dining service that encourages nutritional intake, resident independence, social relationships, and overall well-being. -Proper assistance and encouragement will be given to residents as needed or care planned. 1. Resident #54 was admitted to the facility in November 2023, with a diagnosis of Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) with agitation (state of anxiety or nervous excitement). Review of Resident #54's Activities of Daily Living (ADL) Care Plan, initiated 11/16/23 and edited 11/29/23, indicated the Resident required setup/clean-up assistance for eating. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a BIMS score of zero out of 15 total possible points. Review of Resident #54's Functional Abilities for Eating Record for 5/1/24 through 5/6/24 indicated the Resident's functional abilities for eating varied from requiring partial/moderate assistance to independent. On 5/7/24, between 9:10 A.M. and 9:47 A.M., the surveyor observed the following in the Dementia Special Care Unit (DSCU) Dining Room: -Resident #54 was sitting at a dining table with two other residents. -The Resident's meal tray was in front of him/her at the table and included the following items: >One breakfast sandwich, cut in half. One half of the sandwich was off the back of the plate. >One partially eaten muffin on the plate. >One banana, unpeeled, on the tray, behind the plate and out of view of the Resident. >One covered, unopened plastic cup of water. >One unopened carton of milk. >One uncovered bowl of oatmeal. >One uncovered ice cream cup. >One unopened plastic cup of orange juice with a tin foil cover. -Resident #54 held a spoon and knife and was rubbing them together. -At 9:12 A.M., the surveyor observed Resident #54 pick up the milk carton and attempt to pull on the top of the carton repetitively. -At 9:14 A.M., the surveyor observed Resident #54 holding the unopened milk carton in his/her left hand and the uncovered pudding cup in his/her right hand. -The Resident placed the ice cream cup back on the tray, continued to hold the unopened carton of milk and began pulling at the top of the carton again. -The Resident then placed the unopened milk carton back on the tray, placed the fingers on his/her right hand into the bowl of oatmeal, removed his/her fingers from the bowl and licked them. -Resident #54 picked up the ice cream cup and attempted to drink it, but no pudding came out of the cup. -At this time, the surveyor observed no staff in the immediate dining area. -At 9:18 A.M., the surveyor observed a staff member entered the Dining Room and walked by the Resident, into the adjacent dining area, but did not stop to assist Resident #54. -At 9:19 A.M., the surveyor observed Resident #54 take his/her spoon and repeatedly push it into the side of the unopened milk carton. -At 9:25 A.M., the surveyor observed another resident at the table take Resident #54's unopened milk carton and attempt to open it using a fork. -The surveyor observed the other Resident then stood and reached onto Resident #54's plate, picked up one half of Resident #54's breakfast sandwich, and took a bite, then picked up Resident #54's pudding cup and ate the pudding. -At this time, Resident #54 placed the unopened orange juice and what was left of the breakfast sandwich on his/her plate with the partially eaten muffin, then pushed him/herself away from the table. On 5/8/24, from 8:32 A.M. through 8:40 A.M., the surveyor observed the following in the DSCU Dining Room: -Resident #54's breakfast tray was on the table where the Resident was sitting. -The breakfast tray included the following items: >One uncovered plate with a muffin and one breakfast sandwich that was cut in half. >One unopened cup of orange juice with a tin foil lid. >One unopened fruit cup with a plastic lid. >One unopened bowl of oatmeal with a plastic lid. >One unopened carton of milk. >One unopened cup of water with a plastic lid. >One unopened ice cream cup. -Resident #54 picked up the unopened fruit cup from the meal tray, attempted to grasp the edge of the lid, then began twisting the lid repeatedly before shaking his/her head side to side, then placing the fruit cup back on the tray. -At 8:35 A.M., Resident #54 pushed him/herself away from the table, then moved him/herself forward in his/her wheelchair, bumping into another resident's chair. -At this time, the other resident began to push Resident #54's wheelchair away from him/her and Resident #54 vocalized an expletive. -No staff were observed to intervene and assist Resident #54 until 8:37 A.M. when the MDS Nurse intervened and asked Resident #54 if she could assist him/her. -At this time, the MDS Nurse assisted Resident #54 back to the table and offered to open the Resident's food items that had not been previously opened. -Resident #54 said yes to allowing the MDS Nurse to open his/her orange juice and oatmeal, and also accepted a plastic cup with a lid and straw containing a soft drink. -Resident #54 then ate some oatmeal and drank all of the soft drink. During an interview on 5/10/24 at 11:15 A.M., the MDS Nurse said Resident #54 would allow staff to assist him/her at times, and would also refuse assistance at times. The MDS Nurse said when staff provide Resident #54 with his/her meal tray, staff should always offer to open the food items, and if the Resident refuses, then staff should wait and re-approach. The MDS Nurse also said if the Resident showed interest in specific food items and was having difficulty accessing or opening the food items, staff would need to intervene and provide assistance for the Resident. 2. Resident #61 was admitted to the facility in April 2021, with diagnoses including: Dementia, Parkinson's Disease (chronic and progressive movement disorder that initially causes tremors and impaired muscular coordination), and Insomnia (sleep disorder with trouble falling and/or staying asleep). Review of Resident #61's MDS Assessment, dated 4/3/24, indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) of three out of 15 total possible points. Further review of the MDS Assessment indicated the Resident required setup and clean-up assistance for eating. Review of Resident #61's ADL Care Plan, initiated 10/2/23 and edited 4/15/24, indicated the Resident was independent for eating following setup/clean-up. Review of Resident #61's Functional Abilities for Eating Record for 5/1/24 through 5/7/24 indicated the Resident's functional abilities for eating varied from requiring substantial/maximal assistance to setup or clean-up assistance. On 5/8/24, from 8:45 A.M. through 9:01 A.M., the surveyor observed the following in the DSCU Dining Room: -Resident #61 was sitting at a table with his/her breakfast tray in front of him/her. The breakfast tray included: >Two whole pancakes, stacked. >One uncovered bowl of oatmeal. >One uncovered cup of orange juice. -Resident #61 held a spoon in his/her right hand, pushed it under one of the pancakes and attempted to pick it up several times, but the pancake fell off the spoon. -Resident #61 brought the spoon to his/her mouth after each attempt to pick up the pancake, but the spoon had nothing on it. -The surveyor then observed Resident #61 use the spoon to scoop across the table cloth, then bring the spoon to his/her mouth. -Resident #61 then picked up another spoon and a fork from the table so that he/she was holding two spoons and one fork in his/her hands. -Resident #61 placed the spoons and fork onto the plate and began closing his/her eyes. -No staff were observed to assist Resident #61 with his/her breakfast meal until 9:01 A.M. when the DSCU Program Director intervened. During an interview on 5/8/24 at 10:15 A.M., the DSCU Program Director said Resident #61 normally fed him/her self after being provided setup assistance for meals. The DSCU Program Director said she knew Resident #61 did not sleep well the night before, so the Resident was tired and required more assistance that day with breakfast. When the surveyor asked what staff should do to assist residents when they require more assistance, the DSCU Program Director said that she could not speak to the facility's expectation for the level of assistance staff should provide for residents during meal time, based off the residents' status. The DSCU Program Director said Unit Manager (UM) #2 would know more about how staff provided assistance to residents based on the residents' needs. During an interview on 5/8/24 at 10:45 A.M., UM #2 said when staff provided meal trays to residents on the Unit, all food items were to be cut up and covered/sealed items were to be opened for the residents. UM #2 said if residents' status' varied and they needed more assistance, then staff were expected to provide the assistance needed in a timely manner. UM #2 said staff should have provided assistance to set up breakfast meals for Resident #54 on 5/7/24 and 5/8/24 and for Resident #61 on 5/8/24, by cutting up the food items and ensuring all food and drink items were accessible to the Residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to provide an environment as free of accidental hazards as possible, consistent with the needs of one Resident (#84) out of a total sample of 20 residents. Specifically, the facility staff failed to provide adequate supervision and assistance for Resident #84 during meal time, when the Resident was assessed and ordered for a pureed (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) diet texture, but was able to obtain and ate regular textured food from another Resident's (#54's) meal tray, increasing the Resident's risk for complications and illnesses. Findings include: Review of the facility's Dining Program Policy, undated, indicated the following: -It was the facility's policy to provide an enhancing resident-centered dining service that encourages nutritional intake, resident independence, social relationships, and overall well-being. -Proper assistance and encouragement will be given to residents as needed or care planned. -Therapeutic diets and consistencies will be adhered to. Review of the American Cancer Society's document titled Living as an Oral Cavity and Oropharyngeal Cancer Survivor, dated 3/23/21, indicated the following: -Cancers of the mouth and throat can sometimes cause problems making it hard to eat. -Some people might need to adjust what they eat during and after treatment . -Surgery . can lead to problems with speech, swallowing, . -Speech Therapists are knowledgeable about speech and swallowing problems and can help one learn to manage them. Resident #84 was admitted to the facility in October 2023 with diagnoses including: Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Malignant Neoplasm (cancerous tumor) of the Hard Palate (the roof of the mouth, separating the cavities of the nose and the mouth). Review of Resident #84's Health Care Proxy (HCP: person who makes health care decisions for someone who is not able to make health care decisions for themselves) Invocation Form, dated 10/25/23, indicated the Resident's Physician permanently invoked (made active) the Resident's HCP on 10/25/23 due to progressive Dementia. Review of Resident #84's Speech Therapy Evaluation and Plan of Treatment, dated 10/26/23, indicated the following: -The Resident had a history of Malignant Neoplasm of the Hard Palate. -The Resident was status post palatal resection (portion of the palate removed and presents swallowing difficulty) due to palatal cancer. -The Resident had a prosthesis (artificial body part) for the hard palate, but did not tolerate using it due to Dementia/confusion. -The Resident had been eating pureed foods since the palate resection. -The Resident's HCP reported that the Resident occasionally experienced nasal regurgitation (swallowing disorder that occurs when food or fluid comes up into the nose while eating or drinking)/emission (discharge) of material in the Resident's mouth. -The Resident was expected to remain on a pureed diet unless he/she wore his/her palate prosthesis. Review of Resident #84's Speech Therapy Discharge summary, dated [DATE], indicated: -The Resident's swallow status was stable. -The Resident required a pureed diet. -Attempt use of palatal prosthetic. Review of Resident #84's Physician's order dated 1/18/24, with no stop date, indicated: -The Order was a Dietary Order. -The Resident required a House (regular), Pureed diet. Review of Resident #84's Minimum Data Set (MDS) Assessment, dated 4/24/24, indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) due to the Resident being rarely/never understood. Further review of the MDS Assessment indicated: -The Resident wandered one to three days during the assessment period. -The Resident required a mechanically altered (changed by means of whipping, blending, chopping, or mashing) diet. Review of Resident #84's Behavioral Symptoms Care Plan, edited 5/3/24, indicated: -The Resident had a behavior of wandering. -The Resident's needs would be anticipated to limit behaviors. -Staff were to provide re-direction and re-approach as needed. Review of Resident #84's Nutritional Status Care Plan, edited 4/9/24, indicated: -The Resident presented with nutritional concerns. -The Resident was missing part of his/her hard palate. -The Resident required a mechanically altered diet. -Diet as ordered. On 5/8/24, between 8:32 A.M. and 9:17 A.M., the surveyor observed the following: -Resident #84 was seated at a table in the Dining Room, next to Resident #54. -Staff provided Resident #84 with his/her meal tray which contained pureed texture food items. -Staff provided Resident #54 with his/her meal tray which included one breakfast sandwich and one muffin. -Resident #54 left the table at 8:56 A.M. and staff removed the Resident's breakfast tray which included a partially eaten breakfast sandwich and one whole muffin. -Resident #84 was still sitting at the table and had eaten all of his/her own food. -Resident #54 returned to the table, next to Resident #84, at 9:02 A.M. -Staff returned Resident #54's breakfast tray to him/her which included the partially eaten breakfast sandwich and the muffin. -At this time, the surveyor observed Resident #84 stand up and begin walking through the dining room. -The Activities Assistant (AA) offered to walk out in the hallway with Resident #84. -The Resident began to walk with the AA, but turned back to the dining room and sat down next to Resident #54 while Resident #54 ate a portion of the breakfast sandwich. -The AA remained in the hallway with another resident at this time. -Resident #54 then left the table and Resident #84 remained seated at the table with Resident #54's meal tray next to him/her on the table. -At this time, the surveyor observed the Dementia Special Care Unit (DSCU) Program Director in the dining area assisting another resident. The DSCU Program Director's back was toward Resident #84 and no other staff were present in the immediate area. -At 9:16 A.M., Resident #84 looked at the surveyor and spoke softly, without enunciating any words, and the surveyor was unable to understand what the Resident said. -At 9:17 A.M., the surveyor observed Resident #84 pick up the muffin from Resident #54's meal tray and take a bite. -The surveyor immediately notified the DSCU Program Director when the surveyor observed that Resident #84 was eating the muffin from Resident #54's tray. -The DSCU Program Director made several attempts to instruct Resident #84 to follow her to the Nurse who was in the hallway. The surveyor observed that by the time the Resident followed the DSCU Program Director instructions and reached the Nurse in the hallway, the Resident had already swallowed the piece of muffin. During an interview on 5/8/24 at 10:15 A.M., the DSCU Program Director said Resident #84 often wandered and picked up items that belonged to other residents. The DSCU Program Director said that she could not speak to the level of supervision and assistance provided for residents for meals, and that Unit Manager (UM) #2 could probably speak better to the level of supervision and assistance provided to residents based on the residents' status. The DSCU Program Director said she did not see Resident #84 retrieve the muffin from Resident #54's tray and take a bite, because she was assisting another resident. During an interview on 5/8/24 at 10:45 A.M., UM #2 said she thought Resident #84 was on a House Diet, so the Resident could eat whatever he/she wanted, but that he/she should not be eating from other residents' trays. UM #2 said Resident #84 should not have had access to retrieve food items from Resident #54's meal tray. During an interview on 5/9/24 at 11:00 A.M., the Speech Language Pathologist (SLP) said she had provided services relative to swallowing for Resident #84. The SLP said Resident #84 previously had a palate resection and had been provided with a palate prosthesis, but the Resident did not tolerate wearing the prosthesis so the prosthesis was not in use. The SLP said that without the use of the prosthesis, there was an opening in the top of the Resident's mouth that made it difficult for the Resident to speak intelligibly and that could impact the Resident's ability to manage food. The SLP said that Resident #84 was admitted to the facility on a pureed diet and SLP had not assessed Resident #84's ability to manage regular diet texture food items, so when the Resident was discharged from Speech Therapy services, it was recommended the Resident remain on a pureed diet. The SLP said that Resident #84 demonstrated sufficient strategies to clear pureed food items from the opening in the top of his/her mouth, but she could not say that the Resident could sufficiently and safely manage regular food textures as this had not been assessed for the Resident. The SLP said since the Resident did not use his/her palate prosthesis, there was no way to close the opening in the top of the Resident's mouth. The SLP said if the Resident accessed and ate regular texture food items for which he/she was not assessed, there was a risk the food items could enter into the opening in the top of the Resident's mouth and a potential the Resident would not be able to clear the food items from the opening. The SLP said if the Resident was unable to clear food items that entered into the opening in the top of the Resident's mouth, there was a risk for the food to remain in that space, which would increase the Resident's risk for bacterial growth and illness. The SLP further said she recommended that Resident #84 remain on a pureed diet at this time as a pureed diet was the safest diet texture for the Resident.

Based on observation, interview, policy and record review, the facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for one Resident (#242) out of a total sample of 19 residents. Specifically, the facility staff failed to obtain Physician's orders to check for gastric residual volume (amount of fluid remaining in the stomach after enteral [passing through the gastrointestinal (GI) tract] nutritional feeding has been given) of a G-tube to identify and prevent complications associated with enteral feeding. Findings include: Review of the facility policy titled Enteral Feedings, last revised 4/30/24, indicated: -to check for gastric residual. -hold the feeding and notify per Physician's orders. -Checking residuals- the nurse should check for residuals once per shift or per Physician order to minimize the potential complications with vomiting, distention and aspiration. Resident #242 was admitted to the facility in April 2024 with diagnoses including cerebral infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and dysphagia (difficulty swallowing) and G-tube. Review of Resident #242's Care Plan for Tube Feedings, dated 4/30/24, indicated an intervention for enteral feeding management per Physician's orders. Review of the May 2024 Physician's orders, with start date of 5/7/24, indicated: -an order to check residuals every shift -notify Physician if residual is greater than 500 cubic centimeters (cc's) -follow Physician directions Review of Resident #242's Medication Administration Record (MAR) for April 2024 and May 2024 did not indicate that the Resident had been ordered for and checked for gastric residuals until 5/7/24. Review of Resident #242's clinical record did not indicate that the Resident had been checked for gastric residuals from the time of admission to 5/7/24 (the first day of DPH survey). During an interview on 5/8/24 at 12:18 P.M., Unit Manager (UM) #1 said that the Physician's order to check for gastric residuals should have been in place per the facility policy upon the Resident's admission and it had not been. UM #1 said that the facility was not following their policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide pain management consistent with professional standards for one Resident (#28) out of a total sample of 19 residents. Specifically, the facility staff failed to appropriately assess Resident #28 for the presence of pain and intensity of pain on each shift. Findings include: Review of the facility policy titled Pain Management last revised April 2017, indicated the following: -Purpose: to provide each resident who is experiencing acute or chronic pain effective assessment and management of symptoms . -The resident will be screened for the presence and intensity of pain on each shift using the Medication Administration Record (MAR) to record the results. -Resident's self-report of pain is to be used as the single most reliable indicator of the existence and intensity of pain. -Pain scale tools which are appropriate for the resident's developmental, physical, emotional, and cognitive status are used to evaluate and assess the effectiveness of a pain management plan. They are: Numerical (0-10), Verbal or Non- Verbal for the cognitively impaired. -Consistent documentation of the effectiveness of pain management is done in the Electronic Medication Administration Record (eMAR) and at intervals on the care plan. Resident #28 was admitted to the facility in December 2023, with diagnoses including malignant neoplasm of reproductive system (Cancer) and Mild Cognitive Impairment (trouble with memory, language or judgement) of unknown cause. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #28: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of a possible score of 15. Review of the Physician's orders dated 4/8/24 to 5/8/24 indicated the following: -Pain Assessment Every Shift, assess for level of comfort via Verbal Pain Scale: -0 = no pain -1-2 = slight pain -3-4 = mild pain -5-6 = moderate pain -7-8 = severe pain -9-10 = very severe pain. Check off pain three times a day. Start date 12/20/23. -Dilaudid (Hydromorphone: opioid pain medicine) Schedule II, oral liquid, 1 milligram (mg) per milliliter (ml), give 2 mg per 2 ml orally as needed for moderate pain every four hours. Start date 4/4/24 -Dilaudid, Schedule II oral liquid, 1 mg per 1 ml, give 4 mg/4 ml orally as needed for severe pain. Start date 4/4/24. -Dilaudid, Schedule II oral liquid 1 mg per 1 ml, give 2 mg orally twice a day at 6:00 A.M. and 8:00 P.M. for pain. Start date 4/9/24. During an interview on 5/7/24 at 11:51 A.M., Resident #28 said he/she had terminal cancer and is supposed to get pain medicine around the clock for the pain in his/her stomach. Resident #28 said that one night the Nurse only gave him/her half of the pain medication that was ordered. Resident #28 said that if he/she did not keep on top of the pain then he/she is in too much pain to do anything. On 5/8/24 at 8:58 A.M., the surveyor observed Resident #28 sitting a wheelchair, dressed and eating breakfast. Resident #28 said the pain was in his/her stomach and his/her pain level was a four out of 10. Resident #28 also said he/she just received his/her pain medication. On 5/8/24 at 1:44 P.M., the surveyor observed Resident #28 sitting in a recliner. Resident #28 said his/her pain level was a six out of 10 and he/she has not asked for any additional pain medication. During an interview on 5/8/24 at 1:49 P.M., Nurse #2 said that Resident #28 received scheduled doses of Dilaudid twice a day and as needed doses of Dilaudid if he/she has additional pain and asks for the medication. Nurse #2 said that she used the 1-10 numeric pain scale to assess Resident 28's pain and documented the pain level on the Treatment Administration Record (TAR). Review of the December 2023, January 2024, February 2024, March 2024, April 2024 and May 2024 MARs and TARs for Resident #28 indicated no evidence that a numeric pain scale assessment tool had been implemented to assess the presence and intensity of Resident #28's pain level. During an interview on 5/8/24 at 2:02 P.M., Charge Nurse #3 said that pain levels were assessed using the 1-10 numerical pain scale and the numerical pain level was documented on the TAR in the spaces corresponding to the order. The surveyor and Charge Nurse #3 reviewed the clinical record and Charge Nurse #3 said there was no evidence that Resident #28's pain levels had been assessed every shift as ordered, because there were no numerical pain levels documented for the Resident. During an interview on 5/8/24 at 2:11 P.M., Unit Manager (UM) #1 reviewed the clinical record and said that she could not provide any documentation that Resident #28's pain level had been assessed every shift as ordered. UM #1 said the numeric pain assessment should have been documented on the TAR but the numeric pain assessment had not been documented because the Physician's order had been entered into the computer incorrectly.

Based on interview, record and policy review, the facility failed to perform trauma assessments at the time of admission to the facility for two Residents (#45 and #79) out of a total sample of 19 residents. Specifically, the facility staff failed to: 1. For Resident #45, complete a trauma assessment to determine whether the Resident had any history of trauma (emotional response to a deeply distressing or disturbing experience), and/or determine any triggers which may cause re-traumatization. 2. For Resident #79, screen the Resident for a history of trauma since his/her admission to the facility, to recognize and respond to any signs and symptoms of trauma. Findings include: Review of the facility policy titled Trauma Informed Care, effective October 2022, indicated the following: -It is recognized that residents may have experienced trauma in their past that could potentially impact their care or response to care. -All residents are assessed upon admission, as part of their social service history and asked if they have experienced any trauma in their life. 1. Resident #45 was admitted to the facility in June 2023, with a diagnosis of Dementia (a group of symptoms that affect memory, thinking and interferes with daily life) and Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #45's clinical record included no evidence that the facility staff assessed the Resident for a history of trauma (emotional response to a terrible or threatening event). During an interview on 5/9/24 at 10:25 A.M., the Social Worker (SW) said that she interviewed families and residents upon admission and would ask them about any history of trauma. The SW said that a trauma assessment would not have been completed if a history of trauma had not been identified. 2. Resident #79 was admitted to the facility in May 2023, with diagnoses including: Dementia and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #79's clinical record included no evidence that the facility staff assessed the Resident for a history of trauma. During an interview on 5/9/24 at 10:57 A.M., the Social Worker (SW) said she was responsible for screening all residents for a history of trauma when the residents were admitted to the facility. The SW said that there was no evidence that Resident #45 and Resident #79 had ever been screened for a history of trauma since their admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medications were stored and administered in a secure and safe manner, according to professional standards for one Resident (#47), out of a total sample of 19 residents. Specifically, the facility staff failed to adhere to safe medication administration practices when medications were left unattended in a medication cup at Resident #47's bedside. Findings include: Resident #47 was admitted to the facility in July 2023 with diagnoses including Arthrosclerosis (a buildup of plaque and fat inside arteries) of arteries in both legs, Atrial Fibrillation (quivering or irregular heartbeat), mild cognitive impairment of unknown cause, and Dysphagia (difficulty or discomfort in swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible score of 15. Review of the facility policy titled Storage of Medications, last revised August 2020, indicated the following: -Medications are stored safely, securely, and properly . -Only licensed nurses, pharmacy personnel and those lawfully authorized are permitted to access medications. -Medication rooms, carts and medication supplies are locked when they are not attended to by persons with authorized access. Review of the facility policy titled Administration Procedure for All Medications, last revised August 2020, indicated the following: -Medications will be administered in a safe and effective manner. -After administration, return to (medication) cart, and document administration in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Review of the facility Self-Administration of Medication assessment dated [DATE], indicated that due to Resident 47's cognitive, physical or visual ability, the interdisciplinary team (IDT) feels that Resident #47 was not a candidate for self-administration of medications. On 5/7/24 at 10:53 A.M., the surveyor observed a small plastic cup containing multiple pills on the bedside table next to Resident #47. During an interview at the time, Resident #47 said that the staff trust him/her to take the medications so they usually leave his/her medications on the bedside table. Resident #47 said it takes a while for him to take all the medications because he/she takes the pills one at a time. During an interview on 5/7/24 at 11:00 A.M., Nurse #2 said she left Resident #47's medications on the table next to the bed because Resident #47 likes to take the medications independently. Nurse #2 said that she should have watched Resident #47 take the medications and should not have left Resident #47's medications at the bedside. During an interview on 5/7/24 at 11:53 A.M., Unit Manager (UM) #1 said that Resident #47 had not been assessed to safely administer his/her own medications and Nurse #2 should not have left any medications at Resident #47's bedside unattended.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility failed to have an RN working at least eight consecutive hours for four days between 10/1/23 to 12/31/23, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Findings include: Review of the Fiscal Year Quarter One (dated 10/1/23 through 12/31/23) Payroll Based Journal (PBJ: reporting system to which nursing facilities report on staffing data) Report indicated that the facility reported No RN in the facility for eight consecutive hours on the following dates: -10/1/23 -10/29/23 -11/12/23 -12/3/23 During an interview on 5/7/24 at 8:36 A.M., the facility Administrator said the facility had no Nurse staffing waivers. During an interview on 5/9/24 at 11:12 A.M., the surveyor and the Facility Scheduler reviewed the staffing schedule and the Facility Scheduler said that there was no RN scheduled for eight consecutive hours on 10/1/23, 10/29/23, 11/12/23 and 12/3/23. During an interview on 5/9/24 at 12:04 P.M., the Director of Nurses (DON) reviewed the staffing schedule and said there was no RN scheduled for the identified days reported on the PBJ report. During an interview on 5/9/24 at 1:07 P.M., the facility Administrator said there was no RN in the facility for the required eight consecutive hours on the dates reported on the PBJ report.

Based on observation, record review, and interview, the facility failed to ensure that its staff provided the necessary grooming/hygiene services to one Resident (#40), out of a total sample of 19 residents. Specifically, the facility staff did not provide services as needed of fingernail care for the Resident who was unable to care for his/her own fingernails. Findings include: Resident #40 was admitted to the facility in August 2017 with diagnoses including Dementia-severe and Alzheimer's disease. On 12/27/22 at 9:20 A.M., the surveyor observed that Resident #40's fingernails appeared very dirty with dried black debris under each nail. Review of most recent Minimum Data Set (MDS) Assessment, dated 11/30/22, indicated that the Resident was severely cognitively impaired and required extensive physical assistance from staff for personal hygiene which included washing of hands. Review of the Resident's Activities of Daily Living (ADLs) Functional Care Plan, edited 12/13/2022, indicated that the Resident required the assistance of one staff and was dependent on staff for bathing and grooming tasks. Review of the Certified Nursing Assistant (CNA) Care Card indicated that staff should provide assistance of one staff to dependent care for the Resident with bathing and grooming tasks. Review of the completed CNA care flow sheets indicated that the Resident received the following care: -12/26/22 Day shift dependent care by one staff for bathing and personal hygiene tasks, shower given. -12/27/22 Evening shift dependent care by one staff for bathing and personal hygiene tasks, partial bath given. Review of the Resident's clinical record did not show any evidence of refusal of personal hygiene or bathing assistance. On 12/28/22 at 8:04 A.M., the surveyor observed the Resident's fingernails. The fingernails still appeared with significant dirt under the nails. The Resident's fingernails appeared just as they had on the previous morning. On 12/28/22 at 10:15 A.M., during an interview and an observation the surveyor and Unit Manager #1 together observed that the Resident's fingernails, and the fingernails appeared as previously observed with black dried debris under each nail. The surveyor noted that there was no difference from the condition of the Resident's nails noted on 12/27/22 at 9:00 A.M., and the present condition of the fingernails. UM #1 said that morning care had already been provided for the current day (12/28/22) and that the Resident required complete care from staff to clean and care for his/her fingernails. UM #1 also said that the Resident's fingernails were not acceptable in this condition and should have been cleaned during morning care but had not been.

Based on record review and interview, the facility failed to ensure its staff provided care and services consistent with professional standards for one Resident (#26), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of a sample of 19 residents. Specifically, the facility failed to ensure complete and accurate communication documentation with the dialysis facility as required. Findings include: Review of the facility policy titled Hemodialysis, Care of the Resident Receiving, dated January 9, 2010, indicated the following: -A dialysis communication book will be provided to each resident requiring hemodialysis. -The book will contain preprinted communication tools to be completed by the nurse sending the resident to the dialysis center and from the dialysis center. Resident #26 was admitted to the facility in May 2019 with diagnoses including End Stage Renal Disease (ESRD-Kidney failure), and dependence on renal dialysis. Review of the signed Physician orders for December 2022 indicated the following: - Dialysis every Tuesday-Thursday- Saturday . - Please enter weight from dialysis book once a day on Tuesday-Thursday- Saturday . Review of the dialysis communication book for Resident #26 did not show any evidence of completed communication forms, including the Resident's weight as ordered by the Physician, for 11 of the 12 dialysis treatments for the month of November 2022 and 11 of the 12 dialysis treatments through December 27, 2022. Communication forms were not available for the following November dates: -Tuesday 11/1/22, 11/15/22, 11/29/22 -Thursday 11/3/22,11/10/22,11/17/22 -Monday 11/21/22 (off schedule) -Wednesday 11/23/22 (off schedule) -Saturday 11/5/22,11/12/22,11/19/22 Communication forms were not available for the following December dates: -Tuesday 12/6/22,12/13/22,12/20/22, -Thursday 12/1/22, 12/8/22, 12/15/22,12/22/22 -Saturday 12/3/22, 12/10/22, 12/17/22, 12/24/22. Review of the Treatment Administration Record (TAR) for December 2022, indicated the following order: -Please enter weight from dialysis book once a day on Tuesday, Thursday, and Saturday. Review of the Treatment Administration Record (TAR) for December 2022, a nursing note on 12/24/22 at 9:16 P.M., indicated that the weight was not administered due to the dialysis book not being filled out. During an interview on 12/28/22 at 1:45 P.M., Unit Manager (UM) #2 said the Resident went to dialysis three days a week on Tuesday, Thursday, and Saturday during the months of November 2022 and December 2022. UM #2 and the surveyor reviewed the dialysis communication book for Resident #26 and UM #2 said the dialysis communication sheets were not completed for every dialysis treatment for November 2022 and December 2022, but they should have been.

Based on observations and interviews, the facility failed to ensure its staff maintained the minimum wash temperature necessary for the dish machine utilized for cleaning dishware for resident use in the main facility kitchen. Specifically, Dietary Aide (#1) was operating the dish machine after lunch service that was registering below 160 degrees Fahrenheit (F) for the wash cycle. Findings include: Review of the Champion (type of dish machine) Operation, Cleaning and Maintenance Manual, dated 8/1/17, indicated the following: -READY: the status bar indicates 'Ready' when the machine is full of water. WAIT FOR THE WASH TEMPERATURE to read 160 degrees F before inserting a dish rack into the machine. -slide the dish rack into the machine until the wash pump (s) start. The conveyor will catch the rack and move it through the machine. The minimum wash temperature displayed must be 160 degrees F when the rack is in the wash zone. During a walk through of the kitchen with the Food Service Director (FSD) on 12/29/22 from 1:00 P.M.-1:25 P.M., the surveyor observed the following: -The dish machine was running and Dietary Aide #1 was working on dirty end of the machine and was pre-rinsing, loading dirty dishware/meal trays onto dish racks and placing them within the dish machine to be washed. During this process, the dish machine wash temperature was observed to fluctuate and was maintaining temperatures below 160 degrees (F) (154-159 degrees F). -During an interview at this time, Dietary Aide #1, who has worked at the facility for eight years, said that the minimum wash temperatures needed to utilize the dish machine were between 140-160 degrees F. -At this time, the FSD provided verbal education to Dietary Aide #1 and said the wash temperature for the dish machine needed to be 160 degrees or higher. The FSD proceeded to show the surveyor and Dietary Aide #1 the sticker on the upper side of the machine (which was located behind a red bucket containing a cloth and sanitation solution) that indicated the required minimum dish machine temperatures for the wash and the final rinse cycles. An observation of the sticker indicated that the minimum wash temperature was 160 degrees F. -The FSD was observed instructing Dietary Aide #1 to stop the dish machine, let the temperature for the wash rise so that it was over 160 degrees F prior to restarting the machine for use. She further instructed the dietary staff to run the previously run racks back through the dish machine once the minimum wash temperature of 160 degrees F was obtained. -The surveyor observed Dietary Aide #1 stop the machine, wait for the wash temperatures to reach over 170 degrees F and then re-wash a rack of bowls. After the rack of bowls was cleaned, the dish machine temperature was observed to fall below 160 degrees F. Dietary Aide #1 proceeded to utilize the dish machine despite the education of the minimum temperature required for use. -The FSD intervened again to instruct Dietary Aide #1 to stop the machine and wait for the temperatures to rise above the required minimum temperature prior to restarting. At this time, the FSD left the dish area and the surveyor continued to observe the process. -Dietary Aide #1 was observed to again utilize the dish machine when the wash temperature was below 160 degrees F. The surveyor intervened and she was observed to stop the machine and wait for it to rise above 160 degrees F. After continued observation, the surveyor noted that the wash temperatures of the dish machine would indicate over 170 degrees when stopped and drop drastically to below 160 when running after a single rack of dishware was run through. During an interview on 12/29/22 at 1:30 P.M., the FSD said that the dish machine was purchased new about two years ago and that there have been continued issues with maintaining the wash temperatures. She said that they recently had a part placed on 12/14/22 which seemed to help but for the last several days, she noticed the wash temperatures were decreasing and had contacted the vendors for the dish machine repair. When the surveyor asked if the dish machine temperatures were logged during use, the FSD showed the surveyor the temperature logs which were located on a clip board outside of the dish room. The last entry on the log sheet was dated 12/28/22 for breakfast and indicated the wash temperature was 161 degrees F. There were no other entries for breakfast, lunch and dinner after this date/time. Further review of the Dish Machine Temperature and Sanitizer Log did not indicate what the minimum wash and final rinse temperature required for the dish machine. The FSD said that if the dish machine temperatures fall below the required temperatures, she had the ability to switch the chemical sanitizer for the final rinse that was used for low temperature dish machines. The FSD said that because the dish machine temperatures were not consistently holding at 160 degrees, she would switch the chemical sanitizer for the final rinse immediately so that the dish machine was safe to use. The surveyor asked about education provided to dietary staff about the the minimum requirements for safe operation of the dish machine. During a follow up interview on 12/29/22 at 3:17 P.M., the surveyor relayed the concern for safe operation of the dish machine despite verbal education with Dietary Aide #1 regarding the minimum temperature requirements. The FSD said that she understood the concern. During an interview on 12/29/22 at 3:30 P.M., with the Administrator and FSD, the Administrator said that he was made aware of the wash temperature concerns for the dish machine. The Administrator said that he understood the concern of the surveyor relative to the operation of the dish machine by Dietary Aide #1 despite numerous education/interventions about the minimum temperatures required for use. Prior to survey exit, there was no documented evidence that education had been provided to the Dietary staff relative to the minimum temperatures required for the safe operation of the dish machine.