Based on observation, record review and interview, the facility failed to update the care plan for Activities of Daily Living (ADL) for one Resident (#75) out of a total sample of 28 residents. Findings include: Review of the Facility's Policy titled Care Plans Comprehensive Person-Centered, dated 4/25/22, indicated that assessments of the residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Resident #75 was admitted to the facility in February 2025 with diagnoses including stroke and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated that Resident #75 was rarely/never understood and a staff assessment for Brief Interview for Mental Status (BIMS) indicated severe cognitive impairment. The MDS further indicated Resident #75 required partial/moderate assistance with meals, was holding food in mouth or cheeks or residual food in mouth after meals and had a mechanically altered diet. On 3/25/25 at 8:37 A.M., the surveyor observed Resident #75 sitting up in bed eating breakfast. Resident #75's breakfast tray included a lip plate, but did not have built up utensils. There was no staff present in the room providing assistance and the Resident was not visible from the hallway. On 3/26/25 at 8:12 A.M., the surveyor observed Resident #75 sitting up in bed eating breakfast. Resident #75's breakfast tray included a lip plate, but did not have built up utensils. There was no staff present in the room providing assistance and the Resident was not visible from the hallway. On 3/26/25 at 12:20 P.M., the surveyor observed Resident #75 sitting up in wheelchair in his/her room eating lunch. Resident #75's lunch tray included a lip plate, but did not have built up utensils. Resident #75 said he/she used to have built up utensils but guessed they changed the rules. There was no staff present in the room providing assistance and the Resident was not visible from the hallway. On 3/27/25 at 8:24 A.M., the surveyor observed Resident #75 sitting up in bed eating breakfast. Resident #75's breakfast tray included a lip plate, but did not have built up utensils. There were no staff present in the room providing assistance and the Resident was not visible from the hallway. Review of Resident #75's physician's order, 2/26/25, indicated: built up utensils and lip plate at all meals. Review of Resident #75's physician's order, dated 3/13/25, indicated diet: soft and bite sized texture. Review of Resident #75's plan of care for ADL's, dated 2/21/25, indicated assist with eating as needed. Review of Resident #75's plan of care for diet, dated 3/3/25, indicated uses adaptive equipment: built up utensils, lip plate and 1:1 dependent. Review of Resident #75's Speech Language Pathologist's (SLP) treatment note, dated 3/18/25, indicated patient was noted to be provided with weighted utensils on this date. Patient has order for built up utensils in place. Occupational Therapy (OT) consulted and made aware. During an interview on 3/27/25 at 11:17 A.M., the SLP said that Resident #75 should be seated upright during meals and have his/her food cut up. Resident #75 does not need to be supervised for meals. He said that OT had initiated the built-up utensils but had reassessed the utensils to be too large for Resident #75 to manage so they were discontinued. Review of Resident #75's OT evaluation, dated 2/24/25, indicated Resident required partial/moderate assist for eating. Review of Resident #75's OT treatment note, dated 3/25/25, indicated Resident required set up for eating. Review of Resident #75's Documentation Survey Report (indicates level of assist Resident requires with care), indicated the following: Eating: 1:1 dependent, built-up utensils, lip plate. During an interview on 3/27/25 at 11:22 A.M., Unit Manger #1 and the surveyor reviewed Resident #75's Documentation Survey Report, physician's orders, and plan of care. She said Resident #75 only requires set up for meals and no longer requires built up utensils. She was unaware that the care plan, physician orders, and Documentation Survey Report did not reflect Resident #75's current level of care, but they should. During an interview on 3/27/25 at 1:06 P.M., the Director of Nursing said Resident's care plan should be updated to reflect level of care required for the Resident.

Based on record review and interview, the facility failed to follow professional standards of practice for one Resident (#494) out of a total sample of 28 residents. Specifically, the facility failed to implement a physician's order to notify provider (physician, nurse practitioner) if Resident #494's daily weight indicated an increase of greater than two pounds. Findings include: Review of facility policy titled 'Weight Assessment and Intervention' dated March 2023, indicated the following but was not limited to: - Resident weights are monitored for undesirable or unintended weight loss or gain. Resident #494 was admitted to the facility in March 2025 with diagnoses including heart failure and chronic respiratory failure with hypoxia. Review of Resident #494's most recent Minimum Data Set (MDS) assessment, dated 3/19/25, indicated an entry tracking record and a comprehensive MDS had not been completed. Review of Resident #494's physician's orders, dated 3/19/25, indicated daily weights. Notify provider of weight of two pounds or more daily or five pounds in a week in the morning. Review of Resident #494's nursing progress note, dated 3/23/25, indicated notified weight to NP (Nurse Practitioner) Brown, no new order. Continue to monitor the weight. Review of Resident #494's physician notes failed to indicate that the physician was notified of a weight change from 3/24/25 to 3/26/25. Review of Resident #494's daily weights indicated the following: -3/22/25 284.6 pounds (lbs.) -3/23/25 290.0 lbs. (gain of 5.4 lbs). -3/24/25 294.8 lbs. (gain of 4.8 lbs). -3/25/25 295.0 lbs. (gain of 0.2 lbs). -3/26/25 296.0 lbs. (gain of 1.0 lbs) (total gain of 11.4 lbs. since 3/22/25). During an interview on 3/27/25 at 11:22 A.M., Unit Manager #1 said she was unaware the physician had not been notified of Resident #494's weight gain, the physician should have been notified, and that the notification should be documented in the nursing notes. During an interview on 3/27/25 at 1:08 P.M., the Director of Nursing said that physician's orders should be followed, and that Resident #494's weight gain should have been reported to the physician and documented in the nursing notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide care and services consistent with professional standards including ongoing communication and collaboration with the dialysis facility for one Resident (#536), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of 28 total sampled residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility and failed to implement a Dietitian's recommendation to give phosphate binders (a medication to absorb phosphate from the food you eat to help prevent high phosphorus levels) that was communicated in Resident #536's dialysis communication book. Findings Include: Review of the facility policy titled Hemodialysis Pre and Post Care revised March 2010, indicated the following but not limited to: - Document all communications in the hemodialysis communication progress note or dialysis center communication book. - Ensure ongoing communication with dialysis staff. Resident #536 was admitted to the facility in March 2025 with diagnoses including End stage renal disease, Dependence on renal dialysis. Review of Resident #536's most recent Minimum Data Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15, indicating moderate cognitive impairment. Further review of the MDS indicated the Resident received hemodialysis treatment. Review of Resident #536's Dialysis Communication Book document dated March 2025 indicated the following: - The Resident's phosphorous range goal was between 3.0 to 5.5 mg/dL (milligrams per deciliter) and that the Residents phosphorus level was 7.6 mg/dL, indicating his/her phosphorus levels were elevated. - Please be sure patient takes 3 Calcium Acetate with meals related to a high phosphorus. Review of the current physician's orders failed to indicate calcium acetate had been ordered for the Resident. Review of the Medication Administration Record (MAR) for March 2025 failed to indicate the Resident was receiving calcium acetate. Review of Resident #536's care plan date initiated 3/10/25: Renal insufficiency related to chronic renal failure; Coordinate dialysis care with the dialysis center. During an interview on 3/7/25 10:57 A.M., Unit Manager # 1 said it is the responsibility of the medication nurse to check the dialysis communication book in her absence when the resident returns to the facility from dialysis. Unit Manager #1 also stated it appeared that no one had checked the dialysis communication book as the Resident did not have an order for the calcium acetate. During an interview on 3/27/25 11:20 A.M., the Director of Nursing said it is the responsibility of the nurse or unit manager to check the dialysis communication book when the resident returns to the facility and they were responsible for updating the physician on any orders or recommendations from the dialysis center. During an interview on 3/28/25 8:00 A.M., the Dialysis Nurse said communication reports are given by the dietitian on the second week of the month, as monthly labs were drawn on the first of the month. The Dialysis Nurse also said Resident #536 had his/her labs drawn between 3/3/25 and 3/4/25 and would have received the communication report on the week of 12th-14th of March with a follow up communication to the facility by the dietitian.

3. Resident #90 was admitted to the facility in June 2021, and has active diagnoses which include diabetes, malnutrition, depression and chronic obstructive pulmonary disorder. Review of Resident #90's Minimum Data Set assessment, dated 1/30/25, indicated that the Resident had intact cognition. Review of Resident #90's Self-Administration of Medications assessment, dated 2/5/25, indicated nursing staff were to pour the medications, and the Resident was allowed to self-administer them. During an interview and observation on 3/25/25 at 10:13 A.M., the surveyor observed approximately eight pills of different colors and shapes on the floor under Resident #90's bed. Resident #90, who was lying in bed, said an unidentified staff member accidentally knocked the pills off his/her meal tray onto the floor. Resident #90 said the staff person told him/her someone would return to the room to remove the pills, but no one did. Resident #90 said the pills may have been under the bed for a couple of days. During an interview on 3/27/25 at 1:00 P.M., the Director of Nurses (DON) said Resident #90 was assessed and determined to be able to self-administer medications. The DON said that all medications should be secured in the bedroom and not left on the floor. Based on observation and interview the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles on three of three units. Specifically, 1. The facility failed to secure drugs and biologicals on three of three units when two treatment carts and one medication room were accessible to the surveyor unsupervised. 2. The facility failed to properly label and store medications in medication carts on two of three units. 3. The facility failed to secure medications in a resident room for one (Resident #90) of 28 sampled residents. Findings include: Review of facility policy titled Medication Labeling and Storage, dated as revised February 2023, indicated the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication Storage -Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Medication Labeling -Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. -Antiseptics, disinfectants and germicides used in any aspect of the resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular medications. 1. On 3/25/25 at 7:52 A.M., the surveyor observed an unlocked and unattended treatment cart on the first-floor unit. The surveyor was able to gain access to the cart which contained treatment supplies as well medicated creams and ointments. The surveyor observed three staff walk by the unlocked treatment cart without addressing it. During an interview on 3/25/25 on 7:54 A.M., Nurse #1 said that the treatment cart should be locked when unattended. On 3/25/25 at 7:59 A.M., the surveyor observed an unlocked and unattended treatment cart on the second-floor unit. The surveyor was able to gain access to the treatment cart which contained treatment supplies as well as medicated creams and ointments. During an interview on 3/25/25 at 8:00 A.M., Nurse #3 said that the treatment cart should be locked when unattended, but it was not. On 3/25/25 at 10:43 A.M., Nurse #4 unlocked the medication room on the third floor to let the surveyor in the medication room. She left the surveyor alone in the medication room and walked away. During an interview on 3/25/25 at 10:45 A.M., The Infection Preventionist said that the nurse should not have left the surveyor unsupervised in the medication room. During an interview on 3/25/25 at 2:06 P.M., the Director of Nurses said that treatment carts should be locked when they are unattended, and nurses should not leave unauthorized people in the medication room alone. 2. On 3/25/25 at 9:03 A.M., the surveyor observed the following in the first floor A side medication cart: -Two unopened vials of Humalog insulin in the medication cart. -One unopened Lantus insulin pen. During an interview on 3/25/25 at 9:06 A.M., Nurse #2 said that unopened insulin should be stored in the fridge until it is opened and not in the medication cart. On 3/25/25 at 10:46 A.M., the surveyor observed the following on the third floor B side medication cart: -A bottle of liquid protein opened, and without an open date. The bottle reads 3-month shelf life from date opened. -Dried and sticky spills from a red liquid in one of the drawers of the medication cart where medications are stored. During an interview on 3/25/25 at 10:49 A.M., Nurse #4 said that the liquid protein should be labeled with an open date, but it was not, and that the medication cart was dirty and needed to be cleaned where leaks or spills from medication had happened. On 3/25/25 at 10:52 A.M., the surveyor made the following observations on the third floor A side medication cart: -Cleaning wipes stored in the same compartment as oral medications. -A Lupin inhaler with Tiotropium Bromide inhalation capsules stored in a bag, unlabeled without any resident identification on the bag or inhaler. During an interview on 3/25/25 at 10:58 A.M., Nurse #5 said that the inhaler should be labeled with a resident name to identify who it is for and that the cleaning wipes should not be stored with medications. During an interview on 3/25/25 at 11:05 A.M., the Infection Preventionist said that medication carts should be clean and cleaning products should not be stored with medications. She also said that medications with shortened expiration dates should be labeled when opened and medications should have a resident label on them. During an interview on 3/25/25 at 2:06 P.M., the Director of Nurses said unopened insulin should be stored in the fridge until it is opened. She further said that she would expect that medication carts are clean and without spills. The Director of Nurses also said that medications should be labeled with open dates if they have shortened expiration dates. Further she said that cleaning supplies should not be stored with medications.

Based on observations, record reviews and interviews, the facility failed to provide services that met professional standards of quality to three Residents (#61, #41 and #214) out of a total sample of 28 residents. Specifically, 1.) For Resident #61, the facility failed to transcribe and implement physician's orders for changes in a pressure wound treatment, 2.) For Resident #41, the facility failed to implement a physician's order to apply a dressing to an arterial wound, and 3.) For Resident #214, the facility failed to implement a physician's order to remove sutures. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1.) Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018), indicated, but was not limited to: -The nurse shall describe and document/report the following: current treatments. -The physician will order pertinent wound treatments, including dressings. Resident #61 was admitted to the facility in May 2021 with diagnoses including dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/1/24, indicated Resident #61 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS also indicated that Resident #61 had two pressure ulcers, including one stage four pressure ulcer. Review of Resident #61's active physician's order, dated 3/14/24, indicated: Wound Documentation: Right heel wash with Nacl (sodium chloride, which is a wound cleansing solution), pat dry, cover with Oil Emulsion f/b (followed by) Hydroconductive. cut to size f/b bordered foam & wrap with kerlix twice daily and PRN (Pro Re Nata, which is a Latin phrase meaning as necessary). Review of the Wound Physician's progress note, dated 4/3/24, indicated Resident #61 right heel stage four pressure ulcer was worsening and indicated the following treatment recommendations: 1. Wound cleanser. 2. Apply Hydroconductive to base of the wound. 3. Secure with Rolled gauze, Zetuvit (type of wound dressing). 4. Change Twice a day, PRN for soiling, saturation, or accidental removal. Review of form titled Unavoidable Pressure Ulcer Physician Documentation, dated 1/10/24, indicated Resident #61 was determined by his/her physician that the development of this pressure ulcer was unavoidable for factors including Parkinson's, immobility, incontinence, palliative with PACE (Program of All-Inclusive Care for the Elderly) program, and comfort measures and care. On 4/8/24 at 1:12 P.M., the surveyor observed Nurse #5 and the Assistant Director of Nursing (ADON) change the dressing on Resident #61's right heel. Nurse #5 prepared to place an oil emulsion dressing on Resident #61's heel, but the ADON instructed Nurse #5 to administer a different dressing because the order had changed last week. Nurse #5 applied a hydroconductive dressing to the base of the wound and applied a Zetuvit dressing on the ADON's instruction. During an interview on 4/8/24 1:51 P.M., the ADON said Physician #1 approved the Wound Physician's treatment recommendation on 4/3/24 and the order should have been transcribed but was not. The ADON said because it was not transcribed so Resident #61 had continued to receive the incorrect wound dressing. The ADON said she knew the wrong dressing was received because during the dressing change there was an oil emulsion dressing removed and the incorrect order in the Treatment Administration Record (TAR) was signed off. The ADON said Resident #61 should not have had oil emulsion applied to his/her right heel wound from 4/3/34 to 4/8/24. Review of Resident #61's Treatment Administration Record (TAR), dated 4/3/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24, and 4/8/24, indicated the following order was documented as implemented: -Wound Documentation: Right heel wash with Nacl, pat dry, cover with Oil Emulsion f/b (followed by) Hydroconductive. Cut to size f/b bordered foam & wrap with kerlix twice daily and PRN. On 4/9/24 at 11:07 A.M., the surveyor observed Unit Manager #2 and the ADON change the dressing on Resident #61's right heel in order to assess if the wound had worsened. During this dressing change, a black area was noted in the right heel wound bed. The ADON said this area was eschar. The ADON said eschar is worse than slough. The ADON said there is more pain documented in the TAR. The ADON said new treatment orders should be transcribed to try to prevent decline, prevent infection, and prevent pain, but deterioration of the wound was expected. Review of the Treatment Administration Record (TAR) order for Wound Documentation, dated 4/6/24, indicated Resident #61's wound had worsened and there was the presence of eschar in the wound bed. Review of Resident #61's medical record failed in indicate the presence of eschar in the wound prior to 4/6/24, three days after the physician ordered the wound treatment be changed. Review of the Treatment Administration Record (TAR), dated 4/5/24, 4/6/24, 4/7/24, and 4/8/24, indicated an increased frequency pain in the right heel wound, which previously was documented less frequently. During an interview on 4/9/24 at 11:41 A.M., Physician #1 said he approved the change to the treatment order because the wound had worsened. Physician #1 said it was a concern that the order was not followed. Physician #1 said Resident #61 is care and comfort, and the goal is not to heal, but to maintain skin integrity and prevent pain and odor. During an interview on 4/9/24 at 11:49 A.M., the Wound Physician said Resident #61's goal is to maintain skin integrity and would not be surprised if it deteriorated. Review of Resident #61's plan of care related to right heel stage three pressure ulcer, revised 4/9/24, indicated: - Goal: Will develop no new areas of skin breakdown. - Goal: Will heal without complication. - Administer treatments per physician orders. During an interview on 4/9/24 at 12:22 P.M., The Director of Nursing (DON) said wound orders from physicians should be transcribed and should be followed. 2.) Resident #41 was admitted to the facility in June 2023 with diagnoses including dementia and anemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #41 had an arterial/venous wound. Review of wound physician progress note, dated 3/20/24, indicated Resident #41 had an unhealed right ankle arterial ulcer. This note indicated Resident #41's had a physician's order to apply iodosorb (a gel that's applied to the skin to treat wet ulcers and wounds) and then apply gentac (a gentle silicone adhesive dressing) to his/her right ankle arterial ulcer. Review of Resident #41's physician's order, dated 3/15/24, indicated: -Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam (border foam), change daily, and PRN (Pro Re Nata, which is a Latin phrase meaning as necessary.) On 4/7/24 at 9:18 A.M., 4/8/24 at 8:19 A.M., and 4/8/24 11:54 A.M., Resident #41 was observed with a wound on his/her right ankle that had yellowish/brown hardened scab-like wound bed that was approximately the size of a pea. There was no dressing on his/her right ankle. During an interview on 4/8/24 at 8:19 A.M., Resident #41 said the nurse had not put a dressing on his/her right ankle wound since Friday (4/5/24) because there is nobody around to do it. Resident #41 said he/she asked for a dressing to be put on, but the nurse did not because they were too busy. Resident #41 said he/she likes to have a dressing on it, because it hurts when things touch it without the dressing on. Review of Treatment Administration Record, dated 4/7/24 and 4/8/24, indicated the nurses had documented the physician's order for Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam, change daily, and PRN had been implemented. Review of the plan of care related to right ankle arterial wound, revised 4/2/24, indicated: -Administer treatment per physician's order. Review of the nursing progress notes, dated 3/10/24 to 4/9/24, failed to indicate resident refused wound treatments or care. During an interview on 4/9/24 at 7:48 A.M., Nurse #4 said a dressing should be on Resident #41's ankle wound and was put on yesterday (4/8/24). Nurse #4 said if a Resident has an order for a wound dressing, the dressing should be in place. During an interview on 4/9/24 at 9:22 A.M., Unit Manager #2 said Resident #41 does not refuse treatments or care. Unit Manager #2 said he/she had rejected care initially when admitted last year, but recently has not refused any dressings or care. During an interview on 4/9/24 at 9:22 A.M., the Assistant Director of Nursing (ADON) said if dressing is ordered it should be on. The ADON said if the dressing fell off, it should be replaced because there a PRN order. The ADON said she was not aware of Resident #41 refusing care or wound dressings, and if it were refused, the refusal should be documented.3.) Resident #214 was admitted to the facility in April 2024 with diagnoses that included fracture of left patella, asthma and insomnia. Review of Resident #214's Brief Interview for Mental Status (BIMS), dated 4/5/24, indicated he/she scored a 15 out of 15 on the BIMS indicating the Resident is cognitively intact. On 4/7/24 at 8:16 A.M., the surveyor observed Resident #214 in bed. Resident #214 said he/she recently fell and has stitches (sutures) in his/her nose that will be coming out today. On 4/8/24 at 7:35 A.M., the surveyor observed Resident #214 in his/her room, stitches were observed in the Residents' nose. Resident #214 said the nurse never came in to remove the stitches and said he/she would really like them out. During an interview and observation 4/8/24 at 11:30 A.M., the surveyor and Nurse #1 observed Resident #214's nose. Nurse #1 said the Resident still has stitches in his/her nose. Nurse #1 said the nurse from yesterday should have taken the Residents' stitches out as ordered and did not. Review of Resident #214's physician orders, dated 4/4/24, indicated Remove sutures from nose on 04/07 (4/7/24). Review of Resident #214's April 2024 Medication Administration Record (MAR), indicated on 4/7/24 on the 7:00 A.M. to 3:00 P.M. shift the order for Remove sutures from nose on 04/07 (4/7/24) every day shift was checked off as completed. During an interview on 4/8/24 at 11:33 A.M., Unit Manager #1 said if the order is signed off by the nurse, then the sutures should not be in the Residents' nose. Unit Manager #1 said she worked on 4/7/24 and the nurse assigned to Resident #214 never asked her for assistance to remove the sutures. During an interview on 4/8/24 at 11:35 A.M. the Director of Nursing (DON) said Resident #214's sutures should have been removed as ordered. The DON said if the order was signed off as completed then the sutures should not be in the Residents' nose. The DON said if the Resident refused then there should be a nursing progress note to indicate that and the physician should have been notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #41 was admitted to the facility in June 2023 with diagnoses including dementia and anemia Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated that, without the use of hearing aids or other hearing appliance, Resident #41 has minimal difficulty hearing. Review of nursing progress note, dated 1/28/24 indicated: -Resident won't talk at times, may have a lot to do with his/her poor hearing. Review of the plan of care related to hearing loss, revised 4/2/24, indicated: -Resident had difficulty communicating related to hearing loss. -Refer to audiology evaluation as needed. Review of a form, titled Attending Physician Request for Services/Consultation, dated 8/23/23, indicated a request for an audiological consultation by the facility's contracted Audiologist servicer for the purpose of obtaining additional information necessary for the evaluation of the need for or appropriate type of medical or surgical treatment of a new hearing deficit or a related medical problem. Reason's for this consultation that were indicated on this form included: -Family/staff notices a decreased patient responsiveness. -New complaint of blocked ears. -Complains of newly decreased hearing. -New verbal communication difficulties such as need to have commands repeated, note turning when spoken to, difficulty understanding speech. On 4/7/24 at 9:18 A.M., the surveyor observed Resident #41 without hearing aids. Resident #41 said he/she cannot hear what the surveyor says, even with adjusted volume and repeated communication. Resident #41 said he/she wants hearing aids and was supposed to get hearing aids when he/she came here, but never did. On 4/9/24 8:21 A.M., the surveyor observed Staff Member #1 talking to Resident #41 about removing his/her meal tray. Staff Member #1 had to repeat questions several times, even with adjusted volume of speech. Staff Member #1 said Resident #41 is hard of hearing and requires repeating communication, adjusting volume, and showing items if he/she cannot hear. On 4/09/24 1:15 P.M., the surveyor attempted to ask Resident #41 questions about her ability to participate in activities and socialize, but Resident #41 was unable to hear the surveyors questions, even with adjusted volume and repeated speech. The surveyor wrote questions down in large print on a notebook, and Resident #41 was unable to see the written words. Resident #41 said he/she has poor vision. On 4/9/24 at 1:18 P.M., the surveyor asked Regional Nurse #1 to assist her with asking questions because Resident #41 could not hear the surveyor. Regional Nurse #1 communicated by directing speech directly and closely into Resident's left ear. Resident #41 said he/she used to use a hearing amplifier and it helped him/her hear better. Resident #41 said he/she would like to have a hearing amplifier again. Review of Resident #41's medical record including care plans and physician's orders failed to indicate that new interventions, audiology consultations, or hearing assistive devices were implemented after the request for audiology services for a hearing decline on 8/23/23. During an interview on 4/9/24 9:06 A.M., the Assistant Director of Nursing (ADON) said Resident #41 never had hearing aids or a hearing amplifier. The ADON said if a consent was signed and request was made for a Resident to be seen by the audiology, then the Resident should have been seen. During an interview on 4/8/24 at 12:36 P.M., the Unit Secretary said the facility started to doing audits in January 2024 and realized the contracted Audiology services have not been coming and she does not know how often they should be coming in. The Unit Secretary said audiology service consent and request for treatment was completed and signed on 8/23/23 for Resident #41, but the audiologist had never seen the Resident. The Unit Secretary said Audiology was last in the facility in November 2023. During an interview on 4/8/24 at 2:07 P.M., the Unit Secretary did not know why other services are not being offered if the contracted Audiology company has not been coming in consistently. During an interview on 4/9/24 at 12:56 P.M., the Director of Nursing (DON) said the facility needs to find other interventions for the hard of hearing residents since our consulting services are not coming in. During an interview on 4/09/24 at 2:01 P.M., the Director of Nursing said Resident #41 was given a hearing amplifier at some point when he/she was on the first floor, but that Resident #41 did not have one and nobody had been using one. Based on observations, record review and interview, the facility failed to provide appropriate treatment and services related to hearing for two Residents (#91 and #41) out of a total of 28 sampled residents. Specifically, the facility failed to ensure Resident #91 and Resident #41 were ever seen by Audiology services or were provided assistive devices for hearing. Findings include: Review of the facility policy titled Physician Orders for Consultation, revised and dated 1/5/22, indicated the following: - Referrals and consultations will be ordered by the attending physician or designated practitioner. - Ensure that consultations for specialty care or ancillary services (including audiology services) are ordered by the attending physician to meet the medical or clinical care needs of each patient. - The interdisciplinary team (including the attending physician, nurses, therapists, and social workers) will identify the need for consultative services. - The attending physician or designated practitioner will order consultative services when necessary to meet individualized medical and clinical needs of the resident. - The center will assist residents with obtaining services as needed including making appointments and arranging transportation. 1.) Resident #91 was admitted to the facility in February 2022 with diagnoses including spondylosis (abnormal wear on the cartilage and bones of the neck) and type 2 diabetes mellitus. Review of Resident #91's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15 indicating that the Resident has moderate cognitive impairment. Further review of the MDS indicated that Resident #91 requires total dependence on staff for activities of daily living. During an interview on 4/7/24 at 7:57 A.M., Resident #91 said he/she has a hard time hearing what the surveyor is saying and has not seen the ear doctor in a long time and would like it. The surveyor had to repeat multiple times as Resident #91 could not hear what the surveyor was saying. During an interview on 4/8/24 at 8:16 A.M., Resident #91 said it is hard not being able to hear other people and he/she wants to get his/her ears looked at. The surveyor had to repeat multiple times as Resident #91 could not hear what he was saying. As the surveyor was approaching the room, Resident #91's television could be heard from multiple rooms away. Review of a quarterly care conference progress note date 9/1/22 written by the social worker indicated the following: - A referral was also placed with the contracted Audiology service for hearing care. Review of Resident #91's medical record which includes care plans and physician's orders failed to indicate that any interventions or orders were ever implemented related to Audiology services or assistive devices for his/her hearing. During an interview on 4/8/24 at 11:05 A.M., the Unit Secretary said she just started this position in November and was trying to catch up with all the residents being seen by the contracted services offered which includes Audiology services. The surveyor and Unit Secretary reviewed the progress note and she said she was not sure why it was not addressed, and she would expect a referral to have been followed up since then as it was 19 months ago, and the Resident was admitted to the facility in February 2022. During an interview on 4/8/24 at 11:41 A.M., the Unit Secretary provided a consent form to be seen by Audiology services on 6/20/22. When asked why Resident #91 has not been seen she did not know. The Unit Secretary provided a new consent form for Audiology Services dated 3/30/24. Under the Audiology section, the following was checked off: Family/staff notices recent decreased patient responsiveness. Review of the history of visits from the contracted Audiology company the facility uses failed to indicate that Resident #91 was ever seen by Audiology. During an interview on 4/8/24 at 11:51 A.M., the Staff Development Coordinator (SDC), covering as the third-floor unit manager, said if a referral was made for Audiology services, then Resident #91 should have been seen. During an interview on 4/8/24 at 1:08 P.M., the Director of Nursing (DON) said she would expect the referral to be followed up on given it was in 2022. During an interview on 4/8/24 at 2:07 P.M., the Unit Secretary did not know why other services are not being offered if the contracted Audiology company has not been coming in consistently. During an interview on 4/8/24 at 12:36 P.M., the Unit Secretary said the facility started to doing audits In January 2024 and realized the contracted Audiology services have not been coming and she does not know how often they should be coming in. The Unit Secretary said Audiology was last in the facility in November 2023. During an interview on 4/9/24 at 12:56 P.M., the Director of Nursing said the facility needs to find other interventions for the hard of hearing residents since our consulting services are not coming in. She continued to say that the Rehabilitation department offered amplifiers for residents, but she did not know if Resident #91 was ever offered one. During an interview on 4/9/24 at 1:09 P.M., Resident #91 said someone came by today to offer him/her a headset to help him/her hear. Resident #91 continued to say this was the first time anyone has ever offered him/her this device. He/she continued to say he/she really wants to get his/her ears checked by the doctor and he/she feels like his/her hearing has gotten worse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, interviews, and record review, the facility failed to ensure nursing provided treatment and services consistent with professional standards of practice to promote healing and prevent development of new pressure ulcers for two Residents (#18 and #71), out of 28 total sampled Residents. Specifically, 1a.) For Resident #18, the facility failed obtain a physician order to discontinue a dressing for a recently healed pressure ulcer. 1b.) For Resident #18, the facility failed to obtain a physician order to discontinue an air mattress ordered for skin integrity management. 2.) For Resident #71, the facility failed to ensure an air mattress was at the correct settings for a Resident with multiple pressure ulcers. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, indicated, but was not limited to: - The nurse shall describe and document/report the following: current treatments. - The physician will order pertinent wound treatments, including dressings. 1.) Resident #18 was admitted to the facility in June 2023 with diagnoses including diabetes and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the most recent Norton Plus Skin Risk Assessment, dated 3/4/24, indicated Resident #18 was at high risk for skin breakdown as evidenced by a score of 7. 1a.) On 4/7/24 at 8:43 A.M., the surveyor observed boxes of wound dressings on Resident #18's dresser. Resident #18 said he/she has a couple sores on his/her buttocks, and said staff does not use these dressings. Resident #18 said the sores are treated only with a cream. Review of Resident #18's physician's order, dated 3/8/24, indicated: Wound Documentation - Left Buttock- cleanse with wound cleanser apply Collagen cut to size and cover with b-foam (border foam), change daily and PRN. This wound treatment order failed to indicate an end date or instructions to discontinue when the wound is healed, and was indicated as discontinued by Physician #1 on 4/7/24. During an interview on 4/8/24 at 9:15 A.M., Certified Nurse Assistant (CNA) #7 said Resident #18 does not need a dressing for his/her buttocks, and only gets a cream put on it. CNA #7 said she regularly cares for Resident #18 and the last time she saw a dressing when doing incontinence care was at some point the previous week. On 4/8/24 at 9:24 A.M., the surveyor observed multiple small open wounds on Resident #18's left buttock/upper thigh with Nurse #7 and the Assistant Director of Nursing (ADON). The ADON said this appears to be moisture associated skin damage. **Review of Skin Observation Tool, dated 3/26/24, indicated: -Boder [sic] foam apply to left buttock to release pressure at the area. During an interview on 4/8/24 11:39 A.M., Unit Manager #2 said when she looked at Resident #18's left buttock yesterday there was not a dressing on it, so she discontinued it. Unit Manager #2 said she did not obtain an order from the physician because the wound was healed and she didn't need to. During a telephonic interview on 4/8/24 at 11:29 A.M, Physician #2 said Physician #1 had been on vacation since 4/5/23. Physician #2 was on call and said the facility did not call to obtain any orders to discontinue any dressings for Resident #18 since Physician #1 left for vacation 4/5/24. Physician #2 said she would expect an order to be obtained to discontinue a dressing order. During an interview on 4/8/24 at 1:01 P.M., the Director of Nursing (DON) said a physician's order is required to discontinue a dressing. 1b.) On surveyor 4/7/24 at 8:43 A.M. and 4/8/24 at 7:52 A.M., the surveyor observed Resident #18 in bed, not on an air mattress. Resident #18 said his/her air mattress was broken and had been removed a few weeks ago. Resident #18 said he/she was supposed to get a new air mattress, but said it had not come yet. Resident #18 said the regular mattress he/she is on is not comfortable and would like the air mattress when it comes in. Review of Resident #18's physician's order, dated 12/29/23, indicated: - Air mattress to bed Setting ALT (alternating) 250 or per resident comfort. Check placement and function Q (every) shift. Review of Resident #18's plan of care relating to risk for alteration in skin integrity, last revised 2/28/24, indicated: - Air mattress to bed Setting ALT 250 or per resident comfort. Check placement and function Q shift. Review of TELS (an electronic system used to request maintenance services) work order, dated 3/26/24, indicated a request to replace air mattress was created on 3/26/24 at 1:59 P.M This order has a status update of completed on 3/27/24 at 9:36 A.M. Review of Treatment Administration Record (TAR), dated 3/27/24, 3/28/24, 3/29/24, 3/30/34, 3/31/24, 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/5/24, and 4/6/24, indicated the order to check for air mattress placement and function was documented as implemented. During an interview on 4/8/24 at 9:52 A.M., Unit Manager #2 said she put in a request in the TELS system to replace Resident #18's air mattress with another air mattress on 3/25/24. Unit Manager #2 said it was replaced with a regular mattress and since Resident #18's wound had healed she decided not to request another air mattress. Unit Manager #2 said she noticed there was still an order for it yesterday, and said she discontinued the order without discussing with the physician. During a telephonic interview on 4/8/24 at 11:29 A.M, Physician #2 said Physician #1 had been on vacation since 4/5/23. Physician #2 was on call and said the facility did not call to obtain any orders to discontinue an air mattress for Resident #18 since Physician #1 left for vacation 4/5/24. Physician #2 said she would expect an order to be obtained to discontinue an air mattress. During an interview on 4/8/24 at 9:42 A.M., the Assistant Director of Nursing (ADON) said Resident #18's order to check placement and function of an air mattress order should not be marked on the Treatment Administration Record (TAR) as implemented if the Resident was not on an air mattress. During an interview on 4/8/24 at 1:01 P.M., the Director of Nursing (DON) said a physician's order is required to discontinue physician's orders, including an order for air mattress placement and function.3.) Resident #72 was admitted to the facility in March 2024 with diagnoses that included chronic respiratory failure with hypoxia, dysphagia, and heart failure. Review of Resident #72's most recent 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 is cognitively intact. Further review of the MDS indicated the Resident had a stage three and stage four pressure ulcer and is at risk for developing pressure ulcers. On 4/7/24 at 8:03 A.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. On 4/8/24 from 7:57 A.M. to 9:00 A.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. On 4/8/24 at 11:55 A.M. and 1:28 P.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. On 4/9/24 at 11:41 A.M. and 1:21 P.M., the surveyor observed Resident #72 in bed, the air mattress pump was set to the fourth light from the bottom. Review of Resident #72's actual skin breakdown, dated 3/15/24, indicated Specialty mattress on bed. LAL with 8 LED up from bottom. Review of Resident #72's physician orders, dated 3/28/24, indicated Air Mattress-LAL with 8 LED up from bottom. Check for placement and function every shift. Review of Resident #72's physician orders, dated 3/20/24, indicated Wound Documentation-R heel-Cleanse, pat dry, apply silver alginate (cut to size), cover with foam dressing and wrap in kerlix. Change daily and PRN (as needed). Review of Resident #72's [NAME], dated 4/6/24, indicated he/she scored 11 which indicated he/she was at moderate risk for skin breakdown. During an interview on 4/9/24 at 8:53 A.M., Nurse #2 said Resident #72's air mattress should be set to the 8th light from the bottom as ordered and said it is a wound management intervention. During an interview on 4/8/24 at 1:21 P.M., Unit Manager #1 said Resident #72's air mattress should be set to the 8th light from the bottom as ordered and said the Resident has multiple pressure ulcers. Unit Manager #1 said the air mattress is an intervention for Resident #72's wound management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, record review and interviews, the facility failed to identify and provide interventions for a decrease in range of motion for one Resident (#5) out of a total sample of 28 residents. Findings include: Review of the policy titled Resident Mobility and Range of Motion, dated July 2017, indicated the following: - Residents will not experience an avoidable reduction in range of motion (ROM). - As part of the resident's comprehensive assessment, the nurse will identify the resident's: -c. limitations in movement or mobility - As part of the resident's comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: -e. contractures. - The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. - Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards or practice and be consistent with state laws and practice acts. Resident #5 was admitted to the facility in November 2020 with diagnoses including heart failure and stroke without residual deficits. Review of Resident #5'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 was cognitively intact. Section GG of the MDS indicated the Resident did not have an impairment in range of motion to any joint. During interviews on 4/7/24 at 11:31 A.M. and on 4/9/24 at 8:21 A.M., Resident #5 said he/she has trouble straightening his/her fingers on his/her right hand. Resident #5 said his/her right hand has been getting bad over the last couple of months and would like nursing to address this concern. Resident #5's second and fifth fingers were only able to actively open to approximately 75% of full range of motion and needed to be pushed open with his/her other hand to fully straighten. Resident #5's third and fourth fingers could only straighten to approximately 50% of full range of motion and, even with assistance, could not straighten further. Resident #5 said he/she has new and worse pain in his/her right hand, and it has affected his/her ability to complete tasks. Resident #5 said he/she can still do things for him/herself, but it has become increasingly harder, and he/she has had to adapt to doing things in a different way. At the time of the interview, Resident #5 was eating breakfast and said he/she had to hold the utensils more in his/her palm than with his/her fingers. Review of Resident #5's listed medical diagnoses failed to indicate a neurological or arthritic condition that would lead to an unavoidable decrease in range of motion. Review of the nursing summary, dated 10/22/23, failed to indicate Resident #5 had any decrease in range of motion, contractures, or rigidity. Review of Resident #5's care plans failed to indicate a care plan for impairment in range of motion or contractures. Review of the Occupational Therapy evaluation, dated 12/13/23, indicated Resident #5's range of motion was within functional limits. The evaluation failed to indicate pain in the right hand, a deficit of strength in the right hand, and indicated there was no contracture present. During an interview on 4/9/24 at 8:32 A.M., Nurse #4 said she has not worked with Resident #5 in a while, but when she last worked with him/her, the Resident was able to fully straighten his/her right-hand fingers. During an interview on 4/9/24 at 8:34 A.M., Certified Nursing Assistant (CNA) #4 said she is unaware of Resident #5's limited range of motion. During an interview on 4/09/24 at 8:38 A.M., CNA #3 said she often takes care of Resident #5. CNA #3 said Resident #5's right hand may be gradually closing more but it had never been perfectly straight. During interview on 4/09/24 at 9:22 A.M., the Occupational Therapist (OT) said she previously had worked with Resident #5 and remembered that the Resident's right finger joints would deviate to the side but could not remember if they were closed and unable to open. The surveyor described how she had observed Resident #5's hand and the OT said this sounded different from before and would go to see for herself. During a follow-up interview on 4/9/24 at 9:36 A.M., the OT said she just observed the Resident's right hand. The OT said the third and fourth fingers of the right hand were definitely stuck in a bent position and the Resident is unable to straighten them. The OT said Resident #5 definitely complained of more pain now and had less range of motion than when he/she was previously seen for therapy. The OT said Resident #5 is cognitively intact and would be accurate if reporting worsening range of motion and more pain. During an interview on 4/9/24 at 10:06 A.M., the Director of Nursing said she would expect nursing to make a referral to therapy if a change in range of motion were to occur. During an interview on 4/9/24 at 10:44 A.M., the Director of Rehabilitation (DOR) said the therapy department completes screenings of all residents in the building quarterly and annually. The DOR said changes in range of motion would be looked at during screens, but nursing also would send a referral to therapy if a resident experienced a change in range of motion. The DOR said Resident #5 had previously been on therapy after falling but does not remember the Resident ever needing an evaluation for a change in range of motion. The DOR said Resident #5 is vocal about his/her impairments and said if the Resident is complaining of pain or a decline in range of motion it is most likely accurate. During an interview on 4/9/24 at 11:23 A.M., Unit Manager #2 said she was unaware of Resident #5's change in range of motion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #29 was admitted to the facility in January 2021 with diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3 and vascular dementia. Review of Resident #29's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 9 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated Resident #29 requires assistance with all activities of daily living. Resident #29's medical record indicated that he/she receives services through the Program of All-Inclusive Care for the Elderly (PACE). Review of Resident #29's Weights and Vitals summary indicated the following: - 02/8/24: 204.5 lbs. - 03/1/24: 179.8 lbs. From 2/8/24 through 3/1/24, Resident #29 had a significant weight loss of 12.08%. Review of Resident #29's care plan for at risk for malnutrition, revised and dated 11/3/22, indicated the following interventions: - Nutrition related medication management. - Weights as ordered. Review of Resident #29's Quarterly Nutrition Follow-Up Evaluation completed by the Registered Dietitian (RD) dated 1/30/23 indicated the following: - Nutrition Problems and Interventions: Impaired nutrient utilization, at risk for malnutrition. - Nutrition interventions include: continued communication/collaboration with RD team. - Recommendations: RD will continue to monitor. Review of Resident #29's progress note, written by the RD on 3/21/24, indicated the following: - Reweigh requested. Value: 179.8 lbs. The Registered Dietitian requested a reweigh for Resident #29 twenty days after the Resident was documented having a significant weight loss. Within that time frame, Resident #29 was not assessed/evaluated for a significant weight loss and no interventions were implemented. During an interview on 4/8/24 at 8:54 A.M., the Staff Development Coordinator (SDC), covering as the third floor unit manager, said when residents are enrolled with PACE, a representative will come in and assess the resident and input a note into the resident's medical record so the facility can monitor the resident. The SDC continued to say the facility is in communication with the RD from PACE and they will communicate with the facility's RD for any recommendations if a significant weight change is identified or if interventions need to be implemented. During an interview on 4/8/24 at 11:30 A.M., Certified Nursing Assistant (CNA) #6 said CNAs weigh the residents and would either tell the nurses the resident's weight or document it on the resident's flow sheets in a binder. During an interview on 4/8/24 at 1:16 P.M., the Registered Dietitian (RD) said she works in the building four days each week. The RD said when a resident gets weighed it gets inputted in the medical record. She continued to say if a significant weight change is identified the medical record system will trigger it and alert her. The RD said when a significant weight change is identified a reweigh needs to be done as soon as possible. When asked about Resident #29's documented significant weight loss, she said a reweigh should have been implemented sooner than 20 days so the resident could be assessed and start interventions if needed. The RD continued to say she communicates with the PACE RDs who implement the primary interventions for Resident #29, and she would monitor their recommendations. She said without verifying Resident #29's documented significant weight loss the PACE RD's would not know to implement interventions. During an interview on 4/8/24 at 1:08 P.M., the Director of Nursing (DON) said she would expect a reweigh to happen in a timelier manner for Resident #29 to determine if the significant weight change was accurate which would lead the resident being assessed. Based on record review, interview and policy review the facility failed to maintain acceptable parameters of nutrition status for two Residents (#69 and #29) out of a total sample of 28 residents. Specifically, 1.) For Resident #69, the facility failed to identify and put an intervention in place for a significant weight loss, and 2.) For Resident #29, the facility failed to identify and address a potential significant weight loss by not reweighing the Resident in a timely manner to confirm a significant weight loss. Findings include: Review of the facility policy titled Weight Assessment and Intervention, revised 6/15/22, indicated the following: - Weights obtained by the dialysis center, hospice, or other provider may be referred to in clinical documentation but should not be entered into the electronic medical record as the facility obtained weight. - A weight change of 5 lb (pounds) or more in a patient weighing more than 100 lbs. since the last weight assessment will be retaken for verification. If the weight is verified, nursing notifies the Dietitian. For non-significant weight changes either the dietitian or provider is notified upon consideration of the resident's overall clinical condition. - The Dietitian will respond timely to a verified significant weight change. - Weights are reviewed monthly to follow individual weight trends over time. Negative trends are evaluated to determine significant unplanned and undesired weight loss. - The threshold for significant unplanned and undesired weight loss is based on the following criteria (where percentage of body weight loss = (usual weight - actual weight)/ (usual weight) x 100): -a. 1 month - 5% weight loss is significant. -b. 6 months - 10% weight loss is significant. 1.) Resident #69 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of Resident #69's Minimum Data Set (MDS), dated [DATE], indicated the Resident was not able to complete the Brief interview for Mental Status (BIMS) and staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #69 required maximal assistance with bathing/showering. Resident #69 was not able to be interviewed secondary to his/her level of cognition. During an interview on 4/8/24 at 2:05 P.M., Resident #69's spouse said she was aware the Resident had not been eating well but had never been told by the facility staff if the Resident had lost weight. Resident #69's spouse said she would want an intervention to be put in place if the Resident had lost weight. Review of Resident #69's weights indicated the following: - On 2/20/23, the Resident weighed 201.5 lbs. (pounds) - On 2/22/24, the Resident weighed 201.4 lbs. - On 2/26/24, the Resident weighed 200.6 lbs. - The Resident was not weighed in the month of March secondary to being admitted to hospice services. - On 4/3/24 the Resident weighed 183.4 lbs., an 8.98% weight loss since 2/20/24. Review of Resident #69's hospice care plan, last revised on 4/3/24, indicated the following intervention: -Report skin breakdown, lack of analgesia effectiveness, unexpected weight loss or decline in appetite. Review of the nutritional assessment, dated 3/29/24, indicated Resident #69 was admitted to hospice services but the Dietitian would continue monitor and be available as needed. During an interview on 4/8/24 at 1:15 P.M., the Registered Dietitian (RD) said she works at the facility four days a week and checks the weight report frequently. The RD said the electronic Medical Record triggers all significant weight loss and will alert her in a report. The RD said all significant weight losses are treated with a new weight loss intervention which may include double portions of food, adding supplements, adding sweets (ice cream) or speaking with the physician to add an appetite stimulant. The RD said this process applies to all residents, even those that are on hospice services. The RD reviewed Resident #69's weights with the surveyor and said the Resident had a significant weight loss of over 7.5% in 3 months or less. The RD said she was unaware of Resident #69's significant weight loss as neither the nursing staff or electronic medical record alerted her to the loss. The RD said she would have still put in an intervention for Resident #69 even though he/she is receiving hospice services. During an interview on 4/8/24 at 1:27 P.M., the Staff Development Coordinator (SDC), who was working as Unit Manager, said all weights are taken as ordered. The SDC said nursing enters the weights and should notice if a significant weight change has occurred. The SDC said if a significant change in weight occurs, nursing needs to notify the Physician and Dietitian. The SDC said a weight loss intervention should be put in place right away. The SDC said that although Resident #69 is on hospice services, the nursing staff should have identified the Resident's significant weight loss and followed the process of referring him/her to the Dietitian for a weight loss intervention. During an interview on 4/9/24 at 8:53 A.M., the Director of Nursing (DON) said she was unsure why the Resident was not weighed since he/she was on hospice services. The DON said whether the weight was supposed to be taken or not, once taken, the nurses should have identified the weight loss and followed the facility procedure of notifying the Resident's family, the Dietitian and the physician and put an appropriate intervention in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews, the facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two Residents (#49 and #69) out of a total sample of 28 Residents. Findings include: Review of the facility policy titled Psychotropic Medication Use, dated 2/2/23, indicated psychotropic medications are not prescribed or given on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. 1. If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1.) Resident #49 was admitted to the facility in March 2014 with diagnoses that included dementia, dysphagia, and major depressive disorder. Review of Resident #49's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. Review of Resident #49's physician orders indicated the following: - Lorazepam (Ativan) (an anti-anxiety medication) oral tablet 0.5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for anxiety/agitation. The Lorazepam order failed to indicate an end date. During an interview on 4/9/24 at 8:22 A.M., Unit Manager #1 said if a resident has an as needed (PRN) Ativan order there needs to be a stop date with an re-evaluation by the doctor to continue the as needed order. 2.) Resident #69 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of Resident #69's Minimum Data Set (MDS), dated [DATE], indicated the Resident was not able to complete the Brief interview for Mental Status (BIMS) and staff assessed him/her to have severe cognitive impairment. Review of Resident #69's physician orders indicated the following: - Ativan (an anti-anxiety medication) oral tablet 0.5 MG (milligrams). Give 0.5 mg by mouth every 4 hours as needed for anxiety/agitation. The Ativan order failed to indicate an end date. During an interview on 4/8/24 at 11:14 A.M., Nurse #6 said all as needed psychotropic medications need to be re-evaluated after one month. Nurse #6 said the process for psychotropic medication use is the same whether a resident is on hospice or not. During an interview on 4/8/24 at 11:17 A.M., the Staff Development Coordinator (SDC) who was covering as Unit Manager, said any psychotropic medications that are used on an as needed basis need to be re-evaluated after the first 14 days. The SDC said if the medication is continued after the first 14 days, there needs to be a clinical reason for its use and the order also needs to have an end date so the ordering physician will re-evaluate the need for the medication again. The SDC said she was unaware Resident #69's order for Ativan failed to have an end date/reassessment date.

Based on observation, interview and policy review, the facility failed to provide a dignified dining experience on the second and third floor units. Findings include: Review of the facility policy titled Assistance with Meals, revised March 2022, indicated the following: - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. - Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals; avoiding the use of labels when referring to residents (e.g., feeders). Review of the facility policy titled Dignity, dated February 2021, indicated the following: - When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. The surveyor made the following observations on the third-floor unit: - On 4/7/24 at 8:20 A.M., while organizing the meal carts in the hallway, staff referred to a resident as a feeder with other residents sitting nearby in the hallway. - On 4/8/24 at 8:31 A.M. and 8:45 A.M., while organizing the meal carts in the hallway, staff were heard saying she's a feed with other residents sitting nearby in the hallway. - On 4/8/24 at 9:10 A.M., a staff member was observed standing over a resident sitting in his/her wheelchair feeding him/her oatmeal, not at eye level in the dining room. The surveyor made the following observation on the second-floor unit: - On 4/8/24 at 11:42 A.M., a staff member was heard saying she is a feeder in the hallway with other residents nearby. During an interview on 4/9/24 at 9:30 A.M., the Staff Development Coordinator, who was covering as the third-floor unit manager, said staff should be sitting at eye level when assisting residents with feeding. She continued to say staff should not be referring to residents as feeders or feeds. During an interview on 4/9/24 at 9:58 A.M., the Director of Nursing (DON) said staff should not be standing while feeding other residents or refer to residents as feeders or feeds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Review of the facility policy titled Assistance with Meals, revised March 2022, indicated the following: - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. - Facility staff will serve resident trays and will help residents who require assistance with eating. - The nursing staff will prepare residents for eating. Resident #95 was admitted to the facility in December 2021 with diagnoses including dysphagia (difficulty swallowing), unspecified psychosis and anxiety disorder. Review of Resident #95's most recent Minimum Data Set Assessment (MDS), dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires supervision/touching assist for eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 4/7/24 at 8:13 A.M., Resident #95 was lying in his/her bed with his/her breakfast tray in front of him/her. There was no staff in Resident #95's room providing supervision or assistance and the Resident could not be seen from the hallway eating. Resident #95 asked the surveyor for help finding his/her utensils so he/she could eat his/her breakfast. Resident #95 began eating his/her breakfast. At 8:29 A.M., 16 minutes after the Resident started eating, a staff member checked in on the Resident. - On 4/7/24 at 12:14 P.M., Resident #95 was lying in his/her bed with his/her lunch tray in front of him/her. There was no staff in Resident #95's room providing supervision or assistance and the Resident could not be seen from the hallway eating. - On 4/8/24 at 7:53 A.M., Resident #95 received his/her breakfast tray, a staff member set up his/her tray and left the room. At 7:56 A.M., Resident #95 was observed with food on his/her chest that spilled as the Resident was bringing the food to his/her mouth. There was no staff in Resident #95's room providing supervision or assistance and the Resident could not be seen from the hallway eating. Review of Resident #95's physician's order, dated 6/6/23, indicated the following: - Regular diet pureed texture, mildly thick consistency, for risk for malnutrition. Review of Resident #95's [NAME] (a form indicating the level of assistance a resident requires) indicated the following: - Eating: supervised with meals, mildly thick liquids. Review of Resident #95's Activities of Daily Living (ADL) deficit care plan, dated 1/5/22, indicated the following: - Assist of (1-2 person) with ADL's. - Supervision with meals. Review of Resident #95's Diet care plan, dated 12/16/21, indicated the following interventions: - Diet Texture: Pureed. - Liquid consistency: Mildly Thick. Review of Resident #95's Nutrition Evaluation, dated 12/5/23, indicated the following: - Chewing/swallowing difficulty related to dysphagia as evidenced by modified diet, see Speech Language Pathologist notes. - Average ~50% intake with supervision/assistance. He/she reports some meal fatigue, especially at dinner time. Review of Resident #95's Nutrition Evaluation, dated 3/4/24, indicated the following: - Chewing/swallowing difficulty related to dysphagia as evidenced by modified diet, see Speech Language Pathologist notes. - Feeding assistance as needed/accepted. - Continues with supervision/assistance Review of the document titled Speech Therapy SLP Recert, Progress Report & Updated Therapy Plan, dated from 8/6/23 - 9/4/23, indicated the following: - Impairments: Decreased safety awareness, impulsivity, decreased bolus control, decreased mastication skills. - Justification for Continued Skilled Services: Skilled SLP interventions warranted for analysis of oral/pharyngeal function with PO (by mouth) trials and education and training of compensatory safe swallow strategies to minimize the risk of aspiration/choking and promote patient's overall safety during PO intake. -Long-Term Goal: Patient will tolerate least restrictive diet for reduced aspiration pna (pneumonia) risk and adequate nutrition/hydration 90% via caregiver cues/assist as needed. During an interview on 4/9/24 at 9:22 A.M., Certified Nursing Assistant (CNA) #5 said she knows her residents well and knows what level of care they all need. CNA #5 said Resident #95 needs supervision with meals, and he/she is on pureed foods for safety since his/her throat is very sensitive. During an interview on 4/9/24 at 9:28 A.M., Nurse #3 said Resident #95 needs supervision at all times when eating. Nurse #3 continued to say that staff looks at the Resident's [NAME] to know what level of care they need. During an interview on 4/9/24 at 9:30 A.M., the Staff Development Coordinator (SDC), covering as the third-floor unit manager, said supervision with meals means we need to have our eyes on the residents while they are eating at all times. The SDC continued to say that Resident #95 needs to be supervised when he/she is eating. During an interview on 4/9/24 at 9:58 A.M., the Director of Nursing (DON) said Resident #95 needs to be supervised with meals. She continued to say that supervision means watching a resident while they eat. After the surveyor shared his observations of Resident #95, the DON said, it sounds like he/she needs it (referring to supervision). 3.) Review of the facility policy titled Urinary Continence and Incontinence - Assessment and Management, revised August 2022, indicated, but was not limited to, the following: - The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. - Management of incontinence will follow relevant clinical guidelines. - As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. - As appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. - A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort to protect the skin. Resident #61 was admitted to the facility in May 2022 with a diagnosis of dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #61 scored a 4 of 15 on a Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated Resident #61 was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #61's activities of daily living care plan indicated the following intervention: - Assist of two persons dependent with activities of daily living. Review of Resident #61's urinary incontinence care plan related to impaired mobility, decreased sensation unaware of need to void: -Adjust toileting times to meet patient needs. Review of Resident #61's bowel incontinence care plan related to disease process impaired mobility, medications: -Provide incontinence care as needed. Review of Resident #61's most recent bowel and bladder assessment, dated 1/31/24, indicated the Resident was not continent of bowel or bladder and that Resident #61 was unable to express urge sensation. Review of the Certified Nursing Assistant (CNA) Flowsheets indicated Resident #61 was dependent on staff for toileting and incontinent of bowel and bladder every day in March and April of 2024. During an interview on 4/8/24 at 1:40 P.M., CNA #8 said residents with incontinence should be checked for incontinence every two hours. CNA #8 said Resident #61 was incontinent of both bowel and bladder, and that he/she would not be able to verbalize when he/she needs to be toileted. During an interview on 4/8/24 at 1:46 P.M., Nurse #5 said residents with incontinence should not go more than three hours without being checked for incontinence and changed if needed. Nurse #5 said Resident #61 was incontinent of both bowel and bladder, and that he/she would not be able to verbalize when he/she needs to be toileted as he/she is alert to self only. On 4/8/24 at 8:53 A.M., the surveyor observed Resident #61 seated in the common area across from the nurses station on the second floor unit. The Resident was taken into the dining room at 10:28 A.M., where he/she remained until after lunch. During the five hour continuous observation from 8:53 A.M., until 1:58 P.M., Resident #61 was not checked for incontinence or changed until the surveyor brought the concern to the attention of facility staff. During an interview and observation on 4/8/24 at 2:00 P.M., a surveyor observed Resident #61 receiving incontinence care for the first time since 8:53 A.M. The Resident's briefs and pants were saturated from his/her buttocks up to his/her lower back; there was an odor of urine. CNA #8 said the brief was saturated with urine, and that there were streaks of stool. During an interview on 4/8/24 at 2:00 P.M., the Assistant Director of Nursing (ADON) said residents with incontinence should be checked around breakfast time and again around lunch time, the ADON said Resident #61 should not have gone five hours without being checked for incontinence. During an interview on 4/9/24 at 12:53 P.M., the Director of Nursing said residents with incontinence should be checked, and changed if needed, every two to three hours. During an interview on 4/9/24 at 1:30 P.M., Resident #61's spouse said the Resident was incontinent, and that he/she would expect staff to check and change the Resident during regular intervals even when he/she is visiting with family. Resident #61's spouse said the Resident would not be able to verbalize when he/she needs to be toileted. REF F725 Based on observations, record review, policy review and interviews, the facility failed to provide assistance for Activities of Daily Living (ADLs) for five Residents (#414, #100, #19, #95, and #61) out of a total sample of 28 residents. Specifically, 1.) For Residents #414, #100, and #19, the facility failed to provide showers, 2.) For Resident #95, the facility failed to provide supervision during meals, and 3.) For Resident #61, the facility failed to provide incontinence care. Findings include: 1.) Review of the facility policy titled Bath, Shower/Tub, dated 2001, indicated the following: - The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. - If a resident refused the shower/tub bath, the reason(s) why and the intervention taken. [sic] 1a.) Resident #414 was admitted to the facility in June 2023 with diagnoses including chronic respiratory failure, diabetes and pneumonia. Review of Resident #414's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (MDS) score of 5 out of a possible 15, which indicated he/she had severe cognitive impairment. During an interview on 4/7/24 at 8:35 A.M., Resident #414 was observed lying in bed. His/her hair looked greasy. Resident #414 said he/she has not been assisted with a shower and has all bathing completed at sponge bath level. Resident #414 said he/she would really like a full shower. Review of Resident #414's ADL care plan, last revised 6/30/23, indicated the following intervention: - Assist to bath/shower as needed. Further review of Resident #414's care plans failed to indicate the Resident refused showers or care. Review of the document titled Documentation Survey Report, dated for the months of February 2024, March 2024 and April 2024 indicated the following: - In February, Resident #414 had only 2 out of 8 scheduled showers. - In March, Resident #414 had only 2 out of 8 scheduled showers. - In April, Resident #414 had not been provided with a shower in the first 9 days of the month. Review of Resident #414's medical record failed to indicate the Resident refused showers. During an interview on 4/9/24 at 11:09 P.M., Certified Nursing Assistant (CNA) #2 said all residents are scheduled for a shower twice a week and are provided more if needed. CNA #2 said the staff would document any shower refusals in the electronic medical record and would also let the nurse know. CNA #2 said Resident #414 is able to take a shower and needs to be assisted because he/she fatigues easily. CNA #2 was unable to remember the last time Resident #414 was provided with a shower. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC), who is filling in as Unit Manager, said residents are scheduled for two showers a week and are also given a shower as needed/requested. The SDC said the CNAs document care provided in the electronic medical record and should be documenting if a resident refuses a shower. The SDC said the CNAs should alert the nurses if a resident refuses a shower so the nurse can also document the refusal. The SDC said she was unaware Resident #414 had not had a shower. During an interview on 4/9/24 at 12:19 P.M., the Director of Nursing (DON) said all residents are scheduled to receive showers two times a week and are provided additional showers as needed. The DON said CNAs and nursing should document if the resident refuses. 1b.) Resident #100 was admitted to the facility in April 2023 with diagnoses including depression, anxiety and schizophrenia. Review of Resident #100's most recent Minimum Data Set (MDS), dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #100 was dependent on staff for showering tasks. During an interview on 4/7/24 at 8:40 A.M., Resident #100 said he/she is not able to fit in the shower chair and has not been provided with his/her scheduled showers. Resident #100 said he/she would like a shower so he/she can feel most clean. Review of the nursing note, dated 3/12/24, indicated the following: - Resident on call light frequently for drinks, snacks. Nurse assisted CNA (Certified Nursing Assistant) w/ (with) inc (incontinence) care, resident difficulty w/rolling in bed, CNA washed resident, resident c/o (complained of), 'I want a deep cleaning wash between my legs,' nurse washed area a second time, attempt to satisfy resident needs, repositioned, resident placed a ziploc bag of hair products between (his/her) legs. Review of Resident #100's ADL care plan, last revised 4/21/23, indicated the following intervention: - Assist/dependent to bathe/shower as needed. Further review of Resident #100's care plans failed to indicate the Resident refused showers or care. Review of the document titled Documentation Survey Report, dated for the months of February 2024, March 2024 and April 2024 indicated the following: -In February, Resident #100 was not provided with a shower. -In March, Resident #100 had only 2 out of 8 scheduled showers. -In April, Resident #100 had not been provided with a shower in the first 9 days of the month. Review of the shower schedule indicated Resident #100 is scheduled for showers on Fridays during the day shift and Mondays during the evening shift. During an interview on 4/9/24 at 10:46 A.M., Resident #100 said he/she did not get his/her scheduled shower last night (Monday). Review of Resident #100's medical record failed to indicate the Resident refused showers. During an interview on 4/9/24 at 11:09 P.M., Certified Nursing Assistant (CNA) #2 said all residents are scheduled for a shower twice a week and are provided more if needed. CNA #2 said the staff would document any shower refusals in the electronic medical record and would also let the nurse know. CNA #2 the facility has a shower chair that Resident #100 can fit into, however it is on a different unit. CNA #2 said Resident #100 often refuses a shower, so they just provide a bed bath all the time and don't offer a shower. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC), who is filling in as Unit Manager, said residents are scheduled for two showers a week and are also given a shower as needed/requested. The SDC said the CNAs document care provided in the electronic medical record and should be documenting if a resident refuses a shower. The SDC said the CNAs should alert the nurses if a resident refuses a shower so the nurse can also document the refusal. The SDC said Resident #100 was just transferred to this unit about a month ago and the report from the other unit was that the Resident did not like to take showers. During an interview on 4/9/24 at 12:19 P.M., the Director of Nursing (DON) said all residents are scheduled to receive showers two times a week and are provided additional showers as needed. The DON said CNAs and nursing should document if the resident refuses. 1c.) Resident #19 was admitted to the facility in July 2023 with diagnoses including Alzheimer's Disease. Review of Resident #19's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) of 4 out of a possible 15, which indicated he/she had severe cognitive impairment. During an interview on 4/7/24 at 9:06 A.M., Resident #19's spouse translated for the Resident. Resident #19's spouse said Resident #19 is not given showers frequently and both the spouse and the Resident would like him/her to have a shower. Resident #19's spouse said the Resident is supposed to have a shower twice a week and that never happens. Review of Resident #19's ADL care plan, last revised 8/1/23, indicated the following intervention: - Assist to bath/shower as needed. Further review of Resident #19's care plans failed to indicate the Resident refused showers or care. Review of the document titled Documentation Survey Report, dated for the months of February 2024, March 2024 and April 2024 indicated the following: - In February, Resident #19 had only 3 out of 8 scheduled showers. - In March, Resident #19 had only 3 out of 8 scheduled showers. - In April, Resident #19 had not been provided with a shower in the first 9 days of the month. Review of Resident #19's medical record failed to indicate the Resident refused showers. During an interview on 4/9/24 at 11:09 P.M., Certified Nursing Assistant (CNA) #2 said all residents are scheduled for a shower twice a week and are provided more if needed. CNA #2 said the staff would document any shower refusals in the electronic medical record and would also let the nurse know. CNA #2 said Resident #19 used to take showers, but he/she jumped in the shower and now needs two staff members to assist in the shower for safety. CNA #2 could not remember the last time Resident #19 was provided with a shower. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC), who is filling in as Unit Manager, said residents are scheduled for two showers a week and are also given a shower as needed/requested. The SDC said the CNAs document care provided in the electronic medical record and should be documenting if a resident refuses a shower. The SDC said the CNAs should alert the nurses if a resident refuses a shower so the nurse can also document the refusal. The SDC said Resident #19 is not aggressive and she is unsure why he/she has not been provided showers as scheduled. During an interview on 4/9/24 at 12:19 P.M., the Director of Nursing (DON) said all residents are scheduled for to receive showers two times a week and are provided additional showers as needed. The DON said CNAs and nursing should document if the resident refuses.

Based on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure hairnets were worn in the food preparation area, food was labeled, and dented cans of food were not stored with usable cans. Findings include: Review of the facility's policy titled Food Preparation and Service, revised November 2022, indicated, but was not limited to, the following: - Food and nutrition service staff wear hair restraints (hair net, hat, beard restraint etc.) so that hair does not contact food. Review of the facility's policy titled Food Receiving and Storage, revised November 2022, indicated, but was not limited to, the following: - Policy Interpretation and Implementation: 5. When food is delivered to the facility it is inspected for safe transport and quality before being accepted. -Refrigerated/frozen storage: 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date.) 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. -Foods and Snacks Kept on Nursing Units: 1. All food items to be kept at or below 41 degrees Fahrenheit are placed in the refrigerator located at the nurses' station and labeled with a use by date. 2. All foods belonging to residents are labeled with the resident's name, the item and the use by date. 4. Beverages are dated when opened and discarded after 72 hours unless otherwise indicated on the manufacturer's label. 5. Other opened containers are dated and sealed or covered during storage. Review of the facility's policy titled Refrigerators and Freezers, revised November 2022, indicated, but was not limited to, the following: - Policy Interpretation and Implementation: 7. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. 8. Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage policy. 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates or to decipher codes on packaging. On 4/7/24 at 7:00 A.M., the surveyor made the following observations during the initial walkthrough of the kitchen: - One staff member was in the food preparation area without a hair restraint. - A significantly dented can of marinara on the can rack in the dry storage room. - A container labeled tuna salad, with a prepared-on date of 4/4 and use-by date of 4/6 in the walk-in refrigerator. - A container labeled egg salad, with a prepared-on date of 4/1 and use-by date of 4/5 in the walk-in refrigerator. - Six sandwiches on a plate, wrapped but undated in the walk-in refrigerator. - Two salads with lettuce, egg, tomato and deli meat wrapped but undated in the walk-in refrigerator. The lettuce showed signs of decomposition as evidence by browning. - Two containers of pureed texture food, undated and unlabeled in the walk-in refrigerator. - A container labeled pasta cooked with a prepared on date of 4/2 and a use by date of 4/5 in the walk-in refrigerator. - Two containers of juice, opened but unlabeled in a reach-in refrigerator. On 4/7/24 at 8:31 A.M. the surveyor made the following observations in the second floor unit kitchenette's refrigerator: - Three containers of juice opened, but undated. - A salad wrapped with a prepared-on date of 4/4 and use-by date of 4/6. - Two undated containers of resident food containing fish, carrots, beets and potatoes. On 4/7/24 at 8:45 A.M. the surveyor made the following observations in the third floor unit kitchenette's refrigerator: - Five containers of juice opened, but undated. - A container of resident food dated 3/28. - Two containers of a fortified nutritional shake open, but undated. Both containers were nearly empty. On 4/7/24 at 8:52 A.M. the surveyor made the following observations in the first floor unit kitchenette's refrigerator: - An unlabeled and undated mayonnaise-based sandwich on a plate with a plate cover. - Three juices opened but undated. During an interview on 4/8/24 at 7:14 A.M. the Food Service Director (FSD) said all food should be labeled when opened or prepared. The FSD said the use-by date is automatically generated by the label-printing system which has pre-programmed use-by dates depending on the food item. The FSD said he defers to the pre-programmed use-by dates as they are updated regularly, and all food items should be discarded after the use-by date. The FSD said the dietary department is responsible for regularly checking the kitchenette refrigerators and that all unlabeled foods, or food kept for over three days must be discarded. The FSD said all staff members in the food preparation area of the kitchen should be wearing hairnets at all times. The FSD also said cans should be inspected on delivery and that all dented cans, including the observed dented can of marinara, should be placed in his office to be discarded and should not be placed on the can rack as this poses a risk for botulism (a serious illness caused by a toxin produced by Clostridium botulinum bacteria that attacks the body's nerves and causes difficulty breathing, muscle paralysis, and even death).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #18 was admitted to the facility in June 2023 with diagnoses including diabetes and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the physician's order, dated 12/29/23, indicated: -Air mattress to bed Setting ALT (alternating) 250 or per resident comfort. Check placement and function Q (every) shift. Review of Resident #18's plan of care related to actual skin breakdown, last revised 2/28/24, indicated: -Air mattress to bed Setting ALT (alternating) 250 or per resident comfort. Check placement and function Q (every) shift. Review of TELS (an electronic system used to request maintenance services) work order, dated 3/26/24, indicated a request to replace air mattress was created on 3/26/24 at 1:59 P.M. This order has a status update of completed on 3/27/24 at 9:36 A.M. Review of Treatment Administration Record (TAR), dated 3/27/24, 3/28/24, 3/29/24, 3/30/34, 3/31/24, 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/5/24, and 4/6/24, indicated the order to check for air mattress placement and function was documented as implemented. On 4/7/24 at 8:43 A.M. and 4/8/24 at 7:52 A.M., the surveyor observed Resident #18 in bed, not on an air mattress. Resident #18 said his/her air mattress was broken and had been removed a few weeks ago. Resident #18 said he/she was supposed to get a new air mattress, but it had not come yet. During an interview on 4/8/24 at 9:52 A.M., Unit Manager #2 said she put in a request in the TELS system to replace Resident #18's air mattress with another air mattress on 3/25/24. Unit Manager said it was replaced with a regular mattress and since Resident #18's wound had healed she decided not to request another air mattress. Unit Manager said she noticed there was still an order for it yesterday, when the survey began, so she discontinued the order without discussing with the physician. During an interview on 4/8/24 at 9:42 A.M., the Assistant Director of Nursing (ADON) said the order to check placement and function of an air mattress order should not be marked on the Treatment Administration Record (TAR) as implemented if the Resident was not on an air mattress. During an interview on 4/9/24 at 12:22 P.M., the Director of Nursing (DON) said the order to check placement and function of an air mattress order should not be marked on the Treatment Administration Record (TAR) as implemented if the Resident was not on an air mattress. 3.) Resident #41 was admitted to the facility in June 2023 with diagnoses including dementia and anemia Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #41 had an arterial/venous wound. Review of wound physician progress note, dated 3/20/24, indicated Resident #41 had an unhealed right ankle arterial ulcer. This note indicated Resident #41's had a physician's order to apply iodosorb (a gel that's applied to the skin to treat wet ulcers and wounds) and then apply gentac (a gentle silicone adhesive dressing) to his/her right ankle arterial ulcer. Review of Resident #41's physician's order, dated 3/15/24, indicated: -Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam (border foam), change daily, and PRN (Pro Re Nata, which is a Latin phrase meaning as necessary.) On 4/7/24 at 9:18 A.M., 4/8/24 at 8:19 A.M., and 4/8/24 11:54 A.M., Resident #41 was observed with a wound on his/her right ankle that had yellowish/brown hardened scab-like wound bed that was approximately the size of a pea. There was no dressing on his/her right ankle. During an interview on 4/8/24 at 8:19 A.M., Resident #41 said nursing had not put a dressing on his/her right ankle wound since Friday (4/5/24) because there was nobody around to do it. Resident #41 said he/she asked for a dressing to be put on but the nurse did not because they were too busy. Review of Treatment Administration Record, dated 4/7/24 and 4/8/24, indicated the nurses had documented the physician's order for Wound Documentation: Right lateral ankle cleanse with wound cleanser, pat dry apply iodosorb and over with Gentac/b-foam, change daily, and PRN had been implemented. During an interview on 4/9/24 at 9:22 A.M., the Assistant Director of Nursing (ADON) said if dressing was not completed, it should not be documented as implemented. During an interview on 4/9/24 at 12:22 P.M., the Director of Nursing (DON) said if an order was was not implemented, it should not be documented as implemented. 4.) Resident #61 was admitted to the facility in May 2021 with diagnoses including dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/1/24, indicated Resident #61 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Review of dietitian note, dated 9/1/23, indicated Resident #61's order for liquid protein was discontinued. This note indicated collaboration with Resident #61's provider. Review of physician's orders history indicated the following order was discontinued by provider 9/1/23: -Active Liquid Protein **Sugar Free 16 GM (gram)/30ML (milliliter). Review of physician note, dated 2/21/24, indicated Resident #61 should continue with daily liquid protein supplements for malnutrition and a stage four pressure ulcer. During an interview on 4/10/24 at 9:20 A.M., Regional Nurse #1 said the physician documented this in error because Resident #61 had an order for liquid protein discontinued based on his/her clinical status on 9/1/23. During an interview on 4/10/24 at 9:45 A.M., the Director of Nursing (DON) said the physician documented the plan to continue liquid protein in error because the physician had discontinued the order. Based on record review and interviews, the facility failed to maintain accurate medical records for four Residents (#100, #18, #41, and #61) out of a total sample of 28 residents. Specifically, 1.) For Resident #100, the facility failed to complete daily documentation for Activities of Daily Living (ADLs), 2.) For Resident #18, the facility failed to ensure nursing accurately documented the presence and function of an air mattress, 3.) For Resident #41, the facility failed to ensure a nurse accurately documented a wound dressing as not completed, instead of as completed, and 4.) For Resident #61, the facility failed to ensure a physician's plan of care for liquid protein for wound healing and malnutrition was documented accurately. 1.) Resident #100 was admitted to the facility in April 2023 with diagnoses including depression, anxiety and schizophrenia. Review of Resident #100's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #100 was dependent on staff for transfers. Review of the shower documentation section on the document titled, Documentation Survey Report, dated April 2024, indicated documentation was incomplete for 15 of the possible 27 nursing shifts. During an interview on 4/9/24 at 11:47 A.M., the Staff Development Coordinator (SDC) said Certified Nursing Assistants (CNAs) document daily for ADLs. The SDC said CNAs should document every shift and there should be no holes(incomplete sections) in the documentation. During an interview on 4/9/24 at 12:19 A.M., the Director of Nursing (DON) said CNAs should be documenting a Resident's level of care/assistance needed during all shifts of care. The DON said CNA documentation has been identified as an issue in the building and the facility needs to develop a plan to ensure all documentation is completed throughout all shifts.

Based on staffing level reviews and interviews, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs. Findings include: During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report, submitted by the facility for Fiscal Year (FY) Quarter 1 2024 (October 1, 2023 - December 31, 2023), was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. Review of the facility assessment indicated the following: - Based on the above information and programming goals, a staffing plan has been developed to meet the professional, technical and administrative needs of the center. The plan is informed by historical experience, and projected changes. The approach takes into consideration both the type of staff (licensure or other credential) and number provided. SEE ATTACHMENT 1 - Staffing by shift. -Attachment 1 indicated the total Direct Care PPD (Per Patient Day) was .87 and Nursing PPD was 3.91. The Administrator provided the surveyor with the expected daily PPD of the facility. The weekday expected PPD was 3.392 and the weekend expected PPD was 3.22. Review of the daily schedules from October to December 2023 indicated that 59 of 66 weekday shifts during this time frame were below the facility's expected staffing levels, with only 7 weekday shifts reaching a PPD of 3.392. Review of the daily schedules from October to December 2023 indicated that 19 of 27 weekend shifts during this time frame were below the facility's expected staffing levels, with only 8 weekend shifts reaching a PPD of 3.22. Review of the daily schedules from January to April 2024 indicated that 65 of 73 weekday shifts during this time frame were below the facility's expected staffing levels, with only 8 weekday shifts reaching a PPD of 3.392. Review of the daily schedules from January to April 2024 indicated that 12 of 28 weekend shifts during this time frame were below the facility's expected staffing levels, with only 16 weekend shifts reaching a PPD of 3.22. During an interview on 4/9/24 at 1:45 P.M., Certified Nurse Aide (CNA) #4 said she is unable to shower residents and is unable to change residents on time due to staffing levels at the facility. CNA #4 said it is hard to answer call lights when they are short staffed during the week and the weekend. During an interview on 4/9/24 at 1:46 P.M., CNA #7 said she is unable to shower residents at times and is unable to always check and change incontinent residents during both the week and weekend shifts due to staffing. During an interview on 4/9/24 at 7:48 A.M., Nurse #4 said she did not know the residents on her assignment because she does not usually work on this unit and has to float around to different assignments. During an interview on 4/10/24 at 7:57 A.M., the Administrator said staffing is always difficult, but she feels the building has made significant improvement in staffing levels over the past few months. The Administrator said the facility has been focusing on recruitment and has been able to hire a lot of new staff, which has helped their staffing levels. The Administrator said she feels the daily staffing PPD levels have been met. The Administrator said it is common in all buildings for staff to complain there is not enough staff in the building and that the facility staffs to the census.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error when his/her admission Physician Order for Metoprolol, (medication used to treat high blood pressure) was not transcribed into his/her Medication Administration Record (MAR) and as a result, he/she was not administered the medication for several days. Findings Include: The Facility Policy titled Adverse Consequences and Medication Errors, dated as revised February 2023, indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with Physician's Orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. The Policy indicated that examples of medication errors included omission, when a drug is ordered but not administered. Resident #1 was admitted to the Facility in December 2023, diagnoses included muscle weakness, depression, acute kidney failure, atrial fibrillation (an irregular often rapid heart rate commonly causing poor blood flow), and hypertension (high blood pressure). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was to be administered Metoprolol Succinate XL 50 mg, one tablet by mouth daily. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/26/23, indicated that on 12/19/23 it was discovered that Resident #1 had not received his/her Metoprolol Succinate 50 milligrams (mg) daily from 12/08/23 through 12/12/23, which had been prescribed upon admission. The Report indicated that the medication omission had been discovered after Resident #1 had been re-admitted to the Facility after he/she had been transferred from the Facility to the Hospital Emergency Department for high blood pressure. Review of the Facility Medication Error Report, dated 12/19/23, indicated that when Resident #1 was admitted to the Facility, an order for his/her Metoprolol Succinate 50 mg by mouth daily had not been transcribed (onto his/her MAR) upon admission. Review of Resident #1's MAR, for the month of December 2023, indicated there was no order for Metoprolol and therefore he/she had not been administered the medication by nursing from 12/08/23 through 12/12/23. Review of the Situation, Background, Assessment, and Recommendation (SBAR) Form, dated 12/12/23, indicated Resident #1 experienced a change of condition and was hypertensive. The Form indicated that Resident #1's blood pressure was 198/99 and his/her heart rate was 123 (beats per minute) and indicated that 911 was called. During an interview on 02/12/24 at 1:52 P.M., Nurse #6 said when she admitted Resident #1 to the Facility, she had not transcribed Resident #1's Metoprolol onto his/her MAR by mistake and said it was an oversight. During an interview on 02/12/24 at 2:48 P.M., the Director of Nursing (DON) said nursing had not administered five doses of Resident #1's Metoprolol because it had not been transcribed onto his/her MAR from the Hospital Discharge Summary Orders upon admission. The DON said the medication error occurred because the transcription error was an oversight on Nurse #6's part. On 02/12/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 12/20/23, Unit Managers and/or their designee began audits on the next business day for residents newly admitted and/or readmitted to ensure a medication reconciliation has been completed and that admission Orders are accurately transcribed. Audit sheets will be submitted to the DON. B) 12/21/23, the DON and Regional Clinical Nurse completed audits on all residents newly admitted and/or readmitted over past thirty days, which included reviewing the resident's admission orders and comparing them to the resident's MAR. C) 12/22/23, the DON and Facility Educator educated nursing staff about the procedure for order transcription during the resident admission process and about ensuring that orders transcribed into a resident's MAR are double checked by a second nurse. D) DON will continue with follow-up audits by reviewing five random resident Medical Records daily to ensure the resident's admission and Physician's Orders were transcribed accurately. This will be completed for three weeks and then will be completed monthly for two months. E) 01/31/24, the DON presented the Facility's Plan of Correction and audits to the Quality Assurance Performance Improvement Committee and will continue to present the Plan of Correction for two more months. F) DON and/or Designee are responsible for overall compliance.

Based on record review and interview, the facility failed to to report, to the State Agency (SA), an allegation of abuse for 1 discharged (DC) Resident (#DC1) out of a total 33 sampled residents. Findings include: The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, indicated the following: * All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of a filed grievance, dated 4/25/22, indicated the following: * Resident #DC1 reported on Sunday 4/24/22 that he/she rang his/her call bell due to needing assistance with care. He/she stated no one answered his/her call bell for over one hour. Resident #DC1 reported that by the time staff came to assist him/her, the urine had dried. Resident #DC1 also informed the writer he/she contacted the elder abuse hotline today to report lack of assistance. * The facility's response to the grievance indicated verbal education with 1st floor staff to ensure compliance with call bell response time. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) failed to indicate the allegation of neglect/abuse was reported. During an interview on 2/01/23 at 9:26 A.M., the Social Worker #1 said in this case, I think this was something that should have been reported, but that the decision was made to not report by the former Administrator. During an interview with the current Administrator on 2/01/23 at 10:32 A.M., she said the allegation should have been reported to the State Agency.

Based on record review and interview the facility failed to investigate an allegation of abuse by one discharged (DC) Resident (# DC1) out of a total 33 sampled residents. Findings include: The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated as revised September 2022, indicated the following: * All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. * Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations. 7. The individual conducting the investigation as a minimum: d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; l. documents the investigation completely and thoroughly. 8. The following guidelines are used when conducting interviews: d. witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain the statement. Review of a filed grievance, dated 4/25/22, indicated the following: * Resident #DC1 reported on Sunday 4/24/22 that he/she rang his/her call bell due to needing assistance with care. He/she stated no one answered his/her call bell for over one hour. He/she stated by the time staff came to assist him/her, the urine had dried. He/she also informed the writer he/she contacted the elder abuse hotline today to report lack of assistance. * The facility's response to the grievance indicated verbal education with 1st floor staff to ensure compliance with call bell response time. The grievance failed to indicate any witness statements were obtained from any other residents or staff or that a thorough investigation into the incident had been completed. During an interview on 2/01/23 at 9:26 A.M., Social Worker #1 said that the facility expectation, when there is an allegation of abuse, is that the social worker meet with the resident to find out what the specific concern is in order to initiate an investigation. Social Worker #1 said in this case, I think this was something that should have been investigated, but that the decision was made by the former Administrator to treat it as a customer service concern and provide customer service training to the staff on the unit. During an interview with the current Administrator on 2/01/23 at 10:32 A.M., she said the allegation should have been investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to identify a new pressure area on 1 Resident (#107) out of a total sample of 33 residents. Findings include: Resident #107 was admitted to the facility in December 2021 with diagnoses including muscle weakness. Review of Resident #107's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident has a Brief Interview for Mental Status of 13 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #107 requires extensive assistance from staff for bed mobility tasks. During an interview on 1/29/23 at 8:19 A.M., Resident #107 said his/her right outer ankle has been painful with an open skin lesion for 3-4 days and he/she has been asking the nursing staff for a bandaid. Resident #107 said the staff have repeatedly told him/her that they would let the doctor know, however no one has followed-up with him/her. Resident #107's right outer ankle was observed to have a small open area with redness surrounding it. Review of the Treatment Administration Record for the month of January 2023 indicating Resident #107 had been receiving diabetic foot care nightly. Review of the Medication Administration Record for January 2023 indicated skin checks had not been completed on 1/3/23 and 1/17/23. Review of Resident #107's medical record failed to indicate an observation, assessment or treatment of the area to the Resident's right ankle until 1/31/23. Review of the nursing note dated 1/31/23 indicated a new pressure area to Resident #107's right ankle. During an interview on 1/31/23 at 11:16 A.M., the Assistant Director of Nursing (ADON) said nurses providing diabetic foot care would look at the skin condition of the entire foot which would also include the ankle. The ADON said if a resident had an open area on the ankle, this would be observed during diabetic foot care.

Based on observation, interview and record review the facility failed to ensure 1 Resident (#91) was assessed and evaluated after sustaining a fall, out of a total sample of 33 Residents. Findings include: Resident #91 was admitted in January 2021 with diagnoses that included Dementia, dysphagia, and hypertension. Review of the facility's policy, titled Falls, dated March 2018, indicated the nurse shall assess, and document/report. On 1/29/23 at 7:00 A.M., two surveyors observed Resident #91 on his/her knees next to his/her bed. The Resident said he/she fell. Resident #91 had a light green comforter wrapped around his lower legs. Resident #25 was observed to have a cut to the left elbow with bruising and bleeding. The surveyors observed a Certified Nurse Aide (CNA) #2 report the fall to the 11-7 nurse who stated I will need help. Review of Resident #91's Medical Record failed to indicate that any assessment status post fall was completed. Review of Resident #91's Progress Notes failed to indicate that any assessment status post fall was completed or that the Physician was notified. Further review of the progress notes indicated the last note written was on 1/26/23. Review of Resident #91's At Risk for Falls Care Plan indicated the last revision date was 8/5/22. During an interview on 1/30/23 at 11:03 A.M., Unit Manager #1 said the process when a resident falls is the nurse would obtain vitals, assess the patient, get assistance if needed, call the Physician to inform them of the fall, call the Health Care Proxy if it is invoked, obtain witness statements, complete the fall packet, obtain neuro checks if it is an unwitnessed fall and send the resident to the hospital if needed. The Unit Manager acknowledged that the 11-7 nurse did not pass off in shift report that Resident #91 had fallen and none of the assessments have been completed, she also said the Physician or Health Care Proxy had not been informed. During an interview on 2/01/23 at 8:09 A.M., the Director of Nursing said her expectation after a resident falls is that the nurse on shift immediately starts an investigation and a fall packet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to replace the dentures of 1 Resident (#100) out of a total sample of 33 residents. Findings Include: Review of the facility policy, titled Dentures, Cleaning, and Storing, revised March 2018 indicated the following: *Damaged, broken, ill-fitting, or lost dentures. The certified nursing assistant should report to the licensed nurse or social services, as required by facility policy. Resident #100 was admitted in August 2022 with diagnoses including mild cognitive impairment. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #100 scored an 8 out of a possible total score of 15 on the Brief Interview for Mental Status (BIMS), which indicates mild cognitive impairment. Resident #100 relies on the extensive assistance of one staff member for personal hygiene, including oral care. Review of the Dental Exam, dated 8/31/22, indicated Resident #100 had no top teeth and had requested new dentures. The dentist recommended fabrication of new dentures, obtained a signed consent, performed impressions for the Resident's new dentures and informed the nurse. Review of the Dental Exam, dated 9/29/22, indicated Resident #100 received the new dentures, and the nurse was informed. Review of the Dental Exam, dated 12/12/22, indicated that Resident #100's new dentures were missing, and the nurse was informed. During an interview on 1/29/23, at 7:10 A.M., Resident #100 said that he/she used to have dentures, and had asked facility staff for new dentures a few months prior but has not heard back or received a replacement. During an observation on 1/29/23, at 7:10 A.M., dentures were not present in Resident #100's room or mouth. During an interview on 1/31/22, at 9:53 A.M., Unit Manager #2 said that he was unsure if Resident #100 had dentures, and that the Resident's dentures were not documented on Unit Manager #2's list of pertinent information. During an interview on 1/31/22 at 10:00 A.M., the Director of Nursing (DON) said that if dentures are misplaced the facility will try to locate them. If the facility is unable to locate the dentures this will be reported to social services, a grievance will be filed and the dentures will be replaced. The DON is unsure if Resident #100 has dentures. During an interview on 1/31/22, at 1:50 P.M., the Administrator said the dental office confirmed that the Resident received new dentures in September 2022 and she had started the process for replacing the dentures today, two months after nursing was informed of the missing dentures by the dentist. She said that social services was not aware of the missing dentures. The Assistant Director of Nurses (ADON) said that if a nurse is informed of missing dentures, the expectation would be that the nurse reports this information to management and/or social services. The ADON said that management was not aware that the dentures were missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure accurate medical records for 2 Residents (#94 and #97) out of a total sample of 33 residents. Findings include: 1. Resident #94 was admitted to the facility in July 2021 with diagnoses including muscle weakness, diabetes and stroke. Review of Resident #94's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 15 out of a possible 15 which indicates he/she is cognitively intact. On 1/29/23 at 12:37 P.M., Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. On 1/30/23 at 8:10 A.M, Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. On 1/31/23 at 6:35 A.M., Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. Review of Resident #94's physician orders indicated the following orders: *Apply ace wraps to RLE (right lower extremity) daily at 6am off at 6pm, every day and evening shift, initiated on 6/2/22. Review of the Medication Administration Report for the month of January 2023 indicated the nurse marked the order as complete for January 29, 30 and 31, despite the observations the ace wraps were not present. During an interview on 1/31/23 at 8:05 A.M., Nurse #9 said she was unaware Resident #94 had orders for ace wraps and did not know why they were not on. Nurse #9 said she could not look at orders that took place before her shift started at 7:00 A.M. During an interview on 1/31/23 at 8:21 A.M., Unit Manager #2 was unaware that Resident #97 was not wearing the ordered ace wraps during the surveyor observations and was also unaware that the overnight nurse had marked the order as complete even though it was not. 2. Resident #97 was admitted to the facility in January 2021 with diagnoses including stroke and hemiplegia. Review of Resident #97's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 5 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #97 requires extensive assistance from staff for all functional daily tasks. On 1/29/23 at 9:59 A.M., Resident #97 was observed lying in bed. He/she did not ave any ace wraps to his/her leg. On 1/30/23 at 6:56 A.M., Resident #97 was observed lying in bed. He/she did not ave any ace wraps to his/her leg. Review of Resident #97's physician orders indicated the following order: * Apply ace wraps to RLE (right lower extremity) daily at 6am off at 6pm, every day and evening shift. Review of the Medication Administration Record for January 2023 indicated the nurse marked the order as complete for January 29th and 30th, despite the observations the ace wraps were not present. During an interview on 1/30/23 at 8:21 A.M., Unit Manager #2 observed Resident #97's legs and said the ace wraps were not on as ordered. Unit Manager #2 was unaware the nurse had marked the order as complete, even though it had not been done.

Based on record review and interview, the facility failed to monitor a Quality Assurance and Performance Improvement (QAPI) plan for the call bell wait times from the month of July 2022 to present. Findings include: Review of the resident council minutes for the year of 2022 indicated that from July 2022 to present, the resident council expressed that call bell wait times were a concern in the facility. During an interview on 2/1/23 at 10:26 A.M., the Administrator said that call bell wait times was brought to QAPI in the months of January, March, April, and July. The Administrator said that if call bell wait times was a consistent issue that was brought to resident council then she would expect a QAPI plan to be developed for the issue. The Administrator said she couldn't see a QAPI plan done since July for the call bell wait time concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #60 was admitted in June 2022 with diagnoses that included major depressive disorder, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood. Review of the facility's policy titled Care Planning, dated March 2022, indicated the interdisciplinary team is responsible for the development of the resident care plans. Review of Resident #60's Behavioral Health Note dated 7/1/22, indicated Substance Use / Addiction History: records indicate Polysubstance abuse Nicotine. Review of Resident #60's Behavioral Health Note dated 12/31/22, indicated Substance Use / Addiction History: records indicate Polysubstance abuse Nicotine. Review of Resident #60's Nursing Progress Note dated 1/23/23, indicated Patient (pt) was assessed in his/her room to be nonresponsive. Respiratory depression. VS 96.7-58-12-106/60, 80% on room air. Pt was nonverbal, unconscious. Applied 5 L o2 (liters of oxygen) on nonrebreather. Lung sounds were labored and shallow. Administered 4 mg naloxone (a medication used for a suspected overdose) intranasal at 11:05 and 11:20. Review of Resident #60's Nurse Practitioner Progress Note, dated 1/26/23, indicated Today pt (resident) seen at NSG (nursing) request in f/u on recent event of unresponsiveness w/ slow reaction to narcan x2, meds were not administered from the night before. Pt w/ recent visitors,? narc brought from outside. Pt was tx (transported) to the hospital where also had unresponsive episode responded to IV narcan. Review of Resident #60's Hospital Discharge summary, dated [DATE], indicated Has prior history of substance use disorder as well as per facility history of pocketing prescription pain medication. Etiologies include medication overdose. Review of Resident #60's medical record failed to indicate that a history substance abuse care plan was developed. During an interview on 1/31/23 at 12:07 P.M., Unit Manager #1 said Resident #60 had a known history of substance abuse and said it hasn't been proven but staff have wondered if he has cheeked medication during his stay here. During an interview on 1/31/23 at 12:23 P.M., the Director of Nursing said she would expect a care plan to be developed with someone with a past history of substance abuse especially because Resident #60 went to the hospital for a suspected overdose. 2. For Resident #94, the facility failed to follow a physician's order for ace wraps and skin checks. Resident #94 was admitted to the facility in July 2021 with diagnoses including muscle weakness, diabetes and stroke. Review of Resident #94's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 15 out of a possible 15 which indicates he/she is cognitively intact. On 1/29/23 at 12:37 P.M., Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. On 1/30/23 at 8:10 A.M, Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. On 1/31/23 at 6:35 A.M., Resident #94 was observed lying in bed. Both legs were exposed, and he/she was observed wearing a johnny only, without any ace wraps to either leg. Review of Resident #94's physician orders indicated the following orders: *Apply ace wraps to RLE (right lower extremity) daily at 6am off at 6pm, every day and evening shift, initiated on 6/2/22. *Weekly skin check every Thursday, initiated on 1/5/23. Review of the Medication Administration Report for the month of January 2023 indicated skin checks had not been completed on 1/5/23 and 1/19/23. During an interview on 1/31/23 at 8:05 A.M., Nurse #9 said she was unaware Resident #94 had orders for ace wraps and did not know why they were not on. During an interview on 1/31/23 at 8:21 A.M., Unit Manager #2 was unaware that Resident #94 was not wearing the ordered ace wraps during the surveyor observations and was also unaware of the missed skin checks. Based on record review and interview, the facility failed to 1. develop a care plan for 2 Residents (#209 and #206), after expressing suicidal ideation, 2) failed to implement physician orders for 1 Resident (#97) and 3) failed to develop a care plan for substance abuse for 1 Resident (#60) out of a total sample of 33 residents. Findings include: Review of the facility policy, titled Depression- Clinical Protocol, dated November 2018, indicated the following: -The physician and staff will review available information and inquire further to identify and document individuals who have a history of depression or another mood disorder, other psychiatric disorders, psychiatric treatment or hospitalizations, or suicide attempts. -The staff will provide pertinent individualized non-pharmacological interventions for the individual with depression; for example, addressing related psychological, spiritual, and family issues. 1a. Resident #209 was admitted in 08/2021 with diagnoses including depression, schizzoaffective disorder, and obsessive compulsive disorder. Review of the minimum data set (MDS), dated [DATE], indicated that Resident #209 scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS), which indicates intact cognition. Review of the progress note, dated 9/23/21, indicated that Resident #209 had a change in condition and was hearing voices, called 911 several times, and was sent to the hospital. Review of another progress note, dated 9/23/21, indicated that the hospital had called the facility and said that Resident #209 stated that if he/she came back to the facility, then he/she was going to kill him/herself. Review of the clinical record indicated that Resident #209 was re-admitted to the facility on [DATE]. Review of the clinical record did not indicate that Resident #209's care plan was updated or a care plan was created after the new onset of suicidal ideation. Review of the clinical record indicated that on 10/29/21, Resident #209 was found in his/her room attempting to kill him/herself with the metal piece of the call bed light. Review of the care plan indicated that, on 11/1/21, a care plan for suicidal risk related to depression was created, 6 days after Resident #209's re-admission back to the facility. During an interview on 1/30/23 at 8:41 A.M., Social Worker #1 said that when a resident expresses suicidal ideation, a care plan should be created and if someone was admitted with a history of suicidal ideation, then a care plan should be developed. 1b. Resident #206 was admitted to the facility in 01/2023 with diagnoses including dementia. Review of the minimum data set (MDS), dated [DATE], indicated that Resident #206 was unable to participate in the Brief Interview for Mental Status (BIMS). Review of the progress note, dated 10/23/23, indicated that Resident #206's family told the facility that Resident #206 had asked for his/her pills to kill him/herself due to being sick 3 days prior to admission. The progress note indicated that Resident #206 declined depressive thoughts or a plan. Review of the care plan did not indicate that a care plan had been initiated for Resident #206 regarding suicidal ideation. During an interview on 1/31/23 at 11:55 A.M., Social Worker #2 said that he would expect a care plan to be initiated for anyone that expresses suicidal ideation. During an interview on 1/30/23 at 8:41 A.M., Social Worker #1 said that when a resident expresses suicidal ideation, a care plan should be created and if someone was admitted with a history of suicidal ideation, then a care plan should be developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #46 was admitted to the facility in January of 2022 with diagnoses that included Dementia, unspecified protein-calorie malnutrition and type 2 diabetes . Review of the facility's policy titled, Weight Assessment and Intervention, dated June 2022, indicated residents are weighed upon admission and at intervals established by the interdisciplinary team such as: as ordered. Weights will be recorded in each resident's medical record. Review of Resident #46's Medical Record indicated the only weight taken in December 2022 was on 12/2/22 which was 137.6 pounds and in January 2023 was on 1/9/23 which was 132.5 pounds, no further weights have been taken since. Review of Resident #46's Nutrition Care Plan, dated 1/31/22, indicated weights as ordered. Review of Resident #46's January Physician Orders indicated Weekly Weights. Review of Resident #46's Nutrition Evaluation, dated 1/4/23, indicated weekly weights. Review of Resident #46's Certified Nurse Aide (CNA) [NAME], dated 1/30/23, indicated Weigh Weekly. During an interview on 1/31/23 at 8:23 A.M., CNA #1 said the Resident's [NAME] will tell us how to care for the resident and how often they should be weighed. During an interview on 1/31/23 at 8:24 A.M., the Assistant Director of Nursing and Unit Manager #1 said the CNA [NAME] will tell what assistance level a resident needs and the care plan which filters into the CNA [NAME]. During an interview on 1/31/23 at 12:10 P.M., the Dietitian said she would expect nursing to obtain the weekly weight as ordered. During an interview on 2/01/23 at 8:09 A.M., the Director of Nursing (DON) said if someone has an order for weekly weights she would expect the weight to obtained weekly. The DON also said she would expect that the nursing staff would read the Physician's order and not just look for an empty block on the MAR. 3. Resident #79 was admitted to the facility in June 2021 with diagnoses including dementia. Review of Resident #79's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 6 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #79 requires extensive assistance from staff for bed mobility. On 1/29/23 at 11:09 A.M., Resident #79 was observed lying in bed with his/her air mattress set to the level of 320 lbs (pounds). On 1/30/23 at 2:00 P.M., Resident #79 was observed lying in bed with his/her air mattress set to the level of 320 lbs. On 1/31/23 at 6:41 A.M., and at 10:45 A.M., Resident #79 was observed lying in bed with his/her air mattress set to the level of 400 lbs. Review of Resident #79's weight log indicated her was last weighed on 12/1/22 and his/her weight was 133.4lbs. Review of Resident #79's physician orders indicated the following order initiated on 12/7/22: *Air mattress with setting of 4 lights down from the top. Check placement and function every shift Review of Resident #79s skin integrity care plan, last revised 1/27/23, indicated the following intervention: *Pressure relieving mattress on bed and cushion on wheel chair - air mattress with setting of 160 lbs. During an interview on 1/31/23 at 10:50 A.M., Nurse #8 said she was unaware of what setting Resident #79's air mattress should be set to. During an interview on 1/31/23 at 10:55 A.M., Unit Manager #1 said the air mattress should be set to the level that the physician order is written to. Unit Manager #1 said she was unaware that Resident #79 was on an air mattress that was set by weight, not level as the current physician order read. Unit Manager #1 said the air mattress should be set to the Resident's weight and that 300-400 pounds is too heavy of a weight for Resident #79. During an interview on 1/31/23 at approximately 11:00 A.M., the Assistant Director of Nursing (ADON) said Resident #79's type of air mattress must have changed once he/she was admitted to hospice and the physician order did not match the newer air mattress that the Resident is currently using. The ADON said the air mattress should be set to the Resident's weight. Based on observation, record review and interview the facility failed to ensure professional standards for 1. staff sleeping while on resident units, 2. obtaining weekly weights as ordered for one Resident (#46) and 3. setting a Resident's (#79) air mattress at the setting ordered by the physician, out of a total 33 sampled residents. 1. Review of the facility's Human Resources Policies and Procedures Manual, dated June 2007, indicated Inappropriate Workplace Behavior/ Inappropriate Professional Behavior- The Facility (Care One) expects all employees to serve as a positive reflection of the facility by being courteous and respectful to co-workers and residents at all times. Sleeping on the job. During an observation on 1/30/23 at 3:57 A.M., on the 2nd floor unit the surveyor observed a Certified Nursing Assistant (CNA) #4 slumped low in a chair, soundly sleeping. During an interview on 1/30/23 at 3:59 A.M., Nurse #6 said it was the expectation that staff not sleep on the resident units. During an observation on 1/30/23 at 4:00 A.M., CNA #4's alarm sounded loudly. Nurse #6 and the surveyor observed CNA #4 wake up, sit up and turn off the alarm on his telephone. During an interview with CNA #4 on 1/30/23 at 4:02 A.M., he acknowledged that he had been sleeping and said that he was exhausted because he had worked a double shift. During an observation on 1/30/23 at 3:59 A.M., the surveyor observed a Certified Nurses Aide (CNA #3) asleep in a chair with her head on a bedside table on the third floor. During an interview on 1/30/23 at 4:03 A.M., Nurse #1 said the expectation for the CNA is to stay awake all shift so they can provide care to the residents and said she does try to wake them if she notices they are asleep. Review of the facility's grievance log book indicated a grievance dated 7/28/22, with a concern staff seen sleeping at desk or end of hallways on 11pm -7 am shifts. During the Resident Group interview on 1/30/23 at 10:10 A.M., 2 of 5 residents participating in the meeting said that they had seen staff sleeping on the 11-7 shift and that it had been reported to Nurse Unit Manager #2. During an interview on 2/01/23 at 7:59 A.M., the Administrator and the Director of Nursing (DON) said that it is the expectation that staff stay awake their entire shift. The DON said if staff are tired they should clock out and tell the nurse on duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #50 was admitted to the facility in October of 2018 with diagnoses that included Alzheimer's Disease, feeding difficulties and dysphagia. On 1/29/23 the surveyor observed the following: * From 8:47 A.M. to 9:09 A.M., the surveyor observed Resident #50 in bed staring at his/her breakfast tray, not initiating self feeding without supervision. * From 12:37 P.M. to 12:40 P.M., the surveyor observed Resident #50 in bed staring at his/her lunch tray, not initiating self feeding, without supervision. On 1/30/23 the surveyor observed the following: * From 8:27 A.M. to 8:39 A.M., the surveyor observed Resident #50 in bed staring at his/her breakfast tray and was crying, not initiating self feeding, without supervision. On 1/31/23 the surveyor observed the following: * From 12:13 P.M. to 12:25 P.M., the surveyor observed Resident #50 in a chair next to his/her bed alone with his/her lunch tray. Review of Resident #50's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #50 was unable to complete the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS also indicated for eating that Resident #50 needed a one person physical assist with limited assistance. Review of Resident #50's Certified Nurse Aide (CNA) [NAME], dated 1/30/23, indicated continual supervision (1:8) with eating may and need to be fed. Review of Resident #50's Activity of Daily Living (ADL) Care Plan, dated 7/13/21, indicated continual supervision (1:8) with eating and may need to be fed. Review of Resident #50's Nutrition Follow Up Note, dated 1/3/23, indicated chewing/swallowing difficulty, diet modified in texture weight loss. During an interview on 1/31/23 at 8:23 A.M., CNA #1 said the Resident's [NAME] will tell us how to care for the resident. During an interview on 1/31/23 at 8:24 A.M., the Assistant Director of Nursing and Unit Manager #1 said the CNA [NAME] will tell what assistance level a resident needs and the care plan which filters into the [NAME] and said they would expect supervision to be provided as the [NAME] or care plan reads. 3. Resident #91 was re-admitted in January 2021 with diagnoses that included Dementia, dysphagia, and hypertension. On 1/29/23 the surveyor observed the following: * From 8:49 A.M. to 8:58 A.M., Resident #91 was observed sitting on the edge of the bed eating his/her breakfast alone without supervision. * At 12:45 P.M., Resident #91 was observed sitting on the edge of the bed eating his/her lunch alone without supervision. On 1/30/23 the surveyor observed the following: * From 8:12 A.M. to 8:33 A.M., Resident #91 was observed sitting on the edge of the bed eating his/her breakfast alone without supervision. On 1/31/23 the surveyor observed the following: * From 8:26 A.M. to 8:29 A.M., Resident #91 was observed sitting on the edge of the bed eating his/her breakfast alone without supervision. * From 12:23 P.M. to 12:28 P.M., Resident #91 was observed sitting on the edge of the bed eating his/her lunch alone without supervision. Review of Resident#91's most recent Minimum Data Set (MDS) dated [DATE], indicated for eating Resident #91 needed one person physical assist and supervision. The MDS also indicated Resident #91 was unable to complete the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. Review of Resident #91's Certified Nurse Aide (CNA) [NAME] dated 1/30/23 indicated continuous supervision of 1:8 for meals, needs encouragement. Review of Resident #91's Activity of Daily Living (ADL) Care Plan, dated 3/4/21, indicated continuous supervision of 1:8 for meals, needs encouragement. During an interview on 1/31/23 at 8:23 A.M., CNA #1 said the Resident's [NAME] will tell us how to care for the resident and how much assistance they need for ADLs. During an interview on 1/31/23 at 8:24 A.M., the Assistant Director of Nursing and Unit Manager #1 said the CNA [NAME] will tell what assistance level a resident needs and the care plan which filters into the [NAME] and said they would expect supervision to be provided as the [NAME] or care plan reads. Based on observation, record review and interview the facility failed to provide required Activity Daily Living (ADL) assistance to 3 Residents (#35, #50 and #91), out of a total 33 sampled residents. Findings Include: 1. Resident #35 was admitted to the facility in October 2020 and has diagnoses that include dementia and encephalopathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/22, indicated Resident #35 was unable to complete the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #35 required extensive 1 person physical assistance with eating and bed mobility. During an observation on 1/29/23 at 8:31 A.M., Resident #35 was observed on the side of his/her bed, hunched over a tray table, feeding him/herself breakfast. No staff were present to supervise or assist the Resident. During a record review the following was indicated: * A Licensed Nursing Summary, dated 1/28/23, indicated Resident #35 requires continual supervision 1:8 ratio with meals. * An Activities of Daily Living (ADL) care plan: Supervision with eating 1:8 and assist of (1 person) with ADLs. * The current [NAME] (resident specific instructions for staff on resident's care needs) indicated Resident #35 requires supervision of 1:8 with eating. * The Certified Nursing Assistant (CNA) task documentation indicated Resident #35 ate meals with continual supervision in the previous 14 days. * The most recent Nutrition Assessment, dated 1/19/23, indicated Resident #35 consumes meals with supervision. During an observation on 1/30/23 at 8:04 A.M., Resident #35 was observed laying in bed, alone in his/her room. A staff person placed a breakfast tray beside the bed, exited the room and continued passing trays to other residents. Staff failed to assist Resident #35 to a seated position or to provide supervision for the meal. During an observation 1/31/23 at 7:48 A.M., Resident #35 was observed laying in bed, alone in his/her room. Resident #35 was observed leaning on his/her side, attempting to reach the food on the tray. After multiple attempts Resident #35 picked up a piece of toast, then laid back down in bed and ate the food while laying flat. Staff failed to assist Resident #35 to a seated position or to provide supervision for the meal. During an observation on 2/01/23 at 8:10 A.M., Resident #35 was observed alone in his/her room, drinking a bowl of oatmeal. Moments later he/she began to cough profusely. During an observation and interview on 2/01/23 at 8:12 A.M., the surveyor and Nurse (#3) observed Resident #35 alone in his/her room, coughing as he/she drank oatmeal. Nurse #3 said supervision with meals meant that someone should be with Resident #35 the entire time he/she eats. During an interview with a CNA (#5) on 2/01/23 at 8:17 A.M., she said Resident #35 required assist with all his/her care and supervision with meals. CNA #5 said that she tried to supervise Resident #35 today but had to take care of the other residents on her assignment. During an interview with the Nurse Unit Manager (#2) on 2/01/23 at 8:20 A.M., he said that Resident #35's CNA had called out that day. He said that it was the expectation that Resident #35 be supervised throughout his entire meal and be assisted to a seated position to eat. During an interview with the Director of Nursing on 2/01/23 at 9:12 A.M., she said that it was her expectation that resident's that require assistance with bed mobility and supervision with meals receive the assistance.

Based on observation, record review and interview the facility failed to change a wound dressing, as ordered, for 1 Resident (#22) out of a total 33 sampled residents. Findings include: 1. Resident #22 was admitted to the facility in May 2022 and had diagnoses that included excoriation (skin picking) disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/10/22, revealed that on the Brief Interview for Mental Status exam, Resident #22 scored an 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #22 had no behavior of rejecting care. During an observation and interview on 1/29/23 at 9:27 A.M., Resident #22 was observed seated in his/her room in a wheelchair with a bandage on his/her left shin dated 1/27/23. Resident #22 said the nurses are supposed to do a treatment and change the bandage every day but don't. Resident #22 then pointed to his/her shin and said look this hasn't been changed in days. Review of the current Physician order's for Resident #22 indicated an order, started 1/27/23, for Wound care LLE (shin)-cleanse with NS (normal saline), pat dry, apply collagen, cover with foam dressing and change daily and as needed. During an observation 1/29/23 at 1:15 P.M., Resident #22 was observed seated in his/her wheelchair with a bandage on his/her left shin dated 1/27/23. During an observation and interview on 1/31/23 at 7:52 A.M., Resident #22 was observed seated in his/her room in a wheelchair with a bandage on his/her left shin dated 1/29/23. Resident #22 said that no one had treated the wound or removed the bandage for several days. During an interview with the Nurse #4 on 1/31/23 at 8:46 A.M., he said that Resident #22 had an order for a daily dressing change to a shin wound. He said that if a resident refused a treatment it would be documented as refused in the Treatment Administration Record (TAR). He reviewed the TAR and indicated there was no refusals documented for the treatment to Resident #22's shin wound in the past week. Review of the clinical progress notes failed to indicate Resident #22 had refused treatment to his/her left shin wound in the past week. During an interview with the Nurse Unit Manager #2 on 1/31/23 at 8:51 A.M., he said that the nurse the previous day wrote the wrong date on the bandage. During a follow-up interview with Resident#22 on 1/31/22 at 9:10 A.M., the Surveyor inquired if Nurse Unit Manager #2 or a Nurse had looked at the bandage the previous day and he/she said absolutely not, no one has looked at it in days. During an interview with the Director of Nursing on 2/01/23 at 9:14 A.M., she said that it was her expectation that if a resident has an order for a daily dressing that it be performed, unless the resident refuses and then it should documented in the TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure that 1.) medications were dated when opened and disposed of when expired for 3 of 6 medication carts and 2.) failed to ensure medication carts were secured and locked on 2 of 3 units. Findings Include: Review of the facility's policy, titled Storage of Medications, dated 11/20, indicated the nursing staff are responsible for maintaining medication storage. 1.) The facility failed to ensure medications were properly dated when opened and disposed of when expired. * During an observation on [DATE] at 6:17 A.M., the surveyor observed on the third floor medication cart 1: - one Breo Ellipta inhaler, opened and undated, review of manufacture's guidelines indicated to discard the inhaler 6 weeks after opening. * During an observation on [DATE] at 6:21 A.M., the surveyor observed on the third floor medication cart 2: - one Advair inhaler, opened and undated, review of manufacture's guidelines indicated for staff to discard one month after opening. - one Combivent Respimat inhaler. opened and undated, review of manufacture's guidelines indicated for staff to discard after 3 months after opening. During an interview on [DATE] at 6:22 A.M., Unit Manager #1 said inhalers should be dated and labeled when the nurse opens them - they should be thrown out after 28 days. Acknowledged these are all past 28 days. During an interview on [DATE] at 6:23 A.M., Nurse #1 said the inhalers should be dated and labeled upon opening. * During an observation on [DATE] at 6:46 A.M., the surveyor observed on the second floor medication cart 1: - one Arnuity inhaler, opened and undated, review of manufacture's guidelines indicated for staff to discard after 6 weeks after opening. During an interview on [DATE] at 6:48 A.M., Unit Manager #2 said the inhalers should be dated and labeled once they are opened and said they are usually they are thrown out after 28 days. During an interview on [DATE] at 6:49 A.M., Nurse #2 said the inhalers should be dated and labeled upon opening. 2.) The facility failed to ensure medication carts were secured and locked. During an observation on the third floor on [DATE] at 6:40 A.M., the surveyor observed, two out of two of the third floor medications carts open and unlocked. There were no staff present in the hallway. During an interview on [DATE] at 6:42 A.M., Nurse #7 said the medication carts should be locked at all times but said she was busy passing medications out to the residents. During an interview on [DATE] at 6:44 A.M., the Staff Development Coordinator said the expectation is that the medication carts should be locked when the nurse is not at the cart. During an observation on the 2nd floor unit on [DATE] at 6:35 A.M., the surveyor observed an unlocked medication cart with two cups containing medication placed on top. There were no staff present in the hallway. During an observation and interview on [DATE] at 6:40 A.M., the surveyor observed Nurse #5 exit a resident room at the end of the hall. Nurse #5 said that the medication cart is supposed to be locked at all times and medications locked in the cart, not on top of the cart. During an observation on the 2nd floor unit on [DATE] at 7:58 A.M., the surveyor observed an unlocked medication cart. There were no staff present in the vicinity of the cart and the surveyor was able to open the cart. During an observation and interview on [DATE] at 7:59 A.M., the surveyor observed Nurse #10 exit a resident room further down hallway. Nurse #10 said the medication cart was supposed to be locked when not attended to but that she was just in a resident room giving medication.

Based on observation, and interview the facility failed to follow appropriate infection control practices, specifically pertaining to the use of personal protective equipment (PPE), to prevent the potential spread of COVID-19. Findings include: Review of the current Department of Public Health (DPH) and Centers for Disease Control (CDC) guidelines indicate that masks are required for staff and visitors in skilled nursing facilities. During an observation on 1/29/23, at 9:19 A.M. on the 1st floor non-covid Unit, a staff member was observed wearing a surgical mask worn around their chin exposing their mouth and nose. During an observation on 1/30/23, at 3:58 A.M. on the 1st floor non-covid Unit, a staff member was observed wearing a surgical mask worn around their chin exposing their mouth and nose. During an observation on 1/30/23, at 3:59 A.M. on the 2nd floor unit, a staff member was observed wearing a surgical mask worn around their chin exposing their mouth and nose. During an observation on 1/30/23, at 4:00 A.M. on the 1st floor covid unit, a staff member was observed wearing a surgical mask worn around their chin exposing their mouth and nose. During an interview on 2/1/23, at 9:30 A.M., the Infection Preventionist (IP) said that surgical masks should be worn on all non-covid designated units by all staff members at all times, and that N95 masks should be worn on the designated covid-19 unit by all staff members at all times.