**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have a consistent medical order honoring Advanced Directives for two Residents (#1 and #123), in a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the physician's order and medical record for Advance Directives matched the court ordered directives; and 2. For Resident #123, to ensure the physician's order and medical record reflected the resident's executed Advance Directives. Findings include: 1. Resident #1 was admitted to the facility in [DATE]. Resident #1 has a legal guardian who is responsible for making healthcare decisions. Review of the medical record indicated Resident #1 was admitted to hospice services on [DATE]. Review of Resident #1's Physician's Orders indicated: Code Status: Full Code revised [DATE]. Review of the Resident's record indicated a decree to authorize the guardian to consent to the following Advanced Directives: Do Not Resuscitate (DNR) and Do Not Intubate (DNI), dated [DATE]. During an interview on [DATE] at 8:35 A.M., Nurse #6 said Resident #1's Advance Directives are a full code at this time. Nurse #6 reviewed the Advanced Directives in the physical chart and the electronic health record (EHR) and said they did not match. During an interview on [DATE] at 8:41 A.M., Unit Manager #1 said the Resident is a DNR/DNI due to the court's order. She said the resident's code status is a DNR and DNI. She said the information in the computer indicated the Resident was a full code. She said this was not accurate and should have been updated. During an interview on [DATE] at 10:14 A.M., Hospice Staff #1 said the Resident is a full code at this time. During an interview on [DATE] at 1:26 P.M., Unit Manager #1 said she would expect that the advanced directives in the physical chart and the EHR match. She said it could get confusing during an emergency if they do not match. During an interview on [DATE] at 1:32 P.M., the Director of Nurses (DON) said her expectation is the physician's orders should match the court decree form. She expects the EHR and the physical chart to have the same advanced directives documented. 2. Resident #123 was admitted to the facility in [DATE]. Review of Resident #123's physical chart indicated a Massachusetts Order for Life Sustaining Treatment (MOLST) form was completed on [DATE], and the Resident's Advance Directives indicated DNR/DNI. Review of Resident #123's Physician's Orders indicated: Code Status: Full Code/CPR, dated [DATE]. During an interview on [DATE] at 1:51 P.M., Unit Manager #1 said the Advance Directives should be the same in the physical chart and the EHR. She said she needed to update the physician's orders in the computer to match the MOLST form. She said it could be confusing in an emergency if there is conflicting information regarding the Advance Directives. During an interview on [DATE] at 1:32 P.M., the DON said when a MOLST is completed the nurse who receives the MOLST should update the physician's orders to match the Advance Directives signed by the physician. She said Resident #123's orders needed to be updated as they incorrectly reflected his/her current code status.

Based on interview and record review, the facility failed to notify the Resident's physician about changes in condition so as to re-evaluate the potential need to alter the treatment plan for one Resident (#90), from a total sample of 28 residents. Specifically, the facility failed to notify the primary physician of a new pressure ulcer in order to alter the treatment plan to prevent deterioration. Findings include: Resident #90 was admitted to the facility in February 2021. Review of the medical record indicated the Resident switched primary care physicians in October 2024. Review of the care plans for Resident #90 indicated the Resident was at risk for alterations in skin integrity related to weakness, poor safety awareness, and diabetes. Review of the current Physician's Orders indicated an order for triad paste (a zinc-oxide based sterile coating designed to manage low to moderate levels of exudate (drainage), while promoting a moist wound healing environment) to the coccyx (base of the spine, near the top of the buttocks) was implemented on 9/2/24. Review of the Pressure Injury Evaluation tool, dated 11/13/24 (locked 11/20/24), indicated Resident #90 had a new facility acquired, unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer on the coccyx. The pressure ulcer measured 2.5 centimeter (cm) in length by 1.8 cm in width by an unmeasurable depth with 100 percent (%) eschar (dead or devitalized tissue that is hard or soft in texture). The evaluation indicated this was the start of treatment and the comment section for treatment was blank. Further review of the Pressure Injury Evaluation tool, dated 11/13/24, indicated the physician and responsible parties were notified. Review of the Pressure Injury Evaluation tool, dated 11/20/24, indicated the unstageable pressure ulcer to the coccyx had 50% healthy tissue and 50% unhealthy tissue, noted as yellow to white. The Pressure Injury Evaluation tool indicated the physician was notified. Review of the Physician's Orders indicated a new treatment began on 11/21/24 for the coccyx. The treatment was to wash with wound cleanser, pat dry, apply Calcium Alginate to wound base and cover with a foam dressing. The treatment was electronically signed by the primary physician on 11/26/24. Review of the medical record on 12/24/24 failed to include any documentation from the consultant wound physician. During an interview on 12/24/24 at 8:39 A.M., the Assistant Director of Nurses (ADON) said the consultant wound physician visit notes were not kept in the medical record and were kept in the office of the Wound Nurse. During an interview on 12/26/24 at 10:05 A.M., the Wound Nurse said on 11/13/24 she was notified of a new pressure ulcer on the coccyx of Resident #90 and went and evaluated it. She said she notified a physician who said to continue the triad paste that had been in place since September 2024. She said she could not remember who she contacted and who ordered the continued Triad paste. She said there was no documentation to indicate who she spoke with. She said the wound changed between 11/13/24 and 11/20/24 but she did not know when because there was no additional documentation from nurses between the weekly Pressure Injury Evaluations. Review of Physician Progress Notes from 11/13/24 through 12/10/24 from the Nurse Practitioner and Primary Physician failed to indicate Resident #90 had a pressure ulcer. During an interview on 12/26/24 at 12:00 P.M., the surveyor inquired about the pressure ulcer for Resident #90 and the Nurse Practitioner replied, The what? The Nurse Practitioner said she had been providing care to the Resident since October 2024 and did not know the Resident had a pressure ulcer. She said she was in the facility twice per week and was on call for all interim needs. She said she had recently discovered that staff were initiating treatment orders without obtaining physician verification of orders. She said she wanted to be actively involved in resident care and wanted to be called to verify recommendations and treatments. During an interview on 12/26/24 at 12:28 P.M., the Primary Physician said she did not recall being told about the pressure ulcer for Resident #90. She said she does not take calls from the facility and calls for orders or treatments were deferred to the Nurse Practitioner, and she addressed issues if she was in the facility. She said she was not in the facility on 11/13/24 or 11/20/24. She said if she had known about the pressure ulcer, she would have documented it in her visit on 12/10/24. During an interview on 12/26/24 at 12:35 P.M., the Wound Nurse said her process was to call the physician following wound rounds, including identification of a new wound. She said she cannot remember who she called on 11/13/24 and who she contacted was not documented anywhere. During an interview on 12/26/24 at 2:10 P.M., the Director of Nurses (DON) said the physicians for Resident #90 are saying they were unaware of the pressure ulcer. She said the consultant wound physician sends their consults to the primary physician. Review of the consultant wound physician visit summaries (11/25/24, 12/2/24, 12/9/24 and 12/16/24) indicated the previous primary physician was notified and not the current physician who started caring for the Resident in October 2024. The DON said she had not noticed that the incorrect primary physician was designated on the visit summaries. She said there was no additional information to verify the physicians were notified of the pressure ulcer.

Based on record review and interview, the facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) was completed for one Resident (#91) with a diagnosed mental condition, out of a total sample of 28 residents. Findings include: Resident #91 was admitted to the facility in January 2024 with diagnoses including bipolar disorder and alcohol abuse. Review of the Hospital Medical Intensive Care Unit (MICU) admission Note, dated 1/1/24, indicated the Resident's past medical history included bipolar disorder and alcohol use disorder. Review of the Psychiatric Evaluation and Consultation for Resident #91, dated 2/19/24, indicated the Resident's diagnoses included bipolar disorder and alcohol abuse. Review of the Minimum Data Set (MDS) assessment for Resident #91, dated 12/3/24, indicated under Section I (Active Diagnoses) the Resident had bipolar disorder coded as an active diagnosis. Review of the medical record failed to indicate a Level 1 PASARR was completed for Resident #91. During an interview on 12/23/24 at 4:31 P.M., Social Worker #1 said that the facility's three social workers are responsible for completing the PASARR prior to or at the time of admission to the facility. Social Worker #1 and the surveyor reviewed Resident #91's record and confirmed the only PASARR in the record was completed in 2020 by another facility when he/she was admitted there. Social Worker #1 said another PASARR should have been completed for the Resident when he/she was admitted to this facility. During an interview on 12/23/24 at 5:04 P.M., Social Worker #1 said she confirmed with the PASARR agency that the Resident did not have a Level 1 PASARR completed upon admission to the facility.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#91), out of 28 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address Resident #91's BiPAP (Bilevel Positive Airway Pressure, a non-invasive ventilation therapy that delivers air through a face mask to help with breathing) machine use. Findings include: Review of the facility's policy titled C-Pap (Continuous Positive Airway Pressure) and Bi-PAP Ventilatory System, undated, indicated but was not limited to the following: -Place the mask or pillows on the patient's face, and explain to the patient that he or she should breathe in and out normally. Resident #91 was admitted to the facility in January 2024 with diagnoses including chronic obstructive pulmonary disease (COPD), pneumonia, acute and chronic respiratory failure with hypoxia (low oxygen levels), and obstructive sleep apnea (airway collapse with an associated decrease in oxygen levels or waking from sleep). Review of the Minimum Data Set (MDS) assessment, dated 12/3/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS assessment indicated the Resident utilized oxygen and a non-invasive mechanical ventilator (CPAP or BiPAP). Review of Resident #91's Physician's Orders indicated but was not limited to the following: -BiPAP - apply at HS (bedtime), remove in AM (morning). Settings: 6 cm (centimeters) H2O (water) (11/21/24) -BiPAP Headgear/Strap hand wash in mild soap and air dry as needed (11/21/24) -BiPAP Humidifier - Change distilled water daily right before bed every evening shift (11/21/24) -BiPAP Humidifier - Clean chamber weekly and let air dry every night shift every Monday (11/21/24) -BiPAP Replace disposable filter per manufacturer's guidelines per order as needed (11/21/24) Review of Resident #91's Medication Administration Record (MAR) for December 2024 indicated that the Resident's BiPAP was administered as ordered every evening shift 12/1/24 through 12/17/24 and 12/19/24-12/23/24. The MAR indicated that the Resident refused the BiPAP on the evening shift on 12/18/24. Review of Resident #91's care plan failed to indicate a care plan for his/her BiPAP use had been developed. During an interview on 12/19/24 at 2:16 P.M., Resident #91 said that he/she got a BiPAP machine after his/her last hospitalization but he/she had not used it. During an interview on 12/23/24 at 4:02 P.M., Nurse #1 said that Resident #91 should be using a BiPAP machine at night but refused to use it. During an interview on 12/26/24 at 12:00 P.M., the Director of Nursing said that a care plan should have been developed and implemented for Resident #91's BiPAP use. The Director of Nursing said that if the Resident refuses to use the BiPAP, it should be documented in the Resident's record and care planned.

Based on observation, interview, and record review, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line device (inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart) was provided in accordance with professional standards of practice for one Resident (#92), out of a total sample of 28 residents. Specifically, the facility failed to ensure physician's orders were obtained and implemented for the care and maintenance of the Resident's PICC line. Findings include: Review of the facility's policy titled Central Venous Access Device Flushing, dated January 2022, indicated but was not limited to the following: 2. A prescriber order is required for vascular access device (VAD) flushing. The order will be specific with regards to flush solution, volume, and frequency. 3. The VAD will be flushed before and after intravenous medication administration, in between multiple medication administration, and routinely, at established intervals, when the VAD is not in use. Review of the facility's policy titled Central Venous Access Device Needleless Connector Change, dated January 2022, indicated but was not limited to the following: 2. Needleless connector will be changed according to the IV Therapy Order or Parenteral Nutritional Order: -Upon admission -At least every 7 days -After blood sampling from a CVAD (central venous access device) -Each time a bag of PN (parenteral nutrition) has infused -PRN for any complications 3. A needleless connector will be placed on the hub of all lumens of the VAD. Review of the facility's policy titled Central Venous Access Device (CVAD) Catheter Dressing Change, dated January 2022, indicated but was not limited to the following: 2. The IV therapy order for care and maintenance is required. 4. Dressing changes will occur according to the IV Order and when the dressing is compromised (drainage/moisture observed, loose, soiled). If at time of admission the transparent dressing is clean, dry, intact, dated and not due to be changed, it is NOT necessary to change the dressing at the time. If catheter is newly inserted and transparent dressing is clean, dry, intact and dated, it is NOT necessary to change the dressing 24 hours after insertion. If gauze is present, refer to the IV Order Form for frequency. 9. VAD assessment should occur: -At least every 2 hours during a continuous infusion -Before, during, and after medication administration -During dressing changes -At a minimum of once each shift, when not in use -At prescribed intervals if complications are observed 10. With each site assessment of the VAD, presence of the following, at a minimum, should be include [sic]: -Erythema -Drainage -Induration -Tenderness -Warmth -Swelling, of the extremity (if applicable) and at the site -Sutures, if present -External catheter length NOTE: External catheter site is measured from catheter exit site to the 0 mark or, if no 0 mark is present, to the suture flange. Each line is measured at 1cm. Review of the facility's policy titled Continuous Medication Administration, dated January 2022, included but was not limited to the following: 5. Continuous administration sets will be changed every 96 hours, when contamination is suspected, and as outlined in Policy IV3.3 Administration Set Change. 6. The licensed nurse will evaluate the venous access site at least every 2 hours, for signs and symptoms of complications, during the infusion. Review of Lippincott Manual of Nursing Practice, Twelfth Edition, indicated: -Administration tubing set change - label with date, time opened, and initials. a. Continuous tubing administration sets used for medications and solutions should be changed no more frequently than every 96 hours but at least every 7 days. -Ensure proper vascular access site assessment and care. Change the IV dressing on a routine basis and immediately if it becomes damp, loosened, or soiled. a. Gauze dressing that prevents visualization of the site should be changed every 48 hours. b. Transparent semipermeable dressing should be changed every 7 days. Resident #92 was admitted to the facility in April 2021 with diagnoses including chronic osteomyelitis (an infection of the bone), resistance to Vancomycin (an antibiotic), ESBL resistance (Extended-Spectrum Beta-Lactamase, enzymes produced by some bacteria that cause resistance to many common antibiotics), and Crohn's disease (an inflammatory bowel disease) with fistulas (connections between two body parts that don't normally connect). Review of the Minimum Data Set (MDS) assessment, dated 12/9/24, indicated Resident #92 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #92's care plans indicated but was not limited to the following: Focus: Resident is receiving IV therapy for prevention of dehydration due to high out [sic] ostomy (5 liters/24 hr in hospital) Interventions: -Change IV tubing per policy and PRN -IV as ordered -Observe insertion site for s/s (signs/symptoms) of infection ( i.e., pain, redness, swelling, warmth, infiltrate) and document. -Resident receives IV hydration via a picc Review of the Resident's records from a long-term acute care hospital, dated 11/18/24, indicated Resident #92 was admitted there in October 2024 for continued care of high output ileostomy (a surgically made opening connecting the lower end of the small intestine to the abdominal wall), abdominal fistulas, therapy services, and TPN (total parenteral nutrition, feeding administered intravenously). The records indicated the Resident was treated for Staphylococcus capitis bacteremia (a bacterial infection in the bloodstream) and the Resident's existing IV access catheter was removed. The Resident had a new PICC line placed on 11/15/24. The Resident's record failed to include any additional PICC line insertion information. Review of the Nursing Visit Record from a consultant IV insertion nurse, dated 12/18/24, indicated the Resident's right arm PICC line was pulled back 4 centimeters (cm) per recommendations from the radiologist and the PICC line dressing was changed. No additional PICC line information, such as catheter length or arm circumference, were included in the record. Review of Resident #92's Physician's Orders indicated but was not limited to the following: -Sodium Chloride Intravenous Solution 0.45% Use 90 milliliters per hour (ml/hr) intravenously every shift for hydration (12/20/24) -Sodium Chloride Intravenous Solution 0.9% Use 60 ml/hr intravenously every shift for hydration continuously (12/26/24) The Resident record failed to include orders for the care and maintenance of the Resident's PICC line, such as IV flushing, site assessment, dressing changes, catheter measurement, and arm circumference measurement. Review of Resident #92's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated but was not limited to the following: -Potassium chloride in NaCl (sodium chloride) intravenous solution 20-0.9% milliequivalents per liter (meq/l) Use 90 ml/hr intravenously every shift for hydration continuous infusion at 90 ml/hr documented administered on 12/18/24 11:00 P.M.-7:00 A.M. and 12/19/24 7:00 A.M.-3:00 P.M.) -Sodium Chloride intravenous solution 0.45% Use 90 ml/hr intravenously every shift for hydration (documented as administered 12/20/24 7:00 A.M.-3:00 P.M. through all shifts on 12/25/24) Review of Resident #92's Infusion Therapy Flowsheet for December 2024 in the paper record indicated that the Resident had a right upper arm PICC line in place. The space for documentation of the date inserted, total catheter length, arm circumference, and external catheter length were blank. Further review of the Infusion Therapy Flowsheet indicated but was not limited to: -Dressing care and maintenance: The IV nurse changed the Resident's PICC line dressing on 12/18/24 and that the transparent dressing was to be changed weekly. The dressing change scheduled for 12/25/24 was not documented as completed. -Needleless connectors: No documentation indicating needleless connectors were ever changed. -Tubing change: The flowsheet indicated the Resident was on a continuous infusion and the tubing should be changed every 96 hours. The tubing was marked as changed on the 11:00 P.M.-7:00 A.M. shift on 12/18/24 and 12/24/24. No exact hour was indicated and the box indicating the tubing was to be changed on 12/22/24 was left unsigned. -PICC/Midline Measurements: The flowsheet indicated external catheter length was to be documented prior to medication administration, weekly, and as needed. The external catheter length was measured at 0 cm on 12/18/24. No other catheter length measurement was documented. -Site assessment: The flowsheet indicated site assessment was to be completed every 2 hours while on continuous therapy and at least once every shift. No site assessment was documented as completed on 12/19/24 after 2:00 P.M. until 12/20/24 at 4:00 P.M., 12/21/24 at 12:00 A.M. until 4:00 P.M., 12/22/24 at 12:00 A.M. until 8:00 A.M. and 12/22/24 at 4:00 P.M. until 12/23/24 at 8:00 A.M., and 12/23/24 at 4:00 P.M. until 12/24/24 at 12:00 A.M. Review of Resident #92's Infusion MAR for December 2024 in the paper record indicated that the Resident received Potassium Chloride 20 meq in Sodium Chloride 0.9% at 90 ml/hr continuously starting 12/19/24 and Sodium Chloride 0.45% at 90 ml/hr continuously starting on 12/20/24. During an observation with interview on 12/19/24 at 9:50 A.M., the surveyor observed Resident #92 with a dual lumen IV in his/her right upper extremity and Potassium in Sodium Chloride 20-0.9 meq/l-% was infusing via an IV pump at 90 ml/hr. The Resident said he/she had the IV line for a while and had been receiving fluids. On 12/23/24 at 8:22 A.M., the surveyor observed Resident #92 to have a dual lumen Bard Power PICC in his/her right upper extremity with a transparent dressing in place, undated. A bag of IV Sodium Chloride 0.45% dated 12/23/24 was infusing at 90 ml/hr via an IV pump with tubing dated 12/22/24. On 12/26/24 at 9:20 A.M., the surveyor observed Resident #92's PICC line dressing in place, undated, with the bottom medial corner of the dressing slightly lifted. A bag of NaCl 0.9% was infusing via an IV pump at 60 ml/hr. The IV bag and tubing were not labeled with a date and time. During an interview on 12/26/24 at 11:28 A.M., Nurse #4 said the facility utilizes two paper forms for IV documentation and there are no additional places IV information is documented aside from the electronic medical record and the paper forms. During an interview on 12/26/24 at 12:00 P.M., the Director of Nursing (DON) said Resident #92's PICC information (insertion date, length, etc.) should be included in the Resident's record and the nurses should be documenting dressing changes, external catheter length, arm circumference, and needleless connector changes on the flowsheet weekly. The DON said all IV fluids and tubing should be dated and that the facility has stickers that should be used for this. The DON said Resident #92's PICC line dressing should be changed per orders and the dressing dated.

Based on observations, interviews, and record reviews, for one Resident (#92) of 28 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary drugs and was not used for an excessive duration. Specifically, the facility failed to ensure the Resident's Fosfomycin (an antibiotic) was administered for only one weekly dose instead of daily, resulting in an additional three administrations of the medication. Findings include: Resident #92 was admitted to the facility in April 2021 with diagnoses including chronic osteomyelitis (an infection of the bone), resistance to Vancomycin (an antibiotic), ESBL resistance (Extended-Spectrum Beta-Lactamase, enzymes produced by some bacteria that cause resistance to many common antibiotics), and Crohn's disease (an inflammatory bowel disease) with fistulas (connections between two body parts that don't normally connect). Review of the Minimum Data Set (MDS) assessment, dated 12/9/24, indicated Resident #92 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the After Visit Summary for Resident #92, dated 12/17/24, indicated the Resident had a urinalysis done which showed a urinary tract infection and the Resident was given antibiotics to treat the infection and will continue to get antibiotics to lower the risk of future urinary tract infections. The medication list indicated that the Resident should start taking Fosfomycin - Mix 1 packet (3 grams) with 3-4 ounces of cool water and take by mouth for 1 dose. The Resident had last received Fosfomycin on 12/17/24 at 2:56 P.M. while at the hospital. Review of Resident #92's nursing progress note, dated 12/18/24, indicated that the Resident returned from the hospital and had new orders for Fosfomycin 3 grams as prophylaxis. Review of Resident #92's Physician's Orders indicated the Resident was prescribed Fosfomycin 3 grams daily on 12/18/24 and the order was discontinued on 12/22/24. Review of the Medication Administration Record (MAR) for December 2024 indicated Resident #92 received Fosfomycin daily on 12/18/24, 12/19/24, 12/20/24, and 12/21/24. During an interview on 12/26/24 at 12:00 P.M., the Director of Nursing said the Resident's order for Fosfomycin was entered with a frequency of daily in error and should have been entered with a frequency of weekly. During an interview on 12/26/24 at 1:14 P.M., Physician #1 said that she had been on vacation the week prior and could not recall what frequency of Fosfomycin should have been ordered for Resident #92. During an interview on 12/26/24 at 2:37 P.M., Physician #1 said that she reviewed the Resident's record and a colleague had seen the Resident when he/she had returned from the hospital the week prior, but his note did not indicate the frequency Fosfomycin should have been prescribed. Physician #1 said Fosfomycin is typically dosed weekly, not daily.

Based on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, for Resident #53, the facility failed to ensure that a bottle of Fluticasone nasal spray (a medication used to treat allergy symptoms), a Trelegy inhaler (a medication used to treat symptoms of lung disease, such as shortness of breath and wheezing), a bottle of Calcium Carbonate chewable tablets (a medication used to treat indigestion), and a tube of Diclofenac cream (a topical medication used to treat pain) were not left unsecured in the Resident's room. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated February 2018, indicated but was not limited to the following: -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. -Storage for other medications will be limited to a locked medication room. Resident #53 was admitted to the facility in January 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, a lung condition causing airflow obstruction) and Diabetes. Review of the Minimum Data Set (MDS) assessment, dated 11/10/24, indicated that Resident #53 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. On 12/19/24 at 9:17 A.M. and 12/23/24 at 8:15 A.M, the surveyor observed the following in Resident #53's room: -A bottle of Fluticasone nasal spray on the Resident's overbed table, unsecured -A Trelegy inhaler on the Resident's overbed table, unsecured -A large bottle of Calcium Carbonate chews on the Resident's overbed table, unsecured -A tube of Diclofenac cream on the Resident's overbed table, unsecured. During an interview on 12/19/24 at 9:17 A.M., Resident #53 said he/she kept medications at his/her bedside and self-administered them. During an interview on 12/23/24 at 9:30 A.M., Nurse #1 said that she was aware Resident #53 kept medications at his/her bedside but was not responsible for administering those medications. Nurse #1 said that another nurse had given the Resident his/her nasal spray and inhaler and subsequently, the Resident refused to allow staff to remove the medication from his/her room. Nurse #1 said the Resident has not been assessed for self-administration and should not have medications in his/her room. During an interview on 12/23/24 at 4:08 P.M., the Director of Nursing (DON) said she was unaware that Resident #53 had medications in his/her room and that medications should not be left unsecured at the Resident's bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean and homelike environment for six Residents (#82, #93, #96, #59, #104, #54) on the [NAME] Unit. Specifically, the facility failed to provide the Residents with assistive devices (wheelchairs and walkers) that were maintained in a clean and comfortable manner and promptly addressed any repair needs as required. Findings include: Review of the facility's policy titled Rehabilitation Services Policy and Procedure Manual, dated 1/17, indicated but was not limited to the following: -Adaptive devices will be checked with each use. Needed replacement parts will be kept in inventory to ensure timely replacement. Tightening of nuts/bolts will be done when needed as will wiping off of tips to prevent slipping. -All equipment malfunctions are to be reported immediately to the Rehab Program Manager. The equipment will be tagged Do Not Use and stored in a non-patient treatment area until repaired. On 12/19/24 at 9:05 A.M., the surveyor observed the following during the initial tour of the [NAME] unit: -Resident #82's rolling walker had a right arm pad with an approximate 5-inch crack in the foam that was taped together to prevent the foam from falling off. -Resident #93's wheelchair had a loose armrest on the left-hand side along with a ripped seat back and ripped arm rest. -Resident #96's wheelchair had multiple rips in the fabric of the seat back exposing inside foam cushion. -Resident #59's wheelchair was labeled with another Resident's name, had a ripped seat back that was separating the fabric on the back of the wheelchair to the handles, with an observed frayed fabric. -Resident #104's wheelchair was fraying and loose on the seat back where it attached to wheelchair handles. There was an approximate 4-inch rip in the fabric of the wheelchair exposing yellow foam inside cushion. -Resident #54's wheelchair was missing a padded armrest on the left side of the chair. There was a metal bar where there should have been a cushion. Review of the [NAME] Unit's Maintenance Log on 12/19/24 at 2:03 P.M., indicated the last entry in the log was dated 12/6/24, and was not for any of the above Residents' items. During an interview on 12/23/24 at 5:11 P.M., Resident #82 said he/she has put tape along the arm cradle of the walker to prevent it from breaking off. Resident #82 said he/she requested glue from nursing staff to keep it in place more securely. During an interview on 12/24/24 at 8:32 A.M., Nurse #2 said the wheelchairs were not in good condition and she wasn't sure what the process was for routine repairs and upkeep. She said there is a wheelchair washing day, but someone should go around and review the condition of the chairs, some need to be replaced or repaired. She said Resident #59's wheelchair was labeled with another resident's name who was discharged over three months ago. During an interview with observation on 12/24/24 at 8:46 A.M., Rehab Staff #1 toured the unit with the surveyor and said she wasn't sure how the condition of this equipment was overlooked by facility staff. She said the wheelchairs with rips, loose parts, and holes should be replaced or repaired immediately. She said the wheelchairs and equipment should be clean, comfortable, and in good repair at all times.

Based on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for one Resident (#79), out of 28 sampled residents. Specifically, the facility failed to ensure wound care treatments for Resident #79 were reflective of recommendations from the wound consultant physician and in line with the primary physician's treatment plan. Findings include: Review of the facility's policy titled Treatments, dated April 2015, indicated but was not limited to the following: -in order for residents to achieve an optimum in their physical state, various treatments may be necessary -these treatments may be ordered by the physician or, within the scope of nursing -it is the responsibility of all nursing staff to constantly evaluate the health state of residents as to the need for treatments -once treatments are ordered, they are to be carried out as prescribed -an order is written for each treatment indicating type, frequency and location -treatments are reviewed daily and the physician notified of all healed areas Resident #79 was admitted to the facility in October 2024 with a diagnosis of localized swelling, mass and lump to the right upper limb. Review of the Minimum Data Set (MDS) assessment, dated 11/21/24, indicated Resident #79 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. During an interview with observation on 12/19/24 at 9:10 A.M., Resident #79 said he/she had a large mass on their right elbow and showed the surveyor. The surveyor observed the right elbow swollen on all sides, there was no dressing and the area was open to air. The Resident said he/she had an upcoming appointment to have the cyst drained. Review of the care plans indicated the Resident had a right ulnar (elbow) and thigh cyst (initiated 10/23/24) with interventions including but not limited to administering treatments as ordered and wound consult as needed. Review of the Physician Progress Note from the Nurse Practitioner, dated 11/4/24, indicated Resident #79 had a large cyst to the right elbow and thigh with erythema (redness) and a wound from a cyst that opened with a plan to continue antibiotics until seen by the dermatologist, obtain dermatology evaluation, and continue to monitor clinically. Review of the Treatment Administration Record (TAR) indicated Resident #79 had the following treatment to the right elbow cyst from 11/4/24 through 11/18/24: mupirocin ointment (antibiotic ointment, also referred to as Bactroban), apply to right elbow cyst topically every day and evening shift: wash with wound cleanser, pat dry, apply Bactroban, followed by Alginate and dry dressing. Review of the nursing progress notes indicated the following: -11/4/24: Resident seen by consultant wound physician for the right elbow cyst with a new order for wound cleanser, pat dry, apply Bactroban followed by Alginate and dry dressing. -11/9/24: right elbow draining clear fluid -11/12/24: right elbow draining clear fluid -11/14/24: resident sent to hospital for change in mental status -11/20/24: resident returned from hospital -11/22/24: no dressing to right elbow cyst, not needed, no open area -12/2/24: right leg cyst with necrosis (dead tissue) Review of the consultant wound physician Visit Notes indicated the following: 11/11/24: right elbow draining large amount of serous exudate (a clear or pale yellow, watery fluid that drains from a wound as part of the healing process). Treatment: Adaptic (a primary wound contact layer made of knitted cellulose acetate with a woven mesh structure impregnated with petrolatum), Alginate (a highly absorbent dressing) followed by a dry, protective dressing, twice per day. 11/25/24: right elbow draining moderate amount of serous exudate. Treatment: Adaptic, Alginate and dry protective dressing, change daily. Review of the Physician Progress Note from the Nurse Practitioner, dated 12/2/24, indicated the right thigh cyst had opened and started draining and to continue to monitor. Review of the consultant wound physician Visit Notes indicated the following: 12/9/24: right elbow draining moderate amount of serous exudate. Treatment: Adaptic, Alginate and dry protective dressing. New right thigh cyst with moderate amount of purulent exudate (a thick, opaque, milky fluid that drains from a wound and indicates an infection). Treatment: Bactroban, Alginate, and dry protective dressing daily. 12/16/24: right elbow draining moderate amount of serous exudate. Treatment: Adaptic, Alginate and dry protective dressing. Right thigh cyst with moderate amount of purulent exudate (a thick, opaque, milky fluid that drains from a wound and indicates an infection). Treatment: Bactroban, Alginate, and dry protective dressing daily. Review of the medical record for the month of December 2024 failed to include monitoring or treatments to the right elbow cyst or the right thigh cyst. On 12/20/24 at 12:48 P.M., the surveyor observed Resident #79 sitting on the edge of the bed. The surveyor observed the cyst to the right elbow open to air and cyst to the right thigh open to air. During an interview on 12/24/24 at 10:43 A.M., the Nurse Practitioner said the plan for the Resident was to continue treatments as recommended by the consultant wound physician and the treatment could change as indicated by an external dermatologist, if needed. She said she defers treatments to the consultant wound physician and both the right elbow cyst and the right thigh cyst should have treatments. Review of the medical record on 12/19/24 failed to indicate any current treatments, dressings or monitoring of the cysts on the right upper or lower extremities. During an interview on 12/24/24 at 12:50 P.M., Nurse #2 said Resident #79 did not receive any dressing to the elbow or thigh. She said there used to be a treatment to the elbow, but there was not one any longer. During an interview on 12/24/24 at 1:35 P.M., the Assistant Director of Nurses (ADON) said the treatment for the elbow was discontinued in November 2024. She said the process was for the Wound Nurse to review the recommendations from the consultant wound physician, contact the primary physician and implement treatment orders. During an interview on 12/24/24 at 1:55 P.M., the ADON said she reviewed the consultant wound physician recommendations and the recommendations for changes to the treatment of the right elbow had not been implemented and the new treatment to the right thigh had also not been implemented. During an interview on 12/26/24 at 9:55 A.M., the Wound Nurse said the nurse should not have discontinued the treatment to the right elbow on 11/22/24. She said she was not sure why the wound treatment for the right elbow was not changed with the recommended change in treatment on 11/11/24. She said there was a miscommunication on who was entering the orders for the treatment to the right thigh and that was why it had not been implemented. She said the monitoring process included weekly assessments of wounds. She reviewed the medical record and said she was not sure why there were no weekly evaluations for the wounds for Resident #79, but there should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary respiratory care and services for one Resident (#91), in a total sample of 28 residents. Specifically, the facility failed to administer oxygen at the correct liter flow per physician's orders, failed to ensure oxygen equipment was maintained in a sanitary manner to help decrease the risk of potential contamination and infection, and failed to ensure the Resident was referred to a pulmonologist. Findings include: Review of the facility's policy titled Oxygen Administration, undated, indicated a physician's order is necessary for the administration of oxygen. Review of the facility's policy titled Oxygen Concentrators, undated, indicated but was not limited to the following: -Verify the physicians order and review the patients' chart. -Adjust the liter flow in accordance with the physician's order by rotating the flow selector knob on the flow meter located on the front panel of the unit. Review of the facility's policy titled C-Pap (Continuous Positive Airway Pressure) and Bi-PAP Ventilatory System, undated, indicated but was not limited to the following: -Place the mask or pillows on the patient's face, and explain to the patient that he or she should breathe in and out normally. Resident #91 was admitted to the facility in January 2024 with diagnoses including chronic obstructive pulmonary disease (COPD), pneumonia, acute and chronic respiratory failure with hypoxia (low oxygen levels), and obstructive sleep apnea (airway collapse with an associated decrease in oxygen levels or waking from sleep). Review of the Hospital Discharge summary, dated [DATE], indicated Resident #91's discharge diagnoses included respiratory failure with hypercapnia (too much carbon dioxide in the blood). The Discharge Summary indicated the Resident would need BiPAP at discharge given his/her underlying neurologic disorder and hypercapnia and that per review with the Case Manager, this was delivered to the facility. The Discharge Summary also indicated that the Resident should follow-up with pulmonology on a regular basis. The Resident's most recent vital signs at time of discharge included a pulse oximetry (measurement of oxygen levels in the blood) of 96% on 2 liters/minute (L/min) of oxygen. Review of the Minimum Data Set (MDS) assessment, dated 12/3/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS assessment indicated the Resident utilized oxygen and a non-invasive mechanical ventilator (CPAP or BiPAP). Review of Resident #91's care plans indicated but was not limited to the following: Focus: Resident has respiratory disease related to resp (respiratory) failure SOB with HOB (head of bed) flat Interventions: -Assist to reposition for maximum airflow -Auscultate lung sounds as indicated -Encourage resident to pace activities to prevent episodes of dyspnea and fatigue -If resident has shortness of breath, adventitious lung sounds, dyspnea or exertion [sic], fever or changes in mental status, this may indicate an infection. -O2 sats and O2 as ordered -Provide gentle touch, reassurance, emotional support as needed -Respiratory conversation technique training -SOB while lying flat elevate HOB to position of comfort for patient Review of Resident #91's Physician's Orders indicated but was not limited to the following: -Change O2 (oxygen) tubing every Sunday on 11:00 P.M.-7:00 A.M. (11/22/24) -Oxygen continuously via NC (nasal cannula) at 2 Liters/minute every shift Check pulse ox and liters per minute (LPM) (11/22/24) -BiPAP - apply at HS (bedtime), remove in AM (morning). Settings: 6 cm (centimeters) H2O (water) (11/21/24) -BiPAP Headgear/Strap hand wash in mild soap and air dry as needed (11/21/24) -BiPAP Humidifier - Change distilled water daily right before bed every evening shift (11/21/24) -BiPAP Humidifier - Clean chamber weekly and let air dry every night shift every Monday (11/21/24) -BiPAP Replace disposable filter per manufacturer's guidelines per order as needed (11/21/24) Review of Resident #91's Medication Administration Record (MAR) for December 2024 indicated that the Resident's BiPAP was administered as ordered every evening shift 12/1/24 through 12/17/24 and 12/19/24-12/23/24 and the Resident refused the BiPAP on the evening shift on 12/18/24. Further review of the MAR indicated the Resident's oxygen liter flow was set at 2-4 L/min, not 2 L/min as indicated in the physician's order. Review of Resident #91's Treatment Administration Record (TAR) for December 2024 indicated the Resident's oxygen tubing was changed on 12/1/24, 12/8/24, 12/15/24 and 12/22/24. On 12/19/24 at 9:39 A.M., the surveyor observed Resident #91 in bed, wearing a nasal cannula. The oxygen concentrator was observed to be set at 3.5 L/min and the oxygen tubing was dated 12/9/24. The Resident's BiPAP machine was on the nightstand. On 12/23/24 at 2:16 P.M., the surveyor observed Resident #91 in bed, wearing a nasal cannula. The oxygen concentrator was observed to be set at 3.5 L/min and the oxygen tubing was dated 12/23/24. The Resident's BiPAP machine was on the nightstand in the same position as it was on 12/19/24. On 12/26/24 at 9:25 A.M., the surveyor observed Resident #91 in bed, wearing a nasal cannula. The oxygen concentrator was observed to be set at 3L/min. The Resident's BiPAP machine was on the nightstand in the same position as it was on 12/19/24. During an interview on 12/19/24 at 2:16 P.M., Resident #91 said that he/she got a BiPAP machine after his/her last hospitalization but he/she had not used it. During an interview on 12/23/24 at 4:02 P.M., Nurse #1 said that Resident #91 should be using a BiPAP machine at night but refused to use it. Nurse #1 said that Resident #91's oxygen concentrator should be set at 2-3 L/min. Nurse #1 said that the Resident's order for oxygen was for 2 L/min, but when he/she returned from his/her last hospitalization she was told he/she was on 3 L/min. During an interview on 12/26/24 at 11:28 A.M., Nurse #4 said she did not work regularly on the unit but was aware that Resident #91 had a BiPAP machine. Nurse #4 said the BiPAP mask was not on the Resident when she arrived for her shift that morning. Nurse #4 said that the Resident's oxygen concentrator should be set at 2 L/min. During an interview on 12/26/24 at 11:49 A.M., Nurse #4 said she checked the Resident's oxygen concentrator and it was set at 3 L/min. During an interview on 12/26/24 at 12:00 P.M., the Director of Nursing (DON) said that physician's orders should be implemented as written. During an interview on 12/26/24 at 2:16 P.M., the DON said Resident #91 had not been scheduled for a pulmonology appointment and she could not find any documentation that the Resident had been seen by a pulmonologist while at the facility but should have been referred to one.

Based on record review and interview, the facility failed to ensure three Residents' (#1, #123, and #87) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure a gradual dose reduction (GDR) of the antipsychotic medications risperidone and chlorpromazine were attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; 2. For Resident #123, to ensure a GDR of the antipsychotic medication olanzapine was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; and 3. For Resident #87, to ensure a GDR of psychotropic medication was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug. Findings include: Review of the facility's policy titled Psychotropic Medication Management, dated 4/15, included but was not limited to the following: -Each resident's drug regimen will be free from unnecessary drugs. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. -Review should include verification that adequate indications for use of the psychotropic medication exist, the medications are not being used for extended duration, and the residents are free of duplicate therapy and being monitored for adverse consequences, per professional standards of practice. Review of the facility's pharmacy policy titled Psychotropic Medication Management, revised 12/19, included the following: -If a Resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually. -A GDR is considered clinically contraindicated if target symptoms return or worse after most recent attempt of a GDR and the physician documents the clinical rationale for why any attempted dose reductions would impair the resident's function, or the continued use is in accordance with relevant current standard of practice and the physician documents the clinical rationale for why any attempted GDR would impair the resident's function. 1. Resident #1 was admitted to the facility in May 2019 with diagnoses which included epilepsy (seizure disorder), dementia, traumatic brain injury, and bipolar disorder. Review of the Physician's Orders included the following medications: Risperidone 2 milligrams (mg), dated 5/30/24 Chlorpromazine 25 mg, dated 5/29/24 Review of the medical record indicated Resident #87 was signed on to hospice services on 10/25/24. Further review of the medical record failed to indicate a GDR had been attempted in the previous 12 months. Review of the Minimum Data Set (MDS) assessment, dated 11/11/24, indicated the Resident did not have any symptoms of psychosis including delusions or hallucinations. On 12/20/24 at 12:45 P.M., the surveyor observed the Resident sitting in the hallway with his/her eyes open, quietly watching staff. On 12/23/24 from 10:28 A.M to 12:09 P.M., the surveyor observed the Resident sitting in the hallway in a reclining Broda chair (positioning chair) with no behavioral disturbances. Resident #1 was smiling and waving to staff as they passed by and occasionally closed his/her eyes. On 12/23/24 at 02:16 P.M., the surveyor observed the Resident being invited to attend an activity and nodded to attend in agreement. Resident #1 closed their eyes during the movie and slept in the dining room in a reclining Broda chair. During an interview on 12/24/24 at 8:23 A.M., Nurse #2 said the behavioral health service team will make psychotropic medication recommendations as well as the pharmacy. If it's not an emergency, we put the recommendations in a folder for the doctor to review. She said she was unsure if Resident #1 had a GDR attempted, she said he/she has had a physical decline and is on hospice services and has not had any symptoms of psychosis. During an interview on 12/24/24 at 11:36 A.M., the Director of Nurses (DON) said they have begun to review some residents beginning in October for GDRs as they were not previously being attempted for residents on antipsychotic medication. She said she could not provide evidence that a GDR was discussed or attempted for this Resident in the past year. 2. Resident #123 was admitted to the facility in January 2024 with diagnoses including but not limited to visual hallucinations and dementia. Review of the Physician's Orders indicated: Olanzapine 2.5 mg one time a day, dated 1/15/24 Olanzapine 7.5 mg one time a day, dated 1/15/24 Review of the MDS assessment indicated that the Resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Further review of the MDS indicated that the Resident had no signs or symptoms of delirium. Review of the Resident's behavioral health notes indicated the following: no changes in medications were recommended. The Resident had no hallucinations/ paranoia/delusions and no combative or aggressive behaviors. Review of the nursing progress notes from June 2024 through December 2024 failed to indicate Resident #123 exhibited any behaviors or changes in mood. Further review of the medical record failed to indicate a GDR had been attempted since the Resident was admitted to the facility. During an interview on 12/24/24 at 8:23 A.M., Nurse #2 said she wasn't sure how GDRs were reviewed or attempted. She said that Resident #123 is very pleasant with behaviors that are easily redirectable. She was unsure if the Resident's antipsychotic medication had been reviewed for a GDR. During an interview on 12/24/24 at 11:36 A.M., the DON said they have begun to review some residents beginning in October for GDRs as they were not previously being attempted for residents on antipsychotic medication. She said she could not provide evidence that a GDR was discussed or attempted for this Resident in the past year. 3. Resident #87 was admitted to the facility in June 2021 with a diagnosis of dementia, major depressive disorder, post-traumatic stress disorder, developmental disorder of scholastic skills, and traumatic brain injury. Review of the medical record indicated Resident #87 was admitted to hospice services on 3/1/24. Review of the care plans indicated Resident #87 had a Focus for psychotropic medications with Interventions including but not limited to review with the IDT (interdisciplinary team) for GDR as indicated. Review of the Physician's Orders included the following medications: Lorazepam (antianxiety) tablet 0.5 mg- twice per day (4/30/24) Melatonin (supplement to aid in sleep) 3 mg at bedtime (10/6/23) Olanzapine 5 mg in the morning (1/4/23) Olanzapine 2.5 mg twice per day (10/6/23) Sertraline (antidepressant) 25 mg once per day (7/12/23) Trazodone (antidepressant) 50 mg three times per day (7/11/23) Review of the December 2024 Medication Administration Record indicated Resident #87 did not have any behaviors on any shift from 12/1/24 through 12/24/24. During an interview on 12/19/24 at 1:22 P.M., the family member of Resident #87 said the Resident had been putting his/her head on the table for about a year and she was not sure if this was related to his/her mood, the Resident was on a lot of medication to manage his/her mood and she was not sure if the medications were making the Resident tired. The surveyor observed Resident #87 during the following days of survey: 12/19/24 at 10:06 A.M. in the unit day room with his/her head on the table, eyes closed 12/19/24 at 1:00 P.M. in unit day room with head on a pillow on the table 12/20/24 at 8:41 A.M. in unit day room, having breakfast, sitting up right 12/20/24 at 8:53 A.M. in unit day room with a baby doll on the table in front of him/her 12/20/24 at 9:31 A.M. resident with chin tucked to chest and eyes closed 12/20/24 at 10:00 A.M. in unit day room with face hovering over table and staff placed a pillow between the Resident and the table 12/20/24 at 12:59 P.M. in unit day room with head down on a pillow on the table, rubbing nose around in circles 12/20/24 at 1:18 P.M. Resident did not respond when Certified Nursing Assistant (CNA) asked Resident if they would like to go to bed 12/24/24 at 10:15 A.M. in bed sleeping 12/24/24 at 12:51 P.M. in unit day room, head leaning back and forth During an interview on 12/24/24 at 12:55 P.M., CNA #1 said Resident #87 refused care at times, but was easily redirected. She said the Resident mostly sits in the unit day room with his/her head down on the table, rubbing his/her face. She said Resident #87 did not exhibit any other behaviors. Review of the nursing progress notes from June 2024 through December 2024 failed to indicate Resident #87 exhibited any behaviors or changes in mood. Review of the Psychiatric Evaluation and Consultation notes indicated the Resident was seen by the consultant psychiatric Nurse Practitioner for an initial evaluation on 2/14/24. All notes were reviewed and indicated the following: 2/14/24: no acute psychiatric needs or worsening mood/behavior reported 4/12/24: Resident refusing to leave dining room; continue to monitor behaviors and redirect verbally; no changes are indicated 5/18/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 6/22/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 7/20/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 8/17/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 9/14/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 10/12/24: presents pleasant with minimal agitation, semi-confused and suspicious at times; no behaviors observed or reported this visit 11/9/24: presents pleasant with minimal agitation, semi-confused and suspicious at times; no behaviors observed or reported this visit 12/7/24: presents pleasant with minimal agitation, semi-confused and suspicious at times; no behaviors observed or reported this visit Review of the hospice Plan of Care, dated 10/17/24, indicated Resident #87 was leaning forward and resting their head on the table, and even when repositioned, would rub his/her nose on the table in circles, with increased lethargy and sleeping and would spend an entire day in bed sleeping and the next day be up in a chair but still slept on and off with their head on the table. Review of the medical record failed to indicate a GDR had been attempted in the previous 12 months. During an interview on 12/20/24 at 1:53 P.M., the Hospice nurse said the Resident had recently been recertified for Hospice services. She said the Resident at baseline will sit in the unit day room with his/her head on the table rubbing their nose on the table or sleeping, which was why the Resident was provided with a pillow or towel. She said she had not reviewed the psychotropic medications for GDRs and did not realize the last change in medications occurred in October 2023, prior to signing on to hospice services. During an interview on 12/20/24 at 2:50 P.M., the DON said she reviewed the medical record for Resident #87 and there had been no attempts for a GDR in at least the last 12 months. During an interview on 12/24/24 at 11:32 A.M., the DON said the facility had been attempting to work on GDRs for residents, but Resident #87 had not been discussed at their IDT meetings.

2. Resident #92 was admitted to the facility in April 2021. Review of the Minimum Data Set (MDS) assessment, dated 12/9/24, indicated Resident #92 had one Stage IV pressure injury and the Resident's care included the application of non-surgical dressings. Review of Resident #92's Physician's Orders indicated but was not limited to the following: -Treatment order: wash with wound wash, pat dry, apply skin prep to wound edge, apply calcium alginate, daily cover with foam dressing Location: sacrum as needed for drainage (9/5/24) - Treatment order: wash with wound wash, pat dry, apply skin prep to wound edge, apply calcium alginate, daily cover with foam dressing Location: sacrum every day and evening shift (9/5/24) Review of Resident #92's care plans indicated but was not limited to the following: Focus: Resident has a stg IV Pressure Ulcer Interventions: -Provide with a pressure relieving mattress -Signs of infection may include purulent drainage, swelling, increased pain, elevated temp, redness of wound, change in drainage. -Skin checks per facility protocol -Treatment as ordered Review of the medical record failed to include visits from the consultant wound physician for the last year. During an interview on 12/24/24 at 8:47 A.M., the ADON said the Wound Nurse (also the ICP) has kept the consultant wound physician's visit paperwork for the last year in her office. The surveyor was provided with the Resident's consultant wound physician visit documentation for the last year, which had not been included in the electronic or paper medical record. Based on observations, record review, and interviews, the facility failed to maintain accurate medical records in accordance with professional standards and practices for four Residents (#58, #92, #79, and #90), out of 28 sampled residents. Specifically, the facility failed for Residents #58, #92, #79, and #90 to ensure that documentation of wound physician visits was part of the medical record in a timely manner. Findings include: Review of the facility's policy titled Thinning of the Clinical Record, dated September 2015, indicated the following records were to be maintained in the active clinical record: Consultations: Most current year with exception of a one-time only consult. 1. Resident #58 was admitted to the facility in February 2019 with diagnoses including traumatic brain injury and protein calorie malnutrition. Review of Resident #58's current Physician's Orders indicated but was not limited to: -Monitor dressing site: left foot dressing every shift, dated 12/19/24 -Monitor dressing site: right foot dressing every shift, dated 11/21/24 -Treatment order: Wash with wound cleanser, pat dry apply Iodosorb followed by dry protective dressing. Location: right 3rd toe and right 4th toe every day shift, dated 12/19/24 -Treatment order: Wash with wound cleanser, pat dry apply skin prep to peri wound followed by Iodosorb, cover with dry protective dressing. Location: left plantar, left 5th toe every day shift, dated 12/19/24 -Treatment order: Wash with wound cleanser, pat dry, apply skin prep to peri wound, apply adaptic followed by calcium alginate to wound bed and cover with gauze, wrap with Kerlix. Location: right foot web space between 4th and 5th toe, and right lateral foot every day shift, dated 12/26/24 During an interview on 12/20/24 at 10:41 A.M., Nurse #5 said Resident #58 was being followed by the consultant wound physician. The surveyor and Nurse #5 reviewed the medical record and could not locate the wound physician's documentation. Nurse #5 said the Infection Control Preventionist (ICP) made rounds with the wound physician and oversaw the wound program. Nurse #5 said the ICP must keep the wound physician's notes in her office. Review of Resident #58's wound physician's visit notes, provided to the survey team by the Assistant Director of Nurses (ADON), on 12/24/24 at 8:47 A.M., indicated the Resident had been seen on the following days: -12/16/24 -12/9/24 -12/2/24 -11/25/24 -11/18/24 -11/4/24 -10/21/24 -10/14/24 During an interview on 12/26/24 at 12:21 P.M., the ICP said Resident #58's medical record did not contain his/her wound physician's visit notes. The ICP said she had them in a folder in her office. The ICP said they should have been put in Resident #58's medical record. 3. Resident #79 was admitted to the facility in October 2024. Review of the medical record indicated Resident #79 had large cysts to the right upper extremity and the right lower extremity. Review of the medical record indicated the Resident was followed by the Nurse Practitioner (NP) and the Primary physician. Review of the Physician Progress Note dated 12/2/24 indicated the right lower cyst had opened and was draining. Review of the medical record on 12/19/24 failed to indicate any current treatments, dressings or monitoring of the cysts on the right upper or lower extremities. During an interview on 12/24/24 at 8:47 A.M., the ADON said the Wound Nurse (also the ICP) has kept the consultant wound physician visit paperwork for the last year in her office. The surveyor was provided with a large stack of papers. During an interview on 12/24/24 at 10:44 A.M., the NP said Resident #79 was being followed by the consultant wound physician for the right upper and lower extremity cysts. Review of all wound consultant physician visits for the last year included wound consultant visits for Resident #79 on the following dates: 10/28/24, 11/11/24, 11/25/24, 12/9/24 and 12/16/24, which had not been included in the electronic or paper medical record. 4. Resident #90 was admitted to the facility in February 2021. Review of the medical record indicated Resident #90 had developed a pressure ulcer on 11/13/24. During an interview on 12/24/24 at 8:40 A.M., the ADON said the Wound Nurse (ICP) does wound rounds with the consultant wound physician on Mondays and the visit summaries are kept in the office of the Wound Nurse. Review of all wound consultant physician visits from the office of the Wound Nurse included wound consultant visits for Resident #90 on the following dates: 11/25/24, 12/2/24, 12/9/24 and 12/16/24, which had not been included in the electronic or paper medical record. During an interview on 12/26/24 at 10:05 A.M., the Wound Nurse (ICP) said the consultant wound physician comes to the facility on Mondays and then sends the visit summaries to her. She said she thought the consultant wound physician was uploading the visit summaries to the electronic medical record and had not realized that none of the visits had been uploaded this year.

Based on record review and interviews, the facility failed to ensure a discussion regarding advance directives occurred for one sampled Resident (#46), in a total sample of 27 residents. Findings include: Resident #46 was admitted to the facility in August 2023 with a history of rectal cancer and new diagnosis of lung cancer. Review of the Minimum Data Set (MDS) assessment, dated 8/8/23, indicated the Resident was moderately cognitively impaired, as evidenced by a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the medical record indicated the Health Care Proxy (HCP) was activated on 8/12/23. Review of the medical record, including progress notes, care plan meeting notes, and assessments for Resident #46 failed to indicate evidence of a discussion regarding advance directives with the activated HCP. Review of the physician's progress note, dated 9/4/23, indicated the facility was waiting for the activated HCP to complete the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST). Review of the handwritten physician's orders included an order written on 9/4/23 to complete the MOLST with the HCP. The surveyor observed the MOLST form for Resident #46 to be flagged in the paper medical record on the following dates: -9/26/23 at 1:50 P.M., -9/27/23 at 10:50 A.M., and -9/28/23 at 11:30 A.M. The MOLST form contained the Resident's name and the rest of the form was not completed to indicate advanced directives. During an interview on 9/29/23 at 7:50 A.M., Unit Manager #2 said a care plan meeting had been held with the Social Worker and the HCP. She said advanced directives and the MOLST form were not reviewed with the HCP at that time. She said the Social Worker was responsible for reviewing the advanced directives with the HCP and the Unit Manager had not reviewed the advanced directives with the HCP at any other time. During an interview on 9/29/23 at 8:45 A.M., the HCP of Resident #46 said the Resident had been battling cancer and had been declining. The HCP said the facility had not discussed advanced directives including life-sustaining treatment with her and she would like to include Resident #46 in that discussion. During an interview on 9/29/23 at 11:00 A.M., the Regional Social Worker said the Social Worker for Resident #46 was unavailable. The Regional Social Worker said she had reviewed the documentation for Resident #46 and believed the Social Worker and Unit Manager had reviewed the advanced directives with the HCP. She said she did not have any supporting documentation and was unaware of the physician's order and progress note to review advanced directives with the HCP of Resident #46.

Based on interviews and record review, the facility failed to ensure a physician was notified of recommended medication changes for one Resident (#78) in order to alter the treatment, in a total sample of 27 residents. Specifically, the facility failed to notify the physician in a timely manner of recommendations from Hospice to increase pain medications and decrease psychotropic medications. Findings include: Resident #78 was admitted to the facility in November 2020 with a diagnosis of dementia and hospice services were initiated in September 2023. Review of the medical record included the following recommendations from hospice on 9/21/23: -decrease Trazodone (antidepressant) to 50 milligrams (mg) twice per day -decrease Zyprexa (antipsychotic) to 2.5 mg twice per day -start Morphine (narcotic for pain management) 20 mg/milliliter (ml); give 0.125 ml=2.5 mg by mouth three times per day at 8:00 A.M., 2:00 P.M. and 8:00 P.M. for pain. Additional recommendations noted as to have on hand, does not need this visit: -Morphine 20 mg/ml give 0.25 ml=5 mg every four hours as needed for shortness of breath or severe pain -Ativan 0.5 mg by mouth every four hours as needed for anxiety/excessive fidgeting -Benadryl 25 mg by mouth every six hours as needed if itching occurs from Morphine -Zofran 4 mg by mouth every six hours as needed if nauseous from Morphine Review of the nursing progress notes on 9/26/23 failed to indicate the physician was contacted regarding the recommendations made on 9/21/23. Review of the Physician's Interim/Telephone Orders indicated an order written on 9/26/23 for all of the recommendations made on 9/21/23, five days earlier. During an interview on 9/29/23 at 7:55 A.M., Unit Manager #2 said the process was for hospice to leave the recommendations in the paper chart and to communicate any recommendations to the Unit Manager or the nurse on the medication cart. She said she had contacted the Physician regarding the recommended medication changes on 9/26/23 (5 days after they were recommended). She said she was not sure why the Physician had not been notified of the recommendations sooner and the recommendations must have been missed. During an interview on 9/29/23 at 10:30 A.M., the Director of Nurses said the expectation is for the Physician to be notified of hospice recommendations for medication changes as soon as possible, but not more than 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the bathroom in a clean, comfortable, working order for one Resident (#63), out of a sample of 27 residents. Findings include: Resident #63 was admitted to the facility in May 2021 with diagnoses of dementia and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 8/4/23, indicated the Resident was moderately cognitively impaired as evidenced by a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS). On 9/26/23 at 9:45 A.M., the surveyor observed Resident #63's bathroom and found the toilet clogged, the water was running in the sink, the floor molding was lifting away from the wall on the left side and from behind the toilet, the sink was pulled away from the wall with an approximate 2-3 inch gap, the wall paper behind the sink was peeling, the wooden bracket built to support the sink was pulled away on the left side of the sink, and the 11 tiles in front of the toilet and to the right were heavily soiled with a blackish/gray substance. The surveyor was unable to shut off the running water in the sink. During an interview on 9/26/23 at 9:46 A.M., Resident #63 said they can never shut off the water. On 9/26/23 at 4:05 P.M., the surveyor observed Resident #63's bathroom and found the condition of the bathroom the same, with the exception that the toilet was not clogged. The water in the sink was still running. During an interview on 9/28/23 at 3:40 P.M., Certified Nursing Assistant (CNA) #12, who was working on the [NAME] Unit, said if something is broken on the unit the staff just call maintenance or tell them if they see them in the hallway. She said there is no logbook to write down things that are broken. She said she was not aware of anything broken in Resident #63's bathroom or room. During an interview on 9/28/23 at 3:44 P.M., Nurse #7 said if something is broken, she just calls maintenance to tell them. She said there is no maintenance logbook and she searched the nursing station on the [NAME] Unit and could not find a maintenance book. She said she does not report broken items in the TELS system (a live cloud-based electronic building management communication system to schedule and track maintenance services and repairs) and added she doesn't know how to access the TELS system on the computer. She said she was not aware of anything being broken in Resident #63's room. During an interview on 9/28/23 at 4:04 P.M., Maintenance Staff #1 said the staff usually call down if something is broken and they go fix it. He said they just recently started a new system in which the Director of Maintenance logs all the work orders into TELS, and they no longer use the maintenance books on the units. Maintenance Staff #1 said he was not aware of any problems in Resident #63's room. On 9/28/23 at 4:04 P.M., the surveyor and Maintenance Staff #1 went to Resident #63's room and observed the bathroom, which was in the same condition as previously observed by the surveyor, including running water and the clogged toilet. Maintenance Staff #1 said the bathroom needs to be fixed; the sink, the floor, sink handles and the molding. He said he could not smell a urine smell but described the bathroom smell as stale. He said the water should shut off if you push both handles forward, but the handles are broken and you have to find just the right spot to shut off the water. During an interview on 9/29/23 at 11:24 A.M., the Administrator said they use the TELS systems, and some units still have the book to log in maintenance requests. She said she was made aware of Resident #63's bathroom today and she will address it. During an interview on 9/29/23 at 11:16 A.M., Maintenance Staff #1 and #2 both said they were not aware of the condition of the bathroom in Resident #63's bathroom. The Director of Maintenance was not available for interview.

Based on record review, policy review, observation, and interview, the facility failed to implement the physician's orders for an air mattress and accurately document its use for one Resident (#105) with a history of pressure ulcers, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Bed - Use Of Specialty, dated April 2015, indicated but was not limited to: - Specialty beds are used to provide pressure relieving capabilities for select residents/patients with multiple Stage 2 pressure ulcers on more than one turning surface, Stage 3 pressure ulcers and Stage 4 pressure ulcers, residents/patients with full thickness wounds and with select other needs. - Procedure: assess each resident individually for appropriate specialty bed therapy, obtain approval for the use of the specialty beds according to corporate policies and order according to policy, and provide correct mattress setting if needed. Resident #105 was admitted to the facility in February 2021 with diagnoses which included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 8/25/23, indicated Resident #105 weighed 165 pounds (lbs.). The MDS assessment indicated Resident #105 had one stage 3 pressure ulcer and was at risk for developing pressure ulcers/injuries. The assessment also indicated Resident #105 was utilizing a pressure reducing device for the bed. Review of Resident #105's Physician's Orders included but were not limited to: - Air mattress in place, check settings (200 lbs.) and function q-shift [every shift], start date 5/4/23. Review of the clinical record indicated Resident #105 was followed by a consultant wound care Physician. Review of Resident #150's wound care Physician documentation, dated 7/31/23, indicated stage III pressure ulcer to right heel with a size of 1.1cm x 0.8cm x 0.1cm. Resident #105 was followed weekly by wound care Physician and stage II pressure ulcer was monitored. Wound care Physician documentation, dated 9/6/23, indicated stage III pressure ulcer located on the right heel appears healed. Further review of documentation from the wound care Physician on 8/7/23, 8/14/23, 8/21/23, 8/28/23, 9/6/23, and 9/18/23 indicated Resident #105 utilized pressure relief surfaces. Review of Resident #105's Treatment Administration Record (TAR) indicated air mattress settings were checked and functioning. On 9/26/23 at 9:46 A.M., the surveyor observed Resident #105 lying in bed with head of bed elevated. The air mattress settings were set at 250 lbs., alternating pressure. A handwritten piece of tape on top of the air mattress box indicated setting of 200 lbs. On 9/27/23 at 2:55 P.M., the surveyor observed Resident #105 lying in bed with head of bed elevated. The air mattress settings were set at 250 lbs., alternating pressure. A handwritten piece of tape on top of the air mattress box indicated setting of 200 lbs. On 9/28/23 at 9:44 A.M., the surveyor observed Resident #105 out of bed in a wheelchair. The air mattress settings were set at 250 lbs., alternating pressure. A handwritten piece of tape on top of the air mattress box indicated setting of 200 lbs. On 9/28/23 at 10:54 A.M., the surveyor observed Resident #105 out of bed in a wheelchair. The air mattress settings were set at 250 lbs., alternating pressure. A handwritten piece of tape on top of the air mattress box indicated setting of 200 lbs. During an interview on 9/28/23 at 10:53 A.M., CNA #7 said they would check to make sure air mattress settings were set appropriate while caring for a resident. CNA #7 said there is a piece of tape on each air mattress box indicating the setting. CNA #7 said they would let the nurse know if there was a discrepancy. During an interview on 9/28/23 at 11:00 A.M., Unit Manager #1 said each resident has an order for air mattress settings and air mattress settings are measured by a resident's weight. Unit Manager #1 said settings are checked daily to ensure they are correct. Unit Manager #1 said there is a piece of tape with the proper setting applied to each air mattress box, matching the order. Unit Manager #1 and the surveyor observed Resident #105's air mattress with settings at 250 lbs. and alternating pressure. Unit Manager #1 said the air mattress should not be set to 250 lbs. Unit Manager #1 checked the physician's orders for Resident #105 which confirmed setting of 200 lbs. Unit Manager #1 reset the air mattress to match the physician's orders. During an interview on 9/28/23 at 2:10 P.M., the DON said their expectation was for air mattress settings to follow physician's orders.

Based on observations, interviews, record review, and policy review, the facility failed for one Resident (#70), out of a total sample of 27 residents, to ensure staff provided adequate supervision and assistance to prevent two falls. Findings include: Review of the facility's policy titled Falls Management, dated as revised August 2018, indicated but was not limited to the following: -A fall is defined as any incident in which a resident unintentionally has a change in elevation/plane, including an incident where a resident rolls off a bed or mattress. -Anytime a resident is found on the floor, a fall is considered to have occurred. -The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells), abnormal posture, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/25/23, indicated Resident #70 was unable to complete the Brief Interview for Menal Status (BIMS) because the Resident is rarely or never understood. Further review of the MDS indicated the Resident requires assistance of two people for bed mobility (turning side to side), toileting, and positioning. Additionally, the Resident has impairment on both sides of his/her body affecting both upper and lower extremities. Review of the care plan indicated Resident #70 was dependent on two staff for dressing, toileting, and bathing. Review of the medical record indicated Resident #70 fell out of bed on 8/23/23 and 9/26/23. Review of the Incident Report, dated 8/23/23, indicated Resident #70 rolled off the bed during care, was totally dependent with care, and unable to assist in any way. Additionally, the incident report indicated the Resident was a two person assist and the Certified Nursing Assistant (CNA) was providing care alone when the Resident started to slide. The CNA was unable to pull him/her back resulting in the Resident falling off the bed onto the floor. Review of the Incident Report, dated 9/26/23, indicated Resident #70 fell off the bed while the CNA was providing care alone. The CNA turned the Resident onto his/her side, and he/she fell off the bed. His/her Foley catheter (indwelling catheter inserted into the bladder to drain urine) dislodged and the Resident had to have a new one inserted. Review of the Resident Care Card (used as a reference guide for CNAs), dated 9/23, indicated Resident #70 required assistance of two staff members for toileting, personal hygiene, dressing, bathing, transfers, and bed mobility. During an interview on 9/28/23 at 10:00 A.M., CNA #9 said Resident #70 required two person assist with turning, positioning, and washing per his/her resident care card. The CNA said when the Resident fell on 9/26/23, the other CNA was doing the Resident's care alone. CNA #9 said she was working the day of the fall and she had been with the nurse and both staff responded after the other CNA called for help, and the Resident was already on the floor. During an interview on 9/28/23 at 11:13 A.M., Nurse #6 said Resident #70 is a two person assist, the CNA was not following the plan of care when he/she fell, and this is the second time he/she fell out of bed during care. Additionally, she said staff usually try to add new interventions with every fall, however, in this case education was provided to the CNA that didn't follow the care plan both times, and I don't see any other new interventions on the care plan. During an interview on 9/28/23 at 11:22 A.M., Nurse #7 said on 9/26/23 the CNA did not request help to provide care, she did it alone, and Resident #70 fell off the bed. Nurse #7 said no additional intervention was added after the fall that she was aware of. Additionally, she said Resident #70 doesn't have any specific fall prevention interventions, just that the bed should be low. She said, the Resident does not have floor mats next to his/her bed and the ones in the room are the roommates. Nurse #7 said he/she is supposed to have two staff to provide care as he/she is heavy and cannot help in any way. During an interview on 9/28/23 at 2:41 P.M., the Director of Nurses (DON) said Resident #70 requires a two person assist and the expectation is that the staff follow the plan of care and resident care card. Additionally, the DON said the bed should be as low to the floor as it can be and staff were not following the care plan by failing to have two staff members present to assist with turning and changing.

Based on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#105) with a history of trauma, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, undated, included but was not limited to: - It is the policy of this facility to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice. - Social Service will screen each resident for a history of trauma upon admission. - Documentation regarding the resident's psychosocial well-being including their response to stressful life events/trauma and coping mechanisms will be reflected in the Initial Social Service Assessment and/or Social Service Progress Notes. - A trauma informed care plan will be documented in the resident's medical record by Social Service in conjunction with the IDT. Resident #105 was admitted to the facility in February 2021 with diagnoses including anxiety and Post Traumatic Stress Disorder (PTSD - a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being). Review of the Minimum Data Set assessment, dated 8/25/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. Further review of the MDS assessment indicated Resident #105 had a diagnosis of PTSD. During an interview on 9/26/23 at 9:46 A.M., Resident #105 said he/she had a history of trauma related to his/her childhood. Resident #105 said he/she meets with Social Services at the facility once per week. Resident #105 said he/she sometimes feels alone. Review of the Initial Social Services Assessment Summary, dated 2/9/21, indicated Resident #105 had a history of trauma related to childhood. The assessment failed to indicate specific triggers related to Resident #105's history of trauma. Review of Social Service Quarterly Assessments, dated 2/18/23 and 8/21/23, indicated Resident #105 is followed by psychological services. The assessments failed to indicate specific triggers related to Resident #105's history of trauma. Review of the facility's Consultant Psychotherapist Notes, dated 7/6/23, 7/17/23, and 8/11/23, documented Resident #105's diagnoses to include PTSD. The documentation indicated Resident #105 continued to improve and psychosocial support was provided but did not indicate specifics related to traumas or the Resident's triggers. During an interview on 9/28/23 at 11:17 A.M., Unit Manager #1 said Resident #105 has a history of trauma and PTSD. Unit Manager #1 said there were times that Resident #105 refused treatment or did not want care from certain staff members. Review of the medical record failed to indicate facility staff collaborated with the Resident representative, or any other health care professional that provided care to the Resident to gather information related to the Resident's PTSD to develop a person-centered plan of care that identified potential triggers or trauma with interventions to prevent re-traumatization. Review of Resident #105's care plan indicated a care plan was in place for history of trauma, but it was not individualized related to triggers or history of PTSD. During an interview on 9/28/23 at 11:28 A.M., Social Worker #1 said Social Services completes assessments related to residents with a diagnosis of trauma or PTSD on admission to facility. Social Worker #1 said referrals are then made for residents to be followed by a psychiatric Nurse Practitioner in the facility. Social Worker #1 said triggers should be included in the initial PTSD care plan. Social Worker #1 and the surveyor reviewed the medical record, including care plans, for Resident #105. Social Worker #1 said Resident #105's current care plan did not identify triggers related to his/her PTSD/trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs, without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications for one Resident (#87), out of a total sample of 27 residents. Specifically, the facility failed to monitor for adverse side effects of an anticoagulant (blood thinning medication to prevent clots), including signs/symptoms of bruising, bleeding, and deep vein thrombosis (DVT-blood clot). Findings include: Resident #87 was admitted to the facility in August 2023 with the following diagnoses: fracture of fifth lumbar vertebrae, fracture of the sacrum, cardiac pacemaker, atrioventricular heart block, hypertension, and heart failure. Review of the Minimum Data Set (MDS) assessment, dated 8/17/23, indicated Resident #87 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, the Resident takes anticoagulants (blood thinning medication) daily. Review of the current Physician's Orders indicated an order for Eliquis (anticoagulant) 5 milligram (mg) by mouth twice daily. Further review of the physician orders failed to indicate an order to monitor for signs/symptoms of adverse consequences (i.e., side effects) related to the use of an anticoagulant. Review of the Bristol-[NAME] Squibb Eliquis (Apixaban) package insert, revised September 2021, indicated the following: -Eliquis is a factor Xa inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation and for the prophylaxis of DVT, which may lead to pulmonary embolism. -Warnings and Precautions: Eliquis can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. Review of Resident #87's care plan failed to indicate a care plan was implemented for the Resident's cardiac conditions or for the anticoagulant medication he/she is taking to treat those conditions. During an interview on 9/28/23 at 12:01 P.M., Nurse #6 said there was no order to monitor for side effects of the Eliquis but there should be. During an interview on 9/28/23 at 2:52 P.M., the Director of Nurses (DON) said there was no order to monitor for side effects of the anticoagulation medication and there should be. She said there is an order set that should have been put in place and it was not.

Based on record review, policy review, and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic medications without adequate monitoring for behaviors to ensure the safe administration of medications for one Resident (#87) out of a total sample of 27 residents. Specifically, the facility failed to ensure for Resident #87, resident specific, targeted behaviors were identified and monitored for the use of Xanax (used to treat anxiety), Buspar (used to treat anxiety), Zoloft (used to treat depression and anxiety) and Trazodone (used to treat depression). Findings include: Resident #87 was admitted to the facility in August 2023 with the following diagnoses: anxiety, depression, and adjustment disorder with anxiety. Review of the Minimum Data Set (MDS) assessment, dated 8/17/23, indicated Resident #87 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and takes psychotropic (anti-anxiety and anti-depressant) medications daily. Review of the current Physician's Orders indicated but was not limited to the following: -Xanax 0.5 milligrams (mg) by mouth three times daily. -Buspar 15 mg by mouth once daily in the morning and 10 mg by mouth every night. -Zoloft 200 mg by mouth once daily. -Trazodone 100 mg by mouth every night. The physician's orders failed to identify resident specific, targeted behaviors for the use of the psychotropic medications, and failed to include monitoring of targeted behaviors. Review of the medical record (care plan and treatment administration record) failed to indicate that staff monitored resident specific, targeted behaviors for the use of psychotropic medication as required. Review of the psychiatric evaluation note, dated 9/15/23, indicated Resident #87 had increased depression, anxiety, and insomnia related to adjustment to the skilled nursing facility (SNF) setting, medical stressors, and loss of independence. Medication adjustments were recommended due to increased anxiety related to adjusting to the SNF setting. During an interview on 9/28/23 at 11:59 A.M., CNA #9 said the nurses do the behavior monitoring on their computer, not the CNAs. During an interview on 9/28/23 at 12:01 P.M., Nurse #6 said all residents on psychotropic medications should have specific behavior monitoring and Resident #87 did not have any in his/her orders. During an interview on 9/28/23 at 2:52 P.M., the Director of Nurses (DON) said all residents on psychotropic meds should have specific behavior monitoring until they are stable. Additionally, she said her expectation for new residents and new medications that there should be monitoring. She said Resident #87 should have behavior monitoring for anxiety and he/she does not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and only authorized personnel were permitted access. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated February 2018, indicated but was not limited to: -Storage for other medications will be limited to a locked medication room. On 9/27/23 at 1:48 P.M., the surveyor observed the [NAME] Unit (a locked unit with multiple cognitively impaired residents) medication room door to be propped open, with no nursing staff present at the nurses' station. Nurse #4 returned to the medication cart located outside of the nurses' station at 1:51 P.M. At 1:59 P.M., Nurse #4 left the medication cart and entered the activity/dining room, the medication room door continued to be propped open and unattended with no nursing staff present at the nurses' station. Residents were present in the area of the nurses' station both times the medication room was observed to be open and unattended. During an interview on 9/27/23 at 2:03 P.M., Nurse #4 said she did not realize the medication room door was propped open but she believed the door was propped open because they had been stocking the medication room. Nurse #4 said the medication room door should not be propped open and should not have been left unattended. During an interview on 9/28/23 at 12:38 P.M., the Director of Nurses (DON) said the medication room doors should be closed and locked when unattended.

Based on observations, interviews, policy review, and records reviewed for one Resident (#18) of 27 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #18, the facility failed to initiate replacement of lost/missing dentures. Findings include: Review of the facility's policy titled Dental Services/Dentures, dated as revised September 2017, indicated but was not limited to: -The facility must promptly, within 3 days refer the resident with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what was done to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. -An investigation will be conducted to determine the cause for loss or damage to a resident's dentures. If staff mishandling of dentures is found to be a causative factor, the facility will be responsible for repair or replacement. Resident #18 was admitted to the facility in June 2021 with the following diagnoses: dysphagia (difficulty swallowing) and edentulous (no natural teeth). Review of the most recent Minimum Data Set (MDS) assessment, dated 7/21/23, indicated that Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #18's care plan failed to indicate a care plan for the use of dentures and his/her edentulous status. During an interview on 9/26/23 at 9:38 A.M., Resident #18 said his/her top denture had gone missing at least two months ago and he/she had not heard from the facility about aiding in replacing the denture. Resident #18 said he/she believed there was nothing that could be done about his/her dentures because neither him/her nor the facility could afford to replace them. During an interview on 9/28/23 at 10:39 A.M., Certified Nursing Assistant (CNA) #4 said the facility used to lock the dentures in the med room at night, so they did not get lost. CNA #4 said Resident #18's top denture had been missing for a while and she was not sure what had happened to them. During an interview on 9/28/23 at 11:14 A.M., Nurse #3 said Resident #18's denture had been missing for at least a month, and she did not know anything about them. During an interview on 9/28/23 at 2:57 P.M., Resident #18 said at one point some of the nurses would ask him/her for the dentures at night, but that did not consistently occur. Resident #18 said his/her top denture had been missing for at least a couple of months. Nurse #3 was present in Resident #18's room and searched his/her belongings, Nurse #3 was unable to locate the top denture. During an interview on 9/28/23 at 11:27 A.M., Unit Manager #1 said she was not aware Resident #18's dentures were missing. During an interview on 9/28/23 at 12:38 P.M., the Director of Nurses (DON) said she was unaware Resident #18 was missing his/her top denture. The DON said the expectation for missing dentures was for a grievance to be completed and for dental services to be set up. During an interview on 9/28/23 at 2:25 P.M., Social Worker #1 said she was not aware that Resident #18's top denture was missing, and a grievance had not been initiated. Social Worker #1 said the expectation for a missing denture(s) was for a grievance to be completed and then the facility would set up an appointment to replace the denture(s).

Based on observation, record review, and interview, the facility failed to ensure a care plan was developed and implemented for four Residents (#70, #87, #106, and #18), out of a total sample of 27 residents. Specifically, the facility failed to: 1. For Resident #70, implement his/her activities of daily living (ADL) care plan of utilizing two staff members during care; 2. For Resident #87, develop a care plan for cardiac conditions and the use of high risk medications; 3. For Resident #106: a. develop a care plan for a pressure ulcer and for the use of antibiotics, and b. implement his/her alteration in skin integrity care plans; and 4. For Resident #18, develop a care plan for impaired skin integrity of the left lateral ankle. Findings include: 1. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells), abnormal posture, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/25/23, indicated Resident #70 was unable to complete the Brief Interview for Menal Status (BIMS) because the Resident is rarely or never understood. Further review of the MDS indicated the Resident requires assistance of two people for bed mobility (turning side to side), toileting, and positioning. Additionally, the Resident had impairment on both sides of his/her body affecting both upper and lower extremities. Review of the care plan indicated Resident #70 was dependent on two staff for dressing, toileting, and bathing. Review of the medical record indicated Resident #70 fell out of bed on 8/23/23 and 9/26/23 while care was being performed by one staff member. Review of the Incident Report, dated 8/23/23, indicated Resident #70 rolled off the bed during care, was totally dependent with care and unable to assist in any way. Additionally, the incident report indicated the Resident was a two person assist and the Certified Nursing Assistant (CNA) was providing care alone when the Resident started to slide; the CNA was unable to pull him/her back alone resulting in the Resident falling off the bed onto the floor. Review of the Incident Report, dated 9/26/23, indicated Resident #70 fell off the bed while the CNA was providing care alone. The CNA turned the Resident onto his/her side, and he/she fell off the bed. Review of the Resident Care Card (used as a reference guide for CNAs), indicated Resident #70 required assistance of two staff members for toileting, personal hygiene, dressing, bathing, transfers, and bed mobility. Additionally, the Care Card indicated the bed should be in a low position for safety. The surveyor made the following observations: -9/27/23 at 11:18 A.M., the Resident was in bed; the bed was not in the low position, it was approximately three feet off the floor (waist height when the surveyor stood next to the bed). -9/27/23 at 12:58 P.M., the Resident was in bed; the bed was not in low position, it was approximately three feet off the floor (waist height when the surveyor stood next to the bed). -9/28/23 at 9:30 A.M., the Resident was in bed; the bed was not in a low position, it was approximately three feet off the floor (waist height when the surveyor stood next to the bed). -9/28/23 at 2:23 P.M., the Resident was in bed; the bed was not in a low position, it was raised greater than two and a half feet off the floor (hip height when the surveyor stood next to the bed). During an interview on 9/28/23 at 10:00 A.M., CNA #9 said Resident #70 required two person assist with turning, positioning, and washing per his/her resident care card. Also, his/her bed should be low, almost to the floor for safety. The CNA said when the Resident fell on 9/26/23, the other CNA was doing the Resident's care alone. CNA #9 said she was working the day of the fall and she had been with the nurse and both staff responded after the other CNA called for help, and the Resident was already on the floor. During an interview on 9/28/23 at 11:13 A.M., Nurse #6 said the Resident requires a two person assist and the CNA was not following the plan of care when the Resident fell. During an interview on 9/28/23 at 2:41 P.M., the Director of Nurses (DON) said Resident #70 required assist of two staff and her expectation was that the staff follow the plan of care and the resident care card, and they were not. Additionally, the DON said the bed should be as low to the floor as it can be and three feet off the floor is too high, it should be lower than that. 2. Resident #87 was admitted to the facility in August 2023 with the following diagnoses: fracture of fifth lumbar vertebrae, cardiac pacemaker, atrioventricular heart block, hypertension, and heart failure. Review of the MDS assessment, dated 8/17/23, indicated Resident #87 was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS. The MDS indicated the Resident took anticoagulants (blood thinning medication to prevent clots) and diuretics (medication to reduce fluid buildup in the body) daily. Review of the current Physician's Orders indicated Resident #87 had orders for Eliquis 5 milligram (mg) by mouth twice daily (anticoagulant) and Lasix 40 mg by mouth daily (diuretic). Review of Resident #87's care plan failed to indicate a care plan had been developed for the Resident's cardiac conditions or for the high-risk medications (Eliquis and Lasix) he/she was taking to treat those conditions. During an interview on 9/28/23 at 12:01 P.M., Nurse #6 said there should be a cardiac care plan and monitoring for adverse side effects of the anticoagulation medication orders should have been written and they were not. During an interview on 9/28/23 at 2:52 P.M., the DON said there should be a cardiac care plan in place and there was not. Additionally, she said the anticoagulation medication should have specific monitoring for adverse side effects, and there was an order set for the monitoring that should have been put in and it was not. The Resident was not being monitored for adverse side effects of Eliquis. 3. Resident #106 was admitted to the facility in May 2023 with the following diagnoses: colitis, diverticulitis (inflammation of the colon), and chronic osteomyelitis (infection of the bone). Review of the most recent MDS assessment, dated 8/11/23, indicated that Resident #106 was cognitively intact as evidenced by a BIMS score of 15 out of 15, had a stage four pressure ulcer that was present on admission, and received antibiotics on 7 out of 7 days reviewed. a. Review of Resident #106's current Physician's Orders included but were not limited to: -Treatment order: Cleansed with wound cleanser, pat dry apply skin prep to peri wound, apply alginate cover with foam dressing every day shift for wound care and as needed for soilage. Location: Sacrum, dated 7/31/23 -Nitrofurantoin Macrocrystal (antibiotic) 100 milligrams (mg) by mouth in the evening for UTI prevention, dated 8/19/23 Review of Resident #106's September 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated he/she had received Nitrofurantoin Macrocrystals and sacral wound dressing changes per the physician's orders. Review of Resident #106's Pressure Injury Evaluation, dated 9/22/23, indicated: -date of origin 5/12/23 and not facility acquired -original stage: 4 -Location: sacrum Review of Resident #106's care plan included: -Potential in alteration in skin integrity r/t incontinence, dated 5/22/23 -Actual alteration in skin integrity related to a surgical wound, status post port removal right chest wall, dated 8/29/23 Further review of Resident #106's care plan failed to indicate a care plan for: -use of antibiotics -stage four pressure injury on the sacrum During an interview on 9/28/23 at 9:02 A.M., the Director of Nurses (DON) said Resident #106 did not have an active care plan for the use of antibiotics or for his/her pressure injury. The DON said a care plan should be in place for the use of an antibiotic and for the pressure injury. b. Review of the facility's policy titled Weekly Body Audit, undated, indicated but was not limited to: -All residents will have a body audit to address any skin issues on a weekly basis. If an alteration in skin integrity (bruise, pressure injury, non-pressure wound, rash, abrasion, skin tear, reddened area, etc.) is discovered it will be documented on the Weekly Skin Audit form as soon as the nurse observes the area. Monitoring of the area will continue until the area is resolved. -The licensed nurse will conduct a weekly body audit, looking for any alteration in skin integrity. Review of Resident #106's current Physician's Orders included but were not limited to: -Skin Protocol: Weekly skin checks on bath/shower day Friday 3-11, dated 6/18/23. Review of Resident #106's care plans indicated: -Focus: Resident has potential in alteration in skin integrity related to incontinence, 5/22/23 -Intervention: complete skin condition at 24 hours and then weekly, 5/22/23 -Focus: Actual alteration in skin integrity related to a surgical wound, status post port removal right chest wall, 8/29/23 -Intervention: skin check assessment weekly Review of Resident #106's weekly skin audit evaluations indicated head-to-toe assessments were completed on: 5/12/23 5/19/23 6/18/23 6/23/23 7/1/23 7/7/23 8/4/23 8/11/23 9/9/23 Further review of Resident #106's medical record indicated he/she was out of facility 6/1/23 through 6/17/23. During an interview on 09/28/23 at 10:02 A.M., Nurse #3 said head to toe skin checks were completed by the facility nurses weekly. During an interview on 9/28/23 at 1:52 P.M., the Infection Control Nurse (whose responsibilities include functioning as the facility wound nurse) said she conducts weekly wound rounds with a physician/physician assistant. The Infection Control Nurse said wound rounds are conducted on a focused area and did not include a head-to-toe assessment. During an interview on 9/28/23 at 11:27A.M., Unit Manager #1 said head-to-toe skin checks should be conducted weekly on shower days even if the resident is being followed by the wound nurse/physician. She said the skin checks were documented in the electronic record. Unit Manager #1 and the surveyor reviewed Resident #106's medical record and were unable to locate weekly skin audits. Unit Manager #1 said she did not know why the Resident's weekly skin checks were missing and were not consistently completed. During an interview on 9/28/23 at 12:38 P.M., the DON said she was not aware why Resident #106 was missing weekly skin assessments. She said full head-to-toe skin checks should be conducted weekly and recorded in the electronic record. 4. Resident #18 was admitted to the facility in June 2021 with the following diagnoses: diabetes mellitus, hypertension, muscle weakness, and an unstageable pressure ulcer of left ankle. Review of the most recent MDS assessment, dated 7/21/23, indicated that Resident #18 was cognitively intact as evidenced by a BIMS score of 13 out of 15. Throughout the survey the surveyor observed a bordered foam dressing on Resident #18's left lateral ankle. The bordered foam dressing remained unchanged and was observed on Resident #18's left lateral ankle on the following days: -9/26/23 at 9:38 A.M. -9/27/23 at 11:47 A.M. -9/28/23 at 11:08 A.M. On 9/28/23 at 11:20 A.M., the surveyor and Nurse #3 observed Resident #18's left lateral ankle to have impaired skin integrity as evidenced by an open area. Review of Resident #18's care plan included: -Resident has potential alteration in skin integrity r/t decreased/impaired mobility or function, history of alteration in skin integrity, location: buttocks, etiology: MASD, incontinence, moisture During an interview on 9/28/23 at 12:38 P.M., the DON said Resident #18 did not have an active care plan for impaired skin integrity. The DON said a care plan should be in place if a resident had impaired skin.

Based on observation, record review, policy review, and interview, the facility failed to maintain professional standards in managing and caring for urinary catheter devices for two Residents (#70 and #15), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #70, to ensure that catheter care and flushes were provided per physician's orders to prevent blockage; and 2. For Resident #15, to ensure that catheter care and monitoring of bedside drainage was performed every shift to prevent catheter complications. Findings include: Review of the facility's policy titled Section U-Urinary Catheter, dates as reviewed March 2023, indicated but was not limited to the following: -It is the policy of this facility that all residents with catheters will receive catheter care to prevent irritation and possible infection. 1. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells), muscle weakness, neuromuscular dysfunction of the bladder, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 8/25/23, indicated Resident #70 was unable to complete the Brief Interview for Mental Status (BIMS) because the Resident is rarely or never understood. Further review of the MDS indicated that the Resident had an indwelling catheter. Review of the Foley Catheter care plan indicated but was not limited to the following: -Foley catheter care every shift and as needed. -Flush catheter as ordered. Review of the Physician's Orders indicated to flush the Foley catheter with 30 milliliters (mls) of normal saline daily every evening shift. Review of the August 2023 Treatment Administration Record (TAR) indicated on the evening shift (3:00 P.M. - 11:00 P.M.) the catheter was not flushed 7 of 31 opportunities. Review of the September 2023 TAR indicated on the evening shift the catheter was not flushed 13 of 27 opportunities. Review of the nursing progress note, dated 9/13/23, indicated the Resident's catheter bag had minimal urine in it; the nurse attempted to flush the catheter and was met with resistance. Upon removal, large amounts of urine expelled from the Resident onto the bedsheet. The Foley catheter was replaced and cloudy urine with sediment drained into the bag. Further review of the TAR indicated the catheter was not flushed 14 of the 16 evenings (8/27/23-9/12/23) prior to blockage occurring on 9/13/23. During an interview on 9/28/23 at 11:13 A.M., Nurse #6 said Foley catheter care and flushes should be done and documented on the TAR. During an interview on 9/28/23 at 11:22 A.M., Nurse #7 said Foley catheter care should be documented in the TAR every day. During an interview on 9/28/23 at 11:42 A.M., Nurse #6 said Resident #70 gets his/her catheter flushed every evening shift to prevent blockages. During an interview on 9/28/23 at 2:41 P.M., the Director of Nurses (DON) said catheter care should be done per physician's orders and documented on the TAR. She said the expectation was for daily flushes to be done daily if they are ordered. The DON reviewed the TARs and said, on these days, it was not signed off as being done. Additionally, she said the purpose of the daily flushes was to keep the catheter patent (unobstructed). 2. Resident #15 was admitted to the facility in August 2018 with the following diagnoses: neuromuscular dysfunction of the bladder, cerebral vascular disease (effects the blood vessels of the brain), epilepsy (neurological disorder), retention of urine, and muscle weakness. Review of the Physician's Orders indicated to provide catheter care every shift and check Foley bedside drainage every shift. Review of the September 2023 TAR indicated that catheter care was not provided on 21 of the 80 opportunities and Foley bedside drainage was not checked on 20 of 80 opportunities. During an interview on 9/29/23 at 10:37 A.M., the DON reviewed Resident #15's TAR and said she was not aware the nurses were not completing that many treatments on the TAR.

2. Review of the facility's policy titled Oxygen Administration Nasal Cannula, revised November 2020, indicated but was not limited to: - To deliver low flow oxygen, per physician's orders (generally 1-6 liters per minute (LPM) and 24-45% concentration) via nasal cannula. - Procedure: Set the oxygen liter flow to the prescribed liters flow per minute. Resident #62 was admitted to the facility in February 2019 with diagnoses including pneumonia and diabetes mellitus. Review of the MDS assessment, dated 9/8/23, indicated Resident #62 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. Further review of the MDS assessment indicated Resident #62 was receiving oxygen therapy. Review of Resident #62's current Physician's Orders indicated but were not limited to: - Oxygen as needed (PRN) via nasal cannula at 2 LPM for O2 [oxygen] saturation < 88% on room air (RA) or patient short of breath (SOB), start date 7/3/23 - Oxygen as needed via nasal cannula at 1 to 2 LPM, start date 8/31/23 - Monitor oxygen saturation on RA every shift, start date 8/31/23 On 9/27/23 at 11:41 A.M., the surveyor observed Resident #62's Oxygen to be set at 3 LPM. On 9/27/23 at 3:18 P.M., the surveyor observed Resident #62's Oxygen to be set at 3 LPM. On 9/28/23 at 9:53 A.M., the surveyor observed Resident #62's Oxygen to be set at 3 LPM. Review of Resident #62's TAR for September 2023 indicated his/her oxygen saturation levels were assessed every shift. During an interview on 9/28/23 at 12:02 P.M., the Staff Development Coordinator (SDC) (whose role on this date included being a floor nurse caring for Resident #62) said before assessing a resident on Oxygen, physician's orders should be reviewed. The SDC reviewed Resident #62's physician's orders and said Resident #62 should be on Oxygen between 1-2 LPM via nasal cannula as needed. The SDC and the surveyor entered Resident #62's room and observed the oxygen concentrator settings. She said Resident #62's Oxygen was set to 3 LPM. The SDC assessed the Resident's oxygen saturation levels and said they were at 95% on 3 LPM and reset the oxygen concentrator to 2 LPM. She said she would reassess Resident #62's oxygen saturation levels in a while to ensure the Resident maintained the proper levels. During an interview on 9/28/23 at 2:01 P.M., the DON said nurses should check oxygen concentrator settings during their rounds of each resident. The DON said oxygen concentrators should be set to follow physician's orders. Based on record review, policy review, and interview, the facility failed to ensure its staff provided respiratory care consistent with professional standards of practice and the comprehensive care plan for two Residents (#70 and #62), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #70, to ensure tracheostomy (trach- an opening created in the windpipe to allow air and oxygen to reach the lungs) care and respiratory evaluations were done per physician's orders and to maintain and monitor the Resident's trach and equipment; and 2. For Resident #62, to ensure Oxygen was administered according to physician's orders. Findings include: 1. Review of the facility's policy titled Tracheostomy Suctioning and Care, dated as revised 9/1/17, indicated but was not limited to: -the objective is to maintain a clear and patent (unobstructed) airway. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells), chronic respiratory failure, chronic obstructive pulmonary disease (COPD- lung disease that causes airflow blockage and breathing related problems). Review of the Minimum Data Set (MDS) assessment, dated 8/25/23, indicated Resident #70 was unable to complete the Brief Interview for Mental Status (BIMS) because the Resident is rarely or never understood. Further review of the MDS indicated the Resident required assistance of two people for activities of daily living, had impairment on both sides of his/her body affecting both upper and lower extremities, and had a tracheostomy. Review of Resident #70's Care Plan indicated but was not limited to the following: -Auscultate (listen to) lung sounds as indicated. -Oxygen and oxygen saturation levels as ordered. -Trach care every shift as ordered. Review of the Physician's Orders indicated but was not limited to the following: -Trach care every shift. -Evaluate and document Respiratory rate, oxygen saturation, and lung sounds and shortness of breath every shift. -Airway type: Tracheostomy Brovana 7-millimeter (mm) cuff deflated document: airway, lung sounds, respiratory rate, and oxygen saturation every shift. -Post nebulizer evaluation: Document respiratory rate, oxygen saturation, and lung sounds. -Change and date trach mask every three days. -Check 7 mm Brovana trach spare at bedside every shift. -Check trach for proper placement every shift. Review of the August 2023 Treatment Administration Record (TAR) indicated but was not limited to the following: -Trach care was not done 13 of 93 shifts. -Airway evaluation was not done 14 of 93 shifts. -Airway type documentation was not done 14 of 93 shifts. -Airway documentation post nebulizer treatment was not done 14 of 93 shifts. -Change and date trach mask was not done 2 of 10 times. -Ensure spare trach is at bedside was not done 13 of 93 shifts. -Check for proper placement of the trach was not done 13 of 93 shifts. Review of the September 2023 TAR indicated but was not limited to the following: -Trach care was not done 22 of 81 shifts. -Airway evaluation was not done 22 of 81 shifts. -Airway type documentation was not done 22 of 81 shifts. -Airway documentation post nebulizer treatment was not done 22 of 81 shifts. -Change and date trach mask not done 2 of 9 times. -Ensure spare trach is at beside was not done 22 of 81 shifts. -Check for proper placement of the trach was not done 22 of 81 shifts. During an interview on 9/28/23 at 11:13 A.M., Nurse #6 said trach care should be done every day and documented on the TAR every shift. During an interview on 9/28/23 at 11:22 A.M., Nurse #7 said trach care should be documented on the TAR every shift. During an interview on 9/28/23 at 2:41 P.M., the Director of Nurses (DON) said trach care should be done and documented everyday per the physician's orders. She said her expectation was that all orders are signed off in the TAR every day and she could see now that they were not.

Based on staff interview and record review, the facility failed to ensure the nursing staff completed training as outlined in the Facility Assessment tool. Specifically, the facility failed to provide documentation that all training was completed for 3 out of 5 staff training records reviewed. In addition, the facility could not verify all licensed nursing staff currently working completed all their competencies and Certified Nursing Assistant (CNA) training was a minimum of 12 hours. Findings include: Review of the Facility Assessment Tool, most recent revision dated 8/1/2023, indicated but was not limited to the following: Staff training/education and competencies: -Employee competencies are those traits, skills, or attributes that employees need to perform their job most effectively. These competencies will vary by job and position, but there are some commonalities that apply to just about any job in just about any organization. -Training topics common to all employees of Plymouth Rehabilitation and Healthcare Center include: -Communication -Resident rights and facility responsibilities -Abuse neglect and exploitation-training that at a minimum educates staff on: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention -Infection control -Culture change -Cultural competency competencies -In-servicing focuses upon the trend of residents with substance use disorders, admitted to nursing homes, and the implications of such in a long-term setting (LTC). Topics include but are not limited to the following: -Understanding addiction associated behavioral challenges, and de-escalation techniques -Medication diversion -Treatment modalities-understanding stigma and its effect on residents -Comprehensive substance use disorder education for all new hires (orientees). Training for nurses' aides includes: -Required in-service training for nurses' aides, in-service and training must: -Be sufficient to ensure the continuing competence of nurses' aides must be no less than 12 hours per year. -Include dementia management training and resident abuse prevention training. -Address areas of weakness as determined in nurses' aide performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. -For nurses' aides providing services to individuals with cognitive impairments, also addresses the care of the cognitively impaired. -Identification of resident changes in condition including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering or improve quality of life. Consider the following competencies: -Person centered care -Activities of daily living -Disaster planning procedures -Infection control -Medication administration -Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone. -Caring for persons with dementia -Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. Review of the facility's Competency Schedule, revised 3/12/20, indicated the following training schedule to be completed: -To be done at licensed staff job specific orientation and annually: Blood spill, cardiovascular assessment, choking and abdominal thrust, clean dressing change, equipment; use of infusion and feeding pump, filling O2 portable tanks, Foley catheter insertion, gastroccult testing, Gastrointestinal assessment, glucose testing/glucometer care, hand hygiene, hemoccult testing, insulin pen, intravenous (IV) dressing change-central line, IV needleless connector change, IV electronic fusion pump, IV use of Dial-A-Flow device, post exposure to body fluids, personal protective equipment (PPE), respiratory assessment, syringe safety, trach care, suctioning, transfer with mechanical lift TST-planting/reading. -To be done at certified nursing assistant (CNA) job specific orientation and annually: Blood pressure monitoring, blood spill, choking and abdominal thrust, clean dressing change, denture care, emptying catheter drainage bag, filling O2 portable tanks, hand hygiene, incontinent care, post exposure to body fluids, PPE, pulse monitoring, trach care, transfer with mechanical lift. Review of the following staff files indicated the staff had completed the following training: 1. Nurse #9 -No record of nursing competencies being completed 2. CNA #10: -Completed annual competency 7/28/21 (two years prior) -Dementia Training-none -Caring Positivity last completed 4/14/21 -Legionella education last completed 7/28/21 -HIPAA compliance last completed 4/13/21 -Nurse Aide Pressure Injury Prevention 7/24/23 (1 hour long) -Bowel monitoring 6/29/23 (15 minutes long) 3. Nurse #11 -Medication Administration Pass completed on 2/1/23 -Point Click Care training modules completed 3/7/23 -No additional record of nursing competencies completed During an interview on 9/29/23 at 12:23 P.M., the Staff Development Coordinator (SDC) Nurse said she just started three and half months ago and only works three days a week. She said prior to her taking the position, there was no one in the role as SDC for two years. She said since taking on the position, she has been focusing on completing the required dementia training and setting up monthly staff education. The SDC Nurse said she has no tracking system to verify all the nurses currently working have completed all of their annual competencies. In addition, she said she had not even looked at the required 12 hours of training for CNAs except the dementia training. The surveyor and the SDC Nurse reviewed Nurse #9, CNA #10, and Nurse #11's education folder for completed education. The SDC Nurse said Nurse #9 does not have the completed competencies packet. She said CNA #10 is due for dementia training and she is not sure the last time she had any dementia training, and most of her training is from 2021 except for a one hour in-service on pressure injury prevention and 15 minutes of bowel monitoring training. She said Nurse #11 is also missing the competency packet. The SDC Nurse provided the surveyor with current sign-in sheets for education/trainings she currently had in progress. The training includes the following in-services: -Pressure Injury Prevention- one hour -Assessment Responsibilities and When to Write Notes- 10 minutes -Respiratory Training- 10 minutes -Bowel In-service- no time noted -Infection criteria- 5 minutes -Locking beds and stairwell alarms- 5 minutes -Reordering narcotics- 5 minutes -Survey results- 10 minutes -Completing wound dressing safely- 5 minutes During an interview on 9/29/23 at 1:05 P.M., the Administrator said she is aware some of the training had not been completed. She said the facility had not had a SDC in two years. She said they finally filled the current SDC position a couple months ago, but she only works three days a week and has been trying to catch up. The Administrator said there is a plan in place for monthly education and by year-end all training should be completed.

Based on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA) completed the required no less than 12 hours of annual training, which at a minimum must include dementia and abuse training for 1 of 2 CNA education files reviewed. In addition, the facility could not provide documentation to show CNAs working in the building completed at least 12 hours of annual in-service training. Findings include: Review of the Facility Assessment Tool, most recent revision dated 8/1/2023, indicated but was not limited to the following: Staff training/education and competencies Training for nurses' aides includes: -Required in-service training for nurses' aides, in-service and training must: -Be sufficient to ensure the continuing competence of nurses' aides and must be no less than 12 hours per year. -Include dementia management training and resident abuse prevention training. -Address areas of weakness as determined in nurses' aide performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. -For nurses' aides providing services to individuals with cognitive impairments, also addresses the care of cognitively impaired. -Identification of resident changes in condition including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering or improve quality of life. Consider the following competencies: -Person centered care -Activities of daily living -Disaster planning procedures -Infection control, medication administration-measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone. Review of the facility Competency Schedule, revised 3/12/20, indicated the following training schedule to be completed: -To be done at certified nursing assistant (CNA) job specific orientation and annually: Blood pressure monitoring, blood spill, choking and abdominal thrust, clean dressing change, denture care, emptying catheter drainage bag, filling O2 portable tanks, hand hygiene, incontinent care, post exposure to body fluids, PPE, pulse monitoring, trach care, transfer with mechanical lift. Review of Certified Nursing Assistant (CNA) #10 education file indicated the following: -Completed annual competency 7/28/21, two years prior. -Dementia Training -Caring Positivity last completed 4/14/21 -Legionella last completed 7/28/21 -HIPAA last completed 4/13/21 -Nurse Aide Pressure Injury Prevention 7/24/23 (1 hour long) -Bowel monitoring 6/29/23 (15 minutes long) During an interview on 9/29/23 at 12:23 P.M., the Staff Development Coordinator (SDC) said she started three and a half months ago and only works three days a week. She said prior to taking the position, there was no one in the role as SDC for two years. She said since taking on the position, she had been focusing on completing the required dementia training and setting up monthly staff education. The SDC Nurse said she had no tracking system to verify the certified nursing assistants (CNAs) had completed their annual 12 hours of training. She said she had not even looked at the required 12 hours of training for CNAs except the dementia training. The surveyor and the SDC reviewed CNA #10's education folder for completed education. The SDC Nurse said CNA #10 is due for dementia training and she is not sure the last time she had any dementia training, and most of her training is from 2021 except for a one-hour in-service on pressure injury prevention and 15 minutes of bowel monitoring training. SDC Nurse provided the surveyor with current sign-in sheets for education/training she currently has in progress. The training includes the following in-services: -Pressure Injury Prevention- one hour -Assessment Responsibilities and When to Write Notes- 10 minutes -Respiratory Training- 10 minutes -Bowel In-service- no time noted -Infection criteria- 5 minutes -Locking beds and stairwell alarms- 5 minutes -Reordering narcotics- 5 minutes -Survey results- 10 minutes -Completing Wound Dressing Safely- 5 minutes During an interview on 9/29/23 at 1:05 P.M., the Administrator said that she is aware some of the training had not been completed. She said the facility had not had a Staff Development Coordinator in two years. She said they finally filled the current SDC position a couple months ago, but she only works three days a week and has been trying to catch up. The Administrator said there is a plan in place for monthly education and by year end all training should be completed.

Based on interviews and policy review, the facility failed to ensure sufficient support staff were available to carry out food and nutrition services to provide a dignified dining experience and maintain clean and well stocked nourishment kitchenettes. Specifically, the facility failed to: 1. Ensure all meals provided to residents were served on dishware, not Styrofoam; and 2. Ensure 4 of 4 nourishment kitchenettes were adequately cleaned and stocked daily, per facility policy. Findings include: 1. During an interview on 9/26/23 at 3:29 P.M., the Ombudsman said the facility has been using Styrofoam instead of dishware during meal service for almost a year and a half, but not daily. The Ombudsmen said the residents cannot cut with plastic utensils. The Ombudsmen further said the facility had decreased the use of Styrofoam from all meals to just breakfast and dinner. During a resident group meeting with the surveyor on 9/27/23 at 10:30 A.M., 6 of 6 residents said that it is typical for meals to be delivered on Styrofoam. The residents in attendance said that all last week, referring to 9/17/23 through 9/23/23, they were served their meals on Styrofoam. The residents further said the last three days the kitchen has not used Styrofoam, but that is irregular. During an interview on 9/27/23 at 3:00 P.M., the Food Service Director (FSD) and the Chef Manager both said they have been using Styrofoam during meal service due to a dietary staffing shortage. The FSD said the staffing issues have been going on since he started in February 2023. The Chef Manager said it takes at least three diet aides and one cook to run a tray line. The FSD said they use Styrofoam during meal service if there is only one diet aide available for that meal service. The FSD said he could not identify what days in the past they had to use Styrofoam, but did say that all last week, referring to 9/17/23 through 9/23/23, they had to use Styrofoam due to a dietary staffing shortage. During an interview on 9/28/23 at 2:30 P.M., the surveyor had a meeting with the Administrator, Food Service Director, and Regional Food Manager. The Administrator said she was aware of some occasions that Styrofoam was used during meal service, instead of dishware, due to a dietary staffing shortage. The Administrator also said paper is unacceptable, and they are recruiting for dietary staff. 2. Review of the facility's policy titled Nourishment Room Supplies, dated May 2015, indicated but was not limited to: -Nourishment rooms will be adequately stocked and rotated with proper supplies in approved containers daily, or as needed. The Dining Department will be responsible for maintaining and stocking supplies. Review of the Nourishment Kitchenette Restock form, not dated, indicated under other tasks for dietary staff to: -Discard any items open for 72 hours, including resident items. -Discard any items that are not labeled and dated, including resident's items. -Clean and sanitize fridge and freezer, and inside microwave. -Insure [sic] that there are no employee personal items stored. -Clean and organize inside cabinets insuring [sic] no employee items present. -Retreave [sic] any leftover trays or items from previose [sic] meal period. During an interview on 9/27/23 at 3:00 P.M., the Food Service Director (FSD) said if they have enough dietary staff, he would send someone up to clean the interior of the refrigerators and microwave, and restock. The FSD said cleaning and restocking the nourishment kitchenettes can occur at any time of the day, depending on the staffing situation, but typically it is a diet aide's job. The FSD said that to his knowledge, the last time the nourishment kitchenettes were cleaned was Monday night (9/25/23), two days prior. Refer to F812

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food is labeled, dated, and stored according to facility policy, and ensure adequate sanitation of equipment in the main kitchen, and 4 of 4 nourishment kitchenettes; and 2. Ensure dish washer temperatures were adequate to wash and sanitize all dishware; and 3. Provide a thermometer or device (T-stick) to ensure the foods brought from home were reheated to an internal temperature of 165 degrees Fahrenheit (F), to prevent potential foodborne illnesses. Findings include: Review of the facility's policy titled Dietary Department, dated May 2015, indicated but was not limited to: Food Service It is the policy of this facility that all food stored, prepared, and served within the facility will meet, at a minimum, all federal, state, and local guidance. These guidelines will include the Centers for Disease Control, Department of Health and Human Services, and Food and Drug Administration recommendations and requirements, as well as individual state Public Health Code and local health Department requirements. -These dietary recommendations and regulations are intended to protect the residents, staff, and visitors from foodborne illness, and to promote an enhancement of each resident's quality of life in all food presentations. Dietary Department Guidelines Dietary Department Supervisor will be a qualified food operator and have completed certification programs as required by state regulation. She or he will oversee the entire dietary program in collaboration with the dietitian, including the purchase, storage, preparation, and serving of food to residents, employees, and visitors as indicated. She or he also will supervise the cleaning and sanitizing of dishware and utensils, as well as the cleaning of the physical plant. She or he is responsible for the training and supervision of all food service employees. -All items stored in the refrigerator will be covered, labeled with the contents and the date. All potentially hazardous foods must be discarded within three (3) calendar days after the date prepared. -Equipment: -All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner and used and repaired according to manufacturer's recommendations. -Dishwashers will not be overfilled and will reach wash temperatures of at least 160 degrees F, or according to manufacturer's specifications/instructions. Rinse temperatures will reach at least 180 degrees F, or according to the manufacturer's specifications/instructions. -Ice machines will be sanitized during manufacturing and dispensing of ice and will be cleaned as per manufacturer's recommendations. Ice scoops will be stored in a separate, covered container and washed in the dishwasher or other sanitizing routinely. Review of the facility's policy titled Nourishment Room Supplies, dated May 2015, indicated the following: -Nourishment rooms will be adequately stocked and rotated with proper supplies in approved containers daily, or as needed. The Dining Services Department will be responsible for maintaining and stocking supplies. -Nourishment room refrigerator temperature log is required and will be assigned to the appropriate staff. It is the responsibility of Dining Services to record temperatures daily in the nourishment refrigerator. 1. MAIN KITCHEN On 9/26/23 at 7:45 A.M., the surveyor observed: Walk-in refrigerator: -Raw hamburger wrapped in clear wrap stored above a container of cooked chicken. -A package of uncooked sausage in a bag, not dated. -Pan of American chop suey not fully covered (sealed 3/4 of the pan, the front portion was open). -A tube of whipped cream was opened on one side, not covered or dated. -Container of sauce with a used by date of 9/25/23. -A bag of chopped chicken that was not labeled or dated. -A pan of cooked pork dated 9/25/23. The Food Service Director (FSD) said the cook labeled them wrong. The cook put them in the refrigerator yesterday, should be dated 9/28/23. The FSD then took a marker and changed the date to 9/28/23. During an interview on 9/26/23 at 8:00 A.M., the FSD said the system they should be using is to date the food the day it should be discarded, right now staff are labeling some food the day it is prepared. He said he has to in-service staff to make sure everyone does it correctly. On 9/26/23 at 7:45 A.M., the surveyor observed: -Walk in freezer (within kitchen), there was no internal thermometer. -Walk in freezer (dry storage areas), there was no internal thermometer. -Milk chest no internal thermometer. During an interview on 9/26/23 at 7:50 A.M., the FSD said he noticed it did not have an internal thermometer. He said the kitchen staff just use the external thermometer to get the temperature. Reach in refrigerator: -Two large containers of iced tea and lemonade dated 9/8/23. -Three bags of lettuce opened, not dated. Two were on the top shelf, one bag was open, the second bag was tied shut. The third bag was on the second shelf, not dated, and looked brown. -Tray of pre-made sandwiches which included the following: -Seafood salad in hot dog rolls dated 9/20/23. -Tuna salad, undated. -Multiple sheet pans of food, located on the right side of refrigerator, that were either not dated or beyond the use by date which included the following: -Container of sliced oranges, undated. -White Styrofoam dishes of applesauce, dated 9/22/23. -Containers of individual served applesauce, dated 9/23/23. -Containers of individual served cottage cheeses, dated 9/23/23. -Containers of individual served cucumbers, green beans and tomatoes salad, undated. -Containers of individual served peaches, no dates. On 9/27/23 at 8:10 A.M., the surveyor observed: -walk-in refrigerator, located in the kitchen, had two containers of pesto not labeled or dated, and a box of Italian garlic bread was stored opened. -reach-in produce refrigerator had three bowls of salads not labeled or dated. The reach-in produce refrigerator gasket had black substance that looked like mold. On 9/28/23 at 12:45 P.M., the surveyor observed the following in the kitchen: -The meat slicer was covered with a clear plastic bag, but when the plastic bag was removed, there was a small puddle of water on the base of the slicer. The FSD was present and said the dietary staff had cleaned it, and covered it, before it dried. -The microwave had multiple food splatters on all surfaces of the interior. -The holder for the ice scoop had water and dirt at the base. NOURISHMENT KITCHENETTES On 9/26/23 at 12:15 P.M., the surveyor observed the Mayflower unit kitchenette: -Microwave oven had a sign on it that read do not use, very dirty with food remnants on door and inside, and had a pungent burnt smell. -Refrigerator was dirty and cluttered. On 9/27/23 at 8:50 A.M., the surveyor observed the Mayflower unit nourishment kitchenette: -two loaves of bread in freezer labeled with name, but no date. On 9/27/23 at 9:00 A.M., the surveyor observed the [NAME] unit nourishment kitchenette: -The microwave was dirty with food splatters on all interior walls. -Obvious dirty floors and sticky when walked on. -All walls badly scratched. -Interior of the freezer was dirty. The freezer also held the following: -A frozen bottle of sugar cane syrup, no label or date. -Two packages of frozen vegetables and one package of a frozen dinner, no label or date. -One frozen pot pie, no label or date. -Inside the refrigerator were three yogurts, no label or date, a can of whipped cream, no label or date, two bottles of salad dressing, no label or date, an expired parmesan cheese container with expiration date of 7/16/23, and a carton of almond milk, no label or date. -The bottom of the refrigerator was dirty and had a collection of brown water at the base of the unit. The refrigerator gasket was dirty, especially in the crevasses. -There was a bottle of MCT (medium chair triglyceride) oil on the top of the refrigerator, not labeled or dated. -Next to the refrigerator was a tower of nine plastic drawers. Each drawer held snacks and food. Each drawer had a buildup of crumbs and debris inside. -There was an open box of cold rice cereal on the open shelves, across from the refrigerator. On 9/27/23 at 9:10 A.M., the surveyor observed the Hopkins unit nourishment kitchenette: -The exterior of all cabinets were sticky to the touch and in need of cleaning. -The interior of the microwave had food splatters and exposed metal in three areas. -The interior of the refrigerator was dirty and had a broken gasket. -The freezer had a box of Uncrustables that was not labeled or dated. -The interior of the six storage drawers were dirty with crumbs. On 9/27/23 at 9:30 A.M., the surveyor observed the [NAME] unit nourishment kitchenette: -The refrigerator log, posted on the outside of the refrigerator, had 15 of 27 days left blank. -Inside the freezer was a frozen meal and box of frozen sausage, both with no label or date. -The interior of three drawers, that held snack items, were dirty and had crumbs along the interior bottom of the drawer. -The upper cabinets had a bottle of hot sauce and honey, both had no label or date. -The interior of the microwave had food splatters. During an interview on 9/27/23 at 3:00 P.M., the FSD said if they have enough staff in the kitchen, he would send someone up to clean the interior of the refrigerators, microwave, and restock each unit. The FSD said cleaning and restocking the nourishment kitchenettes can occur at any time of the day, depending on the staffing situation, but typically it is a diet aide's job. The FSD said that to his knowledge, the last time the nourishment kitchenettes were cleaned was Monday night (9/25/23), two days prior. During a follow up interview on 9/27/23 at 3:30 P.M., the FSD provided the surveyor with a nourishment kitchenette restocking sheet, but said there are no par levels identified, it is all up to the staff's decision how much product they supply the units with. Review of the Nourishment Kitchenette Restock form also indicated under other tasks for staff to: -Discard any items open for 72 hours, including resident items. -Discard any items that are not labeled and dated, including resident's items. -Clean and sanitize fridge and freezer, and inside microwave. -Insure [sic] that there are no employee personal items stored. -Clean and organize inside cabinets insuring [sic] no employee items present. -Retreave [sic] any leftover trays or items from previose [sic] meal period. 2. DISH MACHINE SERVICE On 9/27/23 at 10:15 A.M., the surveyor entered the dish room to observe the dish machine and kitchen clean up after breakfast. The FSD was observed to be sending dish racks through the dish machine. With each attempt, the rinse cycle temperature on the high temperature dish machine did not go above 172 degrees Fahrenheit (F). Normal range is 180 degrees F or higher to adequately sanitize dishware. The last observed wash temperature was 140 degrees F, and the rinse temperature was 172 degrees F. The surveyor and the FSD reviewed the dish machine temperature logs for September 2023 which indicated the following: Between September 1-20, 2023, there were no documented temperatures for breakfast, lunch, or dinner. September 21-27 had 15 of 19 documented rinse temperatures that did not reach 180 degrees F to ensure adequate sanitized dishware, silverware, glassware, and trays. During an interview on 9/27/23 at 10:30 A.M., the FSD said staff have never informed him of the inadequate dish machine rinse temperatures, and he was not aware of this problem until today. He further said, It's no excuse, but I'm short staffed and have been cooking. During an interview on 9/28/23 at 2:00 P.M., the FSD said he was unable to locate the August 2023 Dish Machine Temperature Log, but said he had the July 2023 Dish Machine Temperature Log. Review of the July 2023 Dish Machine Temperature Log indicated that 37 of 93 documented dish machine rinse temperatures were below 180 degrees F. 3. Review of the facility's policy titled Personal Food Policy, dated November 2016, indicated the following, but not limited to: -Facility staff will assist residents with accessing the nourishment kitchens, and with accessing and proper heating of any personal foods. Staff will refer to the reheating chart (included with policy) for specific reheating instructions. Staff will use a thermometer to ensure the food is reheated adequately. If disposable thermometers are used, T 165 sticks must be used and discarded after each use. If non-disposable thermometers are used, they must be sanitized between each use with available alcohol wipes. -In order to assist family and visitors to understand safe food handling practices for microwave usage refer to USDA's Cooking Safely in the Microwave Oven. Any questions should be directed to the nursing supervisor or food and nutrition supervisor. Review of the USDA Cooking Safely in the Microwave Oven, not dated, indicated but was not limited to: -Microwave ovens can play an important role at mealtime, but special care must be taken when cooking or reheating meat, poultry, fish, and eggs to make sure they are prepared safely. Microwave ovens can cook unevenly and leave cold spots where harmful bacteria can survive. For this reason, it is important to use the following safe microwave tips to prevent foodborne illness. -Use a food thermometer or the oven's temperature probe to verify the food has reached a safe minimum internal temperature. -Cooking foods to the following safe minimum internal temperatures: Reheat leftovers to 165 degrees F. On 9/27/23 between 8:50 A.M. and 9:30 A.M., the following was observed by the surveyor in the nourishment kitchenettes: Four of four nourishment kitchenettes had postings about reheating food and the use of a T-stick to be used when reheating food in the microwave. Three of four units did not have any T-Sticks available for use. The Mayflower unit had six T-sticks inside a clear plastic sleeve, attached to the upper cabinet door, however upon inspection, the six T-sticks were heavily soiled and questionable for use. During an observation and interview on 9/27/23 at 4:00 P.M., a family member was observed reheating a container of cream of broccoli soup in the microwave, in the Hopkins unit nourishment kitchenette. The family member said the microwave was broken on the [NAME] unit so she came over to Hopkins unit to reheat soup for her mother, who lives on [NAME]. The family member said staff typically don't help her in reheating foods, she microwaves the food herself. She did not obtain the temperature of the soup, nor did she look for a device to take the temperature of the soup. During an interview on 9/27/23 at 3:00 P.M., the Food Service Director (FSD) and the Chef Manager both said they were not aware that T-Sticks were not available in the nourishment rooms for use. The FSD said he was not sure if he had a supply of T-sticks available in the facility either. During an interview on 9/28/23 at 2:30 P.M., the Administrator, Food Service Director, and the Regional Food Manager were made aware of all dietary observations made by the surveyor during the survey. The Regional Food Manager said the facility policy for reheating foods from outside the facility is to ensure the food is heated adequately to 165 degrees F prior to serving the resident, and T-sticks should be available for use, per the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy review, and document review, the facility failed to maintain and consistently implement an infection prevention and control program. Specifically, the facility failed to: 1. Follow COVID-19 testing guidance during a COVID-19 outbreak for staff; 2. Ensure glucose monitoring equipment was cleaned per written policies and procedures to prevent the potential spread of infection; 3. Ensure two staff members appropriately wore their surgical masks covering their nose; and 4. Ensure the removal of resident's personal items and terminally clean the room, before a new resident was admitted to the room to prevent the potential spread of infection. Findings include: 1. Review of the facility's policy titled COVID-19 Pandemic Resident and Staff Testing, dated as last reviewed/revised 5/16/23, indicated but was not limited to the following: -An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. -Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin per current CDC or state specific guidelines. -Asymptomatic staff or residents identified with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. -In addition, outbreak testing is not necessary for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 Days; testing should be considered for those who have recovered in the prior 31-90 days. Review of the Massachusetts Department of Public Health Memorandum, dated 5/10/23, indicated the following guidance regarding COVID-19 testing: -long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified -once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. During an interview on 9/27/23 at 10:19 A.M., the Infection Control Nurse said residents on the [NAME], Mayflower South, and Hopkins units had tested positive for COVID-19. She said the COVID-19 outbreak had started with a positive resident on 9/20/23 and the affected units were being tested every 48 hours until there were no additional positive residents. The Infection Control Nurse said staff who had worked on the respective units were being tested every 48 hours. The surveyor asked to see the COVID-19 testing logs for staff. The Infection Control Nurse said she did not keep a testing log in the testing room for staff. The Infection Control Nurse said she does not keep a log or documentation of staff who have tested and are negative for COVID-19. She said when a staff member tests positive for COVID-19 they would inform the Supervisor or Infection Control Nurse and she would log it. The surveyor inquired if Certified Nursing Assistant (CNA) #3 had been tested prior to her shift on 9/27/23. The Infection Control Nurse said she was not aware that CNA #3 had worked on the Hopkins unit. The Infection Control Nurse had no evidence of CNA #3's COVID-19 testing. During an interview on 9/27/23 at 11:00 A.M., Nurse #1 said there was one Resident who tested positive on the Hopkins unit. Nurse #1 said she does not test for COVID-19 unless she was symptomatic. Nurse #1 said she wished the facility would go back to testing the staff routinely. During an interview on 9/27/23 at 11:15 A.M., CNA #3 said she was told staff do not test for COVID-19 unless they were symptomatic. During an interview on 9/27/23 at 11:45 A.M., the Director of Nurses (DON) said the facility had initiated broad based testing (testing of all residents and staff) on the [NAME], Mayflower South, and the Hopkins units. The DON said she was not aware that staff who worked the affected units were not being COVID-19 tested following the recommended guidance. During an interview on 9/27/23 at 12:05 P.M., the Administrator said the Infection Control Nurse should be following the facility policy for staff testing on the COVID-19 positive units. The Administrator said staff should be tested on days 1, 3, and 5. During an interview on 9/29/23 at 11:46 A.M., Unit Manager #2 said she did not test for COVID-19. She said she was positive for COVID-19 in July 2023 and did not need to test. During an interview on 9/29/23 at 12:00 P.M., the Infection Control Nurse said she was unaware Unit Manager #2 had not been tested. The Infection Control Nurse said staff who were positive more than 30 days ago should have been tested. During an interview on 9/29/23 at 12:24 P.M., with both the DON and Administrator, the Administrator said Unit Manager #2 should have tested for COVID-19 as Unit Manager #2 was over the 30-day window. 2. Review of the facility's policy titled Glucose Monitoring Equipment, dated as revised 9/18, indicated but was not limited to: -Blood glucose monitoring equipment will be cleaned with bleach wipe before and after and/or as per manufacturer guidelines. -Glucometers will be cleaned/disinfected with bleach wipes per manufacturer guidelines. On 9/27/23 at 8:30 A.M., the surveyor observed Nurse #2, on the Mayflower South Unit, remove the glucometer (machine used to obtain a blood sugar level) from a storage bag, that had been stored in the medication cart, and bring it into a resident room. Nurse #2 cleaned the glucometer with an alcohol swab and proceeded to check the resident's blood sugar. Nurse #2 exited the room and cleaned the glucometer machine with an alcohol swab and placed it back into the storage bag and into the medication cart. During an interview on 9/27/23 at 2:55 P.M., Nurse #2 said the glucometer can be cleaned with either an alcohol swab or a bleach wipe before and after each use. During an interview on 9/28/23 at 12:38 P.M., the DON said the expectation was for nurses to clean the glucometer with a bleach wipe before and after it is used. During an interview on 9/28/23 at 1:00 P.M., the Infection Control Preventionist said glucometers should be cleaned before and after use with a bleach wipe and not an alcohol swab to prevent infection.4. Review of the facility's policy titled Decontamination of Resident Items, revised 2/2019, indicated but was not limited to the following: -It is the policy of this facility to reduce and/or prevent the spread of infection through indirect contact by cleaning, sanitizing, or disinfecting resident equipment, medical devices, and the environment. Review of the form titled Complete Resident Room Cleaning, revised 7/2018, indicated the following: Bedroom cleaning included: Over bed tables cleaned and disinfected (top and bottoms), frequently touched surfaces cleaned and disinfected, walls cleaned and disinfected, over bed lights cleaned and disinfected, floor swept, debris removed, floor mopped and disinfected, bed stripped and cleaned, wash down doors and disinfect doorknobs, wash down bedside table and dresser. Resident #17 was admitted to the facility in January 2023 with diagnoses of colon cancer, malnutrition, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the Resident was moderately cognitively impaired, as evidenced by a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS). On 9/26/23 at 9:45 A.M., the surveyor observed Resident #17's bed and observed a military award hanging above the bed with a different name than Resident #17. Resident #17's roommate said he/she (Resident #17) just moved into this room a couple days ago. On 9/26/23 at 10:00 A.M., the surveyor observed Resident #17's previous room/bed, and the bed was unmade, the dresser and the cabinet were filled with clothing and the side table had personal items in the drawers. During an interview on 9/26/23 at 12:41 P.M., the surveyor observed Resident #17 lying in bed in his/her new room and said he/she was moved to this bed because his/her previous roommate was sick with COVID-19. The surveyor, with Resident's #17 permission, viewed the bedside table drawer, which contained the previous Resident's personal items including, mouthwash, a toothbrush in a basin, toothpaste, skin cream, pens, plastic bag and miscellaneous papers. The dresser and cabinet were observed to have the previous Resident's clothes and other personal items. Resident #17 said those were not his/her items, he/she was returning to his/her previous room when the roommate gets better. During an interview on 9/26/23 at 3:17 P.M., Unit Manger #2 said when a resident passes away, the family is contacted to retrieve the personal belongings, and the room is cleaned, sanitized, and prepared for a new admission or resident transfer. The surveyor and Unit Manager #2 went to Resident #17's new room, and he/she was lying on an air mattress. Unit Manager #2 looked in the dresser, cabinet, and side table and said the clothing items and other personal items belonged to the previous occupant of the room who had passed away. During an interview on 9/26/23 at 4:00 P.M., the Director of Housekeeping said his expectations before another resident moved into a room was the room is terminally cleaned, which includes removing everything from the dresser, the cabinet and bedside table drawers, cleaning inside the cabinet and drawers, cleaning the mattress, moving the furniture away from the walls and cleaning the floors in preparation for the new resident. The surveyor and Director of Housekeeping viewed Resident #17's new room and viewed the previous Resident's items in the drawers and cabinets, and a pink pill, dirt, and paper behind the bedside table. During an interview on 9/27/23 at 3:48 P.M., Corporate Nurse #2 said she was made aware that a resident was moved into a room that still contained the prior resident's personal belongs. She said the room should have been cleaned and all the previous resident's items removed before the new resident was moved in. 3. Review of the Centers for Disease Control and Prevention poster titled Sequence for Putting on Personal Protective Equipment (PPE), undated, indicated for a putting on a mask to: - Secure ties or elastic bands at middle of head and neck - Fit flexible band to nose bridge - Fit snug to face and below chin On 9/27/23 at 8:50 A.M., on the Mayflower North unit, the surveyor observed Nurse #3 wearing a surgical mask below her nose while performing medication pass. On 9/27/23 at 8:15 A.M. and 12:40 P.M., the surveyor observed the evening cook wearing her surgical mask below her nose. During an interview on 9/27/23 at 3:00 P.M., the Food Service Director said that the cook should have worn her mask over her nose at all times.

Based on observation and interview, the facility failed for two Residents (#47 and #133), to ensure the Residents had the ability to exercise their right to smoke, or make reasonable accommodations of such, out of a total sample of 30 residents. Findings include: 1. Resident #47 was admitted to the facility in May 2021. Review of the Minimum Data Set (MDS) assessment, dated 8/13/21, indicated Resident #47 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15. Section J, question J1300 regarding tobacco use was not completed. During an interview on 11/04/21 at 10:17 A.M., Resident #47 said he/she was not happy and felt that the facility was refusing to let him/her smoke and that he/she was offered the patch, but refused saying, I will not let them drug me for their convenience while they violate my rights. Review of the medical record failed to indicate any progress notes educating the Resident or their representative to their right to smoke being temporarily removed. Review of the medication administration record indicated Resident #47 received a nicotine patch at a dose of 21 milligrams (mg) on November 3, 2021 only. Further review of the medical record indicated the Resident to be assessed as a current smoker on 5/19/21, and there was a blank smoking evaluation in the record dated 8/6/21. There was no indication anywhere in the record that Resident #47's right to smoke was suspended. 2. Resident #133 was admitted to the facility in August 2021. Review of the MDS assessment, dated 10/1/21, indicated Resident #133 was cognitively intact, with a BIMS score of 14 out of 15. Section J, question J1300 regarding tobacco use was not completed. During an interview on 11/04/21 at 10:11 A.M., Resident #133 said his/her rights had been removed and he/she had not been allowed to smoke for the last four to five weeks based on a decision by the administration because the facility had COVID-19 cases. He/she said he/she was offered no accommodation or alternative to smoking to help curb his/her cravings. A review of the medical record failed to indicate any progress notes educating the Resident to their right to smoke being temporarily removed, physician orders for smoking cessation medications, or education regarding the use of smoking cessation medications related to this instance. Further review indicated the Resident to be assessed as a current smoker with a smoking careplan in place. There was no indication on the careplan that the right to smoke was suspended. During an interview on 11/04/21 at 10:47 A.M., Nurse #1 said Resident #133 was very verbal about not smoking, but the rule was that no resident could smoke while the facility was in an outbreak for any reason and they would not be brought out for any smoking activity. She said she believed this had been in place since about the middle of October. During a follow up interview on 11/09/21 at 10:30 A.M., Resident #133 said he/she had still not been allowed to smoke and it was related to COVID-19 in the facility. He/she said they had not received any updates on this and his/her goal was to resume smoking as soon as possible and that he/she wanted to smoke every day and was not interested in quitting. He/she said he/she chose to smoke and felt his/her rights were being violated by the facility denying them the right to go out and do this. During an interview on 11/09/21 at 4:48 P.M., Nurse #4 said the administrator and infection nurse told the staff there would be no resident smoking while the facility had any COVID-19 positive residents in it. She said she knew it upset the residents, but it was the rule that had been in place since the start of the outbreak sometime around October 12, 2021. During an interview on 11/9/21 at 4:55 P.M., the infection prevention nurse said no residents were allowed outside to smoke. She said having all the residents in the elevator together at the same time and in the smoking area together at the same time would prevent social distancing and would not be safe. She further said there was no thought or discussion about changing the process to accommodate the smokers during this time and she realized now it was a resident rights violation. She said no accommodations were made, but there should have been. During an interview on 11/10/21 at 10:02 A.M., the Administrator said there were no discussions or accommodations made or considered to continue resident smoking. She said stopping resident smoking was a violation of the residents' rights and should not have occurred the way it did.

Based on observations, record review, policy review, and interviews, the facility failed to ensure that one Resident (#27) was assessed by the Interdisciplinary Team (IDT) for the self-administration of medications, out of a total sample of 30 residents. Specifically, the facility failed to ensure that Resident #27 was assessed to self- administer the over-the-counter medication Airborne (Immune support supplement that contains Vitamin C plus 13 other vitamins, minerals and herbs). Findings include: Review of the facility's policy titled Self-Administration of Medications, dated July 2015, indicated but was not limited to the following: -Residents are afforded the right to self-administer their own medications, upon request, and after determination the practice is safe. If the resident elects to self-administer his/her own medications, an evaluation of their cognitive, physical and visual ability to perform this task is conducted to ensure accurate and safe medication management. -Complete the self-administration Evaluation and document whether the resident can safely self-medicate or is unable to safely self-medicate. If the resident can't safely self-medicate, document the reasons why. -Inform the resident/responsible party of the decision. -If approved, obtain a physician's order for self-administration of medications. -Up-date the care plan for self-medication to include where the medications will be stored, documentation of self-administration and location of the drug administration. -Perform resident education of all required self-medication protocols and document any education. Resident #27 was admitted to the facility December 2019 with diagnoses including traumatic brain injury, vitreous hemorrhage, and cerebral vascular accident. During an interview on 11/08/21 at 10:45 A.M., the Resident said how important it was to take Vitamin C, especially with COVID-19-19-19-19-19-19 being so prevalent in the facility. The Resident said that he/she feels that the extra Vitamin C helped so that the symptoms of COVID-19-19-19-19-19-19 were not as pronounced. The Resident then went to his/her bedside cabinet and showed the surveyor a box of Airborne. The Resident said that he/she takes it daily. Record review indicated that the Resident had never been assessed to self-administer the above medication, there was no physician's order in place for the self-administration of the medication or care plan addressing the Resident's ability to self-administer the above medications as per the facility's policy. During an interview on 11/15/21 at 12:38 P.M., Unit Manager #2 indicated she was going up to speak with the Resident as she was not aware that the Resident had the Airborne in the bedside cabinet and that the Resident was self-administering the medication daily. During an interview on 11/15/21 at 12:38 P.M., the Director of Nursing and Unit Manager #2 said that there had been no self administration assessment on this Resident as per the facility policy/protocol for the self-administration of the medication Airborne.

Based on observation, interview, and record review, the facility failed to ensure staff met the needs of one Resident (#83), out of a total sample of 30 residents, by ensuring his/her call bell was within reach. Findings include: Resident #83 was admitted to the facility with diagnoses including multiple sclerosis (MS) (potentially disabling disease of the brain and spinal cord), neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet), and right-sided hemiplegia (paralysis of one side of the body). Review of the Minimum Data Set (MDS) assessment, dated 9/12/21, indicated Resident #83 required total assistance with bed mobility. Review of the Physical Therapy Care Plan, initiated 11/3/21, indicated Resident #83 demonstrated decreased functional mobility and required a call button to be placed within reach on his/her bed. Review of the facility's policy titled Call Light, Use Of, dated April 2015, included but was not limited to the following: - All .resident/patients will have a call light or alternative communication device within his/her reach when unattended. - When providing care to residents/patients be sure to position the call light conveniently, telling/showing resident/patient where the call light is located. On 11/4/21 at 12:36 P.M., the surveyor observed Resident #83's right wrist in a fist. His/her call bell was located above his/her head underneath folded bed linens. The call bell was not within Resident #83's reach. During an interview on 11/4/21 at 12:36 P.M., Resident #83 said he/she had MS and needed the call bell within reach on his/her lap to get help from staff when needed. He/she said, I'm very limited in what I can do. On 11/16/21 at 10:05 A.M., the surveyor and Nurse #5 observed Resident #83's call bell underneath his/her bed linens. The call bell was not within Resident #83's reach. During an interview on 11/16/21 at 10:05 A.M., Resident #83 said his/her call bell was not within reach. During an interview on 11/16/21 at 10:05 A.M., Nurse #5 said the call bell should have been within Resident #83's reach, but was not. During an interview on 11/15/21 at 4:01 P.M., the Director of Nurses said Resident #83's call bell should have been within his/her reach.

Based on record review and interview, the facility failed to ensure that advanced directives were updated and accurate for one Resident (#125), out of a total sample of 12 residents. Findings include: Resident #125 was admitted to the facility in April 2018 with diagnoses including quadriplegia and disorder of the autonomic nervous system. Review of the Minimum Data Set (MDS) assessment, dated 12/10/21, indicated Resident #125 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Record review indicated the Resident had a recent hospitalization in February 2022. Review of the hospital discharge summary indicated the Resident had requested to be a Do Not Attempt Resuscitation (DNAR) and Do Not Intubate (DNI). A DNAR/DNI means that no Cardiopulmonary Resuscitation (chest compressions, cardiac drugs, or placement of a breathing tube) will be performed. Record review of the Resident's advanced directives prior to the hospitalization was that the Resident had requested to be a Full Code (all resuscitation procedures will be provided) since 2018. As per the hospital discharge summary, the wishes of the Resident had changed during the hospital stay and the hospital discharge summary had not been reviewed upon the Resident's return to the facility. The advanced directives in the Resident's record were inaccurate according to the most current wishes of the Resident, as the record still indicated that Resident #125 was a Full Code. During an interview on 3/8/22 at 11:30 A.M., Unit Manager (UM) #1 reviewed the hospital discharge summary which had indicated there had been a change in the Resident's advanced directives. UM #1 alerted Social Services. Review of the Social Services note, dated 3/8/22 at 1:09 P.M., included but was not limited to: Social Worker was informed that the Resident would like to update his/her code status. Resident updated to DNR, DNI. Form left for physician (MD) to review. During an interview on 3/9/22 at 8:10 A.M., the Director of Nursing said the Resident's advanced directives should have been updated/honored and were not, until after surveyor intervention.

2. Resident #118 was admitted to the facility in March 2021 with diagnoses including myoclonus (quick, involuntary muscle jerks). Review of the MDS assessment, dated 9/24/21, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Further, the MDS indicated there were no restraints in use for the Resident. On 11/04/21 at 7:57 A.M. and 2:38 P.M., the surveyor observed Resident #118 awake and lying flat in bed with full bilateral siderails up and padded. On 11/09/21 at 9:52 A.M., 1:28 P.M., and 2:03 P.M., the surveyor observed Resident #118 awake lying in bed, moving around in a flailing manner, restless and kicking his/her legs with full bilateral siderails up and padded. Review of the Resident's medical record indicated in nurses' notes the Resident had his/her legs over the edge of the bed/siderails and was pulling at padded side rails on 10/13/21, 10/14/21, and 11/9/21. The record failed to indicate any evidence that the full siderails had been assessed as a potential restraint, a physician order for the use of the full siderails, or a careplan indicating use of full siderails and alternatives used prior to the implementation of those full siderails. Further review indicated an incomplete siderail evaluation with an effective date of 9/18/21; the evaluation was blank. During an interview on 11/09/21 at 2:22 P.M., the Director of Rehabilitation Services said she was aware Resident #118 had full siderails which were padded but rehab was not involved with the siderails or their implementation and said that would be a nursing thing. During an interview on 11/09/21 at 4:01 P.M., the Director of Nurses said her expectation was no resident should have full siderails period. She went on to say if, for some reason, full siderails were warranted the record would have a completed siderail assessment, restraint assessment, consent and care plans that specified the reason for the full siderails and all previous attempted devices or interventions. On 11/09/21 at 4:46 P.M., the surveyor observed Resident #118 lying flat in bed with full bilateral padded siderails in the upright position. During an interview on 11/09/21 at 4:46 P.M., Nurse #4 reviewed the Resident's medical record with the surveyor and said there was no restraint assessment in the chart related to the use of full siderails and she could not find any documentation of a physician's order or alternatives used prior to the siderails. Based on observations, interviews, record review, and policy review, the facility failed to ensure two Residents (#136 and #118), out of a total sample of 30 residents, were free from physical restraints. Specifically, 1. Resident #136 was placed in a reclined geriatric chair (Geri-chair) to prevent rising and wandering; and 2. Resident #118 was not evaluated for the need for a physical restraint (bilateral full-length side rails) and was unable to exit the bed. Findings include: 1. Review of the facility's policy titled Restraint Management, revised August 2018, indicated the following: A. When a resident's condition indicates that an intervention is necessary for safety or positioning, all alternatives to restraints will be tried first and documented in the nurses notes and/or in the careplan. These alternatives are discussed by the interdisciplinary team (IDT). B. When all appropriate alternatives outlined in the careplan are unsuccessful, the Restraint evaluation will be completed by the IDT, prior to initiating the use of restraint. C. It defines a physical restraint as any manual, mechanical or physical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily. Resident #136 was admitted to the facility in March 2018 with a diagnosis of dementia and was on hospice services. Review of the Minimum Data Set (MDS) assessment, dated 10/4/21, indicated Resident #136 was ambulatory with an assist of one person. Review of the medical record indicated on 11/2/21 the hospice services nurse ordered a Geri-chair. On 11/4/21 at 9:39 A.M., the surveyor observed Resident #136 reclining in a Geri-chair near the nurses' station. On 11/4/21 at 11:16 A.M., the surveyor observed Resident #136 in his/her room ambulating with the assist of Nurse #8. On 11/4/21 at 1:37 P.M., the surveyor observed Resident #136 in his/her room alone, reclined in a Geri-chair and actively trying to push his/her self up, but was unable due to the reclined position. During an interview on 11/5/21 at 9:38 A.M., Hospice Staff #1 said the facility staff reported Resident #136 was awake at night and restless with increased weakness in his/her legs. She said the order for the Geri-chair was to have the Resident up out of bed when lethargic, such as over nights. She said the Resident did not have to be reclined in the Geri-chair so that he/she could stand up when he/she wanted to. She said the expectation was to utilize the Geri-chair only as needed and she had relayed the information to Unit Manager #2. She said if Resident #136 was awake and attempting to get up the staff should not have him/her reclined in the chair. On 11/12/21 at 1:00 P.M., the surveyor observed Certified Nursing Assistant (CNA) #13 assisting Resident #136 with eating. Resident #136 was observed to continue to try to stand up from the chair. CNA #13 and CNA #9 were then observed to recline Resident #136 in the Geri-chair and continue to feed him/her. On 11/12/21 at 1:12 P.M., the surveyor heard CNA #13 say to CNA #5 that she felt she could not leave Resident #136 alone reclined in the Geri-chair because he/she was going to fall. The surveyor observed the Resident attempt to lift his/her trunk from the reclined chair. The surveyor heard CNA #5 respond that Resident #136 was probably going to fall as it had happened before and it would happen again. On 11/12/21 at 1:18 P.M., the surveyor observed Resident #136 reclining in the Geri-chair and rocking back and forth attempting to get out of the chair. The regional Food Service Director ran over to the Resident and called CNA #9 over for assistance. CNA #9 said someone needed to sit with Resident #136, but there was not enough staff. During an interview on 11/12/21 at 1:20 P.M., CNA #13 said she reclined Resident #136 in the Geri-chair because he/she kept trying to stand up. On 11/12/21 at 3:19 P.M., the surveyor observed Resident #136 reclining in the Geri-chair and rocking back and forth in front of the nurses' station. Nurse #7 told the staff to get Resident #136 out of the Geri-chair because if the Resident was attempting to get out of the chair and could not, then it would be considered a restraint. During an interview on 11/16/21 at 8:26 A.M., the Director of Nurses said if a resident was reclined in a Geri-chair and attempting to get up then that would be considered a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure an allegation of abuse was immediately reported to the Department of Public Health within two hours in accordance with federal guidelines and to the State Survey Agency within five working days of the incident and per the facility policy for one Resident (#125), out of a total sample of 30 residents. Findings include: Review of the facility's policy titled Abuse Prohibition Policy, dated September 2020, included but was not limited to the following: -Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his or her personal property. DEFINITIONS: Abuse/Potential Abuse: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. The Administrator shall assume the overall responsibility to ensure that incident reports are accurately completed, and personnel statements are obtained timely, to ensure proper completion of the Internal Facility Investigation. The Administrator shall ensure that the appropriate agencies are notified in writing, as warranted, of abuse allegations. Immediate Action: - Notify the nursing supervisor. The supervisor or designee will: - Notify the Administrator and/or DNS. - Notify involved parties per Reporting requirements. REPORTING/DOCUMENTATION REQUIREMENTS: The Administrator, Director of Nursing or their designee assumes responsibility for the immediate verbal notification of the incident to the following: 1. The resident or his/her conservator/responsible party. 2. The physician of record and/or the facility medical director if physician of record not available. 3. The Department of Public Health: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24- hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and protective services where state law provides for jurisdiction in Long-term care facilities) in accordance with State law through established procedures. 4. Reporting the results of all investigations to the Administrator, Director of Nursing or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. Resident #125 was admitted to the facility in April 2018 with diagnoses including, quadriplegia, disorder of the autonomic nervous system, and neuromuscular bladder dysfunction. Review of a Minimum Data Set (MDS) assessment, dated 9/24/21, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS also indicated the Resident was totally dependent with bed mobility, transfers, bathing, personal hygiene, and dressing, required the assist of two persons. Review of the Resident's care plan indicated: Transfer Device Mechanical lift (2 staff). During an interview on 11/10/21 at 1:00 P.M., Resident #125 said he/she had some concerns. The Resident told the surveyor about an incident with a Certified Nursing Assistant (CNA) who was attempting to use the Hoyer Lift (a mechanical lift used to transfer a resident out of bed. The Hoyer lift is to always be used by two staff members, no exceptions) independently. Resident #125 said this happened a couple of months ago and that he/she told the CNA that he could not use the Hoyer alone and that he needed two people, as that is the protocol. Resident #125 said that the CNA told the Resident that he was exempt, and he could use the Hoyer lift by himself. Resident #125 said that the CNA continued to use the Hoyer lift without another staff member present. During the transfer, Resident #125 said that the CNA pulled the Resident's wrist so hard that Resident #125 stated he/she heard a pop in his/her shoulder. Resident #125 identified the CNA as CNA #4 and told the surveyor he/she still sees CNA #4 working on his/her Unit. Resident #125 stated that the Administrator was aware of the incident. During an interview on 11/10/21 at 2:30 P.M., the surveyor spoke with the Administrator and inquired about the incident and asked for any documentation she may have on the incident. The surveyor told the Administrator what Resident #125 had relayed to her. The surveyor told the Administrator that there was no report in the Health Care Facility Reporting System (HCFRS) regarding Resident #125's allegation of CNA #4 pulling his wrist so hard that it caused a pop. The Administrator told the surveyor that she did not remember the incident but would get back to her and would look for any documentation on the incident. On 11/15/21, the surveyor reviewed the information in HCFRS, and there was no initial reporting of the alleged abuse by Resident #125, nor was there reporting after the surveyor brought the incident to the attention of the Administrator on 11/10/21. Reporting to HCFRS had not been initiated per the facility policy. During an interview on 11/15 21 at 9:20 A.M., the Director of Nursing (DON) told the surveyor that the Resident had been stating to several staff members that CNA #4 had pulled his arm and Hoyer transferred him with one person. The DON indicated that it should have been reported and was not. The DON stated that CNA #4 told her that the incident did occur and that he did transfer Resident #125 with the Hoyer lift by himself. He further stated that at the time the incident occurred (August 2021) he went down and spoke to the Administrator about the incident. Review of the statement from Nurse #4 indicated that she had reported the incident to Unit Manager #2 at the time of the incident but was unaware/unsure of the date. During an interview on 11/16/21 at 11:41 A.M., Unit Manager #2 said the incident occurred prior to the Resident's hospitalization in August 2021. Unit Manager #2 said she reported the incident to the Administrator and had given her all the documents that she had completed/received concerning the alleged abuse. During an interview on 11/16/21 at 10:31 A.M., the Administrator said she had not located any of the original documentation. The Administrator said that she should have reported the allegation initially but did not. The Administrator said she did not report an allegation of abuse to the Department of Public Health within two hours in accordance with federal guidelines and to the State Survey Agency within five working days of the incident and according to the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure an allegation of abuse was investigated per federal and state guidelines and per the facility policy for one Resident (#125), out of a total sample of 30 residents. Findings include: Review of the facility's policy titled Abuse Prohibition Policy, dated September 2020, included but was not limited to the following: -Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his or her personal property. DEFINITIONS: Abuse/Potential Abuse: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. The Administrator shall assume the overall responsibility to ensure that incident reports are accurately completed, and personnel statements are obtained timely, to ensure proper completion of the Internal Facility Investigation. The Administrator shall ensure that the appropriate agencies are notified in writing, as warranted, of abuse allegations. PROTECTION OF RESIDENTS FROM HARM: Immediate Action: 1. Remove the resident from the alleged abuser or remove the abuser from the resident. 2. Notify the nursing supervisor. 3. Perform a physical assessment of the resident if physical abuse is suspected. 4. Provide any necessary interventions to ensure the resident's safety and well-being. 5. Provide emotional support and reassurance to the resident. The supervisor or designee will: 1. Notify the Administrator and/or DNS. 2. Interview the resident when possible. 3. Obtain a written statement of the event from the employee if one is involved. This statement should be dated and signed, whenever possible. 4. Obtain statements from any alert/oriented residents that may have witnessed the event. 5. Place the employee on administrative leave pending completion of the investigation. 6. Notify involved parties per Reporting requirements. Any allegation of abuse will be thoroughly investigated. REPORTING/DOCUMENTATION REQUIREMENTS: The Administrator, Director of Nursing or their designee assumes responsibility for the immediate verbal notification of the incident to the following: 1. The resident or his/her conservator/responsible party. 2. The physician of record and/or the facility medical director if physician of record not available. 3. The Department of Public Health: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24- hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and protective services where state law provides for jurisdiction in Long-term care facilities) in accordance with State law through established procedures. 4. Reporting the results of all investigations to the Administrator, Director of Nursing or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. Resident #125 was admitted to the facility in April 2018 with diagnoses including, quadriplegia, disorder of the autonomic nervous system, and neuromuscular bladder dysfunction. Review of a Minimum Data Set (MDS) assessment, dated 9/24/21, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS also indicated the Resident was totally dependent with bed mobility, transfers, bathing, personal hygiene, and dressing, required the assist of two persons. Review of the Resident's Care Plan indicated: Transfer Device Mechanical lift (2 staff). During an interview on 11/10/21 at 1:00 P.M., Resident #125 said he/she had some concerns. The Resident told the surveyor about an incident with a Certified Nursing Assistant (CNA) who was attempting to use the Hoyer Lift (a mechanical lift used to transfer a resident out of bed. The Hoyer lift is to always be used by 2 staff members, no exceptions) independently. Resident #125 said this happened a couple of months ago and that he/she told the CNA that he could not use the Hoyer alone and that he needed two people, as that is the protocol. Resident #125 said that the CNA told the Resident that he was exempt, and he could use the Hoyer lift by himself. Resident #125 said that the CNA continued to use the Hoyer lift without another staff member present. During the transfer, Resident #125 said that the CNA pulled the Resident's wrist so hard that Resident #125 stated he/she heard a pop in his/her shoulder. Resident #125 identified the CNA as CNA #4 and told the surveyor he/she still sees CNA #4 working on his/her Unit. Resident #125 stated the Administrator was aware of the incident. During an interview on 11/10/21 at 2:30 P.M., the surveyor spoke with the Administrator and inquired about the incident and asked for any documentation she may have on the incident. The Administrator told the surveyor that she did not remember the incident but would get back to her and would look for any documentation on the incident. During an interview on 11/15 21 at 9:20 A.M., the Director of Nursing (DON) said that CNA #4 told her that the incident did occur and that he did transfer Resident #125 with the Hoyer lift by himself. He further stated that at the time the incident occurred (August 2021) he went down and spoke to the Administrator about the incident. During an interview on 11/16/21 at 11:41 A.M., Unit Manager #2 said the incident occurred prior to the Resident's hospitalization in August 2021 and she had started the initial investigation. Unit Manager #2 said that she reported the incident to the Administrator and had given her all the documents that she had completed/received concerning the alleged abuse. During an interview on 11/16/21 at 10:31 A.M., the Administrator said she had not located any of the original documentation for the investigation. The Administrator said that she should have initiated an investigation but did not. On 11/30/21 at 1:35 P.M., the Administrator said neither she nor Unit Manager #2 could locate the original statements for the allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #83 was admitted to the facility with diagnoses including multiple sclerosis (MS) and right hemiplegia (paralysis on one side of the body). Review of the Minimum Data Set (MDS) assessment, dated 9/12/21, indicated Resident #83 required total assistance with bed mobility. Review of the medical record indicated an interdisciplinary care plan for an activities of daily living (ADL) deficit, initiated 9/19/19, that included, but was not limited to: Focus - Resident has an ADL deficit related to .weakness, MS Goal - Resident will participate in ADL's as able Interventions - Patient to wear right hand cone splint during the daytime up to five hours, initiated 4/30/21 - Patient to wear right hand splint at night up to six hours, initiated 4/1/21 Further review of Resident #83's medical record indicated an Occupational Therapy (OT) Treatment Discharge summary, dated [DATE], that included but was not limited to: Interventions Provided - Patient has trialed his/her hand cone splint and resting hand splint. Caregivers in-serviced on donning (putting on) the cone splint during the daytime and wearing resting hand splint at nighttime. Pt is able to tolerate prefabricated (prefab) hand splint better than the customized resting hand splint at this time. Patient Response - Patient has been motivated to participate, however is limited by decreased memory. She will rely on caregivers to don hand cone splint and prefab splint daily. On 11/4/21 at 12:36 P.M., the surveyor observed Resident #83's right hand in a fist. He/she was not wearing his/her daytime right cone splint and it was not visibly located in his/her room. During an interview on 11/4/21 at 12:36 P.M., Resident #83 said he/she had MS and needed help from staff. He/she said, I'm very limited in what I can do. On 11/9/21 at 12:31 P.M., the surveyor did not observe Resident #83 wearing his/her daytime right hand cone splint and it was not visibly located in his/her room. During an interview on 11/10/21 at 8:26 A.M., the surveyor observed Resident #83 not wearing his/her daytime right hand cone splint and it was not visibly located in his/her room. Resident #83 said he/she wore the splints because of his/her MS and staff had not been putting them on him/her. He/she said his/her right hand felt worse if he/she was not wearing the splints. During an interview on 11/10/21 at 11:05 A.M., Nurse #5 said she was not sure who was supposed to put on Resident #83's right hand splints, but she had not been instructed to do so. She further said it was not located on the Treatment Administration Record (TAR) so, How would I know? On 11/15/21 at 8:54 A.M., the surveyor did not observe Resident #83 wearing his/her daytime right hand cone splint and it was not visibly located in his/her room. During an interview on 11/15/21 at 9:36 A.M., Certified Nursing Assistant (CNA) #16 said she had never seen the splints, and it was not on her Resident Care Card (CNA care instructions). On 11/15/21 at 2:40 P.M., the surveyor did not observe Resident #83 wearing his/her daytime right hand cone splint and it was not visibly located in his/her room. During an interview on 11/15/21 at 4:01 P.M., the Director of Nurses (DON) said if the wrist splints were on the interdisciplinary care plan, then there should have been an order that was carried over to the Treatment Administration Record (TAR), but there was not. During an interview on 11/16/21 at 11:50 A.M., Director of Rehabilitation (DOR) provided the surveyor with a telephone order written on 9/9/21 indicating Resident #83 was to wear a right resting hand splint up to four hours daily and a right-hand cone splint as tolerated daily. The DOR further said the order should have been carried over to the Medication Administration Record (MAR) or TAR by nursing, but was not. Based on observation, record review, and staff interview, the facility failed to ensure that staff developed an individualized comprehensive care plan for one Resident (#83), out of a total sample of 30 residents. Findings include:

Based on record review and interview, the facility failed to review and revise the resident's care plans based on changing needs/status for one Resident (#125), out of a total sample of 30 residents. Specifically, the facility failed to discontinue a focus area related to a nephrostomy tube (a thin tube inserted through the skin into the kidney to drain urine). Findings include: Resident #125 was admitted to the facility in April 2018 with diagnoses including, quadriplegia, disorder of the autonomic nervous system, and neuromuscular bladder dysfunction. Review of Resident #125's Care Plans indicated the Resident has a nephrostomy tube, with an initiation date of 6/3/21. Review of a Nurse's Note, dated 9/28/21, indicated the nephrostomy tube had been pulled out yesterday by the Medical Doctor (MD) and the Suprapubic (S/P) catheter was patent and draining urine. Review of Resident #125's Comprehensive Care Plan indicated the focus area of the nephrostomy tube had not been discontinued. During an interview on 11/16/21 at 5:00 P.M., the Director of Nursing said the facility failed to review and revise Resident #125's care plan.

Based on record review, policy review, and interviews, the facility failed to ensure that care and treatment of a mid-line catheter (a venous access device (VAD) located directly in the basilic vein of the arm and terminates just below the axilla) was provided in accordance with the facility policy/protocols for one Resident (#125), out of a total sample of 30 residents. Specifically, for Resident #125, the facility failed to: -Ensure the mid-line dressing was changed; -Ensure the external length of the catheter was measured; -Ensure the IV tubing was changed every twenty-four hours; -Ensure the mid-line catheter was flushed before and after medication administration; and -Ensure there was documentation when the mid-line was removed. Findings include: Review of the facility's policies/ protocols titled; Midline Catheter-Dressing Change, Midline Catheter-Flushing, and Midline Catheter-Removal, dated 2012, included but not limited to the following: Transparent dressings are changed upon admission or 24 hours post midline insertion, every 7 days or sooner if the integrity of the dressing is compromised (wet, soiled, or loose). With each dressing change, the Licensed Nurse shall measure the external catheter length and notify physician if problem exists such as a deviation from the previous measurement. Document date/time of dressing change, site assessment, measurement of external catheter length, and resident response in the appropriate nursing document. Flushing with 0.9% Sterile Saline (NS) for Injection shall be performed before and after administration of incompatible medications/solutions, followed by Heparinized Saline per physician's order. Midline Catheter Removal Documentation: Document date/time of procedure, patient education, length of catheter removed and catheter integrity, resident's response to procedure, and catheter site assessment on appropriate nursing document. Record review indicated that Resident #125 was hospitalized twice in July 2021. Upon return to the facility, Resident #125 had a midline catheter in place for administration of antibiotics. Record review indicated the Resident initially was to receive Ceftazidime 2 grams three times a day via IV for 10 days. Resident #125 was re-hospitalized and returned on 7/25/21 with an order to discontinue the Ceftazidime and begin Meropenem 500 milligrams IV every six hours for seven days. Review of the Infusion Therapy Flowsheet indicated the initial dressing was changed on 7/23/21 and due to be changed again on 7/30/21. Record review and review of the Infusion Therapy Flowsheet indicated the dressing was not changed on 7/30/21 and it further indicated that on 7/23/21 and 7/30/21 there was no documentation of the measurements of the external catheter length. Review of the Infusion Medication Administration Record indicated the midline was to be flushed before and after the administration of the antibiotic with 10 milliliters (ml) of NS and then Flush with Heparin 5 mls (10units per ml). Further review of the Infusion Medication Record indicated that the above flush protocol was not administered every six hours as ordered for 5 days, 7/26/21 through 7/31/21. Review of a Nurse's Note, dated 8/1/21, indicated Resident #125's midline infiltrated (the medication was infusing into the tissue instead of the vein). An order was obtained to remove the midline catheter, discontinue the current IV Meropenem, and start oral Cipro, twice a day for three days. Further record review indicated no documentation of date/time the procedure was performed, patient education, length of catheter removed, catheter integrity, the Resident's response to procedure, and catheter site assessment. Record review indicated that Resident #125 was hospitalized in August 2021, and upon return to the facility, a midline catheter was in place and he/she was to receive IV antibiotics. Resident #125 had begun the course of initial antibiotics while hospitalized and returned with a physician's order for: Meropenem IV every six hours for 13 more days and then the midline catheter can be discontinued. Review of the Infusion Medication Administration Record for August 2021 indicated the IV antibiotic was started at the facility and was completed on 9/5/21. Further review of the Infusion Medication Administration Record indicated there was no dressing change on 8/22/21. There was a dressing change performed on 8/29/21, however there was no documentation of the catheter length on the Infusion Medication Administration during the entire course of antibiotic administration or within the medical record, no documentation that the midline catheter was flushed every six hours as ordered, or that the IV tubing had been changed every 24 hours. The recommendation from the hospital was to discontinue the midline upon completion of the IV antibiotics. Record review indicated that on 9/8/21 the midline catheter remained in place as there had been no order obtained from the Resident's physician to discontinue the midline catheter. Record review indicated the Resident was hospitalized in October 2021 and returned to the facility with a midline catheter in place. Resident #125 had the midline catheter in place from 10/25/21 through 11/1/21 with no dressing changes completed or measurements of the external catheter length. On 11/1/21 an order was obtained from Resident #125's physician to remove the midline catheter. Record review indicated that the documentation of the removal of the midline catheter did not include the integrity of the midline catheter that was removed. During an interview on 11/15/21 at 9:45 A.M., the surveyor informed the Director of Nursing of her concerns regarding the care of the midline catheter. The DON said the facility failed to ensure that care and treatment of a midline catheter was provided in accordance with the facility policies/protocols.

Based on record reviews, policy review, and interviews, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, through ongoing communication and collaboration with the dialysis facility for one Resident (#139), out of two total residents receiving dialysis. Specifically, the facility 1) Failed to ensure the prescribed fluid restriction for Resident #139 was accurately monitored on an ongoing basis; and 2) Failed to ensure consistent communication between the facility and the dialysis center. Findings include: Review of the facility's policy titled Hemodialysis, dated April 2015, indicated the following: 1. If resident is placed on a fluid restriction, monitor intake. Allocate fluids to be given by nursing and dietary with amounts per shift. 2. Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of: A. Vital signs B. Copy of the medication administration record (MAR) C. Any change from last hemodialysis treatment such as falls, medications, behaviors, change in appetite or weight Resident #139 was admitted to the facility in October 2020 with diagnoses including end stage renal disease. Record review indicated Resident #139 attended hemodialysis offsite on Tuesdays, Thursdays and Saturdays weekly, and required a fluid restriction of 960 milliliters (ml) in a 24-hour period. The record lacked any evidence of specific intake monitoring or an allocation of fluids by discipline. On 11/10/21 at 11:01 A.M., the surveyor observed Resident #139 to have a cup of water in front of him/her at the bedside and indicated he/she had consumed the fluids from the cup. During an interview on 11/10/21 at 11:02 A.M., Nurse #1 said she could not locate a fluid intake monitoring sheet for the Resident, but did have a sign off on the MAR indicating the Resident was on a 960 ml fluid restriction and could receive 120 ml on the night shift, 420 ml on the day shift, and 420 ml on the evening shift. She said she was unsure how much fluid intake Resident #139 had already received for the shift because there was no fluid intake sheet, but could guess it was 360 ml so far for that shift. She said she could not find any evidence of fluid intake for Resident #139 for the month of November 2021 and it appeared the process for fluid restriction and documenting was not being followed. On 11/10/21 at 11:23 A.M., the surveyor observed Ambassador #1 bring the Resident two large, 16 ounce (473 ml) sized, styrofoam cups. One containing tea and the other containing ice. During an interview on 11/10/21 at 11:37 A.M., Ambassador #1 said she was aware of the residents' diets and restrictions from a weekly list provided by the kitchen. She supplied the surveyor with a copy of the list. Review of the list indicated Resident #139 did not have a fluid restriction on the print out used by the Ambassador. During an interview on 11/10/21 at 12:07 P.M., Nurse #1 said she updated the dietary list for the ambassadors and did so for Ambassador #1 that morning. Nurse #1 reviewed the list with the surveyor and said the list was accurate, although it lacked the fluid restriction information for Resident #139. On 11/10/21 at 12:42 P.M., the surveyor observed Resident #139 consuming his/her beverage provided by the Ambassador and his/her large cup of tea was noted to be half empty. The ice cup was also noted to be half empty. During an interview on 11/10/21 at 1:51 P.M., the surveyor made Nurse #1 aware of her observations. Nurse #1 said the Resident should not have been given those additional fluids and she should have given that information to the Ambassador. She said it appeared the Resident had gone over his/her prescribed fluid restriction. During an interview on 11/10/21 at 4:13 P.M., Unit Manager #1 said her expectation of the staff was to have intake sheets completed accurately for each resident on a fluid restriction. She said there was no way for the staff to know the accurate intake of Resident #139 that day since they did not initiate an intake sheet until halfway through the shift. 2. The facility uses a Dialysis Communication Book for ongoing communication with the Dialysis center. This is a form of written communication that occurs between the nursing facility and the Dialysis center that includes, but is not limited to, changes in resident condition, vital signs, contact information, and signature of the charge nurse sending the resident to dialysis. It also includes any recommendations made by the Dialysis center staff for the nursing facility to implement, resident condition before, during and after their dialysis treatment, dialysis access condition, any lab work completed, and the pre and post dialysis weight of the resident. Review of the Resident's Dialysis Communication Book indicated the last hemodialysis communication sheet was completed on 10/23/21. During an interview on 11/10/21 at 11:46 A.M., Nurse #1 reviewed the Resident's Dialysis Communication Book with the surveyor and said there were many days of communication sheets missing. She said the last completed communication sheet was on 10/23/21. She further said the process for completing the sheets was not followed. During an interview on 11/10/21 at 1:37 P.M., Dialysis Nurse #1 said the facility consistently sent the Dialysis Communication Book with the Resident, but there was not consistently any information from the facility for the Resident available in the book. During an interview on 11/10/21 at 3:42 P.M., the Director of Nurses said the communication process for dialysis was not followed. During an observation with interview on 11/6/21 at 8:29 A.M., the surveyor observed Resident #139's Dialysis Communication Book on the Mayflower North nurses' station. Nurse #6 said the Resident was out to dialysis and the communication book should have accompanied him/her. She reviewed the Dialysis Communication Book with the surveyor and said there were no initiated communication sheets for the Dialysis center completed on that day and she would contact the dialysis center and provide them a report. She said the policy is for the communication book to accompany the resident with a new communication sheet each dialysis day and the policy was not followed.

Based on record review, review of hospital discharge summaries and interview, the facility failed to ensure the physician included an evaluation of the resident's condition and total program of care, including medications and treatments, for one Resident (#125), out of a total sample of 30 residents. Specifically, the facility failed to ensure Resident #125's attending physician evaluated the total program of care including recommendations that were made by the Hospital providers after the Resident had six hospitalizations with multiple issues, and recurrent Urinary Tract Infections (UTI). Findings include: Resident #125 was admitted to the facility in April 2018 with diagnoses including, quadriplegia, disorder of the autonomic nervous system, and neuromuscular bladder dysfunction with a suprapubic catheter (a tube that drains urine from your bladder) in place. Record review indicated Resident #125 was hospitalized six times between July 2021 and November 2021 (twice in July and once in each subsequent month). Record review failed to indicate the physician reviewed the follow-up recommendations/hospital discharge summaries upon the Resident's return to the facility as evidenced by: Review of Physician's Progress Notes: - 8/4/21: Stable, Meds (medications) reviewed, continue same treatment and care (these areas were check of boxes). The box for recent hospitalizations was not checked. - 10/13/21: Stable, Meds (medications) reviewed, continue same treatment and care (these areas were check of boxes). The box for recent hospitalizations was not checked. During an interview on 11/10/21 at 1:37 P.M. the Medical Director/Attending physician said, I am connected to the facility by phone only. The MD further said that some weeks he is at the facility every day. The MD said, If someone is readmitted from the hospital they should be seen. If the resident is not stable, I come in the same day. If the resident is stable, then I come in the next day. Record review indicated there were no physician visits/notes after each hospitalization in the medical record and the notes that were reviewed for 8/4/21 and 10/13/21 did not address that the hospital discharge summaries were reviewed and that recommendations made by Hospital providers were addressed. The physician's progress notes did not reflect a comprehensive review of the Resident's medical care.

Based on interviews and record review, the facility failed to ensure a Resident was seen by a physician once every 30 days for the first 90 days of admission for one Resident (#66), out of a total sample of 30 residents. Findings include: Resident #66 was admitted to the facility in August 2021 with diagnoses of chronic respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease (lung disease that block airflow and makes it difficult to breathe), brain shunt, seizures, and traumatic brain injury. Review of the medical record on 11/12/21 for Resident #66 indicated the Resident was seen by a physician on 8/19/21 and 8/20/21. There were no further visits from a physician. During an interview on 11/12/21 at 3:01 P.M., the physician said every resident should be seen every 30 days for the first 90 days following the admission and then every 60 days. The physician said any physician visits would be documented in the paper medical record. During an interview on 11/12/21 at 3:05 P.M., the Nurse Practitioner said she started at the facility one month prior and all of her documentation was in the paper medical record. She said the facility staff was supposed to provide her with a list of residents who needed to be seen and she had never received any list from any staff to ensure that residents were seen every 30 days.

Resident #89 was admitted to the facility in April 2018 with diagnoses of dementia, post traumatic stress disorder, and major depressive disorder. During interview on 11/16/21 at 9:18 A.M., the Director of Nurses (DON) said the process for addressing pharmacy recommendations is that the DON/Assistant Director of Nursing (ADON) receives the recommendations from the pharmacist. The recommendations that require a physician's attention are put into a folder for the physician to accept or decline with the rationale. The DON said that once the pharmacist's recommendations are addressed by the physician, the recommendations are filed into the resident's record. Review of the Progress Notes indicated a Medication Record Review was completed for Resident #89 on 9/5/21 with recommendations. A review of the paper medical record did not include the recommendation. Review of an unsigned copy of a Pharmacy Recommendation, dated 9/6/21, indicated the need for nursing follow-up as Resident #89 did not receive their evening medications on 9/2/21 which included Zocor (to treat high cholesterol) and Valproic Acid (to treat mood disorder), with a note which indicated there are other omissions on the Medication Administration Record (MAR). During an interview on 11/12/21 at 11:22 A.M., the Director of Nurses said there was no follow up to this recommendation and it had not been reviewed by the facility. She said the process was for the Unit Managers to print the monthly recommendations and provide them to the physicians and said the pharmacy recommendations in September 2021 were not reviewed. Based on record review and staff interview, the facility failed to ensure that the licensed Pharmacist's medication regimen review recommendation was addressed for one Resident (#89), out of a total sample of 30 residents. Findings include:

Based on record review and staff interview, the facility failed to ensure residents who use psychotropic medications, as needed, were limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration, for two Residents (#136 and #125), out of a sample of 30 residents. Findings include: 1. Resident #136 was admitted to the facility in March 2018 with a diagnosis of dementia and was on hospice services. Review of the medical record for Resident #136 indicated a hospice recommendation on 11/2/21 for Ativan 0.5 milligrams (mg) every four hours as needed for increased anxiety and restlessness. The medical record included a telephone order for Ativan 0.5 mg one tab by mouth as needed for anxiety or agitation. The order did not include a 14 day limitation or an indication to re-evaluate the medication. During an interview on 11/16/21 at 9:42 A.M., Nurse #7 said she did not know if the Ativan order written on 11/2/21 had a time limitation to be re-evaluated. During an interview on 11/16/21 at 8:30 A.M., the Director of Nurses said the as needed Ativan order should have been written with a date for re-evaluation. 2. Resident #125 was admitted to the facility in April 2018 with diagnoses including, quadriplegia, neuromuscular bladder dysfunction (Supra-Pubic catheter in place), and insomnia. Record review indicated the Resident was prescribed the following: -Seroquel 50 mg tablet. One tablet by mouth at bedtime. The Resident was subsequently hospitalized in October 2021 and the following medication was added to the Resident's medication regime upon return: -Seroquel 50 mg tablet. One tablet by mouth every four hours, PRN anxiety/agitation. Review of the medical record indicated there had been no communication with the physician as to the initiation of the PRN antipsychotic, Seroquel. The Seroquel initiated on 10/26/21 was not limited to 14 days and did not have an indication to re-evaluate the medication in 14 days. During an interview on 11/16/21 at 9:30 A.M., the DON said that the facility does not have a specific policy for the 14 day re-evaluation of PRN psychotropic's but, the facility follows the regulations. The DON said that the PRN Seroquel should have a date for re-evaluation or stop date on or before day 14 written with the order and did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and policy review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart, dated February 2018, indicated the following: 1. Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nurses. 2. Storage for other medications will be limited to a locked medication room. 3. Medication cart is to be locked at all times when not in use by the nurse. The following observations were made on the [NAME] unit by the surveyor: -11/4/21 at 11:25 A.M., three medication cards with pills in them were left on top of the unattended medication cart -11/4/21 at 11:47 A.M., medication room with unlocked open door -11/4/21 at 12:29 P.M., medication cart left unlocked and unattended -11/4/21 at 3:43 P.M., medication room with door open -11/4/21 at 4:16 P.M., Nurse #9 entered open medication room, performed hand hygiene, and exited room leaving the door open -11/4/21 at 5:12 P.M., two residents sitting at the nurses' station with medication room door unlocked and open, no staff at the nurses' station -11/9/21 at 9:06 A.M., medication cart left unattended and unlocked in the hallway -11/16/21 at 3:08 P.M., treatment cart left unattended and unlocked During an interview on 11/4/21 at 11:47 A.M., Nurse #7 said the medication room should be closed and locked. During an interview on 11/16/21 at 3:08 P.M., Unit Manager #2 said the treatment cart contained medicated treatments and should be locked.

Based on record review and staff interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards of practice for one Resident (#85), out of a total sample of 30 residents. Specifically, the facility failed to ensure Resident #85 had a current physician's order to receive Psychiatric consultant services. Findings include: Resident #85 was admitted to the facility March 2021 with diagnoses including adjustment disorder and depression. Record review indicated the Resident was seen by the Psychiatric consultant initially on 4/23/21 and seven times thereafter with the most current consult on 10/22/21. Further record review indicated there was no physician's order to receive these services. During interview on 11/16/21 at 12:18 P.M., the Director of Nursing and Unit Manager #2 said that there should have been a physician's order in place for the services and there was not.

Based on observation, interview, and record review, the facility failed to ensure staff communicated and coordinated hospice care with the attending physician as needed to ensure the needs for one Resident (#6), out of a total sample of 30 residents, were addressed and met. Resident #6 was admitted to the facility with diagnoses including aphasia (loss of ability to understand or express speech) and left hemiparesis (paralysis on one side of the body) following cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 10/15/21, indicated Resident #6 received hospice care. Review of the Hospice Nursing Facility Services Agreement, dated August 2013, included but was not limited to the following: - Professional Standards. Facility shall ensure that all facility services are provided competently and efficiently. - General. Hospice and facility shall communicate with one another regularly and as needed .for each hospice patient .and documenting such communication in its respective clinical records to ensure the needs of hospice patients are met 24 hours per day. Review of the facility Hospice Care Plan, initiated 1/21/20, indicated Resident #6 was admitted to hospice related to cerebrovascular accident (CVA) resulting from brain and lung cancer. Interventions included the following: - Coordinate Resident's daily care with Hospice and/or palliative care givers During an interview on 11/9/21 at 12:53 P.M., Hospice Nurse #2 told Unit Manager #1 and the surveyor she had just seen Resident #6 and, because he/she had lost nine pounds, his/her dentures needed to be fixed as they did not fit properly due to weight loss and four teeth on the upper set were broken. She further said the upper denture was just sitting in there and adhesive would not create the proper fit. Hospice Nurse #2 said she documented this same recommendation on the Hospice Communication Sheet a month ago, on 10/5/21, for the attending physician, but it was not addressed. During an interview on 11/9/21 at 12:53 P.M., Unit Manager #1 said the recommendation from Hospice Nurse #2 was not in Resident #6's medical record and was not sure what happened to it. On 11/9/21 at 1:09 P.M., the surveyor observed Resident #6 sitting upright in his/her electric wheelchair. His/her upper denture was loose and hanging down from his/her gums. Resident #6 moved it up and down with his/her tongue. Broken/missing teeth were observed on the left upper denture. During an interview on 11/9/21 at 1:10 P.M., Unit Manager #1 said she found the Hospice Recommendations, written 35 days earlier, in a folder behind the nurses' station, but said it was not reviewed or addressed by the attending physician. Unit Manager #1 said a better system was needed for communication with the attending physician and hospice. During an interview on 11/10/21 at 8:39 A.M., Nurse #5 said she knew Resident #6's dentures were loose, but did not know they were broken. She further said Hospice Nurse #2 told her the last time she had been there that Resident #6's dentures needed to be replaced. Nurse #5 said she did not refer him/her for dental services because she was waiting for the attending physician to look at the request. On 11/16/21 at 10:08 A.M., the surveyor observed CNA #18 clean and insert Resident #6's dentures with adhesive. The surveyor observed four missing teeth on Resident #6's upper denture, three on his/her left and one on his/her right. During an interview on 11/15/21 at 1:00 P.M., the Director of Nurses said there should have been better communication between the facility and hospice regarding Resident #6's dentures, but there was not. She further said the attending physician should have been notified by means other than just placing the recommendation in a folder.

6. Resident #29 was admitted to the facility in October 2021 with diagnoses including quadriplegia and a pressure ulcer of the sacral region. Review of the current treatment orders for November 2021 indicated a current order for the sacral wound as: Dakins (H-chlor 12) 1/4 (quarter) strength 0.125% to sacral wound: normal saline wash, pat dry cover with gauze damp with Dakins. Order was scheduled to be changed daily as documented on the Treatment Administration Record (TAR). Review of the October 2021 TAR failed to indicate evidence of the dressing being signed off as completed for 6 out of 24 days the Resident was in the facility. During an interview on 11/16/21 at 10:53 A.M., the Director of Nurses (DON) reviewed the TAR for October 2021 with the surveyor and said any day the treatment sheet was not signed off indicated the nurse did not complete the treatment. 7. Resident #139 was admitted to the facility in October 2020 with diagnoses including end stage renal disease. Review of the Resident's MAR indicated Resident #139 had prescribed medications scheduled to be administered at 6:00 A.M., 10:00 A.M., 4:00 P.M., 8:00 P.M., And 10:00 P.M. daily. Record review indicated Resident #139 attended hemodialysis offsite on Tuesdays, Thursdays and Saturdays weekly with a 7:45 A.M. pick up time. During an observation with interview on 11/4/21 at 11:47 A.M., the Resident was not available. Nurse #1 said Resident #139 had not yet returned from dialysis and was usually back by lunch time. During an observation with interview on 11/9/21 at 11:15 A.M., the Resident was not available. Nurse #2 said Resident #139 was still out at dialysis and the Resident would receive his/her 10:00 A.M. scheduled medications once he/she returned from dialysis. During a follow up interview on 11/10/21 at 11:01 A.M., Nurse #1 said the Resident usually returned from dialysis around 12:00 P.M. She said on the Resident's scheduled dialysis days the medications scheduled for 10:00 A.M., were administered to the Resident upon his/her return to the facility at that time. During an interview on 11/10/21 at 1:37 P.M., Dialysis nurse #1 said Resident #139 arrives on Tuesday, Thursday and Saturdays weekly for hemodialysis at approximately 7:45 A.M. and leaves the dialysis center at approximately 11:40 A.M. each day to return to the facility. During an interview on 11/16/21 at 1:46 P.M., the DON said the medications should be timed to accommodate dialysis times and the Resident should not be receiving them more than an hour after their scheduled time. She said the medications were administered late and it was not appropriate and did not follow the standard of practice; the times of the medications would need to be adjusted. 8. During an observation with interview on 11/10/21 at 4:26 P.M. on the Mayflower North unit, the surveyor inspected Nurse #5's medication cart for medication storage. Nurse #5 opened the top drawer and there was a small plastic cup, unlabeled, with four pills inside of it. She said the medications belonged to a resident on the unit and that she poured the medications to administer them and then stored them in the drawer when she left to answer the phone. She said, We are not supposed to be doing that; it is against the rules. During an interview on 11/10/21 at 5:02 P.M., the DON said the expectation was that the nurses do not store pre-poured medications unsecured in the medication cart for any reason. She said the practice of doing so was unacceptable and against the professional standard of nursing practice. 5. Resident #66 was admitted to the facility in August 2021 with a history of cardiovascular accident (CVA) and a mitral mechanical valve replacement. Review of the medical record for Resident #66 indicated the Resident was taking Coumadin (a blood thinner) and the dose was determined by INR (international normalized ratio) laboratory results. Review of the medical record, including the Medication Administration Record (MAR), telephone physician orders, nursing progress notes and laboratory results indicated the following timeline: -9/29/21 INR result was 1.87 (low) and an order was written for Coumadin 2 mg (milligrams) and to recheck INR on 10/2/21. The Coumadin 2 mg was not administered on 10/1/21. -10/2/21 INR laboratory test was not obtained as ordered and the test results from 9/29/21 were reported to the physician as being new results and the physician ordered Coumadin 3 mg and to recheck the INR on 10/5/21. -10/5/21 INR result was 1.14 (low) and an order was written for Coumadin 5 mg and to recheck INR on 10/8/21. -10/8/21 INR laboratory test was not obtained, Coumadin 5 mg was given on 10/8/21, 10/9/21, 10/10/21 with no order to change the laboratory date or continue the Coumadin dosage. -10/11/21 INR result was 1.14 (low) and an order was written for Coumadin 8 mg and to recheck the INR on 10/12/21. Coumadin 8 mg was not documented as administered on 10/11/21 as ordered. -10/12/21 INR laboratory test was not obtained as ordered, a new order to administer Coumadin 7.5 mg was written and to recheck the INR on 10/15/21. The nursing progress note indicated the lab result from 10/11/21 of 1.14 was reported to the physician. -INR results and Coumadin were administered as ordered from 10/15/21 through 10/21/21. -10/21/21 INR result was 2.11 (therapeutic range) and an order was written for Coumadin 12 mg and to recheck the INR on 10/25/21. A review of the MAR indicated the Coumadin was not administered on 10/22/21 and 10/23/21. -10/25/21 INR laboratory test was not obtained as ordered, no Coumadin was administered on 10/25/21 and the order for Coumadin 12 mg continued without any indication it was reviewed by a physician. -10/29/21 Coumadin 12 mg was administered, an INR result of 2.3 (therapeutic range) was obtained and a new order was written for Coumadin 12 mg and to recheck INR on 11/2/21. An additional dose of Coumadin 12 mg was administered on 10/29/21, for a total of 24 mg in one day. A review of the MAR indicated the Coumadin was not administered on 11/1/21. -11/2/21 INR result was 4.05 (high) and an order was written to hold Coumadin and recheck the INR on 11/6/21. -11/6/21 INR result was 1.21 (low) and an order was written to hold Coumadin one night and to recheck the INR on 11/7/21. - 11/7/21 INR result was 1.09 (low) and an order was written for Coumadin 2 mg and to recheck the INR on 11/10/21. -11/10/21 INR laboratory test was not obtained as ordered During an interview on 11/12/21 at 11:30 A.M., the Director of Nurses said she had reviewed the medical record for Resident #66 and had found the physician's orders were not followed for laboratory testing, for administering Coumadin as ordered, and standards of practice were not followed for reporting laboratory results correctly to a physician and obtaining new orders for Coumadin with a missing laboratory result. Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for seven Residents (#125, #30, #69, #85, #66, #29, and #139), out of a total sample of 30 residents. Specifically, the facility failed 1. For Resident #125, to a) Ensure that medication reconciliations were completed upon re-admission to the facility after four hospitalizations; b) Ensure that all information provided to the facility upon re-admission was reviewed; and c) Ensure the physician was notified for clarification; 2. For Resident #30, to a) Ensure that medication reconciliation was completed upon re-admission to the facility after a hospitalization; b) Ensure that weights were obtained as ordered by the physician; c) Ensure that treatments ordered by the physician were completed as ordered; and d) Ensure the physician was notified for a fingerstick blood sugar (FSBS) less than 150 as ordered; 3. For Resident #69, to ensure that medications were administered as per the physician's orders; 4. For Resident #85, to a) Ensure the Resident had a current physician's order to administer oxygen; and b) Ensure the Resident received Continuous Positive Airway Pressure (CPAP) machine as ordered by the physician; 5. For Resident #66, to ensure professional standards of practice were followed for anticoagulation treatment; 6. For Resident #29, to provide prescribed treatments to a Stage 4 pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) as ordered by the physician; 7. For Resident #139, to provide medications as ordered on days the Resident attended their scheduled hemodialysis; and 8. To ensure medications were stored in a safe manner for administration, as identified during a medication cart inspection. Findings include: Review of the facility's policy titled Medication Reconciliation, dated 4/2015, included but was not limited to the following: Medication Reconciliation is a formal process for creating the most complete and accurate list possible of a resident's current medications and comparing the list to those in the resident's medical record or medication orders. (The Joint Commission 2013). -Process: *Any changes in medications will be documented in the Medication Reconciliation. *The nurse will then contact the physician regarding potential discrepancies identified during the medication reconciliation assessment as warranted. *Any discrepancies found between resident/patient medication list will be clarified in a physician order and noted on the Medication Reconciliation. -Procedure when the resident is readmitted from outside inpatient setting: Upon readmission from a setting outside the nursing home, the nursing home receives *Hospital records of medications ordered and given. *Physician orders that list of medications the resident is to take upon readmission to the nursing home. *The admitting charge nurse reviews all available information as well as medications the resident was taking at the nursing home prior to admission to the hospital or other setting and reconciles the medication regime. *The physician is notified for clarification as warranted. 1. Resident #125 was admitted to the facility in April 2018 with diagnoses including, quadriplegia, disorder of the autonomic nervous system, and neuromuscular bladder dysfunction with a suprapubic (S/P) catheter (tube which drains urine from your bladder) in place. Record review indicated Resident #125 was hospitalized on ce each month from August 2021 through November 2021. Further review failed to indicate that after each hospitalization follow-up recommendations were reviewed upon return to the facility as follows: Review of the August 2021 Hospital Discharge Summary indicated: -Recommendation made for a follow-up with the Urologist for consideration preventative therapy of acetic acid irrigations (for S/P catheter) to reduce the risk of recurrent infections. -IV antibiotic (Meropenem IV) should be administered every six hours for 13 more days and then the midline catheter can be discontinued. Review of the August 2021 Infusion Medication Administration Record (MAR) indicated the IV antibiotic was started at the facility on 8/23/21 and was completed on 9/5/21, 14 days and not 13 days as indicated by the Hospital Discharge Summary. Record review indicated that on 9/8/21 the Midline remained in place as there had been no order obtained from the Resident's physician to discontinue the midline catheter after the IV antibiotics had been completed. Record review indicated there was no documentation/follow-up by the physician or nursing staff upon return from the hospitalization that the irrigations of acetic acid were addressed by a Urologist as per the discharge orders, the timeframe of the IV antibiotics, and the removal of the midline catheter when the antibiotics were completed. Review of the September 2021 Hospital Discharge Summary indicated: -Recommendation made for a follow-up with the Urologist for consideration of acetic acid irrigations (for S/P catheter) to reduce the risk of recurrent infections. Record review indicated there was no documentation/follow-up by the physician or nursing staff indicating a follow-up appointment with a Urologist was made upon return from the hospitalization to address the irrigations of acetic acid to reduce risk of urinary tract infections. Review of the October 2021 Hospital Discharge Summary indicated: -Resident #125 was to continue Cefepime IV (IV Antibiotic) for a total of 7 days. Review of a Nurse's Note, dated 10/2021 at 3:50 P.M., included but was not limited to the following: -Patient was readmitted however all the discharge papers were left at the hospital. Patient has a midline at the antecubital fossa. Review of a Nurse's note, dated 11/1/21, indicated may remove midline catheter from right antecubital, competed course of IV antibiotics, a telephone order per MD. Review of a Nurse's note, dated 11/7/21 at 1:24 A.M., included but was not limited to the following: -Resident #125 indicated to the nursing staff that he/she did not feel right and stated that he/she was hallucinating and that something is wrong. Resident #125 was transferred to the hospital. Review of a Nurse's note dated 11/7/21 at 4:16 P.M. included by was not limited to the following: -Hospital called to report that the Resident was found to have a Urinary Tract Infection (UTI) and they will be keeping the Resident overnight. Resident is to return tomorrow on IV antibiotic therapy. Record review indicated that a Physician's Interim/Telephone order (dated 10/13/21) for the following: -Discontinue the hour of sleep Gabapentin (used to treat pain) 600 milligrams (mg) -Start the hours of sleep Gabapentin 800 mg Further review of the October 2021 Hospital Discharge Summary and the Medication Administration Record (MAR) indicated the Resident had an order in place for an as needed antipsychotic (Seroquel). The MAR indicated Resident #125 could be administered Seroquel 50 mg tablet, one tablet every four hours as needed for anxiety, agitation. Prior to the hospitalization, Resident #125 was not receiving this medication and the as needed antipsychotic did not include a time frame/re-evaluation date as required (limited to 14 days). Record review indicated that because the process for medication reconciliation and that all available information was not reviewed upon return to the facility by the nursing staff or the physician, the following was not addressed: -Resident #125 did not receive the IV antibiotic as the hospital physician had ordered. -Gabapentin 800 mg at hour of sleep had not been reconciled and implemented per the physician's order prior to the hospital admission and Resident #125 continued to receive Gabapentin 600mg. Review of the November 2021 Hospital Discharge Summary indicated: -The right heel was noted to have a pressure injury; the treatment performed to the area was an adhesive border foam dressing, due to be changed on 11/10/21. -Resident's skin was not intact and there was a pressure injury present. Record review indicated that upon return to the facility, a Nurse's note indicated that an assessment was done with Vital Signs-Within Normal Limits, no changes in skin integrity prior to leaving Rehab. Resident in stable condition. The pressure injury noted on the hospital discharge summary was not identified upon return to the facility. Record review indicated no documentation that the physician was called upon Resident #125's return to the facility, that the discharge summary had been reviewed and that medications/treatments were checked for any changes and that a head-to-toe skin assessment was completed as per the facility policy. During an interview on 11/15/21 at 9:45 A.M., the Director of Nursing (DON) provided the surveyor with copies of the above discharge summaries and said that there had been no reconciliations done from any of the hospitalizations. The DON said that the staff did not ensure that Medication Reconciliations were performed as per the Medication Reconciliation policy/protocol and that staff failed to provide care and services according to accepted standards of clinical practice. 2. Resident #30 was admitted to the facility January 2019 with diagnoses of insulin dependent diabetes mellitus, chronic diabetic ulcer of the left heel, and dementia. A. Record review indicated that on 10/20/21 Resident #30 was started on Zoloft (antidepressant) 25 mg tablet. Give one tablet by mouth daily. On 10/29/21 at 6:20 A.M., Resident #30 was found on the floor. Resident #30 indicated that she/he had hit her/his head. Resident #30 was sent to the hospital and returned to the facility in November 2021. Review of the Physician's Orders, dated 11/3/21, indicated the Zoloft that had been initiated on 10/20/21 prior to Resident #30's hospitalization had not been resumed. Record review indicated that Resident #30 had a chronic diabetic ulcer of the left heel. Record review indicated that prior to the hospitalization the following treatment was being performed: -Left heel treatment- Normal Saline wash, pat dry. Apply Alginate (type of dressing that can absorb wound fluid and can provide a dry wound with a physiologically moist environment and minimize bacterial infections) followed by gauze and wrap with Kerlix. Change daily and as needed. Further review indicated the above treatment was not restarted upon readmission to the facility in November 2021. On 11/5/21 a Physician's Interim/Telephone indicated to resume prior treatment to left heel. Review of the November 2021 Treatment Administration Sheet (TAR) indicated the above treatment was not initiated until 11/6/21, resulting in a three day delay in providing wound care. Further record review indicated there was no documentation in the medical record upon return to the facility on 11/2021 that all the information available and medication reconciliation had been completed as per the facility policy/protocol. There was no Nurse's note in the medical record indicating that the Resident had returned to the facility and that the physician was contacted. During an interview on 11/16/21 at 12:18 P.M., the DON and Unit Manager #2 said the facility failed to reconcile the medications resulting in the Zoloft 25 mg daily and the wound care not being resumed upon re-admission, resulting in a delay in resuming the treatment. B. Record review indicated a Physician's order, dated 9/14/21, to obtain daily weights for seven days to establish a baseline. Further record review indicated a weight was obtained on 9/15/21, with no further weights until 9/22/21. There no weights obtained on 9/16, 9/17, 9/18, 9/19, 9/20, and 9/21/21. During an interview on 11/16/21 at 12:18 P.M., the DON and Unit Manager #2 said the facility failed to weigh Resident #30 for the seven days as per the physician's order. C. Review of the Physician's Orders and Treatment Administration Sheet (TAR) for September 2021 and October 2021 indicated the following: 1c. Left heel treatment-Normal Saline wash, pat dry. Apply Alginate dressing followed by gauze and wrap with Kerlix. Change daily and as needed. Review of the TAR for September 2021 and October 2021 indicated: -September 2021: the treatment was not documented as being performed 9/1/21 through 9/7/21, 9/9, 9/12, 9/14, 9/15, 9/17, 9/19, 9/20, 9/27, 9/28 and 9/30/21. -October 2021: the treatment was not documented as being performed 10/1/21 through 10/5/21, 10/11, 10/12, 10/17/21 through 10/28/21. 2c. Treatment to Left Lower Extremity (LLE): Monitor Unna Boot every shift for placement and slippage. Notify Wound nurse if occurs. Review of the 10/2021 TAR indicated the treatment was not documented as being performed: 7:00 A.M. to 3:00 P.M. shift-10/4/, 10/5, 10/9/21 through 10/14/21 and 10/17/21 through 10/28/21. 3:00 P.M. to 11:00 P M. shift-10/4, 10/10, 10/11, 10/12, and 10/20/21 through 10/28/21. 3c. Skin Checks on Thursdays on the 3:00 P.M. to 11:00 P.M. shift and document in Point Click Care (PCC-this is the facilities Electronic Medical Record (EMR)). Review of the 10/2021 TAR indicated that the weekly skin checks were not documented as done, but review in the EMR/PCC indicated that were completed as ordered. Review of the 9/2021 TAR indicated that 9/16, 9/23, and 9/30 the weekly skin checks were documented as done on the TAR. Review of the EMR/PCC indicated that although a nurse had initialed the skin check as done, there were no weekly skin audit/check entered. The EMR/PCC indicated that a weekly skin check was completed on 8/26/21 and then the next one was on 10/7/21. D. Review of the October 2021 Physician's Orders indicated the following order: -FSBS four times daily with coverage using Novolog Insulin according to the sliding scale. -FSBS were scheduled for 7:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M. -If the FSBS is less than 150, notify the MD. Further review of the MAR indicated that the following FSBS: -10/1/21 at 7:30 A.M.-96; 11:30 A.M.-96; 4:30 P.M.-103; 8:00 P.M.-108 -10/4/21 at 7:30 A.M.-109; 11:30 A.M.-128 -10/25/21 at 7:30 A.M.-103; 11:30 A.M.-100 Record review indicated that there was no documentation by the Nurse that the physician had been notified regarding the FSBS below 150 as ordered. During an interview on 11/16/21 at 12:20 P.M., the Director of Nursing and Unit Manager #2 said the facility failed to document treatments (wound care and skin checks) as per the physician's orders and failed to notify the physician for a FSBS below 150 as per the physician's order. 3. Resident #69 was admitted to the facility November 2018 with obesity, Type 2 Diabetes, and muscle wasting and atrophy. Record review of the October 2021 Physician's Orders indicated the following: Vitamin D3 capsule, 50,000 units. One capsule by mouth every month on the 15th. Review of the October 2021 MAR indicated the Vitamin D3 capsule, 50,000 units, was not documented as given as per the physician's orders. During an interview on 11/16/21 at 12:20 P.M., the Director of Nursing and Unit Manager #2 said the facility failed to administer the Vitamin D3 as ordered by the physician. 4. Review of the facility's policy titled Oxygen Administration, dated 4/2015, included but was not limited to the following: POLICY To deliver low flow oxygen rates and concentration, per the physician's order PROCEDURE Set the oxygen liter flow to the prescribed liters flow per minute. Resident #85 was admitted to the facility in March 2021 with diagnoses including obesity and chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe). Record review indicated a current Physician's Order (dated 11/2021) for the following: -Continuous Positive Airway Pressure (CPAP) applied per MD orders at bedtime and off in the morning. -There was no current physician's order to administer oxygen On 11/08/21 at 8:06 A.M., the surveyor entered Resident #85's room, and observed oxygen tubing on the floor and not in use by the Resident. The surveyor observed the date written on the piece of tape was 9/19. During an interview on 11/8/21 at 8:06 A.M., Resident #85 told the surveyor that the oxygen was not in use because he/she only uses the oxygen during the night. The surveyor then asked Resident #85 where his CPAP machine was located. Resident #85 told the surveyor that when he was transferred from the Mayflower Unit to the Hopkins Unit, none of his/her belongings were sent with him/her, which included the CPAP machine. Resident #85 then told the surveyor that he/she is better with the oxygen and would rather use the oxygen than the CPAP machine. On 11/10/21 at 11:20 A.M., the CPAP machine still had not been delivered to Resident #85. The surveyor observed Resident #85 residing on the Hopkins Unit on 11/4/21 through 11/10/21 and during this time, Resident #85 did not have the CPAP machine and it was not in use as per the physician's order. During an interview on 11/10/21 at 11:43 A.M., the DON said the CPAP machine was not brought with the Resident when he was transferred resulting in the CPAP machine not being administered as per the physician's orders and Resident #85 did not have a current physician's order for the administration of oxygen.

Based on interview, record review, and policy review, the facility failed to ensure for four Residents (#47, #70, #118, and #139), out of a total sample of 30 residents, that the medication regimen of these Residents were free from potentially unnecessary psychotropic medications. Specifically, for Residents #47, #70, #118, and #139, the facility failed to monitor for both the effectiveness of prescribed psychotropic medications and potential adverse consequences. Findings include: Review of the facility's policy titled Psychotropic medication management guidelines/behavior management guidelines, dated April 2015, indicated the following: 1. Develop behavior plans and medication regimens, when appropriate to optimize the functional abilities of the residents, while monitoring for adverse consequences and improved behaviors. 2. Review behavior monitoring records to ensure targeted behaviors are resident specific and approaches reflect the individual residents' needs. 1. Resident #47 was admitted to the facility in May 2021 with diagnoses including dementia, anxiety, and depression. Review of the current Physician's Orders indicated the Resident had the following psychotropic medications scheduled at least daily: Remeron (an antidepressant), Trazodone (an antidepressant), and Ativan (an anti-anxiety). Review of Resident #47's Care Plans indicated the following: A. Psychotropic medications related to depression and anxiety, with a goal of being free from signs and symptoms of adverse effects of psychotropic drug use. 1A. Interventions include: documentation of mood/behavior issues every shift (see behavior monitoring sheet), monitor for effectiveness of psychotropic drugs, and observe for any signs and symptoms of drug related adverse effects. B. Behavior problem related to diagnosis of dementia, socially inappropriate: yells out vulgar sayings and interrupting others, with a goal of the Resident will have fewer episodes of being socially disruptive. 1B. Interventions include: anticipate care needs, identify stressors that contribute to the behavior, redirect when appropriate, intervene as needed to protect the rights and safety of others: approach in a calm manner; divert attention, remove from the situation or take to another location as needed. Review of the medical record indicated behavior monitoring sheets for the month of November 2021 were blank, further review lacked any documentation regarding monitoring for potential signs of adverse consequences of his/her prescribed psychotropic medications. During an interview on 11/09/21 at 2:43 P.M., Nurse #2 said the current behavior sheets for Resident #47 were incomplete and had no behaviors to monitor on them. She said nurses are to complete the sheets each shift and there is no other documentation that is done, unless a note is written. The surveyor and Nurse #2 reviewed the medical record and she confirmed the current orders for the psychotropic medications and the lack of behavior monitoring. She said there is nowhere to document monitoring for signs and symptoms of side effects (adverse consequences) of the psychotropic medications and that is not a process the facility has. 2. Resident #70 was admitted to the facility in February 2020 with diagnoses including manic depression and anxiety. Review of the current Physician's Orders indicated Resident #70 had the following psychotropic medications scheduled at least daily: Seroquel (an antipsychotic), Wellbutrin (an antidepressant), and Ativan (an anti-anxiety). Review of Resident #70's Care Plans indicated the following: A. Psychotropic drugs related to mood disorder and depression with a goal of will be free from signs and symptoms of adverse effects of psychotropic drug use. A1. Interventions include: document mood and behavior issues every shift (see behavior monitoring sheets), monitor for effectiveness of psychotropic drugs, and observe for any signs and symptoms of drug related adverse effects. B. Behavior problem related to bipolar disorder, mood disorder, anxiety and depression. Hoards clothing and other items, will throw things in room when upset, refuses labs and medical care, is accusatory. B1. Interventions include: administer and monitor the effectiveness and side effects of medications as ordered, anticipate care needs, address behavior and work to alleviate any underlying cause, explain care in advance. Review of the medical record indicated Resident #70 was being monitored for behaviors on his/her behavior monitoring sheets that included: verbally abusive, weepy/delusional, and anxiety, but only had that documentation completed on the sheet for the night shift and only on 11/1/21 - 11/4/21. Further review lacked any evidence of monitoring for signs and symptoms of side effects for the use of his/her antidepressant and antianxiety medications. During an interview on 11/09/21 at 9:49 A.M., Nurse #2 said the behavior monitoring sheets for Resident #70 were incomplete, and had no explanation for why. She further said there was no place that the nurses monitor or document for signs and symptoms of side effects related to the use of psychotropic drugs. 3. Resident #118 was admitted to the facility in March 2021 with diagnoses including myoclonus (quick, involuntary muscle jerks), schizoaffective disorder, major depressive disorder, and anxiety. Review of the current Physician's Orders indicated the Resident had the following psychotropic medications scheduled at least daily: Klonopin (a sedative), Prozac (an antidepressant), and Risperidone (an antipsychotic). Review of Resident #118's Care Plans indicated the following: A. Psychotropic drugs related to depression and anxiety, with a goal of will be free from signs and symptoms of adverse effects of psychotropic drug use. A1. Interventions include: document mood and behavior issues every shift (see behavior monitoring sheets), monitor for effectiveness of psychotropic drugs, and observe for any signs and symptoms of drug related adverse effects. B. Behavior problem related to diagnosis of total brain injury (TBI). Socially inappropriate, disrobing, screaming, calling staff or others names, often vulgar, sexually inappropriate requests and comments, strikes out towards others, instigates conflict. B1. Interventions include: administer and monitor the effectiveness and side effects of medications as ordered, anticipate care needs, intervene as needed to protect the rights and safety of others: approach in a calm manner; divert attention, remove from the situation or take to another location as needed. Review of the medical record indicated behavior monitoring sheets for the month of November 2021 were blank, further review lacked any documentation regarding monitoring for potential signs of adverse consequences of his/her prescribed psychotropic medications. During an interview on 11/09/21 at 12:51 P.M., Nurse #2 had no explanation as to why the behavior sheets were incomplete and said if they are not filled out the nurses simply did not do them. The surveyor and Nurse #2 reviewed the behavior sheet documentation binder for the unit. Nurse #2 said the sheets were incomplete for all of the residents on the unit. 4. Resident #139 was admitted to the facility in October 2020 with diagnoses including dementia, depression, and anxiety. Review of the current Physician's Orders indicated Resident #139 had the following psychotropic medications scheduled at least daily: Prozac (an antidepressant) and Trazodone (an antidepressant). Review of Resident #139's Care Plans indicated the following: A. Psychotropic drugs related to depression, with a goal of will be free from signs and symptoms of adverse effects of psychotropic drug use. A1. Interventions include: document mood and behavior issues every shift (see behavior monitoring sheets), monitor for effectiveness of psychotropic drugs, and observe for any signs and symptoms of drug related adverse effects. B. Behavior problem related to diagnosis of dementia with behavioral disturbance, depression. Verbally abusive, yells out at staff and others, will swear and curse, throws linen on the floor. B1. Interventions include: administer and monitor the effectiveness and side effects of medications as ordered, anticipate care needs, explain care to Resident in advance. Review of the medical record indicated behavior monitoring sheets for the month of November 2021 were blank, further review lacked any documentation regarding monitoring for potential signs of adverse consequences of Resident #139's prescribed psychotropic medications. During an interview on 11/10/21 at 12:02 P.M., Nurse #1 said the night nurse on the night of monthly change over is suppose to set up all the behavior sheets and put them in the unit behavior sheet monitoring binder. The surveyor and Nurse #1 reviewed the binder and the numerous blank monitoring sheets. Nurse #1 said the behaviors are not being monitored. The surveyor and Nurse #1 discussed where the nurses document the monitoring for signs and symptoms of potential side effects for psychotropic medication use and she said there is nowhere the nurses document that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide food that was palatable and at a safe and appetizing temperature. Findings include: On 11/5/21 at 10:21 A.M., the surveyor observed Certified Nursing Assistant (CNA) #11 bringing a resident breakfast. The CNA said the resident needed assistance with eating and the staff had just noticed the resident had not been given his/her breakfast meal. On 11/5/21 at 12:34 P.M., the surveyor observed the lunch meal truck arrive on the [NAME] unit. There were three staff members observed to be passing the lunch meals and the last meal was provided to a resident at 2:05 P.M., one and a half hours after it arrived on the unit. A test tray was sent on the [NAME] unit meal cart on 11/12/21. The surveyor observed the first meal truck (an enclosed, insulated cart) arrive on the [NAME] unit at 12:33 P.M. The second meal cart (an open cart, holding six meal trays) arrived on the unit at 12:37 P.M. At 12:46 P.M., the surveyor observed the CNAs adding utensils to the meal trays on the meal carts and pouring resident drinks. During an interview on 11/12/21 at 12:46 P.M., CNA #5 said the staff on the [NAME] unit were responsible for putting items on the trays including utensils, salt and pepper, butter, creamers and beverages. The first lunch tray was passed at 12:47 P.M., 14 minutes after it arrived on the unit. The surveyor observed two CNAs passing meal trays to 31 residents. The nurse on the medication cart was observed to be distributing medications while the meals were being passed. The last tray was taken from the meal truck at 1:34 P.M., one hour and one minute after it arrived on the unit. A surveyor and the regional Food Service Director obtained temperatures of the food on the test tray. - the chicken parmesan was 105 degrees Fahrenheit (F) and was cool to taste - the pureed chicken parmesan was 90 degrees F and was cool to taste -the broccoli was 90 degrees F and was cold to taste - the pureed mixed vegetable was 100 degrees F and cool to taste -the mashed potatoes were 105 degrees F and tepid to taste During an interview on 11/12/21 at 1:40 P.M., the Regional Food Service Director said passing meal trays to residents should not have taken an hour and the meal truck and meal cart would not be able to hold the temperature of the food for that amount of time. She said the temperatures observed of the test tray were not adequate for meal intake.

Based on interview, review of personnel files and training documentation, the facility failed to ensure three out of five sampled employees were provided with training on dementia management in accordance with State and Federal requirements. Findings include: Review of five employee records failed to include information regarding dementia management training for employees. On 11/16/21 at 4:45 P.M., the Administrator said she was unable to locate documentation regarding dementia management training for Nurse #3, Nurse #7 and Nurse #11.

Based on review of the Facility Assessment, review of in-servicing records, and interview, the facility failed to ensure that nursing staff completed annual competencies with regard to care of the residents with a Tracheostomy (Trach-surgically created artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing) and Intravenous (IV) Therapy annually as per the facility policy and the Facility Assessment. Findings include: Review of the Census and Condition document indicated the facility currently (11/4/21) had three residents with Tracheostomies and two residents receiving IV therapy. Review of the Facility Assessment, dated January 15, 2021, indicated that care provided included but was not limited to: -Medications-Intravenous (peripheral or central line) -Tracheostomy Care Review of a Competency Schedule (revised 3/12/20), given to the surveyor by the Regional Staff Development Coordinator (SDC), and the Clinical Competencies for Tracheostomy Care and IV Therapy indicated competencies are to be done during orientation and annually for the Licensed/Nursing staff for Trach care and IV therapy. Review of In-servicing records indicated the last time annual competencies were completed was June 2020. During an interview on 11/15/21 at 11:01 A.M., the Regional SDC said the expectation is that the nurses would go to receive initial training at the Pharmacy's main office for the initial IV certification course; however these classes are few and far between. The Regional SDC was not able to obtain the initial IV certificates for the nurses. The Regional SDC further said the expectation of the facility is that Trach care and IV care in-services are to be completed annually and upon orientation. During an interview on 11/15/21 at 11:20 A.M., the Regional SDC and the surveyor reviewed the in-servicing records for the Nursing staff and found that the Nursing staff has had no competencies completed since June 2020. The Regional SDC again stated the IV and Trach in-services are to be done annually. The Regional SDC said that because the only in-services that could be located were over a year ago (June 2020) that they probably were not completed as per the facility's policy. During an interview on 11/16/21 at 3:11 P.M., the Administrator reviewed the facility assessment with the surveyor and said the competencies had not been completed as required and documented for the specialty care this year. The Administrator could not provide any competencies after June 2020, and she was aware that it was over the 12 month mark, indicating that the competencies for Trach care and IV therapy had not been done annually as per the Facility Assessment and the facility's policy.

Based on interview and document review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis for a period of one week in September 2021, two weeks in October 2021, and from November 2, 2021, to the time of survey entrance on November 4, 2021. Findings include: During an interview on 11/4/21 at 7:50 A.M., the Administrator said the previous DON left on 10/7/21, but Consulting Staff #3 had served as the interim full-time DON since that time. During an interview on 11/4/21 at 8:45 A.M., Consulting Staff #3 told the surveyors she was not the interim DON as the Administrator had said. She said she was providing clinical support only to the facility and was not asked to put my license on the wall. She further said the previous DON left unexpectedly over the past weekend and the Assistant Director of Nursing Services (ADNS) had been out on maternity leave. She said prior to this there was no DON on/off for approximately two months. On 11/4/21 at 9:18 A.M., during the entrance conference, the Administrator said the previous DON started on 10/18/21, but left on 11/1/21 and the facility had corporate support since that time. She further said the DON prior to that had been there for six weeks and the DON prior to that had been there for two months, but she was not sure of the dates. She said the ADNS was the acting DON right up until she left for maternity leave at the end of September. She said they were not without a full-time DON until 11/1/21. Review of the DON coverage document provided to the surveyor by the Administrator on 11/4/21 at 10:17 A.M. indicated the following: DON #1 - last day worked, 2/24/21 DON #2 - employed 4/21/21- 6/21/21 ADNS - last day worked, 9/7/21 DON #3 - employed 9/13/21-10/4/21 DON #4 - employed 10/18/21-10/29/21 (last day handwritten as 11/1/21) During an interview on 11/4/21 at 10:45 A.M., the surveyor reviewed the document with the Administrator which indicated no full-time DON coverage from 9/8/21-9/12/21, 10/5/21-10/17/21, and 10/30/21 to present. She said there was no full-time DON coverage during the above date ranges and Consulting Staff #3 had not been the interim DON since the ADNS left on 9/7/21.

Based on observation, document review, and interview, the facility failed to ensure the dishmachine operated at required temperatures to ensure all dishes, utensils, and cookware were properly cleaned in order to prevent illness. Findings include: On 11/4/21 at 9:15 A.M., the surveyor observed the dishmachine in use. The following temperatures were observed with Dietary Staff #2: -Wash temperature: 152 degrees Fahrenheit (F) -Rinse: 168 degrees F Review of the October 2021 temperature log for the dishmachine, indicated wash and rinse temperatures which fell below the required temperatures, and that the manager had been notified. Several temperatures had not been logged, but for the ones that had, 19 wash temperatures were below the required 160 degrees, and 40 rinse temperatures were below the required 180 temperature. During an interview on 11/4/21 at 9:15 A.M., Dietary Staff #2 said the dishmachine wash temperature should be 160 degrees F, and the rinse should be 180 degrees F. She further said the rinse is usually between 172 and 180 degrees F. She said she thought the facility was looking into getting a new dishmachine since they had been having problems with the temperatures. She also said the staff was supposed to consistently record the dishmachine temperatures, but they had not. During an observation and interview on 11/4/21 at 9:35 A.M., the Food Service Director (FSD) said there had been issues with the outer thermometers on the dishmachine, so they used a portable thermometer sometimes. The FSD put a portable thermometer through the dishmachine twice. She said the temperature reading on the portable thermometer was 156.6 degrees F after it went through the dishmachine, which would be the rinse temperature. She also said the only way to get the wash temp is via the external thermometer, which was 152 degrees F. She said the wash temperature should be 160 degrees F, but it was not, and the rinse temperature should be 180 degrees, but it was not. She said the dishmachine was not holding the proper temperatures. The FSD said the staff had notified her of the low temperatures, and she passed the information along. She further said, she thought the facility was getting a new dishmachine.

Based on observations and interviews, the facility failed to ensure it was administered in a manner that enables it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: During the recertification survey conducted from 11/4/21 through 11/16/21, the survey team observed concerns with insufficient staff, resulting in residents with weight loss not having weights monitored, residents not having meal intake monitored, residents with tracheostomies not being monitored, residents with pressure areas not being evaluated, and residents not getting out of bed. During an interview on 11/4/21 at 4:30 P.M., the scheduler said there had been a lack of staffing in the facility for at least two months. She said she had been working with one staffing agency. She said she contacted additional agencies this week and last week, but had not contacted them prior. She said when she contacted the agencies they were unable to provide staffing due to lack of payment from the facility ownership to the agencies. She provided a list of 13 staffing agencies that were contacted over the past two weeks, despite a staffing shortage for months. During an interview on 11/12/21 at 11:06 A.M., the scheduler said she had been doing her best to work with facility staff on covering open shifts and felt lack of wages and bonuses contributed to not picking up shifts. She said she had been receiving two staff members from one staffing agency and felt the facility was not provided more due to not paying at a competitive rate. She said the facility had not been able to obtain staffing from other agencies due to non-payment. She said the Administrator was aware of this. During an interview on 11/16/21 at 1:50 P.M., the Administrator said she was aware that staffing agencies were unable to send staff to the facility due to outstanding bills and the facility was not operating at their designated staffing ratios identified in their facility assessment. She said the operating company/ownership handled all accounts payable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility assessment and interview, the facility failed to review and update the assessment, as necessary, to indicate the changes in staff and necessary resources to competently carry out the facility's goals. Finding include: Review of the facility assessment tool, dated January 15, 2021, included but was not limited to the following: - Facility acuity: - Facility does not provide isolation or quarantine for active infectious disease. - Resources needed to provide competent support and care for our resident population every day and during emergencies: - Staffing Plan: A continual process, with ongoing recruitment activities including: advertising, sign on bonus program, nurse aide training, tuition reimbursement. -Nursing: - [NAME] Unit: 0.5 Unit Manager, 1 Nurse (all three shifts), 4 Certified Nursing Assistants (CNAs) (first and second shift), and 1 CNA overnight - Mayflower: 1 Unit Manager, 2 Nurses (all three shifts), 6 CNAs (first and second shift), and 2 CNAs overnight - Hopkins: 0.5 Unit Manager, 1 Nurse (all three shifts), 3 CNAs (first and second shift), and 2 CNAs overnight - [NAME]: 0.5 Unit Manager, 1 Nurse (all three shifts), 5 CNAs (first and second shift), and 2 CNAs overnight - [NAME]: 0.5 Unit Manager, 1 Nurse (all three shifts), 3 CNAs (first and second shift) and 2 CNAs overnight - Staff training education and competencies: -Staff development coordinator has current documentation of training's and competencies for staff. Observations throughout the entirety of the survey by all surveyors indicated the staffing pattern was not followed. During an interview on 11/16/21 at 3:11 P.M., the Administrator reviewed the facility assessment with the surveyor and said the information indicating the facility did not provide quarantine for residents was incorrect and that they should have planned for that when formulating the document. She said the staffing pattern included the floating of other disciplined staff to assist the nursing staffing, but the pattern was wrong and she could not say when the last time the documented required staffing ratios were met for nursing. She further said the competencies had not been completed as required and documented for the specialty care this year and could not provide any competencies after June 2020. She said she was aware that it was over the 12 month mark, but the facility had not had a staff development coordinator consistently. She said she did make sure the facility assessment was completed annually, but they did not use it or otherwise update it when significant changes occurred within the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure that staff implemented infection prevention and control practices and policies. Specifically, the facility (1) Failed to utilize appropriate Personal Protective Equipment (PPE) and perform hand hygiene when entering and exiting the rooms of quarantine residents and when providing high contact care to quarantine residents; (2) Failed to ensure staff knew the COVID-19 status of residents and utilized appropriate infection control precaution signs; (3) Failed to ensure a COVID-19 positive residents maintained quarantined, sanitized communal items utilized by residents who were COVID-19 positive and performed hand hygiene following use of communal items thereby increasing the potential for transmission of COVID-19 within the facility; (4) Failed to ensure that infection control practices were followed as per facility policy/protocols while performing a treatment/dressing change to the Resident's pressure ulcer; and (5) Failed to ensure oxygen tubing that had been observed on the floor was removed and changed. Findings include: 1. During an interview on 11/4/21 at 9:10 A.M., Consultant Staff #3 said the facility follows the more stringent guidance that comes out from either the Centers for Disease Control and Prevention (CDC), Centers for Medicaid and Medicare Services, and Department of Public Health (DPH) guidance for COVID-19 and follows guidance from the epidemiologist that is assigned to their facility. She further said it was a recommendation from the epidemiologist to place all Residents on quarantine. During an interview on 11/4/21 at 9:12 A.M., the Administrator and Consultant Staff #3 said the expectation is that staff wear N95s and face shields/eye protection at all times and full PPE when entering the quarantine rooms. They said the staff are rapid tested (BinaxNOW performed) every day before their shift. The first case of the facility's current outbreak was 10/12/21, and the first positive case of this outbreak was a resident. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus 2019 Pandemic, updated September 10, 2021, indicated healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection, and also patients who have met criteria for 14 day quarantine and should be isolated, that HCP follow recommendations for proper use of personal protective equipment (PPE) including gowns, face masks, eye protection and gloves. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Personal Protective Equipment dated 9/24/21 included but is not limited to the following: HCP who enters the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). For residents requiring transmission-based precautions and placed in quarantine for suspected COVID-19, the CDC recommendation for gown use is to put on a clean isolation gown upon entry into patient room or care area. Change the gown if soiled. Remove and discard the gown into a dedicated waste or linen container before leaving the patient room. Review of the quarantine precaution sign indicated everyone must clean hands when entering and exiting, wear a gown, mask-N95-face mask acceptable if N95 not available., eye protection and gloves. It indicated to keep door closed (when performing an aerosol-generating procedures). LOBBY On 11/9/21 at 8:00 A.M., the surveyor observed a staff member enter the building with a surgical mask in place; the staff member doffed (removed) the mask and attempted to obtain another mask from the box on the reception desk which she discovered was empty. The staff member proceeded to walk around the lobby area without a mask for approximately 7 seconds before exiting the lobby. The staff member obtained another surgical mask, donned (put on) it, and then re-entered the building. The staff member who was at the reception desk did not intervene and either replace the empty box or immediately ask the staff member to leave the area. On 11/10/21 from 6:45 A.M. to 7:50 A.M., the surveyor observed that the Receptionist had donned a surgical mask and never changed into an N95. The facility wants everyone who enters the building to remove their surgical mask and don an N95, unless proceeding directly to the lower level where there are no Resident care areas. Just beyond the double doors in the lobby are the patient care areas, Mayflower North and South. During an interview on 11/10/21 at 10:00 A.M., the Administrator and the Director of Nursing were told of the surveyors' observations of the Receptionist, and they stated that she should have been wearing an N95. MAYFLOWER SOUTH During an observation with interview on 11/4/21 at 9:57 A.M., the surveyor observed the unit to have numerous resident rooms with conflicting signs outside the door, some indicating residents on quarantine and other indicating COVID case in facility in last 14 days. Nurse #1 said the signs are confusing to the staff and the staff wear N-95 masks, and eye protection everywhere and gowns when entering any room with a quarantine sign. On 11/4/21 at 10:21 A.M., the surveyor observed CNA #1 don a gown outside of a resident's room. There were two signs outside the door of the room the first indicated it pertained to the resident in the A bed and said PPE to be used for facility with active COVID-19 cases in the last 14 days. It indicated a gown is to be worn for direct resident care activities. The second sign indicated it pertained to the residents in the B and C beds and indicated quarantine and indicated the PPE to be used included a gown be donned prior to entering the room. The surveyor observed Regional Staff Development Coordinator (SDC) stop CNA #1 from donning the gown and heard her say, You don't need a gown to go in there and give the resident in A bed water, only the residents in beds B and C are quarantined. CNA #1 removed the gown, entered the room, provided the resident in bed A with a cup and left the room performing hand hygiene (HH). During an interview on 11/4/21 at 12:48 A.M., Regional Infection Prevention Nurse (IPN) and Regional SDC were asked about the sign use outside of the residents' rooms and required PPE for rooms with multiple signs. Regional IPN said the expectation is that any staff entering a room with a quarantine sign would don PPE in alignment with quarantine PPE usage which includes a gown upon crossing the threshold of the room. Regional IPN said the signs are confusing for staff. Both the Regional IPN and Regional SDC agreed that if any room had a quarantine sign outside of the door staff should don an N-95, eye protection, gown, and gloves due to having the quarantine resident in the room which makes the whole room a quarantined room. Regional SDC said she redirected CNA #1 incorrectly and CNA #1 should've donned a gown prior to entering the resident room on the Mayflower South Unit. Neither could provide any guidance as to why they implemented this process/procedure but agreed that the quarantine resident makes the whole room quarantine. MAYFLOWER NORTH A. On 11/4/21 at 11:12 A.M., the surveyor observed Nurse #13 enter a quarantine room on the Mayflower North Unit carrying two beverages in Styrofoam cups wearing goggles and a N95 facemask which was not covering her nose. She was not wearing a gown or gloves. She exited the room to get straws then reentered wearing only her goggles and N95 facemask below her nose. An isolation droplet/contact precautions sign was posted directly outside the resident's room indicating full personal protective equipment (PPE) was required upon entering the room consisting of a gown, N95 face mask, gloves, and goggles. During an interview on 11:13 A.M., Nurse #13 said she should have worn full PPE prior to entering the quarantine room but did not. She further said she should have worn her N95 facemask above her nose but did not. On 11/8/21 at 8:05 A.M., the surveyor observed Nurse #5 wearing her goggles on top of her head in the hallway at her medication cart. Nurse #7 arrived at the unit nurses' station without wearing eye protection (goggles or face shield). During an interview on 11/8/21 at 8:05 A.M., Nurse #5 and Nurse #7 said they should have been wearing eye protection on the unit but were not. On 11/15/21 at 7:00 A.M., the surveyor observed Nurse #14 at the nurses' station wearing her personal eyeglasses. She was not wearing eye protection. During an interview on 11/5/21 at 7:00 A.M., Nurse #14 said she was not wearing eye protection because her goggles kept falling off her face every time she bent over. She further said she should have asked for an alternative form of eye protection but did not. B. On 11/15/21 at 8:23 A.M., the surveyor observed a soiled pair of men's underwear and jeans resting on the floor, not bagged, in front of the soiled utility room in the hallway of the Mayflower North Unit. Four staff members walked up and down the hall during breakfast meal service and did not pick up the soiled clothing. During an interview on 11/15/21 at 8:51 A.M., the surveyor observed the Minimum Data Set (MDS) nurse bag the clothing and carry it into the soiled utility room, 28 minutes after it was initially observed by the surveyor and said they should not have been left on the floor in the hallway. C. On 11/15/21 at 2:27 P.M., the surveyor observed a used BinaxNOW swab specimen resting on top of the medical chart tower. The swab was dated 11/14/21. During an interview on 11/15/21 at 2:27, Nurse #15 said it should not have been there. During an interview on 11/15/21 at 3:11 P.M., the DON said the BinaxNOW swab should have been thrown away immediately after use and the soiled resident's laundry should not have been left on the floor in the hallway of the unit. She further said eye protection was required on all units and personal eyeglasses were not an acceptable form of eye protection. [NAME] Unit: On 11/16/21 at 7:00 A.M., the surveyor observed CNA #15 at the [NAME] Unit nurses' station without wearing a facemask or eye protection. He was wearing only his personal eyeglasses. During an interview on 11/16/21 at 7:00 A.M., CNA #15 said a N95 facemask and eye protection was required on the unit, and he should have been wearing them, but was not. During an interview on 11/4/21 at 7:50 A.M., the Administrator said full PPE was required, including an N95 facemask, for all direct care and prior to entering a quarantine room. 2. [NAME] UNIT On 11/4/21 at 8:30 A.M. the surveyors were provided a list of residents who were currently COVID-19 positive, the residents resided on the [NAME] and Hopkins unit. Both units were identified to have COVID-19 residents and COVID-19 recovered residents (COVID-19 positive in the previous three months). A. During an interview on 11/4/21 at 9:31 A.M., Nurse #7, who was assigned to the [NAME] unit, said she did not know which residents on the unit were currently positive for COVID-19 and she did not have a list to indicate which residents currently had COVID-19. She said she had been following the signs on the rooms to determine which residents were on precautions. On 11/4/21 at 9:36 A.M., the surveyor observed conflicting precaution signs posted on rooms 205, 210 and 211. One pink sign indicated there were isolation precautions (droplet/contact) and staff was to wear a gown, an N95 respirator, eye protection and gloves when entering the room and a white sign which indicated general PPE (personal protective equipment) for a facility with COVID-19 cases in the last 14 days and to wear a mask, eye protection and gloves and to wear a gown during high contact care. During an interview on 11/4/21 at 11:09 A.M., Certified Nursing Assistant (CNA) #6 said she did not know which residents on the unit were positive for COVID-19 and did not feel the facility had been following infection control protocols for COVID-19 positive residents. During an interview on 11/4/21 at 12:18 P.M., the Infection Control Preventionist said she had not posted the precaution signs on the resident rooms, and it was the regional Staff Development Coordinator who determined two signs would be used for rooms where one resident was COVID-19 positive and the other was COVID-19 recovered. She said the white sign indicated to staff that they could enter a room with a COVID-19 positive resident to see the resident who was recovered, without donning a gown and gloves. During an interview on 11/5/21 at 8:15 A.M., Nurse #10 said she did not know which residents on the unit were COVID-19 positive and she did not have a list. B. On 11/4/21 at 9:20 A.M., the surveyor approached the room of Resident #9 which had a white transmission precaution sign, indicating there had been COVID-19 positive residents in the facility within 14 days and to wear a gown and gloves while providing direct care. The surveyor entered the room of Resident #9 wearing only an N95 mask and a face shield (no gown or gloves), following the directions on the precaution sign posted on the room. During an interview on 11/4/21 at 9:24 A.M., Resident #9 asked if the surveyor knew he/she was on quarantine related to COVID-19. The surveyor checked the COVID-19 positive list provided by the Infection Control Preventionist, identified the Resident was COVID-19 positive and left the resident room. On 11/4/21 at 9:28 A.M., the surveyor observed CNA #10 enter the room of Resident #9 wearing only an N95 mask and eye protection. During an interview on 11/4/21 at 9:30 A.M., CNA #9 said she did not know if Resident #9 was currently COVID-19 positive and was following the precaution signs on the resident rooms. During an interview on 11/4/21 at 10:58 A.M., Nurse #7 said she had obtained a list of residents on the unit who were COVID-19 positive. At 11:00 A.M. the surveyor observed the general PPE precaution sign still posted on the room of Resident #9, there was no isolation precaution sign to notify staff to don full PPE prior to entering the room. 3A. Resident #102 was on the list of COVID-19 positive residents. On 11/4/21 at 11:34 A.M., the surveyor observed Resident #102 walk out of his/her room at the end of the hall, walk all the way down the hall, say hello to Nurse #7 and enter the unit day room. Resident #102 was observed to enter the unit kitchenette and get ice from the ice cooler and use the communal ice scoop to add ice to his/her personal re-usable cup. Neither the nurse nor the CNA at the nurses' station intervened regarding the Resident being out of his/her room or using communal items. On 11/4/21 at 4:50 P.M., the surveyor observed Rehabilitation Staff #2 exit the room of Resident #102 with a therapeutic band and inflated balloon. The staff was observed to place both items on the nurses' station desk. During an interview, at this time, the rehabilitation staff member said she had not cleaned the items after using the items with a COVID-19 positive resident, then inquired if she was supposed to. On 11/5/21 at 10:26 A.M., the surveyor observed Resident #102 come down the hallway from his/her room. The Resident approached CNA #5 and requested ice and water. The Resident handed his/her re-usable water bottle to CNA #5. CNA #5 was observed to go to the kitchenette and put ice in the re-usable water bottle with a disposable cup, fill the cup with water and hand it back to the Resident. The CNA was not observed to perform hand hygiene prior to going to another resident room and donning a gown and gloves and entering the room. B. Resident #21 was on the list of COVID-19 positive residents. On 11/5/21 at 9:36 A.M., the surveyor observed Resident #21 seated in front of the nurses' station, wearing an N95 mask and using the nurses' station telephone. The Resident was observed to hang up the telephone and go to his/her room. The surveyor did not observe staff sanitize the telephone following use. On 11/5/21 at 12:12 P.M., the surveyor observed Resident #21 seated in a chair near the nurses' station. The Resident was provided a drink with a straw and starts drinking it in the hallway. On 11/05/21 at 12:47 P.M., the surveyor observed Resident #21 seated in front of the nurses' station, wearing a surgical mask and using the nurses' station telephone. The Resident was observed to hang up the telephone and the phone rang. Nurse #7 was observed to answer the phone, without sanitizing it. When she hung up the phone, she approached the medication cart and picked up a thermometer. The nurse was not observed to use hand sanitizer after handling the telephone which had been used by a Resident #21 (positive for COVID-19) and prior to touching a thermometer. 4. Review of the policy titled: clean dressing change, dated: 7/2017 indicated the following: -establish a clean field -gather supplies and place on clean field -remove old dressing, remove gloves, and sanitize hands prior to applying clean gloves On 11/16/21 at 2:02 P.M., the surveyor, with the Resident #29's permission, observed Nurse #11 perform a wound dressing change. Nurse #11 donned her gown and brought the treatment cart of supplies into the Resident's room and parked it at the end of the Resident's bed. The nurse then donned clean gloves removed the old dressing from Resident #29 and then donned a second pair of gloves over the first pair; she did not change her gloves or perform HH in between steps as required. She proceeded to open the treatment cart with her contaminated gloved hands opening the third drawer and retrieving the dressing supplies she needed. She then used clean scissors to cut the primary dressing to the required size for the wound, doff both pairs of her dirty gloves, perform HH and donned a clean pair of gloves. She cleansed the area, doffed her gloves, performed HH and donned a new pair of gloves then applied the primary and secondary dressing to the Resident's wound. She gathered her trash and placed it in a garbage bag, doffed her gloves, performed HH. During an interview on 11/16/21 at 2:08 P.M., immediately following the observation, Nurse #11 said she always brings the treatment cart into the room because if she forgets something she doesn't want to have to doff her gown because it is too time consuming. She said she did not believe she had breached infection control protocols. During an interview on 11/16/21 at 2:27 P.M., Director of nurses (DON) was made aware of the treatment observations and said the treatment cart should not enter a resident's room and it is a breach of infection control protocol. She said the nurse entering the treatment cart with 2 pairs of dirty gloves on was also a breach of infection control and created a potential issue. She said the expectation is that a clean field be set up separate from a dirty area and the procedure follows the policy and standard for dressing changes. She said Nurse #11 did not complete the dressing change per standard or expectation using good infection control practices. 5. HOPKINS During an interview with observation on 11/08/21 at 8:06 A.M., the surveyor entered Resident #85's room and observed the oxygen tubing on the floor, and not in use by the Resident. The surveyor observed a piece of tape on the oxygen tubing dated 9/19. Resident #85 said that he/she only uses the oxygen at night. On 11/9/21 at 10:15 A.M. and 1:00 P.M., the surveyor observed the oxygen tubing on the floor. During an interview on 11/10/21 at 11:43 A.M., the DON said she also was aware of the oxygen tubing on the floor, and said that this was a breach in infection control.

Based on record review, policy review, and interview, the facility failed to ensure the criteria for the initiation of antibiotics, per the facility's Antibiotic Stewardship Policy and infection control requirements, was followed. Findings include: Review of the facility's policy titled Antibiotic Stewardship, dated July 2017, included but not limited to the following: It is the policy of this facility to treat only symptomatic infections meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. The facility will establish an Antibiotic stewardship team dedicated to improving anatomic use. The core members of the team will include but not be limited to the Medical Director, Pharmacy Consultant, Director of Nurses and Infection Preventionist (IP). Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infections with antibiotic resistive organisms. They also can lead to an increase in the development of antibiotic resistance within the facility and burden of excess cost to the resistant, the facility and community (CDC-Core Elements of Antibiotic Stewardship for Nursing Homes). Record review indicated: COVID-19 Protocol: -Hydroxychloroquine 200 milligrams (mg) by mouth daily for ten days -Azithromycin (antibiotic) 500 mg by mouth daily for ten days -Aspirin 81 mg by mouth daily for ten days The above Protocol was initiated for 57 residents. During an interview on 11/09/21 at 4:55 P.M., the surveyors met with the IP to discuss the infection control policies and practices, which included the Antibiotic Stewardship Program. The IP said that she follows the Antibiotic Stewardship program/policy and that she follows the specific criteria to monitor for appropriate antibiotic use. She further said the Medical Director can, at times, be resistant to the Antibiotic Steward ship protocols. The IP had also brought forward the use of the Azithromycin in regards to starting an antibiotic for a virus to the Medical Director's attention, but the Medical Director started the protocol. During an interview on 11/10/21 at 1:37 P.M. with the surveyors and the Director of Nursing (DON), the Medical Director was asked about the clinical rationale for the initiation of an antibiotic which was included in the above protocol, as it goes against the core principals of the Antibiotic stewardship policy/protocol; and COVID-19 is a virus and antibiotics are not effective in treating a virus. The Medical Director said the problem here is that he believes we are dealing with a ghost (COVID-19), and that it is a man-made virus. The Medical Director said that he uses the same protocol the government used but he had changed it to be administered over 10 days and not the exact protocol the government started. On 11/10/21 at 1:37 P.M., the Medical Director said that he did agree with the surveyor that it is not in line with the Antibiotic Stewardship Policy/protocol and that an antibiotic is not effective in treating a virus. He then said that this is the protocol the government used and that the surveyor would have to ask the government about the protocol. Review of the website FDA.gov indicated the FDA cautions against use of Hydroxychloroquine or Chloroquine for COVID-19 and removed the emergency use authorization on 6/15/20. The FDA also recommends antibiotic therapy for patients who have COVID-19 and develop a bacterial infection such as pneumonia. There was no documented evidence of residents having pneumonia.

Based on observation, interview, and policy/protocol review, the facility failed to ensure staff performed the BinexNOW COVID-19 Ag Card test (rapid testing) correctly. Findings include: The BinexNOW COVID-19 Ag Card is a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes COVID-19 in respiratory specimens, for example nasal swabs. This is considered a form of rapid testing as the results are displayed in 15 minutes. Review of the BinexNOW COVID-19 Ag Product insert (revised August 2020) and the BinexNOW COVID-19 Ag Card (revised August 2020) instructions for completing the test included but was not limited to the following: Precautions: Wear appropriate personal protection equipment (PPE) and gloves when running each test and handling patient specimens. Change gloves between handling of specimens suspected of COVID-19. Nasal Swab: To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage or the nostril that is most congested, if drainage is not visible. Using gentle rotation, push the swab until resistance is met (less than one inch into the nostril). Rotate the swab five times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril. Test procedure Open the test card just prior to use, lay it flat and perform assay as follows. (The test card must be flat when performing testing, do not perform testing with the test card in any other position). Hold extraction Reagent bottle vertically, hovering 1/2 inch above the TOP HOLE, slowly add SIX DROPS to the TOP HOLE of the swab well. DO NOT touch the card with the dropper tip while dispensing reaction. Insert sample into BOTTOM HOLE and firmly push upwards so that the swab tip is visible in the TOP HOLE. Rotate (twirl) swab shaft three times CLOCKWISE (to the right). Do not remove swab. Note: False negative results can occur if the sample swab is not rotated (twirled) prior to closing the card. Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. Read results in the window 15 minutes after closing the card. In order to ensure proper performance, it is important to read the results promptly at 15 minutes, and not before. Results should not be read after 30 minutes. Note: When reading test results, tilt the card to reduce glare on the result window, if necessary. Invalid results are as follows: If no lines are seen; If just the Sample Line is seen; The Blue Control line remains blue. On 11/09/21 at 6:50 A.M., the surveyor entered the facility. There were 12 staff members in the lobby and many were not within six feet of one another. There was no staff member at the reception desk ensuring staff did not enter the facility until they performed the self test. At this time, Physical Plant Assistant (PPA) #1, got off the elevator and entered into the lobby and observed the surveyor in the lobby. PPA #1 told the surveyor that he had not been assigned to the reception desk, however he began to monitor the process. He was asked by the surveyor if there is no one assigned to the desk, who's responsibility is it to ensure staff is performing the testing today and he said no one. The surveyor observed numerous BinexNOW cards on the table in the area that the testing is performed. Review of the facility's process is as follows: -Staff member enters the building -The staff member assigned to the desk ensures that a temperature is taken and the staff sign in -The staff member proceeds to the area where the BinexNOW is performed. -The process on how to perform the BinexNOW is posted on the patrician wall (instructions are in English and Portuguese). -The first line of the procedure indicates to don/put on gloves. -All the supplies are located in the testing area. -The BinexNOW supplies are on one table and the cards are to be placed on a separate table after the process is complete. -The staff member performs the BinexNOW independently. -The staff member places the completed test with their name and the time the test was performed on the other table in the area. -The staff then waits for the results in the lobby (15 minute). On 11/09/21 at 7:35 A.M., the surveyor went to the lobby to observe the process of the staff self swabbing and performing the BinexNOW test. The surveyor observed three staff members as follows: Staff Member #1 performed the self test correctly and sat down to wait for the results. She told the surveyor that she self times and has another person, usually the person who is at the desk, verify the results. Staff Member #2 performed the testing incorrectly, as she did not perform the nasal swab correctly. Staff Member #3 performed all the steps correctly except when it was time to insert the nasal swab into the card, she inserted the Q-tip into the card from the top hole and not the bottom hole and closed the card. She went to sit down to await results. At 7:55 A.M. the Administrator entered the building and the surveyor made her aware of the incorrect BinexNOW test performed by Staff member #3. During an interview on 11/9/21 at 7:55 A.M., Staff Member #1 was still in the lobby and the surveyor asked her how she was in-serviced on the correct procedure. She said that she was at the facility one weekend and asked a nurse on duty who gave her instructions and that she had never been inserviced on the process. During an interview on 11/9/21 at 7:57 A.M., the surveyor then asked the Physical Plant Assistant #1 about the process, who is usually assigned to the desk to oversee the process and he stated he did not know who was supposed to be there today He further stated that he was put at the desk today because no one was scheduled. He said that today he just made sure to take everyone's temperature and that all he did because he is not aware of being responsible for anything further because he usually is not at the desk During an interview on 11/09/21 at 4:55 P.M., the Infection Preventionist (IP) said that the Epidemiologist assigned to the facility had directed them to Binex all staff when they enter the building, prior to the start of their shift due to the outbreak (106 COVID-19 positive residents and 28 COVID-19 positive staff) in the facility. The IP said whoever is sitting at the reception desk is responsible for overseeing the process. The IP further said that there should not be numerous staff in the lobby, which the surveyor indicated to her, was observed this morning. The IP said that once the results are ready, the staff member then shows the Binex card to the person at the desk for verification of the results. The IP was aware that the process was not followed this morning and she had not been made aware that there was no staff available or scheduled at the front desk for oversight of the process. She said that that a second staff member is required to verify the results and typically whoever is overseeing the process at the desk verifies the results. The IP was asked about the 11:00 P.M. to 7:00 A.M. shift and said there is no one assigned to oversee the process on that shift. She said that the 11:00 P.M. to 7:00 A.M. shift staff swab themselves and they should have a nurse present to verify the result but does not have any documentation that the results are verified by someone else. At this time, the surveyors made her aware of the observations made by the surveyors of the staff not following the proper procedure to perform the self testing and that there was a concern with the process. The IP said that the staff have all been trained but staff are obviously not performing the self testing correctly. On 11/10/21 at 6:45 A.M., the surveyor observed the following: Receptionist #1 was at the front desk. She had a surgical mask donned (put on). The surveyor asked what her responsibilities were when she was assigned to the front desk. She said that she takes everyone's temperature, ensures that the screening forms are completed and that staff sign in and records the testing results. Receptionist #1 said that she ensures the staff are distanced from each other and that only six staff members are present in the lobby at one time. On 11/10/21 from 6:45 A.M. - 7:45 A.M., the surveyor observed staff members entering the building and observed the following: Staff Members #1 through #7 performed the self testing incorrectly. Staff Member #8 performed the self testing correctly, performing all the necessary steps. Staff Member #9 through #22 performed the self testing incorrectly. The following is what was observed by the surveyor: -Not all staff donned gloves at the start of the process. -Not all staff performed the nasal swabbing correctly. -Not all staff ensured that the testing card laid flat, some even held the folded test card in their hands while placing the drops in the top hole. -Not adding six drops to the top hole (three to ten drops had been observed being added to the top hole and some staff added the drops to the bottom hole). -Not all staff twisted the nasal swab three times after inserting the swab into the testing card. The surveyor observed 22 staff members performing the BinexNOW self testing from 6:45 A.M. through 7:45 A.M. (one hour) and only 1 out of 22 staff members performed the process correctly. During an interview on 11/10/21 at 10:00 A.M., the Administrator and the Director of Nursing (DON) were made aware of the surveyors observations of the staff performing the BinexNOW testing this morning and that only 1 out of 22 staff members performed the self-testing correctly. The surveyor asked for the in-servicing that the staff had received prior to the initiation of this process. The surveyor also asked what type of mask the Receptionist is supposed to have donned, and they said that the expectation was that she would have on an N95 mask. During an interview on 11/10/21 at 12:00 P.M., the Regional Staff Development Coordinator and the Regional IP said the in-servicing had not been completed, but should have been. This resulted in the facility failing to ensure that all staff performing the BinexNOW COVID-19 Ag Card test (rapid testing) were performing the test correctly.