Based on 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 (#73), out of 29 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed for the use of an anticoagulant medication. Findings include: Review of the facility's policy titled Comprehensive Care Plans and Revisions, dated as revised 9/11/24, indicated but was not limited to: -the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that all comprehensive care plans are reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs Resident #73 was admitted to the facility in November 2020 with diagnoses which included a history of venous thrombosis and embolism (blood clot). Review of the Minimum Data Set (MDS) assessment, dated 10/9/24, indicated Resident #73 had received an anticoagulant medication. Review of Resident #73's Physician's Orders indicated but was not limited to: -Apixaban (anticoagulant) 2.5 milligrams (mg) two times a day, dated 5/9/24 Review of the November 2024, December 2024, and January 2025 Medication Administration Records (MAR) indicated he/she had received Apixaban as ordered. Review of Resident #73's care plan failed to indicate a care plan for the use of anticoagulant medication had been developed. During an interview on 1/7/25 at 12:15 P.M., Nurse #2 said residents on high-risk medications including an anticoagulant should have a care plan for it. During an interview on 1/7/25 at 12:42 P.M., Unit Manager #2 said Resident #73 was on an anticoagulant. Unit Manager #2 reviewed Resident #73's medical record and said there was no care plan for the anticoagulant medication but there should have been. During an interview on 1/7/25 at 1:50 P.M., the Director of Nurses (DON) said any resident on an anticoagulant should have a care plan for the use of the anticoagulant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of practice for two Residents (#5 and #35), out of a sample of 29 residents. Specifically, the facility failed: 1. For Resident #5, to ensure a physician's order was in place for the use of compression stockings for bilateral lower extremity edema, swelling caused due to excess fluid accumulation in the body tissues; and 2. For Resident #35, to ensure a physician's order was in place for the use of an air mattress for pain. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #5 was admitted to the facility in December 2022 with diagnoses which included chronic diastolic heart failure, a cardiovascular condition that can cause swelling in the feet, ankles, or legs. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 12/2/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. During an observation with an interview on 1/7/25 at 9:30 A.M., the surveyor observed Resident #5 wearing white compression stockings that covered both legs. Resident #5 said he/she wears the leg stockings due to leg edema. Resident #5 said he/she wears the stockings during the day and they are removed at night. Review of Resident #5's active care plan indicated but was not limited to the following: -Resident is at increased risk for break in skin integrity due to decreased mobility, bilateral lower extremity edema, and incontinence; revised 11/21/23. Additionally, review of Resident #5's care plan failed to indicate a care plan for the use of compression stockings. Review of Resident #5's Physician's Orders failed to indicate an order for compression stockings. During an interview on 1/7/25 at 10:30 A.M., Nurse #1 said Resident #5 wears compression stockings daily due to edema. Nurse #1 reviewed the Resident's current physician's orders and could not find a treatment order to apply compression stockings to the Resident's legs. Nurse #1 said there should be a physician's order and a care plan for Resident #5's compression stockings. During an interview on 1/7/25 at 10:40 A.M., the Director of Nursing (DON) said if a resident is wearing compression stockings on a daily basis as a treatment, there should be a physician's order for the stockings and the use of the compression stockings should be included in the resident's care plan. The DON said Resident #5 should have a physician's order and care plan pertaining to the use of compression stockings for the Resident's bilateral lower extremity edema. 2. Resident #35 was admitted to the facility in April 2023 with diagnoses which included spinal stenosis, restless leg syndrome, and pain in both shoulders. Review of Resident #35's MDS assessment, dated 10/29/24, indicated but was not limited to the following: -no unhealed pressure ulcers; -no venous and arterial ulcers; -no other ulcers, wounds, and skin problems; -skin and Ulcer treatments included a pressure reducing device for bed; -the Resident had been on a scheduled pain medication regimen; -a pain assessment interview was conducted and the Resident reported frequent pain that frequently affected sleep and a pain intensity rating of 8 (on a 00 to 10 rating scale, with 10 being the highest level). -weight of 150 pounds; -a BIMS score of 15 out of 15, indicating the Resident was cognitively intact. On 1/2/25 at 10:15 A.M., the surveyor observed Resident #35's air mattress set to 250 pounds, normal pressure. During an interview on 1/6/25 at 10:10 A.M., the surveyor observed Resident #35 sitting in a chair near the foot of his/her bed. Resident #35 said he/she has an air mattress for pain. The Resident said staff manages the air mattress setting and the Resident was unsure of what the setting should be. The surveyor observed the air mattress setting to be around 240 pounds, normal pressure. The Resident said the air mattress was okay but he/she preferred it to be firmer. Review of Resident #35's active care plan indicated but was not limited to the following: -At risk for break in skin integrity related to decreased mobility, incontinence and polyneuropathy; -Pressure reducing mattress; -Resident #35 expresses right hip/sciatica pain due to spinal stenosis and decreased mobility; -Educate Resident and family regarding pain management; -Evaluate the effectiveness of pain interventions; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; -Observe and report to nurse Resident complaints of pain or requests for pain treatment; -Pain medications as ordered. Review of Resident #35's current Physician's Orders failed to indicate orders for an air mattress. During an interview on 1/6/25 at 4:30 P.M., Nurse #7 said Resident #35's skin was intact and the Resident used an air mattress to help with pain. Nurse #7 could not find a physician's order for an air mattress. During an interview on 1/6/25 at 4:35 P.M., Unit Manager #3 said if Resident #35 used an air mattress for pain, there should be an order and a care plan to reflect that. During an interview on 1/7/25 at 1:50 P.M., the DON said if Resident #35 has an air mattress as a treatment for pain, there should be a physician's order and the air mattress should be included in the Resident's care plan for pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, for one Resident (#14), out of five residents with pressure ulcers investigated and 29 total sampled residents, the facility failed to ensure Resident #14 received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent infection. Specifically, the facility failed to ensure the pressure ulcer was assessed by the Wound team as soon as it was identified, resulting in a delay in treatment, and to conduct daily assessments of the Resident's wound to monitor changes in the wound status between 5/21/24 and 5/30/24. Findings include: Review of the facility's policy titled Documentation and Assessment of Wounds, dated as revised 8/23/21, indicated but was not limited to: -A wound assessment/documentation is required to occur at a minimum 'weekly'. Nurses performing the treatment would perform an as needed assessment/documentation if noted change has occurred i.e., wound has healed/resolved, appears infected, or appears to have declined. Review of the facility's policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, dated as revised 7/9/24, indicated but was not limited to: -a skin assessment/inspection should be performed weekly by a licensed nurse. Any changes or open areas are reported to the Nurse. Nurse will complete further inspection/assessment and provide treatment if needed. -measures to maintain and improve the residents' tissue tolerance to pressure are implemented in the plan of care -when skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident Review of the facility's policy titled Incident and Reportable Event Management, dated as revised 8/15/23, indicated but was not limited to: -Event Management includes but is not limited to, the following types of events: Pressure Ulcer/Injury (in house acquired) greater than stage 1 -To help reduce the risk of an event, all residents receive assistance and supervision as addressed in their care plan. If an event occurs, the facility will follow the 5 I's in an effort to minimize the potential for recurrence. 1. Incident (what happened or was reported as happening) 2. Injury (provide care and document the injury) 3. Interview (who saw the resident last or at the time of the event) 4. Investigate (why did it happen) 5. Intervention (what mitigation effort are we using) Resident #14 was admitted to the facility in November 2022 with diagnoses which included dementia and paraplegia (paralysis of the legs and lower body). Review of the Minimum Data Set (MDS) assessment, dated 12/4/24, indicated Resident #14 had a facility acquired pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence). Review of Resident #14's care plans indicated he/she had a pressure ulcer to coccyx (base of the spine, near the top of the buttocks), initiated on 5/30/24. Review of Resident #14's Weekly Skin Integrity Data Collection Tool, dated 5/15/24, indicated his/her skin was intact. Review of Resident #14's Progress Note, dated 5/21/24, completed by Nurse #3, indicated an open area was noted on his/her coccyx and measured approximately 1.05 centimeters (cm) x 1.01 cm with no drainage. Further review of the progress note indicated there was a new order for normal saline wash followed by triad (a zinc-oxide based sterile coating designed to manage low to moderate levels of drainage, while promoting a moist wound healing environment) to the area. During a telephonic interview on 1/7/25 at 1:17 P.M., Nurse #3 said when a wound is discovered a risk assessment should be initiated, the provider should be notified and new orders should be obtained. Nurse #3 said the facility wound team should be notified when a wound is identified and the wound should be assessed by the wound team as soon as possible. Nurse #3 said Resident #14 had a wound on his/her coccyx but did not recall if she was the one who discovered it or not. Review of Resident #14's Weekly Skin Integrity Data Collection (his/her weekly skin inspection), dated 5/22/24, completed by Nurse #4, failed to indicate any alterations in his/her skin integrity. During a telephonic interview on 1/7/25 at 2:19 P.M., Nurse #4 said a weekly head to toe assessment was completed weekly and any skin abnormalities should be documented. Nurse #4 said the facility wound team should be notified of any new findings. Nurse #4 said when skin status changed, the provider should be made aware and if a wound was not improving it should be documented. Nurse #4 said she did not remember Resident #14's skin status in May 2024. During an interview on 1/7/25 at 3:52 P.M., the Director of Nurses (DON) said when impaired skin integrity is noted the wound should be observed by the wound team as soon as possible and then weekly, on Tuesdays, during wound rounds. Review of the medical record failed to indicate the Wound team assessed Resident #14's new open area on his/her coccyx identified on 5/21/24 prior to or during wound rounds on Tuesday (5/28/24). Review of Resident #14's Weekly Skin Integrity Data collection, dated 5/29/24, completed by Nurse #5, failed to indicate any alterations in his/her skin integrity. During a telephonic interview on 1/7/25 at 2:23 P.M., Nurse #5 said weekly head to toe assessments were completed and if impaired skin was observed the wound team should be notified. Nurse #5 said she did not recall Resident #14's skin status in May 2024. Review of Resident #14's Skin/Wound Note, dated 5/30/24, completed by Nurse #8, indicated during care the Resident was noted to have a wound over his/her coccyx with no drainage. The surrounding skin was reddened with irritation and the wound bed was tacky with dark discoloration. The Resident denied pain or discomfort, the provider was made aware and new orders were obtained. Review of the Wound Observation Tool, dated 5/30/24, completed by the Assistant Director of Nurses (ADON)/Wound Champion, indicated but was not limited to: -Location: Coccyx -Type: Pressure -Stage: Unstageable -Specify: Slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture)/Eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) -Visible Tissue: Overall Impression: first observation, no reference -Visible Tissue: Slough tissue present (yellow, tan, white, stringy) in 50% of the wound bed -Drainage: Small amount of serous (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) drainage -Wound measurements: length 2.5 cm, width 3 cm, depth 0.1 cm -Additional comments: patient noted with open wound to coccyx, wound bed contains slough to center, edges slightly rolled and with minor maceration (the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture) -Treatment Plan: Santyl and Silvercel (a nonadherent dressing used to help manage wound fluid and protect from infection) Review of Resident #14's May 2024 Treatment Administration Record (TAR) indicated but was not limited to: -Triad to coccyx every shift, dated 3/13/24 -Normal saline wash to coccyx followed by triad daily in the evening, initiated 5/21/24 and discontinued 5/30/24 -Treatment to coccyx: Normal saline wash, apply Santyl ointment to base, cover with Silvercel dressing as secondary dressing (cut small piece to fit wound bed) then apply foam dressing, every evening shift, dated 5/30/24 Review of Resident #14's medical record failed to include evidence that the wound worsened between 5/21/24 and 5/29/24. During an interview on 1/7/25 at 12:42 P.M., Unit Manager #2 said Resident #14 had a facility acquired wound in his/her coccyx and was followed by the facility wound team and the wound clinic. Unit Manager #2 said when a wound was discovered the wound team should be notified and an assessment should be completed. Unit Manager #2 and the surveyor reviewed the medical record and Unit Manager #2 said the wound was discovered on 5/21/24 and there was no further documentation of the wound status until 5/30/24. During an interview on 1/7/25 at 12:53 P.M., the ADON/ Wound Champion said Resident #14 had a facility acquired wound on his/her coccyx. The Wound Champion said she was notified of the wound on 5/30/24 and completed both the risk assessment and wound observation tool on that date. The Wound Champion and the surveyor reviewed the medical record, and the Wound Champion said she was not aware that the wound was first identified on 5/21/24 and no risk assessment or wound observation tool had been initiated at that time. The Wound Champion said the expectation was for the wound team to see a new wound as soon as possible. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to: -He/she was sent to the hospital for concern of worsening infection due to abnormal labs and admitted due to an infected sacral ulcer -CT scan of the abdomen and pelvic showed a sacral decubitus with associated gas, without concern for osteomyelitis or abscess formation. -He/she was started on multiple antibiotics and an infectious disease consult was initiated -He/she required surgical intervention for debridement, and he/she underwent I&D for debridement on 6/19/24 which resulted in copious amounts of dark purulent fluid draining from his/her necrotic ulcer. -Wound measurements, post debridement, were 7 cm, x 3.5 cm x 2.5 cm with undermining all around with 2 cm at 2 o'clock, wound bed was 75% yellow/necrotic tissue an 25% red/moist, mild odor, moderate yellow serosanguinous (type of wound discharge that consists of a mix of clear and blood-tinged fluid. It is common after surgery or during wound healing, and may appear as a thin, pale red or pink fluid) drainage.

Based on observation, record review, and staff interview, the facility failed to ensure that appropriate care and services were implemented to prevent the development of urinary tract infections (UTI) for one Resident (#58), of a total sample of 29 residents. Findings include: Review of the facility's policy titled Indwelling Urinary Catheter (Foley) Management issued 4/1/22 and Reviewed 9/10/24, indicated but was not limited to the following: Policy: The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed; -Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. General Urinary Catheter Maintenance Guidelines 2. -Maintain unobstructed urine flow b. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident #58 was admitted in September 2024 with diagnoses which included a history of UTIs and a chronic urinary catheter. Record review indicated that the Resident had been started on Augmentin (antibiotic), every 12 hours x 7 days for a urinary tract infection (UTI) on 1/3/25. The Resident had a past medical history of UTIs. On 1/3/25 at 8:34 A.M., the surveyor observed Resident #58 lying in bed with her/his eyes closed. The Resident's continuous drainage bag from the Foley catheter was observed to be attached to the bed frame and resting directly on the floor without being placed in a privacy bag. During an interview on 1/7/25 at 11:17 A.M., Unit Manager (UM) #2 said that the Resident's continuous drainage bag from the urinary catheter should not be resting on the floor and should always be contained in a privacy bag. UM #2 said that there is a risk for contamination and the policy is to make sure the catheter bag is always positioned so it does not touch the floor to reduce the risk of infection. During an interview on 1/7/25 at 3:48 P.M., the Director of Nurses said that the Resident's catheter bag should not have been resting on the floor.

Based on interview and record review, the facility failed to act upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#14), out of a total sample of 29 residents. Specifically, the facility failed to act on the Consultant Pharmacist's recommendation to consider an antidepressant medication dose reduction. Findings include: Review of the facility's policy titled Medication Regimen Review, dated as revised 8/17/23, indicated but was not limited to: -Facility should encourage Physician/Prescriber or other Responsible Parties receiving MRR and the Director of Nursing to act upon the recommendations contained in the MRR -For those issues that require Physician/Prescriber intervention, facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR and provide an explanation as to why the recommendation was rejected -The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it -If the attending physician has decided to make no changes in the medication, the attending physician should document the rationale in the residents' health record -The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident either 30 or 60 days per applicable regulation Resident #14 was admitted to the facility in November 2022 with diagnoses which included dementia and depression. Review of Resident #14's medical record indicated he/she was seen by the Consultant Pharmacist in August 2024 and recommendations were made. The surveyor was unable to locate the August 2024 Consultant Pharmacist's recommendation in Resident #14's record. After inquiry, the facility provided Resident #14's August 2024 Consultant Pharmacist's Consultation Report. The document indicated but was not limited to: -Resident #14 was receiving two antidepressants for depression, Trazodone (antidepressant) 150 milligrams (mg) every hour of sleep and Venlafaxine Hydrochloride (antidepressant) 75 mg daily and they were due for a dose reduction -The pharmacist recommended the physician consider reducing Trazodone to 125 mg every hour of sleep or Venlafaxine to 50 mg daily -The physician response section was blank Further review of the September through December 2024 MRRs failed to indicate the pharmacist followed up and readdressed the GDR recommended in the August 2024 MRR. During an interview on 1/7/25 at 12:42 P.M., Unit Manager #2 said the process was for the Consultant Pharmacist's Consultation Reports to be provided to the provider for review. Unit Manager #2 said once the physician reviews the recommendation, and provides a response, any new orders are implemented. Unit Manager #2 said the complete Consultation Report forms are filed in the medical record and with the Director of Nurses (DON). During an interview on 1/7/25 at 10:31 A.M., the DON said she had reviewed Resident #14's medical record and the August 2024 Consultant Pharmacist's Consultation Report had not been addressed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, 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 items were properly dated and stored in the main kitchen and kitchenettes; and 2. Ensure two of three ice machines were maintained in a clean and sanitary condition. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's policy titled Food Safety, revised 4/26/23, indicated but was not limited to: Policy: Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Federal Regulation: 483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Review of the facility's policy titled Safe Food Handling, revised 4/26/23, indicated but was not limited to: Policy: All food purchased, stored, and distributed is handled with accepted food-handling practices, and per federal, state and local requirements. Procedure: -Snacks and other food items sent from the food service department will be handled safely in regard to temperature, labeling and storage. Review of the facility's Use by Date Guide, revised 3/18/20, indicated but was not limited to: -The following guide can be used to determine a use by date when labeling opened or unopened food that must be used within a certain time frame. -Please note that this information is used when there are no guidelines on the containers of food. -In some cases, {Facility} may require a shorter timeframe on a food item to reduce the number of items under refrigeration. For example, the food code indicates that leftovers may be kept up to 7 days, however, {Facility} guidelines are for 3 days (72 hours). -All opened containers of food in the dry storage area should be placed in an enclosed container, labeled, and dated with the open date and the use by date. Any unopened cans/packs should be marked with the date received. After opening, then the above guideline is followed regarding opened containers of food. On 1/2/25 at 8:10 A.M., the surveyor observed the following during the initial kitchen tour in the main kitchen: -one bag of sliced pepperoni re-packaged in a freezer bag, no date; -one bag of mozzarella cheese, opened, no date; -one bag of breadsticks, out of original box, no date; -one bag of French fries, out of original box, no date; -one container of cottage cheese about ¼ full, no date; -sliced cheese in plastic wrap, no date. On 1/2/25 at 11:21 A.M., the surveyor observed the following in the [NAME] Unit Kitchenette: -one bottle of vegetable juice, opened, no date; -two containers of prune juice, opened, no date; -20 nutritional shakes, thawed, no thaw date with manufacturer label stating use within 14 days of thawing. On 1/7/25 at 8:06 A.M., the surveyor observed the following in the [NAME] Kitchenette: -two containers of thickened water, opened, no date with manufacturer label stating After opening, may be kept up to 7 days under refrigeration; -two cartons of milk, opened, no date; -20 nutritional shakes, thawed, no thaw date with manufacturer label stating use within 14 days of thawing; -one carton prune juice, opened, no date. During an interview on 1/7/25 at 8:25 A.M., Dietary Staff #1 said they typically stocked and maintained the Unit Kitchenettes. Dietary Staff #1 said they were responsible for the refrigerator, freezer, cabinets, and microwave. Dietary Staff #1 and the surveyor observed the [NAME] Kitchenette together. Dietary Staff #1 said the nutritional shakes are not dated and could not confirm if any of the nutritional shakes in the Unit refrigerator were past the use within 14 days of thawing per manufacturer's instructions. During an interview on 1/7/25 at 8:30 A.M., the Food Service Director (FSD) and the surveyor observed the [NAME] Kitchenette. The FSD said any opened food or drink items stored in the unit kitchenettes should be labeled and dated with the date it was opened. The FSD said dietary staff maintained the Kitchenettes daily which included monitoring the labeling and dating of food and beverage items when they stocked the Kitchenettes. Dietary Staff #1 had already left the Kitchenette. The FSD and surveyor observed the refrigerator which still contained undated, opened containers of thickened water, milk, prune juice, and 20 thawed nutritional shakes. The FSD said all of the items should have a date when they were opened and the nutritional shakes should be labeled with a thaw date to ensure they are used within the 14 days stated by the manufacturer. On 1/7/25 at 9:06 A.M., the surveyor observed the following in the main kitchen: -one opened bag of cake mix, no date; -prune juice and thickened dairy, both opened with no date; -one container cottage cheese, opened and dated 12/19. During an interview on 1/7/25 at 9:06 A.M., the FSD said the cottage cheese was received on 12/19/24 and opened sometime that week. The FSD said any food or drink item that is opened should be labeled and dated with the date it was opened. On 1/7/25 at 10:10 A.M., the surveyor observed the following in the [NAME] Unit Kitchenette: -Lactaid milk, opened, no date with manufacturer label stating use within 14 days of opening; -12 nutritional shakes, thawed, no thaw date with manufacturer label stating use within 14 days of thawing. During an interview on 1/7/25 at 1:46 P.M., the Administrator said she expected the facility to comply with federal and state regulations when storing food, which included labeling and dating opened food/beverages and labeling and dating any undated items that are removed from the packaging. 2. Review of the facility's policy titled Preventative Maintenance - Ice Machines, revised 1/11/23, indicated but was not limited to: Policy: It is policy that all ice machines in the facility will be inspected by the in-house maintenance department on a monthly basis and the coils will be cleaned every quarter. Procedure: Monthly -Any problems will be reported to the maintenance department via a work order; -The maintenance department or outside vendor will inspect each ice machine monthly; -All areas will be checked for cleanliness. Quarterly -All quarterly procedures will be completed by maintenance or outside vendor. On 1/2/25 at 11:21 A.M., the surveyor observed the [NAME] Unit ice machine with yellow and black residue on areas of the interior machine adjacent to where the ice was stored. On 1/7/25 at 8:06 A.M., the surveyor observed the [NAME] Unit ice machine with yellow and black residue on areas of the interior machine where ice was made. Specifically, there was a thick layer of yellow and black residue at the top of the evaporator plate, a metal piece that produces ice by freezing the water that streams down the plate. Additionally, there was milder yellow residue on other parts of the condenser plate. The surveyor observed water running over the residue, freezing, and forming ice. On 1/7/25 at 8:06 A.M., the surveyor observed Nurse #6 in the [NAME] Kitchenette scooping ice from the ice machine into a water pitcher. Nurse #6 said she was preparing water for medication pass. Nurse #6 and the surveyor observed the ice machine's interior. Nurse #6 said the ice machine looked as if it needed cleaning and she did not feel comfortable using the ice for medication pass to the residents. During an interview on 1/7/25 at 8:25 A.M., the Director of Maintenance (DOM) said the maintenance department is responsible for monitoring and maintaining the ice machines. The DOM said the ice machine maintenance schedule is produced by the facility's TELS system, a building management platform. The DOM said the maintenance included checking and cleaning the interior of the ice machine. Additionally, the DOM said the ice machines are cleaned every three months by a vendor. The DOM and the surveyor observed the [NAME] Kitchenette ice machine and the DOM said the machine needed to be cleaned. On 1/7/25 at 10:10 A.M., the surveyor observed the [NAME] Unit ice machine with yellow and black residue on the same areas of the interior machine adjacent to where the ice was stored. The DOM said he also observed the residue inside of the ice machine. Review of the TELS Logbook indicated maintenance of the ice machines on [NAME] and Life Care Plus units were performed on 12/6/24 and 9/6/24, which included: sanitize interior of ice machine per manufacturer's instructions and clean out and sanitize the ice bin. The Logbook indicated maintenance on 12/6/24 was marked done on time by the DOM. The Logbook indicated maintenance on 9/6/24 was marked done on time by the Administrator. During an interview on 1/7/25 at 1:46 P.M., the Administrator said she would expect the ice machines to be maintained and function in a clean and sanitary condition at all times.

B. Resident #88 was admitted to the facility in December 2024 with diagnoses including chronic obstructive pulmonary disease (COPD- a disease caused by damage to the lungs), chronic respiratory failure, and dependence on supplemental oxygen. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/12/24, indicated the Resident was cognitively intact, as evidenced by a BIMS score of 15 out of 15. Further review of the MDS assessment indicated the Resident received oxygen therapy. Review of Resident #88's Physician's Orders indicated but was not limited to the following: -Change oxygen tubing and nebulizer circuit every night shift every Sunday (12/15/24) -Oxygen at 2 liters/minute (l/min) continuously per nasal cannula. Document every shift (12/10/24) Review of the January 2025 Treatment Administration Record (TAR) indicated the Resident's oxygen tubing was due to be changed on the night shift on 1/5/25. The treatment was signed by Nurse #8 and a chart code of 6 was entered, indicating Absent from facility with meds. Review of the Resident's record indicated the Resident was not out of the facility on the night shift on 1/5/25. On 1/6/25 at 8:59 A.M., the surveyor observed Resident #88 utilizing Oxygen at 2 l/min via nasal cannula. The oxygen tubing was dated 12/30. On 1/7/25 at 7:14 A.M., the surveyor observed Resident #88 utilizing Oxygen at 2 l/min via nasal cannula. The oxygen tubing was dated 12/30. During an interview on 1/7/25 at 8:58 A.M., Unit Manager #1 said oxygen tubing should be changed on admission, every Sunday night, and as needed. Unit Manager #1 said Resident #88's tubing should have been changed on the night shift 1/5/25, but the Resident uses longer extension tubing that may not have been available on the unit during that time. During an interview on 1/7/25 at 9:19 A.M., the DON said Resident #88's oxygen tubing should have been changed on the night shift on Sunday 1/5/25 as scheduled. The DON said if the extension tubing was not available at that time, the nurse should have notified someone on the next shift for it to be changed. During an interview on 1/7/25 at 4:33 P.M., Nurse #8 said he prepared new tubing for Resident #88 on 1/5/25 and left the new tubing hanging in a respiratory bag in the Resident's room ready for use. 3. Review of facility's policy titled Transmission-Based Precautions and Isolation Procedures, revised 9/24/24, indicated but was not limited to: Policy: The facility will implement and utilize transmission-based precautions to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. Categories of Transmission-based Precautions: -Contact Precautions are intended to prevent transmission of pathogens that are spread by direct (such as person-to-person) or indirect contact with the resident or environment, and require the use of appropriate personal protective equipment (PPE), including a gown and gloves before or upon entering (such as before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. Procedure: -This facility will utilize the following Lippincott procedures: Contact Precautions Procedure Review of Lippincott Nursing Procedures- 9th edition, dated 2023, section titled Contact Precautions, indicated but was not limited to: -Equipment: gowns, gloves, plastic bags, contact precaution signs; -Perform hand hygiene; -Put on a gown and gloves before entering the patient's room to comply with contact precautions; -Handle all items that have come in contact with the patient as you would for a patient on standard precautions; -Remove and discard your gown and gloves before leaving the room; -Perform hand hygiene before leaving the patient's room. Review of Resident #143's MDS assessment, dated 11/14/24, indicated the Resident had enterocolitis due to Clostridium difficile (C. diff), not specified as recurrent. Review of Resident #143's current Physician's Orders included but were not limited to: -12/31/24, Dificid (an antibiotic) oral tablet 200 milligrams (mg), give 1 tablet by mouth two times a day for C. diff until 1/10/25; -12/31/24, Contact plus precautions for C. diff, every shift. Review of Resident #143's active care plan included, but was not limited to: -The Resident has C. Difficile infection, dated 1/2/25; -Contact plus precautions, dated 1/2/25. On 1/2/25 at 10:30 A.M., the surveyor observed a Contact Precautions sign hung outside of Resident #143's door. The surveyor observed CNA #1 enter the Resident's room and don (put on) gloves without using hand sanitizer or washing hands with soap and water. CNA #1 did not don a gown. CNA #1 wheeled the Resident into their bathroom. The surveyor did not observe CNA #1 exiting the Resident's room. On 1/2/25 at 10:46 A.M., the surveyor observed CNA #1 enter Resident #143's room without sanitizing or washing hands with soap and water. CNA #1 donned gloves and entered the Resident's bathroom. CNA #1 was not wearing a gown. CNA #1 was observed without gloves or a gown when she exited the bathroom with the Resident and wheeled the Resident to their bed. The surveyor did not see any gowns discarded in the Resident's bathroom trash can. During an interview on 1/2/25 at 11:45 A.M., CNA #1 said she did not notice the Contact Precautions sign outside of Resident #143's room. During an interview on 1/7/25 at 10:15 A.M., Unit Manager (UM) #3 said staff caring for residents with C. diff should be gowned and gloved and should wash their hands with soap and water when entering and exiting the resident's room. UM #3 said CNA #1 should have donned a gown and gloves and practiced appropriate hand hygiene upon entering and exiting Resident #143's room. During an interview on 1/7/25 at 1:50 P.M., the DON said staff should utilize the appropriate PPE stated on Precaution signs. The DON said CNA #1 should have donned gloves and a gown and should have cleaned her hands before and after entering the room. 2. Review of the facility's policy titled Hand Hygiene for Residents, Families and Visitors, dated as reviewed on 6/3/24 indicated the following: -the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections -hand hygiene refers to a general term that applies to hand washing, antiseptic handwash, and alcohol-based hand rub -avoid touching eyes, nose or mouth with unwashed hands -the facility should assist either physically or through reminders to residents to perform hand hygiene after toileting and before meals Resident #78 was admitted to the facility in January 2021 with a diagnosis of dementia. Review of the MDS assessment, dated 12/10/24, indicated Resident #78 scored 3 out of 15 on the BIMS, indicating a severe cognitive impairment. Review of the care plans for Resident #78 included a Focus for behaviors including but not limited to the potential to smear feces. Interventions included but were not limited to the following: two staff members when possible related to accusatory behavior, administering medications as ordered, anticipating the needs of the Resident, discuss behaviors and reinforce why not appropriate/acceptable, offer tasks to divert attention, praise progress/improvement in behavior, provide a program of activities of interest. On 1/2/25 at 9:40 A.M., the surveyor observed Resident #78 in bed with a strong smell of feces in the room. The surveyor observed Resident #78 with feces on, around, and underneath the fingernails, on tips of fingers, on the Styrofoam cup and a crumpled tissue on the bedside table. During an interview on 1/2/25 at 9:45 A.M., the surveyor informed Unit Manager #3 of Resident #78 having feces on their hands. The Unit Manager said Resident #78 had a behavior of touching his/her feces. On 1/2/25 at 9:50 A.M., the surveyor observed a Certified Nursing Assistant (CNA) go into the room of Resident #78 to provide care. On 1/2/25 at 11:30 A.M., the surveyor observed Resident #78 in bed. The Resident continued to have feces all around the fingernail bed and under the fingernail on multiple fingers; the fingertips were stained an orange/brown color. Resident #78 was observed to use the side of their index finger to rub their right eye. The surveyor observed the same Styrofoam cup with feces on it on the bedside table. On 1/2/25 at 12:45 P.M., the surveyor observed Resident #78 to continue to have feces on his/her hands and to be eating a tuna sandwich. On 1/3/25 at 8:15 A.M., the surveyor observed Resident #78 in bed having breakfast. The fingertips were cleaned and no longer had the orange/brown stain, the nail beds were cleaned and there were no longer feces around the nail beds. There continued to be feces under the fingernails on a couple of fingers. On 1/3/25 at 12:28 P.M., the surveyor observed the Staff Development Coordinator (SDC) setting up lunch for Resident #78 and assisting him/her with eating. The Resident's nails continued to look the same from four hours prior. At 12:39 P.M., the SDC provided the Resident with a clothing protector while the Resident fed him/herself a grilled cheese sandwich. During an interview on 1/3/25 at 12:44 P.M., the SDC said the process was for staff to use hand sanitizer wipes to clean residents' hands prior to eating. She said she had not cleaned Resident #78's hands because she had started off feeding the Resident. During an interview on 1/3/25 at 12:46 P.M., Nurse #1 said Resident #78 had behaviors which included disrobing and playing with feces with no particular frequency. During an interview on 1/3/25 at 12:48 P.M., CNA #1 said she had provided care to Resident #78 the day before when the Resident had a bowel movement. She said she was cleaning the hands of Resident #78 when the Resident pulled them away. She said the Resident can be resistant to having his/her nails cleaned and that she had done the best she could to get the feces off the nails. During an interview on 1/3/25 at 12:52 P.M., Unit Manager #3 said the process was for staff to clean the hands of residents with hand sanitizer wipes. On 1/7/25 at 8:01 A.M., the surveyor observed Resident #78 in bed with dried feces around the fingernail beds and under the fingernails. On 1/7/25 at 8:15 A.M., the surveyor observed Resident #78 in bed self-feeding a biscuit with his/her hand. During an interview with observation on 1/7/25 at 8:16 A.M., Unit Manager #3 said one hand on the Resident looked cleaner than the other and that there were feces on the nails. She said she knew the staff had worked on the Resident's fingernails over the weekend and the CNA had cleaned the Resident's hands prior to getting breakfast but there were still feces on the nails. Based on record review, observation, and staff interview, the facility failed to ensure that for four Residents (#28, #88, #78, and #143), of a total sample of 29 residents, infection control measures were implemented in order to prevent the potential development and spread of disease. Specifically, the facility failed: 1. For Residents #28 and #88, to ensure respiratory equipment was maintained in a clean and sanitary manner to decrease the risk of potential contamination and infection; 2. For Resident #78, to remove feces from hands prior to providing meals; and 3. For Resident #143, to ensure Contact Precaution measures were followed in a manner to prevent the potential spread of infection for a Resident with non-recurrent Clostridium difficile, a germ that causes diarrhea and colitis (an inflammation of the colon) and can be life-threatening. Findings include: 1. Review of the Policy titled Oxygen Administration, issued on 12/3/18 and revised on 10/1/24, included but was not limited to the following: Policy: -To assure that oxygen is administered and stored safely within the healthcare centers or in and outside storage area. Infection Control: -Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set up or changed out -Store oxygen and respiratory supplies in bag labeled with resident's name name when not in use. A. Resident #28 was admitted in December 2020 with diagnoses which included chronic obstructive pulmonary disease (COPD-chronic lung disorders resulting in blocked air flow in the lungs), chronic respiratory failure with hypoxia, and Alzheimer's dementia. Review of the most recent Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicated the Resident had moderate cognitive impairment. Review of the current Physician's Order indicated: -Oxygen at 2 liters as needed, administer via an oxygen concentrator and nasal cannula. On 1/2/25 at 9:20 A.M., the surveyor observed Resident #28 seated in a wheelchair in his/her room. An oxygen concentrator was observed against the wall adjacent to the left upper side of the bed. The oxygen was not in use, however the the nasal cannula oxygen tubing was observed lying on the floor under the bed and not contained in a bag to protect it from environmental contaminants. The Resident utilized oxygen via the nasal cannula, as needed (PRN), and removed and replaced the nasal cannula adlib, without staff assistance or supervision. On 1/3/25 at 8:16 A.M., the surveyor observed Resident #28's oxygen tubing hanging on the left bed rail and was not contained in a bag to protect it from environmental contaminants. The oxygen tubing was dated 1/2/25. On 1/3/25 at 8:57 A.M., the surveyor observed Resident #28 lying in bed with the nasal cannula oxygen tubing that had been observed on the floor on 1/2/25 and hanging on the bed rail on 1/3/25 in the Resident's nose. On 1/3/25 at 11:54 A.M., the surveyor observed Resident #28's nasal cannula oxygen tubing lying on the floor at the left side of the Resident's bed. During an interview on 1/7/25 at 11:17 A.M., Unit Manager (UM) #2 said that the Resident's oxygen tubing should not be on the floor or hanging on the side rail. UM #2 said that the oxygen tubing should always be stored in a bag when not in use to prevent it from being contaminated and to prevent infection. During an interview on 1/7/25 at 3:54 P.M., the Director of Nursing (DON) said that the Resident's oxygen nasal cannula should not have been on the floor or hanging on the side rail. The DON said that respiratory equipment, such as nasal cannula oxygen tubing, should be stored in a bag when not in use, in order to maintain cleanliness and prevent contamination/infection. She said that due to the Resident's decreased cognition, he/she would not be capable of maintaining the respiratory equipment in a clean and safe manner to prevent contamination and/or the spread of infection.

2. Resident #64 was readmitted to the facility in November 2023 with diagnoses including bacteremia (bacteria in the blood), acute cystitis (infection in any part of the urinary system, the kidneys, bladder, or urethra) and had an indwelling urinary catheter device (inserted into the bladder to drain urine). On 11/7/23 at 9:43 A.M. and 10:27 A.M., the surveyor observed Resident #64 in bed with the privacy curtain open. His/her Foley catheter drainage bag (collects urine) was hanging from the side of the bed draining yellow urine. The drainage bag was fully exposed and not placed in a privacy bag to conceal it from public view. On 11/7/23 at 10:29 A.M., Nurse #1 entered the room with the surveyor, looked at the drainage bag, and said it was draining then left the room. Nurse #1 did not place the drainage bag in a privacy bag or pull the privacy curtain closed. During an interview on 11/9/23 at 3:02 P.M., UM #2 said the catheter bag should have been placed in a privacy bag. On 11/13/23 at 7:15 A.M., the surveyor observed Resident #64 in bed with the privacy curtain partially closed. His/her Foley catheter drainage bag was hanging from the side of the bed draining yellow urine. The drainage bag was in a privacy bag, however, the privacy bag only partially covered the catheter bag and did not fully conceal it from public view. During an interview on 11/13/23 at 2:18 P.M., Nurse #1 said Resident #64's Foley catheter bag should have been placed in a privacy bag. During an interview on 11/13/23 at 4:58 P.M., the Director of Nursing said Foley catheters should have dignity covers on them. Based on observation, record review, and staff interview, the facility failed to ensure that for two sampled Residents (#41 and #64) with indwelling urinary catheters, out of a total sample of 28 residents, that the Residents' dignity was maintained. Specifically, the facility failed: 1. For Resident #41, to consistently place the Resident's urinary catheter continuous drainage (CD) bag in a privacy bag. 2. For Resident #64, to ensure that the Resident's CD bag was consistently placed in a privacy bag. Findings include: 1. Record review on 11/07/23 at 2:35 P.M. indicated that Resident #41 had a #20 suprapubic tube (catheter to drain urine from the bladder) with a 30 cc (cubic centimeter) balloon. On 11/7/23 at 9:15 A.M., the surveyor observed Resident #41's CD bag to be completely full of dark, amber-colored urine. The CD bag was attached to the lower, right frame of the bed. The CD bag was not contained in a privacy bag to conceal it from the view of others and afford the Resident privacy. On 11/7/23 at 2:40 P.M., the surveyor observed Resident #41's CD bag to be 1/3 full and draining dark yellow urine. The CD bag was not contained in a privacy bag to conceal it from the view of others. On 11/9/23 at 8:24 A.M., the surveyor observed Resident #41 lying in bed in their room with the door open. The Resident's CD bag was hanging from the right side of the bed frame and visible from the doorway. The CD bag was draining dark yellow to amber-colored urine. The CD bag was not inside the blue privacy bag that was hanging next to it. On 11/10/23 at 10:00 A.M., the surveyor observed Resident #41 lying in bed. The CD bag was attached to the bed frame and was not enclosed in a privacy bag. During an interview on 11/10/23 at 10:15 A.M., Unit Manager (UM) #3 said that it is the facility practice that a Resident's CD bag should always be in a privacy bag to maintain the Resident's dignity.

Based on record review, policy review, and staff interview, the facility failed to ensure the resident representative was fully informed in advance and given information necessary to make health care decisions on behalf of the resident for one Resident (#34) out of a total sample of 28. Findings include: Review of the facility's policy titled Psychotropic Medication Informed Consent, dated as revised 10/4/22, indicated but was not limited to the following: -The facility will obtain consent or refusal to the use of Psychotropic Medications. This documentation will reflect that the intended or actual benefit is understood by the resident and, if appropriate, his/her family and/or representative(s) and is sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication, dose and duration. -Staff should inform the resident and/or resident representative of the initiation, indication for use, and the benefits/risks associated with the use of psychotropic medications. -The medication should not be started until after approved by resident and, if appropriate, representative. 1. Resident #34 was admitted to the facility in October 2023 with diagnoses including: congestive heart failure, hypertension (high blood pressure), and non-Alzheimer's dementia. Review of the most recent Brief Interview for Mental Status (BIMS) indicated Resident #34 had severe cognitive impairment with a score 5 out of 15. Review of the medical record indicated Resident #34's Health Care Proxy was invoked in August 2023 giving his/her agent authority to make all health care decisions on Resident #34's behalf. Review of Resident #34's current Physician's Orders indicated but was not limited to: - Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 8 hours as needed for anxiety, dated 10/19/23 Review of the medical record failed to indicate informed consent had been obtained for the use of the Lorazepam. Review of the Medication Administration Record (MAR) for October and November 2023 indicated Resident #34 was administered the Lorazepam three times. During an interview on 11/9/23 at 4:47 P.M., Unit Manager #1 reviewed the medical record and could not locate an informed consent form for the Lorazepam. Unit Manager #1 said she could not find any evidence that informed consent was obtained for the use of Lorazepam from the Health Care Proxy. She said it is the expectation that informed consent be obtained prior to administering any psychotropic medication. During an interview on 11/10/23 at 10:15 A.M., the Director of Nursing and Consulting Staff #1 said they are aware of the missing Lorazepam informed consent, and it was not in place as it should have been.

Based on observation, record review, policy review, and interview, the facility failed to develop and implement a baseline care plan within forty-eight hours of admission that included instructions necessary to provide individualized care, for two Residents (#513 and #461) that use oxygen, out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Baseline Care Plan, dated as revised August 2023, indicated but was not limited to the following: - A baseline care plan will be developed for every resident within 48 hours of admission - The baseline care plan will provide an initial set of instructions needed to provide effective and person-centered care that meets professional standards of care - The baseline care plan must include the minimum healthcare information necessary to properly care for a resident - A comprehensive care plan may be developed in place of the baseline care plan if developed within 48 hours of the resident's admission. 1. Resident #513 was admitted to the facility in October 2023 with diagnoses which included chronic respiratory failure with hypoxia (not enough oxygen in tissues to sustain bodily functions), oxygen dependent, and sleep apnea. Review of the most recent Brief Interview for Mental Status (BIMS) indicated Resident #513 had severe cognitive impairment with a score of 5 out of 15. Review of the current Physician's Orders, dated October 2023, for Resident #513 indicated but was not limited to the following: - Continuous Oxygen 1-3 Liters delivered by nasal cannula (device used to deliver supplemental oxygen) - Monitor oxygen saturations (percent of oxygen in your blood) every shift - Monitor lung sounds every shift Review of the baseline care plan failed to indicate any interventions or care strategies necessary for the delivery and maintenance of oxygen therapy. During an interview on 11/10/23 at 8:37 A.M., Unit Manager (UM) #1 reviewed the record for Resident #513 and said there is no care plan in place for the management of the resident's oxygen therapy. She said the Resident should have had one created upon admission and did not. 2. Resident #461 was admitted to the facility in November 2023 with diagnoses including: Metabolic encephalopathy and chronic atrial fibrillation (an irregular heartbeat). Review of the admission nursing assessment indicated Resident #461 was alert and oriented. During an interview on 11/7/23 at 8:32 A.M., Resident #461 said he/she was new to using Oxygen since being in the hospital prior to arriving at the facility. Review of the baseline and current care plans for Resident #461 failed to indicate the Resident used Oxygen. During an interview on 11/8/23 at 4:51 P.M., UM #1 said the Resident is new to Oxygen use and will self-remove it at times. She said the nurses are monitoring oxygen saturations and lung sounds. During an interview on 11/9/23 at 7:43 A.M., Nurse #5 said the Resident self-removes his/her Oxygen frequently and feels he/she doesn't need it, she said the Resident requires close monitoring because of this. During an interview with observation on 11/9/23 at 7:46 A.M., the surveyor observed Resident #461 lying flat in bed, without his/her Oxygen in place, holding the tubing in his/her right hand. The Resident said they take the Oxygen off when they feel they don't need it because it is new to him/her and they do not want to end up having to use it long term. During an interview on 11/10/23 at 8:16 A.M., Nurse #9 said baseline care plans are created off of the hospital discharge summary, admission assessment and needs of the Resident. She said since Oxygen is new to the Resident, a baseline care plan should be in place, as the Resident would have a respiratory risk by having a new oxygen need. During an interview on 11/10/23 at 8:37 A.M., UM #1 said a baseline care plan should be created for new admissions for anything specific to their needs and diagnosis. She said Resident #461 frequently removed his/her oxygen placing him/her at an increased risk. She said there should have been a baseline care plan for Resident #461 that should have reflected the Resident's individual needs, but it was missed, and one was not in place until after the surveyor inquired.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#139), out of a total sample of 28 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to consistently implement orders from the physician to apply Geri sleeves (provides protection to skin on the arms) to the Resident's bilateral upper extremities. Findings include: Resident #139 was readmitted to the facility in April 2023 and had diagnoses including cerebral infarction, aphasia (language disorder that affects a person's ability to communicate) and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment, dated 10/10/23, indicated Resident #139 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of current Physician's Orders indicated the following: -Geri sleeves at all times bilateral upper extremities every day shift for protection, may remove for care, 6/4/23 -Eliquis (anticoagulant, can cause bleeding and bruising) Oral Tablet 5 milligrams (gm), give 1 tablet via G-tube two times a day for clot prevention, 2/7/23 Review of the skin impairment care plan, initiated 6/4/23, indicated the following: Focus: -The resident has impairment to skin integrity of the right upper/outer forearm (discoloration) related to anticoagulant therapy and arm-rest placement Interventions: -Geri sleeves bilaterally, padded arm rests, 6/4/23 On 11/9/23 at 7:24 A.M., the surveyor observed Resident #139 lying in bed. The Resident did not have bilateral upper extremity Geri sleeves applied per physician's order to help prevent impairment to skin integrity and none were observed in the room by the surveyor. No staff were present providing care to the Resident and no family members were present. During an interview on 11/9/23 at 1:57 P.M., Resident Representative (RR) #1 said the Resident was supposed to be wearing the Geri sleeves because he/she is always scratching. On 11/13/23 at 7:17 A.M., the surveyor observed Resident #139 lying in bed. The Resident did not have bilateral upper extremity Geri sleeves applied per physician's order to help prevent impairment to skin integrity and none were observed in the room by the surveyor. No staff were present providing care to the Resident and no family members were present. The surveyor observed Resident #139 scratching with his/her right hand. A piece of gauze and paper tape was observed on the Resident's right upper forearm. Resident #139 said he/she didn't know why it was there and was unable to answer if he/she had had blood drawn or if there was a wound. During an interview on 11/13/23 at 7:20 A.M., Nurse #2 said the Resident was supposed to be wearing the Geri sleeves unless care was being provided to him/her and would get them for him/her. During an interview on 11/13/23 at 1:08 P.M., Certified Nursing Assistant (CNA) #3 said she was assigned to the Resident that day and wasn't sure whether the Resident had Geri sleeves on that morning or not or if he/she was even supposed to have them on. CNA #3 said she thought they stopped putting them on him/her because the Resident kept taking them off. During an interview on 11/13/23 at 1:10 P.M., Unit Manager (UM) #2 said the physician's order was for the Resident to wear the Geri sleeves at all times because he/she picks at his/her skin. UM #2 said the Resident should have been wearing them. During an interview on 11/13/23 at 4:24 P.M., the Director of Nursing (DON) said Resident #139 should have been wearing his/her Geri sleeves at all times to protect his/her fragile skin on his/her arms. The DON said he/she does scratch, has gotten skin tears, and takes aspirin.

Based on observation, interview, and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#139) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medications), out of 28 sampled residents. Specifically, the facility failed to: a. ensure staff labeled the enteral formula container and water flush bag with the Resident's name, date and time hung, the administration rate, duration, and initials of the staff member hanging them. b. ensure staff programmed the Resident's enteral feeding pump (device used to deliver nutrition to patients who cannot consume food and drink by swallowing) properly with the ordered frequency of water flushes (used to maintain patency and provide hydration) causing the Resident to not receive approximately 675 milliliters (ml) of water flushes in a 20- hour period (2pm-10am) between 11/12/23 and 11/13/23; and Findings include: Review of Lippincott procedures, eight edition (2019), titled Tube Feedings, indicated but was not limited to the following: -Verify the practitioner's order, including the patient's identifiers; enteral feeding device; prescribed enteral formula; administration method, volume, and rate; and type, volume, and frequency of water flushes. -Make sure the enteral formula container is labeled with the patient's identifiers; formula name; date and time or formula preparation; date and time the formula was hung; administration route; rate of administration; administration duration (if cycled or intermittent); initials of who prepared, hung, and checked the formula against the order; expiration date and time. -Label the enteral administration set with the date and time that it was first hung. -Flush the enteral feeding tube with at least 30 milliliters (ml) of water as ordered. -If using an enteral feeding pump, follow the manufacturer's instructions for setting the flow rate and starting the infusion. -If you're administering a continuous feeding, flush the enteral feeding tube every 4 hours with at least 30 ml of water, as ordered and tolerated, to maintain patency and provide hydration. Complications: -GI and other systemic problems -Constipation from inadequate hydration -Fluid and electrolyte imbalances Resident #139 was readmitted to the facility in April 2023 and had diagnoses including cerebral vascular accident (CVA), dysphagia (difficulty swallowing), and gastrostomy status. Review of the Minimum Data Set (MDS) assessment, dated 10/10/23, indicated Resident #139 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15 and had a feeding tube. Review of Physician's Orders indicated the following: -Enteral feed order, every 6 hours pump to provide 225 ml of water every 6 hours, 9/19/23 -Hold enteral feed from 10am-2pm one time a day (off 10am-2pm), 2/9/23 -Jevity 1.5, 60 ml/hour x 20 hours enteral feed via G-tube (on 2pm-10am) every shift for feeding order, (off 10am-2pm), document every shift amount consumed in ml, 9/19/23 Review of the G-tube Placement care plan, initiated 2/20/23, indicated the following: Focus: -CVA with dysphasia and nothing by mouth, G-tube placement for nutrition and meds. Interventions: -Observe and report as needed and signs and symptoms of dehydration a. On 11/7/23 at 9:04 A.M., the surveyor observed Resident #139 lying in bed. An enteral formula container and water flush bag were hanging from an intravenous (IV) pole and attached to an enteral feeding pump. The pump was turned off. The enteral formula container and water flush bag were not labeled with the patient's name, date, and time the formula was hung, administration route, rate of administration, administration duration (if cycled or intermittent), initials of who prepared, hung, and checked the formula against the order, and the expiration date and time. Resident Representative (RR) #1 said the Resident had been vomiting that morning so staff turned off the pump. RR #1 said the Resident received nutrition through his/her G-tube only and did not receive oral intake due to a history of stroke. During an interview on 11/7/2 at 9:18 A.M., the surveyor asked Nurse #1 what the flow rate was for the enteral feeding. Nurse #1 said she thought it was 80 ml/hour. Unit Manager (UM) #2 entered the room and said 80 ml/hour was incorrect and she thought it was 65 ml/hour. UM #2 said the feeding container and water flush bag should have been labeled including the flow rate but were not. Nurse #1 said the feeding was placed on hold around 8:00 A.M. that morning after the Resident started vomiting and she was waiting for an x-ray and lab work prior to resuming it per physician's orders. During an interview on 11/7/2 at 12:43 P.M., the surveyor observed the enteral feeding container and administration set no longer hanging. UM #2 said it had been removed while they were awaiting orders from the physician. She said when it was hung it should have been labeled with the Resident's name, date, and flow rate on a sticker or on the container itself. During an interview on 11/13/23 at 12:04 P.M., UM #2 said whenever staff hang a new feeding container or flush bag, they should be labeling them. During an interview on 11/13/23 at 4:24 P.M., the Director of Nursing (DON) said the enteral feeding container should have been labeled with the Resident's name, time hung, date, room number, and initials of who's hanging it. She said the flush bag should be labeled as well and changed every 24 hours. She said if the container gets swapped out for a new one, that should be labeled as well. The DON said the feeding pump should have been set to allow the Resident to receive the flushes every 6 hours when it's running and should have been programmed per physician's orders. She said whatever nurse is working each shift should ensure the settings are correct. b. On 11/13/23 at 7:17 A.M., the surveyor observed Resident #139 lying in bed. His/her enteral feeding container was labeled as hung on 11/13/23 at 1:10 A.M. and was infusing via an enteral feeding pump set at 60 ml/hour. A 1000 ml water flush bag was attached to the administration set and feeding pump. The flush bag was labeled as being hung on 11/12/23 at 2:00 P.M. by Nurse #2 with an infusion rate of 225 ml every six hours. The feeding pump setting for the water flushes was observed programmed at 225 ml every 0 hours, not every six (6) hours per physician's orders. No flush volume was indicated on the pump as having been infused. The 1000 ml water flush bag still had 1000 ml remaining in the bag. The administration set failed to indicate Resident #139 had received approximately 675 ml of water flushes (225 ml every 6 hours) in a 20- hour period from 2:00 P.M. on 11/12/23 to 10:00 A.M. on 11/13/23 to help maintain patency of the G-tube and to provide hydration to the Resident per physician's orders. During an interview on 11/13/23 at 11:46 A.M., Nurse #2 said she was assigned to the Resident that day. She said the Resident received the enteral feedings from 2pm-10am every day, with the feeding turned off from 10am-2pm. Nurse #2 said the Resident was supposed to receive 225 ml of water flushes every 6 hours and said she was the nurse who hung the flush bag the day before on 11/12/23. She said the pump was programmed properly at that time. On 11/13/23 at 11:56 A.M., the surveyor and Nurse #2 entered Resident #139's room and reviewed the programmed settings on the enteral feeding pump. Nurse #2 said the feeding pump was incorrectly set and should have indicated the water flushes were to be administered every 6 hours, not every 0 hours. She said whoever hung the most recent feeding container that morning at 1:10 A.M. should have made sure the pump was programmed properly. Nurse #2 said the flush bag was still full and was the same one she hung the day before. Nurse #2 said Resident #139 did not receive any of the water flushes and would flush his/her G-tube manually at this time. Nurse #2 said she was also responsible to check the pump settings at the beginning of her shift but didn't that day. During an interview on 11/13/23 at 12:04 P.M., Unit Manager (UM) #2 said Nurse #10 was assigned to the previous overnight shift and hung the new feeding container at 1:10 A.M. that morning. She said staff should be making sure the pump is set at the right settings when they hang a new container and should also be checking the settings at the beginning of their shift to ensure they're set per physician's orders. Nurse #10 was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper care and treatment of a midline catheter (long, thin, flexible tube that is inserted into a large vein in the upper arm to administer medication into the bloodstream) device in accordance with professional standards of practice and facility policy/protocol for one Resident (#64), out of a total sample of 28 Residents. Specifically, the facility failed to: a. ensure staff labeled and changed the midline catheter's transparent dressing as needed when visibly soiled; b. ensure staff properly monitored the Resident's upper arm circumference measurement to rule out potential adverse events; and c. ensure staff obtained a baseline insertion external catheter length measurement and properly monitored subsequent measurements to rule out potential migration of the catheter and notify the physician if the length had changed since the last measurement. Findings include: Review of the facility's Skills Checklist: Management of Midlines and Central Venous Access Devices (CVADs), dated 2021, indicated but was not limited to the following: -Dressings will be labeled with nurse's initials, date, and time. -Transparent dressings are changed upon admission 24 hours post insertion, weekly, and as needed. -Upper arm circumference (10 centimeters (cm) above antecubital fossa) and external catheter length is measured, and compared to insertion measurements, on admission, weekly with dressing changes, and whenever question of possible migration. -Seven local/systemic complications and common signs and symptoms include a. Infiltration and extravasation: swelling around intravenous (IV) site, changes in skin temperature around site, pain at site. b. Phlebitis: erythema at access site, pain may or may not be present, red streak along vein, tenderness, warmth, swelling, palpable venous cord. c. Occlusion: unable to infuse, no blood return on aspiration. d. Infection: erythema, edema, induration, warmth and drainage at insertion site, elevated temperature. Resident #64 was readmitted to the facility in November 2023 with diagnoses including bacteremia (bacteria in the blood) acute cystitis (infection in any part of the urinary system, the kidneys, bladder, or urethra) and had an indwelling urinary catheter device (inserted into the bladder to drain urine). During an interview on 11/7/23 at 8:56 A.M., Unit Manager (UM) #2 said Resident #64 was being treated with IV antibiotics via a midline catheter device for a urinary tract infection (UTI) and sepsis (a life-threatening complication of an infection). Review of current Physician's Orders indicated the following: -Observe site before and after administration of intermittent medications and during dressing changes, confirm observation every shift, 11/1/23 -IV: midline catheter - measure circumference upper arm (10 centimeters (cm) above antecubital) as needed with transparent dressing change, 11/1/23 -IV: midline catheter - measure circumference upper arm (10 cm above antecubital) every seven days with transparent dressing change, 11/2/23 -IV: midline catheter site - change transparent dressing as needed with dressing change - measure external catheter length - notify physician if length has changed since last measurement, 11/2/23 -IV: midline catheter site - change transparent dressing every day shift every 7 days, change catheter securement device with dressing change. Measure external catheter length, notify physician if length has changed since last measurement, 11/2/23 a. On 11/7/23 at 10:29 A.M., the surveyor observed the Resident's right upper extremity midline catheter device with Nurse #1 who said Resident #64 was receiving IV antibiotics for a UTI. The transparent dressing was labeled as being last changed on 11/1/23. The dressing was not labeled with the time or the nurse's initials who changed it. The dressing was stained with a moderate amount of dried sanguinous (bloody) fluid obscuring the insertion site. Nurse #1 said she wasn't sure how long the Resident had had the midline as she was not familiar with him/her and wasn't sure what the policy was for changing the dressing if it was new. Review of Skilled/Nursing Progress Notes indicated but was not limited to the following: 11/3/23 (10:34 A.M.) - midline transparent dressing changed on 11/1/23, next change 11/8/23 11/3/23 (2:16 P.M.) - midline right upper extremity, old drainage noted 11/4/23 - old blood at IV insertion site 11/5/23 - old blood at site During an observation with interview on 11/7/23 at 12:39 P.M., the surveyor observed the Resident's midline dressing with Unit Manager (UM) #2. The transparent dressing was labeled with the date 11/1/23. The dressing was not labeled with the time or the nurse's initials who changed it per facility protocol. The dressing was stained with a moderate amount of dried sanguinous fluid obscuring the insertion site. UM #2 said the dressing was changed upon admission on [DATE] but probably should have been changed as needed since then. She said she couldn't visualize the insertion site due to the drainage. Review of the November 2023 Medication Administration Record indicated an initial dressing change was performed on 11/1/23 at 7:53 P.M. then changed on 11/7/23 at 2:26 P.M. by Nurse #1 as evidenced by her initials. During an interview on 11/13/23 at 2:06 P.M., Nurse #1 said the dressing should have been changed as needed if soiled. She said she changed the dressing on 11/7/23 because there was a bloody gauze underneath the transparent dressing, and it obscured the entry site making it difficult to monitor for migration (dislodgement at the entry site) and infection. During an interview on 11/13/23 at 3:02 P.M., UM #2 said the dressing should be changed within 24 hours of admission, then once a week, and as needed if soiled. During an interview on 11/13/23 at 5:33 P.M., the Director of Nursing (DON) said the Resident's midline dressing should be changed as needed because staff need to be able to monitor the site underneath. b. Review of the facility's Midline Catheter Order Sheet and Midline Placement hospital document indicated Resident #64's midline catheter was inserted on 11/1/23. The documents did not indicate a baseline arm circumference measurement for Resident #64. Review of the November 2023 Medication Administration Record (MAR) indicated an admission dressing change was performed on 11/1/23 with an arm circumference measurement documented as being 33 cm. Review of a Nurse Progress note, dated 11/7/23, indicated Nurse #1 changed the midline dressing on 11/7/23 and measured the arm circumference at 29 cm. Review of the November 2023 MAR failed to indicate the arm circumference measurement of 29 cm had been documented, which was four (4) cm different from the previous measurement. During an interview on 11/13/23 at 2:02 P.M., Nurse #1 said she should have documented the Resident's arm circumference measurement on the MAR for comparison but did not. She said she did not look at the previous measurement for comparison and did not know what the baseline measurement was. She said she measured above the insertion line but wasn't sure as to where above the line. During an interview on 11/13/23 at 5:08 P.M., the DON said part of the physician's order was to document the arm circumference on the MAR and, even though Nurse #1's measurement was smaller, Nurse #1 should have still documented her measurement on the MAR. Consulting Staff #1 said the proper way to measure was 10 cm above the antecubital. c. Review of the facility's Midline Catheter Order Sheet indicated a baseline total catheter length of 10 cm with an insertion date of 11/1/23. Review of the order sheet and hospital Midline Placement document did not indicate a baseline measurement for the exposed (external) catheter length for comparison to monitor for potential migration of the catheter. Review of the medical record failed to indicate a baseline external catheter length measurement was obtained until 11/7/23, six days after the Resident was admitted with the midline catheter. Review of a Nurse Progress Note, dated 11/8/23, indicated a clarification by Nurse #1 that the external catheter was 4.5 cm, not 14.5 cm. Review of a Nurse Progress Note, dated 11/9/23, indicated Nurse #2 removed the midline catheter and the total catheter length was 10 cm. Further review of the medical record failed to indicate Physician #1 was notified of the catheter length measurement discrepancies. During an interview on 11/13/23 at 1:59 P.M., Nurse #1 said potential complications with a midline catheter included migration and said she would know if it's migrated by looking at the insertion site and by measuring for any discrepancy. During an interview on 11/13/23 at 2:11 P.M., Nurse #1 said she measured the external length wrong, and it should have been 4.5 cm, not 14.5 cm but did not document that on the MAR. She said she could not recall what the baseline external catheter length measurement was but said potentially it could have migrated. Nurse #1 said she did not have a conversation with the physician regarding the discrepancy. During an interview on 11/13/23 at 2:49 P.M., UM #2 said she did not know where the baseline measurements were for the Resident's midline catheter. She said it was inserted in the hospital, but the information should be in the chart. UM #2 was unable to locate the hospital insertion record in the Resident's medical record and said she would have to ask UM #1. During an interview on 11/13/23 at 2:59 P.M., UM #2 said staff were supposed to measure the external catheter length from the insertion site to the hub to monitor for migration and notify the physician if any deviation in measurement. She said the goal was to monitor appropriately to avoid adverse outcomes. During an interview on 11/13/23 at 3:42 P.M., UM #1 said she helped the admitting nurse complete the facility's Midline Catheter Order Sheet on 11/1/23 and said she was told by the hospital that the baseline total catheter length was 10 cm. She said the exposed external length was not established or documented on the MAR until 11/7/23. UM #1 said the order, if entered correctly, should have prompted a baseline external catheter measurement during the initial dressing change but didn't. UM #1 said when she looked at the dressing, it had a half dollar amount of sanguinous fluid but told the nurse on the unit to not change it if it was inserted the same day. She said she wasn't sure if it was changed the next day or not. UM #1 said she did not get a baseline arm circumference measurement from the hospital, but a nurse documented on the MAR on 11/1/23 that it was 33 cm. She said it was the facility's baseline measurement. During an interview on 11/13/23 at 5:14 P.M., the surveyor reviewed the medical record with Consulting Staff #1 who said the baseline external catheter length was 10 cm but that was the whole catheter length, not the exposed catheter length measurement. She said that's the part that was missing. On 11/13/23 at 5:44 P.M., the Assistant Director of Nursing (ADON) provided the surveyor with the hospital Midline Placement document and said there were no baseline measurements written on it. During an interview on 11/13/23 at 5:23 P.M., Physician #1 said she was not notified of any measurement discrepancies and there were no adverse events associated with the midline that she knew of. She said she understood the surveyor's concern for potential migration, and it could have been how staff were measuring. Physician #1 said staff are to be looking for signs of migration. She further said staff should be changing the midline dressing as needed if actively draining blood to see what is underneath the dried blood to assess the insertion site for erythema, trauma, and swelling.

Based on policy review, record review and interview, the facility failed to ensure psychotropic medications in use by Resident #34 were necessary to treat targeted behaviors or a diagnosis, out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use, dated as revised 10/24/22, indicated but was not limited to the following: -Facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors -Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to use -Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. -All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for Efficacy, risks, benefits, harm or adverse consequences. -Antipsychotic medications used to treat behavioral or psychological symptoms of Dementia must be clinically indicated, and supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause -Facility staff should monitor the resident's behavior using a behavior chart or assessment -Facility staff should monitor behavioral triggers, episodes, and symptoms, and document the number and or intensity of symptoms and resident response to interventions. Resident #34 was admitted to the facility in October 2023 with diagnoses including non-Alzheimer's dementia. Review of the most recent Brief Interview for Mental Status (BIMS) indicated Resident #34 had severe cognitive impairment with a score 5 out of 15. Review of the current Physician's orders, dated 11/9/23, indicated active medication orders for but not limited to: - Seroquel (antipsychotic) 50milligrams (mg) by mouth at bedtime for Dementia Review of the consent form in use by the facility for Seroquel indicated the reason for the medication was to maximize function and reduction of agitated behaviors. Review of the current care plans for Resident #34 failed to indicate any targeted behaviors for the use of the antipsychotic medication. Review of the progress notes dated October 2023 through November 2023 failed to indicate any behaviors for psychotropic medication usage. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate targeted behaviors for psychotropic drug effectiveness. During an interview on 11/9/23 at 2:49 P.M., Nurse #3 said he did not know what behaviors the Resident was receiving the medication for, therefore unable to determine if the medication was effective. During an interview on 11/9/23 at 2:54P.M., Nurse #4 said he is not aware of any targeted behaviors, and there were none indicated for the use of the antipsychotic in the medical record. During an interview on 11/9/23 at 2:56P.M., Unit Manager #1 said the expectation is to have targeted behaviors documented to identify the effectiveness of psychoactive medications and for this Resident they are not. During an interview on 11/10/23 at 8:49 A.M., the Social Worker stated there was no documentation regarding targeted behaviors for the antipsychotic use in the record, therefore, the staff has no way to know if the medication was effective for the behaviors it is supposed to be used for. She said she placed the necessary information in the medical record, after the survey team brought it to her attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that accident hazards were minimized for the residents on the [NAME] Unit, where staff failed to ensure that medications were secure, attended to, and not accessible to residents. Findings include: On 11/9/23 at 3:15 P.M., on the [NAME] Unit, Nurse #8 was observed carrying eight cards of medications she had received from the pharmacy and placed the medications on top of a medication cart that was positioned on the opposite side of the nurses station. Nurse #8 left the medication cards unsecured and unattended. Additionally, a full bottle of Colace tablets was observed on the counter next to where the med cart with the eight cards of medication was positioned. The bottle of Colace was also unsecured and unattended. On 11/9/23 at 3:18 P.M., the surveyor observed Nurse #8 walking away from the medication cart to get something from the nourishment kitchen for a resident. There were no nurses at the nurses' station at that time, and all of the medications remained unsecured and unattended. Nurse #8 was in the nourishment kitchen for 1-2 minutes while a Resident (#71) in a wheelchair was observed wheeling directly past the med cart with the medication resting on top of the med cart. During an interview on 11/9/23 at 3:25 P.M., Nurse #10, who arrived after the medications were left on the medication cart, said that a confused resident could take the medication and be placed at potential harm. During observation on 11/9/23 at 3:28 P.M., the surveyor picked up the unsecured bottle of Colace, handed it to Nurse #10, who placed it in the med cart. During an interview on 11/9/23 at 3:28 P.M., Nurse #10 said that the medication should have been secured in the med cart. Nurse #10 also said that she did not know how the bottle of Colace got left on the counter and that it could be harmful if a resident were to ingest the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were securely stored within locked compartments with only authorized personal having access to the keys, and labeled in accordance with currently accepted professional principles, which included the appropriate cautionary instructions, and expiration date when applicable. Specifically, the facility failed to: 1. Ensure medications were stored under proper temperature controls in two of the two medication storage rooms observed. 2. Ensure staff labeled the open-date on multi-dose vials of biologicals with shortened dates of expiration once accessed, in one of the two medication storage rooms observed. 3. Ensure all drugs were properly contained in packaging with appropriate labeling in three of the four medication carts observed. 4. Ensure all drugs and biologicals remained in locked compartments with only authorized personal having access to the keys, when left unattended on the [NAME] Unit. Findings include: Review of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals, dated as revised [DATE], indicated but was not limited to the following: - Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (vile, bottle, inhaler) when the medication has a shortened expiration date once opened. - If a multi-dose vial of an injectable medication has been opened or assessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. - The facility should ensure that medications and biologicals for each Resident are stored in the containers in which they were originally received. - The facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Review of the facility's policy titled General Dose Preparation and Medication Administration, dated as revised [DATE], indicated but was not limited to the following: - The facility should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.) - If a medication which is not in a protective container is dropped, the facility staff should discard it according to facility policy. Review of the facility's Clinical Nurse Highlight document titled Medication Storage, dated [DATE], indicated but was not limited to the following: - Medication carts are clean, stocked, and organized. - Medications are properly labeled with the patient name, lot number, and expiration date. 1. During an observation on [DATE] at 11:36 A.M., of the Care Plus unit's medication storage room, the following was observed by the surveyor and Unit Manager (UM) #1: - Two unsealed and punctured vials of tuberculin purified protein derivative (Tubersol) (an injectable solution used to test for Tuberculosis) without a storage bag from the pharmacy, were observed in the medication storage refrigerator without a date of initial vial entry written on either the vial or box. - One open and used single patient prefilled Insulin Lispro Injection KwikPen (a medication used to control blood sugar) was observed stored in the medication storage room's refrigerator, next to other unopened vials of the Resident's prescribed insulin. An open date of [DATE] was observed written on the pen. During an interview on [DATE] at 11:43 P.M., UM #1 could not identify when the two vials of tuberculin had first been used. She said the bottles are supposed to be marked when first opened and should not be in the medication refrigerator without a date. She said the two vials of tuberculin required disposal as there was no way of telling how long they had been opened for. UM #1 also said the open Insulin Lispro KwikPen should not have been stored in the refrigerator. She said when the Resident's insulin dose changed, the pen should have remained in the medication cart at room temperature until it had expired or have been placed in the facility's black box for disposal. Review of the manufacturer's instructions for use for the three milliliter (ml) single-patient-use Insulin Lispro Injection KwikPen, dated as revised February 2020, indicated but was not limited to the following: - In-use (opened) Insulin Lispro Injection vials and Insulin Lispro Injection prefilled pens should be stored at room temperature, below 86 degrees Fahrenheit and must be used within 28 days or discarded. Do not refrigerate (open, in-use). Review of the manufacturer's instructions for tuberculin purified protein derivative (Mantoux), (Tubersol), dated [DATE], indicated but was not limited to the following: - A vial of Tubersol which has been entered and in-use for 30 days should be discarded. - Discard opened product after 30 days. 2. During an observation on [DATE] at 12:06 P.M., of the [NAME] unit's medication storage room, the following was observed by the surveyor and UM #3: - One open bottle of Bayshore Ketotifen Fumarate ophthalmic solution 0.025% (an antihistamine, used to treat allergy symptoms occurring in the eye) stored in the medication storage room's refrigerator with an observed refrigerator temperature of 38 degrees Fahrenheit. - One open bottle of [NAME] Brimonidine Tartrate ophthalmic solution 0.2% (a medication used to treat high fluid pressure in the eye) stored in the medication room's refrigerator with an observed refrigerator temperature of 38 degrees Fahrenheit. Review of the manufacturer's drug facts printed on the label for the Ketotifen Fumarate ophthalmic solution 0.025% indicated the medication should be stored at a temperature between 68 to 77 degrees Fahrenheit. Review of the manufacturer's drug facts printed on the label for Brimonidine Tartrate ophthalmic solution 0.2% indicated the medication should be stored at a temperature between 59 to 77 degrees Fahrenheit. During an interview on [DATE] at 12:24 P.M., UM #3 said the observed eye drops stored in the medication storage room's refrigerator should have been stored according to the manufacturer's instructions, not in the refrigerator. 3. During an observation on [DATE] at 12:35 P.M., of the [NAME] unit's hall A medication cart, the following was observed by the surveyor and Nurse #7: - Approximately 24 whole and/or partially crushed tablets of various medications were observed loose within the bottom of the medication cart's second drawer. The tablets were all unidentified, without packaging or labeling. During an interview on [DATE] at 12:40 P.M., Nurse #7 said he did not realize there were loose pills in the medication cart and the overnight nurses were assigned to clean out the carts at night. During an interview on [DATE] at 12:55 P.M., UM #3 said the medication cart should be clean, without any loose medications. 4. During an observation on [DATE] at 1:36 P.M., of the [NAME] unit's A/C hall medication cart, the following was observed by the surveyor and Nurse #2: - Two loose medication tablets and several smaller pieces of crushed pharmaceutical debris were observed in the second drawer of the medication cart. The pills were unidentified, without packaging or labeling. During an interview on [DATE] at 1:45 P.M., Nurse #2 said she was unaware there were loose pills in the medication cart. During an observation on [DATE] at 2:16 P.M., of the [NAME] unit's hall B medication cart, the following was observed by the surveyor and Nurse #8: - One loose tablet of medication was observed in the second drawer of the medication cart without packaging or labeling. During an interview on [DATE] at 2:20 P.M., Nurse #8 identified the pill as likely 5 mg of Eliquis (a medication used to treat and/or prevent blood clots) by its appearance. She did not know which Resident was missing the prescribed tablet of medication. During an interview on [DATE] at 3:41 P.M., the Director of Nursing (DON) said it is the expectation that all medications are appropriately labeled, secured, and stored according to the pharmacy and manufacturer's instructions. She said she expects multi-dose medications to be dated when opened, if needed, and for medication carts to be clean, neat, and organized, and without any medication left out or loose and unlabeled in the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, dated as revised 7/21/22, indicated but was not limited to the following: - The facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. - The facility should ensure that medications and biologicals for each Resident are stored in the containers in which they were originally received. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated as revised 1/1/22, indicated but was not limited to the following: - The facility should ensure that dose preparation areas are well-lit and medication carts are clean and organized. - If a medication which is not in a protective container is dropped, the facility staff should discard it according to facility policy. - After medication administration, the facility staff should take all measures required by facility policy and applicable law, including, but not limited to; clean any reusable equipment or supplies. Review of the facility's Clinical Nurse Highlight document titled Medication Storage, dated March 2022, indicated but was not limited to the following: - Medication carts are clean, stocked, and organized. - Medications should be stored separately according to routes of administration. Further separate routes in medication carts (e.g., oral, injectables, liquids, eyes, ears, nose, inhalers). During an observation on 11/9/23 at 12:35 P.M., of the [NAME] unit's hall A medication cart, the surveyor and Nurse #7 observed the following: - Multiple scattered, loose, medication tablets, thin cardboard punchouts of pill packaging, medication dust, and a thick brown crust of dirt/grime were observed on the bottom surface and along the edges of the medication cart's second drawer. The drawer contained Residents' oral, ophthalmic, and inhaled packaged medications. The brown substance was also observed in ring shaped formations near the drawer's bottles of stored medication. - Drippings of a white opaque substance were observed on a multidose bottle of milk of magnesia and on a side panel of the cart's third drawer. During an interview on 11/9/23 at 12:40 P.M., Nurse #7 said he did not realize there were loose pills in the medication cart and the overnight nurses were assigned to clean out the carts at night. During an interview on 11/9/23 at 12:55 P.M., Unit Manager (UM) #3 said the medication cart drawers should not be dirty or contain any loose medications. During an observation on 11/9/23 at 1:36 P.M., of the [NAME] unit's A/C hall medication cart, the surveyor and Nurse #2 observed the following: - Multiple boxes of boxed eyedrops were stored in pharmacy bags in one small overflowing bin in the medication cart drawer. One pharmacy bag containing three boxes of a Resident's eye drops was ripped with a Quarter sized tear. The same overcrowded bin also contained an opened and punctured multidose vial of injectable insulin glargine and one opened multidose injectable Basaglar Insulin KwikPen (both injectable medications are used to control blood sugar). The insulins were observed mixed in amongst the ophthalmic medications. The multidose vial of insulin glargine was not contained in the manufacturer's boxed packaging and was observed stored and protruding out of, a small plastic pill crushing pouch with the medication stopper unprotected from contamination. - Small crumbles of medication, several strands of hair, a large ring of a dried milky white semi-translucent substance, and darkened circles of buildup of grime, were observed in the right side of the medication cart's second drawer. During an interview on 11/9/23 at 1:45 P.M., Nurse #2 said the eyedrops and insulin were stored in their typical storage location within the cart. During an observation on 11/9/23 at 2:16 P.M., of the [NAME] unit's hall B medication cart, the surveyor and Nurse #8 observed the following: - One multidose bottle of liquid antacid was stored in the medication cart drawer next to two multidose bottles of protein supplements containing thick red liquid. Splattered drops of a thick, red, sticky substance were observed on the antacid bottle, the bottom and side panels of the medication drawer, and in a small, ripped cardboard box containing a single packaged insulin syringe and ten individually packaged lancing needles. There was a large circular area of a dried milky white semi-translucent substance and multiple darkened circles with thick, brown, crusting accumulation of dirt observed in the cart's same drawer. During an interview on 11/9/23 at 2:20 P.M., Nurse #8 said the medication cart was not clean. During an interview on 11/9/23 at 3:41 P.M., the Director of Nursing (DON) said it is the expectation that medication carts are kept in a neat, clean, and organized manner without any loose medications or debris. The DON said the medication carts are professionally cleaned a few times a year but if a cart were to become dirty during a shift, she would expect that the assigned nurse would clean it at that time. She said it is the expectation that medication cart storage areas are checked routinely by Nursing staff for cleanliness, organization, and loose or expired medications. 3. Review of the facility's policy titled Oxygen Administration/Safety/Storage/Maintenance, revised September 2023, indicted but was not limited to the following: -Change oxygen supplies weekly and when visibly soiled. -Clean exterior of concentrators weekly with an EPA registered hospital disinfectant. -External filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed. Dry with a towel and reinsert. Discard and replace when damaged. a. Resident #2 was admitted to the facility in February 2023 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and dependence on supplemental Oxygen. On 11/7/23 at 9:55 A.M., the surveyor observed Resident #2 lying in bed with a nasal cannula (NC) (lightweight tube which one end splits into two prongs which are placed in the nostrils from which a mixture of Oxygen (O2) and air flows) in place attached to an O2 concentrator delivering 2.5 Liters (L) of Oxygen. The exterior of the concentrator was laden with dust and debris. The external filter (sponge like filter that captures dust and other airborne pollutants that can clog the machine and get transferred into the oxygen supply you breathe) was 100% laden with a dusty gray matter. Resident #2 was observed to have a congested cough and said he/she had had it for a while. On 11/9/23 at 8:17 A.M., the surveyor observed Resident #2 lying in bed sleeping with a NC in place attached to an O2 concentrator delivering 2.5 L of Oxygen. The exterior of the concentrator was laden with dust and debris as well as evidence of a dried brown substance. The external filter was 100% laden with a dusty gray matter. Nurse #2 entered the room to observe the findings with the surveyor and said the 11pm-7am shift was responsible for cleaning the filters with soap and water once weekly on Sunday, but nurses were responsible for checking in between and cleaning as needed. Nurse #2 said the exterior concentrator and filter should have been cleaned as needed and didn't know they were like that. During an interview on 11/9/23 at 8:29 A.M., Unit Manager (UM) #2 said nurses should be monitoring in between to ensure both the filter and concentrator are clean. b. Resident #53 was admitted to the facility in October 2023 and had diagnoses including chronic respiratory failure, heart failure, morbid obesity, bacteremia (presence of bacteria in the bloodstream), obstructive sleep apnea (episodes of complete collapse of the airway or partial collapse with a decrease in oxygen saturation or arousal from sleep), and dependence on supplemental O2. On 11/7/23 at 9:31 A.M. and 11/9/23 at 7:29 A.M., the surveyor observed Resident #53 lying in bed sleeping with a NC in place attached to an O2 concentrator delivering 2 L of Oxygen. The exterior of the concentrator was laden with dust and debris. The external filter was 100% laden with a dusty gray matter. On 11/9/23 at 8:19 A.M., the surveyor observed Resident #53 lying in bed with a NC in place attached to an O2 concentrator delivering 2 L of Oxygen. The exterior of the concentrator was laden with dust and debris. The external filter was 100% laden with a dusty gray matter. Nurse #2 entered the room to observe the findings with the surveyor and said the exterior concentrator and filter should have been cleaned as needed and didn't know they were like that. During an interview on 11/9/23 at 8:30 A.M., UM #2 entered the Resident's room with the surveyor to observe the findings and said yes, I see what you mean. She said nurses should be monitoring to ensure both the filter and concentrator are clean and said a clogged filter is concerning as the Resident is receiving Oxygen. She said the equipment needed to be cleaned. During an interview on 11/13/23 at 4:52 P.M., the Director of Nursing said nurses should be checking the Oxygen equipment each shift, including the exterior concentrators and external filters, and clean as needed if visibly soiled.Based on interview, document review, and policy review, the facility failed to maintain an infection control and prevention program to help prevent the potential transmission of a communicable disease. Specifically, the facility failed to: 1. Implement outbreak testing for staff in accordance with their policy, state and national standards when the facility was experiencing an outbreak of COVID-19 infections; 2. Ensure all medication carts were maintained in a clean, sanitary manner, to reduce the risk of contamination of stored medications in three of the four medication carts observed; 3. Ensure for a. Resident #2's Oxygen and b. Resident #53's Oxygen equipment was maintained in a sanitary manner, to help decrease the risk of contamination and infection; and, 4. Ensure for Resident #20, the facility failed to ensure that the Resident's hand held nebulizer was maintained in a clean and sanitary condition. Findings include: 1. Review of the facility policy titled, Coronavirus (COVID-19) (SARS-CoV-2), last revised 6/27/2023, indicated but was not limited to the following: -Massachusetts-the facility should use this guidance in conjunction with the guidance outlined in the COVID-19 policy-Massachusetts addendum. -Facility should follow local and state health department guidelines and state regulations as well as current Centers for Medicare and Medicaid Services (CMS) and Center for Disease Control and Prevention (CDC) guidelines. Review of the facility policy titled, COVID-19 (SARS-CoV-2) HCP (healthcare personnel) testing, last revised 6/21/23, indicated but was not limited to the following: -The policy should plan to test in accordance with the accepted national standards such as the CDC, unless ordered more stringently by local and state health officials. Review of the Department of Public Health (DPH) Memorandum titled, Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 2023, indicated but was not limited to the following: -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. Residents and staff who have recovered from COVID-19 in the last 30 days can be excluded from this testing. During an interview on 11/8/23 at 8:45 A.M., Infection Control (IC) Nurse said the Covid-19 outbreak started 9/25/23 with a dietary aide. She said the facility has not been able to clear seven days with no new cases and remain in outbreak testing. She said currently they are testing staff every other day on the [NAME] and Life Care Plus Unit. If a staff works on the affected unit, they are expected to test every other day while that unit is in outbreak testing. She said if they leave the unit to work on another unit, they are expected to continue to test every other day until they are negative for seven days then they can stop. An audit was performed using the facility weekly testing log crossed referenced with the nursing staff schedules on the [NAME] Unit for time frame 10/21/23 through 10/27/23. During this time frame all staff working on [NAME] Unit were expected to test every 48 hours and the results are as follows: -Twenty-nine staff tested correctly (Two staff members were not required to test due to a positive Covid-19 result in previous 30 days). -Thirteen staff did not test as required every 48 hours. (Three staff members were not on the testing log). An audit was performed using the facility weekly testing log crossed referenced with the nursing staff schedules on the [NAME] Unit for time frame 11/6/23 through 11/9/23. During this time frame all staff working on [NAME] Unit were expected to test every 48 hours and the results are as follows: -Twenty staff tested correctly (Five staff members were not required to test due to a positive Covid-19 result in previous 30 days). -Eighteen staff did not test as required every 48 hours. (Two staff members were not on the testing log). During an interview on 11/9/2023 at 2:00 P.M., The IC Nurse said the staff members test in the room next to her office and there is a list of staff members who are supposed to test. She said the staff know they are supposed to test if they work on an affected unit and they are also told by their managers. She said at the end of the week, she takes the testing log and inputs it into her spread sheet, but she does not reconcile the testing log with who worked and who is required to test. She said it is an honor system and the managers should be reminding staff to test. The IC Nurse said the following is a summary of what unit or department had to test every 48 hours: -Kitchen staff tested 9/24/23 through 10/1/23. -Life Care Plus tested 10/1/23 through 10/16/2023. -Rehab Department tested 10/4/23 through 10/12/2023. -[NAME] Unit 10/7/23 through 10/25/2023. -[NAME] Unit 10/9/23 to the present. -Kitchen staff 10/13/2023 through 10/21/2023. -Life Care Plus Unit 10/25/23 to the present. The IC Nurse continued and said it's harder to get compliance with the testing, the longer the outbreak goes on, the less compliance there is due to testing fatigue with the staff members. She said she can't confirm that everybody that was supposed to test completed their testing, she goes on the honor system and heavily relies on the department managers to have their staff test as they're supposed to. During an interview on 11/10/23 at 1:15 P.M., the Director of Nurses (DON) said it was her expectation that staff test every 48 hours if they are supposed. The surveyor and the DON reviewed the testing logs with numerous staff member working within the designated weeks who were required to be tested for Covid-19 and had not tested. The DON said some staff test on the unit and don't log it in or they test at their other place of employment. The DON said the staff should be logging all their tests in the testing log so they can track who has tested. 4. Resident #20 was readmitted in October 2023 with a history of COPD (chronic obstructive pulmonary disease), acute respiratory failure with hypoxia, and hypertensive heart disease/CHF (congestive heart failure). The facility policy for the care of respiratory equipment Chapter 13, Respiratory, of the Clinical Services Manual, Oxygen Administration/Safety Storage/Maintenance, reviewed on 9/26/2023, indicated for Infection Control: -Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. On 11/8/23 at 9:43 A.M., the Resident was observed resting quietly in bed with his/her eyes closed. The Resident's hand held nebulizer was observed resting on the nightstand and not enclosed or protected in any type of device to maintain it's cleanliness and prevent contamination. On 11/14/23 at 8:40 A.M., the Resident's hand held nebulizer was observed on the floor, between the nightstand and the right upper side of the Resident's bed. During an interview on 11/14/23 at 8:40 A.M., Nurse #8 said to the surveyor that she saw that the hand held nebulizer was on the floor. Nurse #8 did not explain why the equipment was not contained in a plastic bag or device to maintain its cleanliness. During an interview on 11/14/23 at 12:52 P.M., UM #3 said that the facility policy is that residents' respiratory equipment, like hand held nebulizers, must be kept in a plastic bag with the resident's name, and date when the equipment was changed. He said that the night shift are responsible for changing the devices and plastic bags weekly on Sunday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, and interview, the facility failed to fully implement their antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to maintain a complete and thorough tracking system and follow the McGeer's criteria for usage of antibiotics. Findings include: Review of the facility policy titled Antibiotic Stewardship, last reviewed 5/19/23, indicated but was not limited to the following: -The Antibiotic Stewardship program promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. -Assessment of residence suspected of having an infection. The facility will utilize the McGeer criteria when considering initiation of antibiotics. -Tracking: The process measures for tracking antibiotic stewardship track how and why antibiotics are prescribed. Process measures include review of the SBAR and other clinical documentation during clinical meetings and ongoing reviews of completeness of prescribing documentation to include dose, root, duration, and indication for use. Review of the infection surveillance tracking system (line list) and report, dated 10/1/23, provided by the infection prevention nurse indicated the following: -Five catheter associated urinary tract infections (CAUTI) which were healthcare-associated infections (HAIs, acquired while resident resided at the facility), were treated with antibiotics and did not meet the McGeer's criteria for infection or have signs or symptoms recorded on the line listing. -Five urinary tract infections (UTI), were HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection or have signs or symptoms recorded on the line listing. -One pneumonia which was HAIs was treated with antibiotics and did not meet the McGeer's criteria or have signs or symptoms recorded on the line listing. -Two soft tissue infections which were HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection. -One cellulitis (skin infection) which were HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection. -One abscess which was HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection or have signs or symptoms recorded on the line listing. Review of Resident #105's medical record indicated the following antibiotic use: -Physcian orders for Levaquin 750 milligrams one time a day by mouth every other day for UTI for four administrations, initiated on 10/26/23 and completed on 11/3/23. -Review of the line listing indicated resident #105 had a CAUTI diagnosed on [DATE], no signs or symptoms recorded, and the infection did not meet the McGeer's criteria for infection. -Review of Resident #105's nursing note dated 10/22/23, indicated foley catheter patent, draining yellow urine with scant sediment. No odor. -Review of Resident #105's nursing note dated 10/26/23, indicated urinalysis and culture results reported to the physician with new orders for Levaquin 750 milligrams every other day times 4 doses, update MD when sensitivities are available. Review of Resident #105's nursing note dated 10/27/23, indicated resident continues with Levaquin for UTI. Foley catheter patent draining yellow urine. Review of Resident #105's nursing note dated 10/28/23, indicated resident continues with Levaquin for UTI. Foley catheter Patent draining yellow urine free from sediment. No physician notes available for review 10/26/23 through 11/3/23 during antibiotic use. Review of Resident #106's medical record indicated the following antibiotic use: A. Physician order for Macrobid 100 milligrams by mouth two times a day for a UTI for five days 10/5/23 through 10/10/23. -Review of the line listing indicated Resident #106 had a UTI diagnosed on [DATE], no signs or symptoms recorded, and the infection did not meet the McGeer's criteria for infection. -Review of Resident #106's nursing note dated 10/5/23, indicated urinalysis and sensitivity results came back. Resident is positive for UTI. Reported to the physician, new orders from Macrobid 100 milligrams twice a day times 5 days. -Review of Resident #106's second nursing note dated 10/5/23, indicated resident on Macrobid for UTI, resident afebrile, no complaints of dysuria (painful urination), continues with occasional incontinence. No physician notes available for review for 10/5/2023 through 10/10/2023 during antibiotic use. B. Physcian orders for Cefpodoxime Proxetil 200 milligrams one tablet by mouth every 12 hours for UTI for five days 10/29/23 through 11/3/23. - Review of the line listing indicated, Resident #106 had a UTI diagnosed on [DATE], no signs or symptoms recorded, and the infection did not meet the McGeer's criteria for infection. -Review of Resident #106's nursing note dated 10/26/23, indicated Resident complained of dysuria, MD notified. New orders to obtain urine for urinalysis culture and sensitivity. New orders for UTI protocol. -Review of Resident #106's nursing note dated 10/27/23, indicated urinalysis reviewed by physician, culture and sensitivity pending at this time. -Review of Resident #106's nursing note dated 10/29/23, indicated culture and sensitivity positive for proteus mirabillis, per MD start Vantin 200 milligrams twice a day for five days, patient is confused, no behaviors noted patient is afebrile. -Review of Resident #106's nursing note dated 10/30/23, indicated patient continues on Vantin for UTI, afebrile. -Review of Resident #106's second nursing note dated 10/30/23, indicated resident continues on Vantin for UTI, no adverse reaction noted, voiding without difficulty, no complaints of dysuria or hematuria (blood in urine) noted. Resident afebrile. No physician notes available for review for 10/29/2023 through 11/3/2023 during antibiotic use. During an interview on 11/9/23 at 2:00 P.M., the surveyor and Infection Control (IC) Nurse reviewed the October line listing and observed it to be incomplete with numerous residents prescribed antibiotics without meeting the McGeer's criteria for infection and no documented signs and symptoms. The IC Nurse said she uses the census sheet and during morning report picks up people that have started on antibiotics, and she also views the dashboard in Point Click Care (PCC, the electronic medical record) and adds these residents to her line listing. She said she then goes back to look at the nurses' notes and hospital discharge summary to see if she can pick up signs and symptoms to see if they meet the McGeer's criteria for infection. The IC Nurse said the nurses don't always document the signs and symptoms, so she doesn't get them. She said there has been some issues when the on-call physician is informed of the urinalysis results are greater than 100,000 colony forming units/milliliter (CFU/ml, term used to describe the number of microorganisms) they start them on antibiotics right away and they don't always wait for the culture and sensitivity. She said if she catches it, she can review the antibiotic use with the physician, but has not documented any of these conversations with the physicians. The IC Nurse provided her October summary analysis to the surveyor and said for the month of October, there were 39 infections treated with antibiotics, 19 were present on admission, 20 were in house infections (HAI), and only 15% meet McGeer's criteria for infection. She said 15% was a low number for meeting McGeer's criteria. During an interview on 11/14/23 at 10:20 A.M., the Director of Nursing (DON) said it was her expectation the line listing includes tracking symptoms, organisms and following up with the physician if the McGeer's criteria was not met. She was not sure where they were documenting the conversations that were had with the physicians. The surveyor reviewed the October summary analysis provided by the IC Nurse indicating the McGeer's criteria was only met 15% for last month's infections which were treated with antibiotics. The DON said only 15% of the residents meeting the McGeer criteria was a low and she could not speak to the current line listing not being completed with residents' signs and symptoms who were on antibiotics.

Based on interviews and documentation review, the facility failed to ensure that concerns of cold food, identified during Resident Council, were resolved effectively. Findings include: On 7/14/21 at 2:00 P.M., the surveyor conducted a resident group meeting. The residents voiced concerns of cold food and no access to a microwave to reheat foods. During an interview on 7/16/21 at 3:00 P.M., the Activity Director (AD) said that if residents identify concerns at the Resident Council meetings, the department heads receive the information and have to respond. The AD then reports back to the residents what the response is to their concern from the previous month's meeting. The AD said that the Food Service Supervisor (FSS) used to hold food meetings, but was not aware of any during COVID-19 [the public health emergency]. During an interview on 7/16/21 at 3:30 PM, the Administrator said she would be able to provide responses from department heads that were identified at Resident Council meetings, as she (or previous Administrator) has to sign off on the form of the residents' concerns and files the department head response. The responses are not documented in the Resident Council Meeting minutes. Review of the past several months of Resident Council meeting minutes identified food concerns as follows: 1) Meeting minutes, dated 3/15/21, identified food concerns which included: vegetables not cooked enough, soupy mashed potatoes, burnt toast, and cold hot beverages. Review of the Resident Council feedback form, dated 3/15/21, indicated the dietary response was to purchase a new steamer for cooking vegetables, the toast should be better, and the mashed potato will be monitored. There was no mention of a plan for cold food temperatures. 2) Meeting minutes, dated 4/7/21, indicated residents complained that the toast is still too dark, eggs are cold, and vegetables were cold and overcooked. Residents also voiced concerns of no access to reheating foods and missing items on trays. Review of the Resident Council feedback form, dated 4/7/21, indicated the FSS's response was the raisin toast was darkening and will monitor vegetables and missing items. There was no response to the cold food temperatures of eggs or vegetables, other than to request a new tray if unable to reheat. 3) Meeting minutes, dated 5/16/21, indicated residents reported cold food temperatures of soups and breakfast and lunch meals in rooms. Review of the Resident Council feedback form, dated 5/6/21, indicated the FSS's response was to continue to do weekly test trays and make adjustments. 4) Meeting minutes, dated 6/2/21, indicated residents had food concerns of overcooked meats and cold coffee and eggs, as well as missing items on trays. Review of the Resident Council feedback form, dated 6/3/21, indicated the FSS's response was to continue to monitor trays. There was no written plan or resolution for cold food or beverages. 5) Meeting minutes, dated 7/6/21, indicated residents had concerns of cold coffee and soup temperatures; burgers and eggs were overcooked and not palatable. No follow-up response was made available during the survey, and the FSS was away. Review of the facility's test tray documentation from January 2021 to June 2021 validated the resident's concerns of the ongoing issues of cold food as follows: -the test tray, dated 1/31/21, indicated the coffee was 128.6 degrees Fahrenheit (F) and vegetable 124, both cold. -the test tray, dated 2/10/21, the hot beverage was 125 degrees F and cold. -the test tray, dated 4/1/21, indicated the coffee and soup were cold at 128 degrees F and 130 degrees F, and the entree of chicken, mash potato and vegetable, (129, 130, 125 degrees F) were all cold, respectively. -the test tray, dated 4/22/21, indicated the temperatures for the soup, entree vegetable and potato were cool at 124, 124, 114, 127 degrees F, respectively. -the test tray, dated 5/18/21, indicated the coffee and soup was cold at 138 degrees F, the potato and vegetable were cold at 131 degrees F. -the test tray, dated 6/17/21, indicated the house soup was cold at 124.5 degrees F. Review of the FSS's responses to residents' concerns of cold foods has been to continue just to monitor test trays has not shown to be effective as four survey test trays continue to identify cold food temperatures at meals. During an interview on 7/16/21 at 2:15 P.M., the Dietitian said she may attend a Resident Council meeting once a year upon invitation and said that the FSS, who was not here this week, would be the one to attend or respond. The Dietitian said that missing food items on trays has been brought up in quality assurance meetings, and that they are doing test trays. During an interview on 7/20/21 at 8:25 A.M., the Head [NAME] said she has not attended any Resident Council meetings with the residents. The Head [NAME] said she was aware that residents had expressed concerns of cold food temperatures.

Based on policy review, interviews, and record review, the facility failed to ensure the practitioners were notified of a significant weight loss for one Resident (#10), out of a total sample of 23 residents. Findings include: Review of the weight monitoring policy, updated 5/15/20, indicated a decrease in weight of 5% or more in a month should be reported to the practitioner for further evaluation. Resident #10 was admitted to the facility in September 2020 with a diagnosis of End Stage Renal Disease. Review of the Resident #10's medical record and the Registered Dietitian's progress note, dated 6/19/21, indicated the Resident weighed 188 pounds in May 2021 and weighed 175 pounds in June 2021, indicating a significant weight loss of 6.9% in 30 days. The Registered Dietitian recommended notifying all parties. Review of a Nutrition Assessment Recommendation form, dated 6/19/21, indicated Resident #10 had a weight loss and to notify the physician. Review of the medical record indicated the last visit by the Nurse Practitioner (NP) was on 6/7/21. The visit note indicated Resident #10 weighed 179.1 pounds. Further review of the medical record indicated Resident #10 weighed 172.2 pounds on 7/15/21. During an interview on 7/16/21 at 9:08 A.M., Unit Manager #2 said she could not find any documentation in the medical record to indicate the physician had been notified of the significant weight loss that was identified on 6/19/21. During an interview on 7/16/21 at 2:00 P.M., the NP confirmed the last visit for Resident #10 was on 6/7/21 and said at that time, the Resident weighed 179 pounds. The physician and the NP both said they were unaware of the significant weight loss from May 2021 to June 2021 of 13 pounds.

Based on policy review and resident and staff interviews, the facility failed to ensure that one Resident's (#60) grievance was addressed, and prompt efforts were made to resolve the grievance. Findings include: Review of the facility's grievance procedure titled Grievance Procedures and Concern & Comment Program, last revised May 2020, includes, but is not limited to the following: Use of the Concern & Comment Program in response to a reported concern: -Fosters a timely and quality response to the concern and/or comment. -Allows for identification of possible trends and patterns. -Identifies special needs of families and/or residents. -Ensures appropriate follow-up and systemic analysis. -Residents and their families have the right to file a complaint without fear of reprisal. -Residents rights should be protected when voicing complaints to maximize the quality of life for each individual and to promote customer satisfaction with facility care and services. -The Concern & Comment Program is utilized to address the concerns of residents, family members and visitors. The Director of Social Services is responsible for the following: -Assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights, and accommodation of needs. -As necessary taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. -Facilitating meetings and/or conversations with residents and families who have repeated concerns in order to better meet their needs. The Social Services staff and/or the Executive Director are responsible for the following: Following up with the resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident's and family's satisfaction. Administrative staff are responsible for the following: Reporting grievances and concerns to the Executive Director and Director of Nursing. Routing the Concern & Comment form to the Social Services Director and/or the Executive Director as well as the appropriate department manager to investigate and resolve the concern. Resident #60 was admitted to the facility in May 2021 with diagnoses including displaced fractures of the upper end of the left and right humerus (arm bone). The Resident was admitted to the facility for short term rehabilitation. During an interview on 7/14/21 at 9:32 A.M., Resident #60 told the surveyor about the following incident, though he/she could not remember the exact date, but said it was recent: One evening at 11:00 P.M., he/she was startled awake by someone bellowing a song. Resident #60 stated that at 3:00 A.M. someone was bellowing a song again. The Resident said that the person was singing so loudly that it woke up his/her roommate. Resident #60 was told that it was the agency nurse (Nurse #8) who works 11:00 P.M. to 7:00 A.M. singing the gospel songs. Also during this same evening (11:00 P.M. to 7:00 A.M. shift) Resident #60 also said that when his/her roommate (Resident #88) requested pain medication, this same nurse was very rude to Resident #88 and made the Resident feel bad. Resident #60 said that Nurse #8 made Resident #88 feel like he/she was drug seeking and stated that Resident #88 was crying because he/she was in pain. Resident #60 went on to say that at 5:00 A.M. Nurse #8 woke him/her up by tapping very hard on his/her arm to take his/her blood pressure. Instead of gently waking him/her up, Resident #60 said he/she felt a very hard tap (several times) on his/her arm. Resident #60 said that for a person who sings gospel songs you would expect Nurse #8 to practice what she preaches. Resident #60 said Nurse #8 was rude. Resident #60 further said Resident #88 was very upset, but did not want to say anything at the time of the incident because he/she feared repercussions. Resident #60 said that on 7/9/21, Resident #88 told the Director of Social Services about these incidents (nurse singing, nurse being mean, and the issue with the pain medication) before he/she was discharged . Resident #60 said he/she was present when Resident #88 spoke to the Director of Social Services about the incidents, and believed Nurse #8 was still working at the facility. During an interview on 7/15/21 at 8:15 A.M., the Director of Social Services said that she had a conversation with Resident #60 and Resident #88; both said that the nurse woke them up with her singing. She also said that she was told Nurse #8 was somewhat abrupt in her response to Resident #88 when he/she asked for pain medication, saying, You are not due for medication now. The Director of Social Services said that Resident #88 was okay with it not being time to be medicated, however it was the way Nurse #8 responded to him/her. Resident #88 felt that the nurse was rude and somewhat demeaning in her response. The Director of Social Services said that both Residents (#60 and #88) were talking and expressing their opinions of the nurse's response. When asked for documentation regarding these concerns, the Director of Social Services said that she had not documented the concerns brought forward by the Residents, but did report it to the ADON. During an interview on 7/15/21 at 8:40 A.M., the ADON said she did speak to Nurse #8 about her singing on the 11:00 P.M. to 7:00 A.M. shift. The ADON said she did not speak to Nurse #8 about her attitude/ speaking rudely to Resident #88, because she did not perceive it as an issue that needed to be addressed. The ADON stated that she did not document the conservation with Nurse #8. The ADON said if she perceived the situation differently, she would have gone and spoke with both Residents and begun an investigation. The surveyor attempted to review documentation of the Residents' concerns, but neither the Director of Social Services nor the ADON had any documentation. During an interview on 7/15/21 at 8:55 A.M., the Administrator said that there should have been documentation of the conversations with the Residents about their concerns brought forward about the nurse. During an interview on 7/15/21 at 9:15 A.M., the Administrator and the Director of Social Services said they spoke with Resident #8. The Administrator said that the Resident's concerns should have been addressed as a grievance, and there should have been documentation from either the Director of Social Services and/or the ADON, but there was not.

Based on record review, staff interview, and policy review, the facility failed to complete a comprehensive assessment which included an Abnormal Involuntary Movement Scale (AIMS) test, per facility policy, to identify Tardive Dyskinesia (a potentially irreversible movement disorder) related to the administration of an antipsychotic medication for one Resident (#19), out of a total sample of 23 residents. Findings include: Resident #19 was admitted to the facility in December 2018 with diagnoses including psychosis, manic depression, and seizure disorder. Review of the facility's policy titled Tardive Dyskinesia Assessment (AIMS), dated: 4/15/19, indicated residents taking antipsychotic medications must undergo AIMS assessments and the procedure is completed by the nurse per the Lippincott procedure, every 3 months. Review of Resident #19's medical record indicated an AIMS assessment was completed on 9/23/2019 and on 10/27/2020, over a year in between assessments. Review of Resident #19's medical record indicated the Resident received Seroquel, an anti-psychotic medication, until it was discontinued in May 2021. Per the facility's policy, the Resident should have had the AIMS assessment completed at least twice before the discontinuation of the medication. During an interview on 7/16/21 at 2:57 P.M., Unit Manager (UM) #3 said AIMS are completed by the facility nurses every 6 months for any resident on antipsychotic medications. UM #3 reviewed the facility's policy and said she was not aware that AIMS tests were to be completed every three months. UM #3 confirmed there were no additional AIMS assessments in the Resident record and they were not done per the facility policy. During an interview on 07/20/21 at 7:40 A.M., the Director of Nurses (DON) said she was aware that the policy indicated AIMS testing should be completed every 3 months, however the practice of the facility was to do AIMS testing every 6 months. She said the facility does not follow the policy because 6 months is a common acceptable practice.

Based on record review and staff interview, the facility failed to develop and implement an individualized, comprehensive care plan with specific interventions and goals to address the Resident's wounds and maintain the Resident's highest physical and psychosocial well-being for one Resident (#56), out of a total sample of 23 residents. Findings include: Resident #56 was admitted to the facility in May 2021 with diagnoses including displaced bimalleolar fracture of the left lower leg requiring internal fixation with subsequent breakdown of the internal fixation device (pins in the ankle). Review of Resident #56's clinical record indicated the Resident had an unstageable pressure ulcer to the left inner and outer ankle related to splinting of the ankle and immobility. Review of Resident #56's comprehensive care plans indicated that a care plan had not been implemented for the Resident's unstageable pressure ulcer of the left inner and outer ankle that included a focus, goals, and interventions. During an interview on 7/19/21 at 3:44 P.M., Unit Manager #1 reviewed the current care plans for Resident #56 and said that there was no care plan in place to address the pressure wounds on the Resident's inner and outer ankle.

Based on observation, policy review, and staff interview, the facility failed to ensure medications were prepared in a safe manner. Specifically, the facility failed to prepare medications for one resident at a time. Findings include: On 7/14/21 at 10:21 A.M., the surveyor observed an unlabeled cup with three loose pills in it in the top drawer of Nurse #2's medication cart. Review of the facility's policy titled General Dose Preparation and Medication Administration, dated 1/1/13, indicated, but is not limited to the following: 1. Medications should be prepared for one resident at a time. 2. Facility staff should verify each time a medication is administered the correct medication is administered at the correct dose at the correct route, at the correct time for the correct resident. 3. Dispose of unused medications according to facility policy. During an interview on 7/14/21 at 10:21 A.M., Nurse #2 said the medications were pre-poured and belonged to a resident whose medications were stored in the other medication cart on the unit. The medications in the cup consisted of two tablets of acetaminophen and one capsule of probiotic. He said it was not his normal practice and it shouldn't have been done. During an interview on 7/14/21 at 12:18 P.M., the Director of Nurses said it was not acceptable practice to pre-pour and store medications in that manner and it should not have been done.

Based on record review, interviews, and observations, the facility failed to ensure quality of care was provided to 2 Residents (#213 and #68), out of a total sample of 23 residents. Specifically, the facility 1.) Failed to identify and assess an open skin area for Resident #213; and 2.) Failed to assess and assist Resident #68 with optimal comfort in his/her wheelchair seating and positioning. Findings include: 1. Resident #213 was admitted to the facility in July 2021 for respite with a diagnosis of lung cancer. During an interview on 7/13/21 at 9:05 A.M., Resident #213 was observed to have his/her nasal cannula for oxygen resting on his/her chin and not providing oxygen through his/her nose. The Resident said he/she tried to keep the nasal cannula off as much as possible because his/her nose was sore. The surveyor observed a circular open area to the skin under the right nostril. Review of the skin assessment for Resident #213, dated 7/11/21, indicated edema to the right and left toes and left periorbital irritation (which was observed on 7/13/21 below the left eye). During an interview on 7/13/21 at 3:33 P.M., the Hospice Aide said she had provided care to Resident #213 in the community and was following him/her during the respite stay at the facility. The Hospice Aide said the Resident had a small open area below the right nostril related to the oxygen tubing and it had appeared about a week prior to admission to the facility. She said the Resident had received a treatment for this in the community. On 7/14/21 at 2:35 P.M., the surveyor observed Resident #213 in his/her room. The Resident was wearing the nasal cannula which was directly resting on the open area under the right nostril. The Resident said the open area bothered him/her. Frequent reviews of the medical record on 7/13/21, 7/14/21 and 7/15/21 did not include any information regarding the open area under the right nostril of Resident #213. There was no documentation in the medical record to indicate the facility staff had identified or assessed the area. During an interview on 7/15/21 at 2:00 P.M., Unit Manager #3 observed the open area under the right nostril of Resident #213. Unit Manager #3 said she had not previously seen the open area, although she had been the floor nurse on the unit on 7/13/21 and 7/15/21. She said she was not sure why the area was not identified upon admission or identified and assessed by any of the nurses or Certified Nursing Assistants who had worked with the Resident from admission through 7/15/21 when it was brought forward by the surveyor. During an interview on 7/16/21 at 8:55 A.M., Unit Manager #3 and the surveyor reviewed the Wound Observation Tool completed by the Unit Manager the previous day. Unit Manager #3 said the wound had measured 0.3 centimeters (cm) x 0.5 cm with a depth of 0.1 cm. She said the open area should have been identified, assessed, and evaluated upon admission. 2) Resident #68 was admitted to the facility in February 2021 with multiple diagnosis including thoracic and lumbar compression fractures, low back pain and hemiparesis following a recent hospitalization for kyphoplasty (a surgical procedure to restore shape and configuration of the vertebrae in the spine). Review of the Minimum Data Set (MDS) assessment, dated 5/19/21, indicated the Resident had a Brief Interview for Mental Status score of 15 out of 15, indicating he/she was cognitively intact and capable of making their own medical decisions. Further review indicated the Resident was receiving restorative nursing services and used a wheelchair and walker for mobility. Review of the medical record indicated Resident #68 received skilled Occupational and Physical Therapy services and was discharged from those services in March 2021. A review of the discharge information from Occupational Therapy indicated the Resident's seating when out of bed was standard wheelchair with a slight wedge cushion on the seat. The facility placed the Resident on restorative nursing services following discharge from skilled services five times a week. Review of the July 2021 restorative aide flowsheet indicated Resident #68 is receiving restorative services five times a week and can be ambulate approximately 400 feet with supervision and a trailing wheelchair and is transferring at a supervision level. During an interview on 7/13/21 at 9:02 A.M., Resident #68 said he/she was not comfortable in his/her wheelchair because of backpain. During an interview on 7/14/21 at 11:12 A.M., the surveyor observed Resident #68 sitting in the facility provided wheelchair with rolled and folded linens behind his/her back. Resident #68 said the staff gives him/her linens to fold and roll and place behind his/her back to create a more comfortable back rest while in the wheelchair. During an interview on 7/15/21 at 7:17 A.M., Restorative Aide #1 said the Resident is never comfortable in his/her wheelchair because of their back issues and self-pads the backrest of the wheelchair for comfort. She said the Resident has a history of chronic back pain and says he/she cannot be in the wheelchair too long. Restorative Aide #1 could not provide any further information or documentation on reporting the Resident's wheelchair discomfort to nursing or rehabilitation services. She said the Resident seemed comfortable with self-padding the wheelchair and wore a patch on his/her back for discomfort. During an interview on 7/15/21 at 9:55 A.M., the surveyor observed Resident #68 in a wheelchair with numerous pieces of linen folded and rolled behind the Resident's back. He/She said the staff provides him/her with the linens, so he/she can self-pad the back of the chair for comfort; and the staff assists with repositioning the linens as they compress over time. During an interview on 7/15/21 at 11:19 A.M, the Assistant Director of Nurses (ADON) said she was responsible for the management and oversight of the restorative nursing program. She said she does not assess, evaluate or keep any documentation on any Residents on the service. She said she does discuss the residents on caseload with the restorative aide about every two weeks, but said she does not have any experience and has not been trained in the restorative nursing program. She said she was not aware Resident #68 was creating his/her own back support and the expectation would be that a skilled rehabilitation referral be placed for the Resident's seating and positioning. Restorative services are not considered Specialized Rehabilitative Service - As referenced in Section O of the MDS/RAI manual - Restorative services refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A resident may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy. Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. During an interview on 7/15/21 at 12:40 P.M., Physical Therapist # 1 said she screened and evaluated Resident #68 for wheelchair positioning and comfort. She said she removed six folded pads from behind the Resident's back and acknowledged the folded pads and linens as being inappropriate support for the Resident. She said she replaced the folded pads and linens with a lumbar cushion for improved comfort and positioning support with seating. Review of the facility's policy titled Restorative Nursing, dated 5/14/20, indicated the facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcomes and that a licensed nurse must periodically evaluate the services and supervises the activities of the restorative nursing program. During an interview on 7/15/21at 3:51 P.M., the ADON said she had not received any trainings in overseeing the restorative program for the residents at the facility.

Based on record review, observations, and interviews, the facility failed to ensure one Resident (#57), out of a total sample of 23 residents, received their hearing aids daily, to maintain hearing ability. Findings include: Resident #57 was admitted to the facility in May 2020 with a diagnosis of hearing impairment. Review of the medical record for Resident #57 included a care plan indicating the Resident had a hearing impairment, would wear hearing aids daily, and had interventions of staff assisting with hearing aid placement daily. On 7/13/21 at 11:51 A.M., the surveyor attempted to interview Resident #57 but the Resident was not responding to questions. After speaking more loudly, Resident #57 engaged in conversation. The Resident was not observed to be wearing his/her hearing aids at this time. The hearing aids were observed in a charging box on the Resident's window sill. On 7/14/21 at 12:36 P.M., the surveyor observed Resident #57 in a chair, being fed lunch by a Certified Nursing Assistant (CNA). The Resident was not observed to be wearing hearing aids. On 7/14/21 at 2:33 P.M., the surveyor observed Resident #57 in a chair with the television on. The Resident was not observed to be wearing hearing aids at that time. The hearing aids were observed in a charging box on the Resident's window sill. On 7/15/21 at 12:23 P.M., the surveyor observed Resident #57 in a chair, being fed lunch by a CNA. The Resident was not wearing hearing aids at this time. On 7/16/21 at 1:10 P.M., the surveyor observed Resident #57 in the unit day room and he/she was not wearing hearing aids. The surveyor went to the room of Resident #57 and observed the hearing aids on the window sill, in the charging box. During an interview on 7/16/21 at 1:14 P.M., Nurse #6 said she did not know Resident #57 had hearing aids. She reviewed the medical record for Resident #57 and said there was an order to remove the hearing aids in the evenings, but there was not an order to put the hearing aids in. On 7/20/21 at 10:56 A.M., the surveyor observed Resident #57 lying in bed, ready to be lifted by a mechanic lift from bed to a chair. The Resident was not wearing hearing aids. During an interview on 7/20/21 at 11:10 A.M., Nurse #7 said there was an order for Resident #57 to wear hearing aids in the morning. The nurse and the surveyor reviewed the electronic Medication Administration Record, which indicated the order for applying hearing aids was already completed (green status). She said she had not placed the hearing aids in the resident's ear yet as she likes to wait until the resident was out of bed. She could not say why she had already documented that the Resident was wearing the hearing aids.

Based on interviews and record review, the facility failed to ensure changes to a therapeutic diet were offered when there was a nutritional problem for one dialysis Resident (#10), out of a sample of 23 residents. Findings include: Resident #10 was admitted to the facility in September 2020 with a diagnosis of End Stage Renal Disease and was started on dialysis services in November 2020. Review of the pre/post dialysis communication form for Resident #10, dated 7/9/21, included notes from the dialysis center which indicated the Resident's laboratory results were attached for review, to increase protein, to decrease phosphorus, to decrease calcium intake and to speak with the family in regards to food brought in by the family. Review of the laboratory results indicated the following: Albumin 2.7 (low) with notes to increase albumin value by eating more protein; Phosphorus 6.1 (high) with notes to avoid high phosphorus foods (milk, cheese/dairy, dried beans, nuts, chocolate); Calcium 10.4 (high) with notes to avoid food or drinks with added calcium and limit milk products. Review of the pre/post dialysis communication form, dated 7/16/21, included a note from the Registered Dietitian (RD). The RD's note, dated 7/15/21, indicated the family had been educated on Resident #10's diet restrictions and continued to bring in the food the Resident wanted. There was no documentation to indicate a conversation took place with the Resident or any considerations to changes in meals provided by the facility, for increasing protein, decreasing foods with phosphorus, and decreasing calcium products. During an interview on 7/16/21 at 9:26 A.M., the RD said she did not make any dietary changes, per the dialysis communication form on 7/9/21, to Resident #10's diet received at the facility, because it was already a liberal renal diet (no tomatoes, no orange juice, 4 ounces of milk, monitor calcium) and he/she was receiving Prosource, a protein supplement. The RD said she met with Resident #10 on 7/15/21 and the Resident declined to have double portions of protein on the meal trays. The RD said she was not sure why this was not mentioned in her progress note. During an interview on 7/16/21 at 9:40 A.M., Resident #10 said he/she did not recall meeting with the RD the previous day. The Resident said he/she did not have a discussion with anyone the previous day regarding increasing the protein (such as eggs or chicken) on the meal tray. The Resident said he/she was not actually sure what protein was, and when asked, said he/she would be open to learning more about it from the RD. The Resident said he/she did not like protein supplements and would prefer to increase protein through food.

Based on policy review, record review, and staff interview, the facility failed to ensure that care and treatment of a Mid-line catheter (venous access device-VAD-which is located directly in the basilic vein of the arm and terminates at the axilla) were provided in accordance with the facility's policy/protocols for one Resident (#314), out of a total sample of 23 residents. Specifically, the facility failed to ensure staff changed the VAD using sterile technique and failed to obtain the external catheter length at the time of the dressing change as per the physician's orders and the facility's policy/protocols. Findings include: 1. Review of the facility's policy/protocol titled Central Venous Access Device (CVAD) Dressing Change, revised 5/1/16, indicated, but is not limited to, the following: -Length of the external catheter is obtained during dressing change -Documentation in the medical record includes, but is not limited to: *Date and time *Site assessment *Length of external catheter *Reason for dressing change *Resident response to procedure and/or medication *Resident/significant other teaching -The purpose of measuring the external catheter length is to monitor for migration (movement) of the catheter. The catheter length is measured in the same manner each time so that the measurements are consistent and accurate. -Documentation should be present within the medical record so that the catheter migration can be accurately assessed by the nurse who is responsible for the next dressing change and external catheter length measurement. Resident #314 was admitted to the facility in June 2021 with diagnoses including psoas muscle abscess (purulent infectious collection within the psoas muscle) and methicillin susceptible staphylococcus aureus infection requiring intravenous (IV) antibiotics three times a day (every eight hours) for 60 days. The Resident has a mid-line catheter in place for IV antibiotic administration. Review of Resident #314's current physician's orders indicated the following: IV: Midline Catheter site - Change transparent dressing every seven days. Change catheter securement device with dressing change. Measure external catheter length-notify physician if length has changed since last measurement. On 7/15/21 at 11:25 A.M., the surveyor observed Nurse #3 change Resident #314's Mid-line dressing. Nurse #3 followed proper protocol until the following occurred: Nurse #3 opened the package of sterile gloves on the bedside cabinet and donned (put on) them. Instead of beginning the dressing change, he picked up the glove packaging, crumpled it into a ball using his sterile gloved hands and discarded the paper. Because the glove packaging had been resting on the overbed cabinet (surface is neither clean nor sterile) the sterile gloves are now considered contaminated. At this time, the surveyor intervened and informed Nurse #3 that he had contaminated his sterile gloves and needed to don a new pair. Nurse #3 agreed that he had contaminated his gloves and donned another pair. He completed the dressing change without further incident. Once the dressing was in place, he then measured the arm circumference and then dated and initialed the new dressing. The surveyor then asked him if he was going to measure the external catheter length to which he responded, No. Nurse #3 said he didn't think there was an order to do so. He said he would check the physician's order and if he needed would then get a new tape measure to measure the external catheter. Review of Nurse #3 nurse's note for the dressing change indicated that Nurse #3 did obtain a catheter length measurement after the dressing had been changed and it was then re-measured by Unit Manager #1 as there had been a discrepancy in Nurse #3's measurements. Unit Manager #1 alerted the physician of the discrepancy.

Based on policy review, interviews, and record reviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, through ongoing communication and collaboration with the dialysis facility for 2 Residents (#10 and #71), out of 3 total residents receiving dialysis. Findings include: Review of the facility's policy for Dialysis, dated 5/12/21, indicated, but is not limited to, the following: The facility assured resident received care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Day of Dialysis: -Initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis clinic with the resident (this is a form of written communication that occurs between the nursing facility and the dialysis center that includes but is not limited to recommendations made by the Dialysis center staff for the nursing facility to implement and the Residents condition before, during, and after receiving hemodialysis). Post Dialysis: -Obtain vital signs of resident upon return from dialysis and complete the Pre/Post Dialysis Communication Form. -Follow routine dialysis instructions on dialysis transfer form. -Transcribe any diet, medication and/or orders received with resident from the dialysis facility. 1. For Resident #10 the facility failed to ensure recommendations from the dialysis center, in the dialysis communication book, were addressed timely and addressed all areas of concern. Resident #10 was admitted to the facility in September 2020 with a diagnosis of End Stage Renal Disease and was started on dialysis services in November 2020. Review of the pre/post dialysis communication form for Resident #10, dated 06/04/21, included notes from the dialysis center to indicate the Resident's laboratory results were attached for review and to decrease the dairy and calcium intake of Resident #10. Review of the laboratory results indicated the following: Albumin 2.3 (low) with notes to increase the albumin value by eating more protein; Potassium 3.4 (low) with notes to discuss level with Dietitian or physician; Calcium 10.4 (high) with notes to avoid food or drinks with added calcium, limit milk products such as milk, cheese, yogurt, pudding or ice cream. Further review of the entire medical record and dialysis communication book, indicated this communication was not reviewed by the Registered Dietitian (RD) until 6/19/21 (15 days after the communication). Review of the pre/post dialysis communication form for Resident #10, dated 7/9/21, included notes from the dialysis center which indicated the Resident's laboratory results were attached for review, to increase protein, decrease phosphorus, to decrease calcium intake, and to speak with the family in regards to food brought in by family. Review of the laboratory results indicated the following: Albumin 2.7 (low) with notes to increase albumin value by eating more protein; Phosphorus 6.1 (high) with notes to avoid high phosphorus foods (milk, cheese/dairy, dried beans, nuts, chocolate); Calcium 10.4 (high) with notes to avoid food or drinks with added calcium and limit milk products. Review of the medical record and dialysis communication book indicated the RD did not address this until 7/15/21 (6 days after the communication). Review of the communication form, dated 7/16/21, included a note from the RD. The note, dated 7/15/21, indicated the family had been educated on Resident #10's diet restrictions and continued to bring in the food the Resident wanted. There was no documentation to indicate a conversation took place with the Resident or any considerations to changes in meals provided by the facility, for increasing protein and decreasing calcium products. During an interview on 7/16/21 at 9:08 A.M., Unit Manager #2 said the process for notifying the RD of communication from the dialysis center was for the nurse on duty to review the dialysis center's recommendations upon the resident's return from dialysis and notify the RD or the physician of any changes or recommendations. She said the staff could notify the RD by voicemail, email, or in person, and there was no dedicated way to do so. During an interview on 7/16/21 at 9:26 A.M., the RD said she did not normally go through the dialysis communication books on her own, and the nursing staff were responsible for notifying her of any communication. She said she had not been notified regarding the laboratory results and request for review from the dialysis center on 6/4/21. She said she was reviewing the dialysis communication book on her own, on 6/19/21, and found the information. She said that was why there was a delay in responding to the communication from the dialysis center. The RD said for the communication, dated 7/9/21, she had been notified through voicemail on that day (Friday) and had received the voicemail on Monday 7/12/21. She said she did not address this communication until 7/15/21 because she had other priorities that week and she felt she had 72 hours to address it, from when she was notified. The RD said she did not make any dietary changes, per the dialysis communication form, to the diet Resident #10 received at the facility because it was already a liberal renal diet (no tomatoes, no orange juice, 4 ounces of milk, monitor calcium) and he/she was receiving Prosource, a protein supplement. The RD said she met with Resident #10 on 7/15/21 and the Resident declined to have double portions of protein on the meal trays. The RD said she was not sure why this was not mentioned in her progress note. During an interview on 7/16/21 at 9:40 A.M., Resident #10 said he/she did not recall meeting with the RD the previous day. He/she said they did not have a discussion with anyone the previous day regarding increasing the protein (such as eggs or chicken) on the meal tray. The Resident said he/she was not actually sure what protein was and when asked, said he/she would be open to learning more about it from the RD. The Resident said he/she did not like protein supplements and would prefer to increase protein through food. 2. For Resident # 71 the facility failed to ensure recommendations from the dialysis center were addressed. Resident # 71 was admitted to the facility in June 2021 with diagnoses including benign prostatic hypertrophy and end stage renal disease resulting in the Resident receiving hemodialysis three times a week on Monday, Wednesday, and Friday. Review of the Pre/Post Dialysis communication form indicated that on 7/12/21 the Dialysis center made recommendations for the following: *Increase protein with meals/supplements Review of the current physician's orders failed to indicate an order for protein and/or supplements at meals. During an interview on 7/15/21 at 10:41 A.M., Unit Manager #1 said that the communication book with the recommendations by the dialysis center must have been overlooked and that the above recommendations had not been addressed/ implemented by the facility.

Based on observations, interviews, policy review, and record review, the facility failed to implement infection control practices for a newly admitted , unvaccinated from COVID-19, Resident (#213) receiving nebulizer treatments (an aerosol-generating procedure) by placing them with a roommate, out of a total sample of 23 residents. Findings include: During an interview on 7/15/21 at 11:35 A.M., the Infection Preventionist said the facility follows CDC, CMS, and Massachusetts DPH guidance for infection control practices. Review of the guidance from the Department of Public Health titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, dated 6/18/21 indicated the following: Newly admitted or readmitted residents to a long-term care facility or residents returning from any setting outside of the facility who are not recovered from COVID-19 within the previous six months or are not fully vaccinated (14 days or more since their final dose in the vaccine series) and are asymptomatic are no longer required to complete a strict 14-day quarantine period, but should be placed in a private room or, if unavailable, in a room with another resident who is recovered (less than six months from infection) or who is fully vaccinated (14 days or more since their final dose in the vaccine series). Resident #213 was admitted to the facility in July 2021 for respite care related to lung cancer. Review of the medical record indicated Resident #213 was new to the facility and had not been vaccinated for COVID-19. On 7/13/21 at 11:00 A.M., the surveyors observed multiple unoccupied rooms throughout the facility. The surveyors also observed Resident #213 to have a roommate. On 7/13/21 at 11:43 A.M., the surveyor observed the door of Resident #213's room closed with a sign on the door indicating there was an aerosol-generating procedure in progress; Personal Protective Equipment (PPE) of N95 mask, eye protection, gown and gloves were required to enter and the door was to remain closed for one hour after treatment. Review of the medical record for Resident #213 indicated an order for nebulizer treatments every four hours, when the Resident was awake. Review of the facility's bed capacity is 154 residents. At the time of the survey there was a census of 109 residents, indicating 45 available beds or approximately 22 private rooms. During an interview on 7/13/21 at 2:30 P.M. the Infection Control Preventionist said the process for newly admitted , unvaccinated from COVID-19 residents was to have them assigned to a private room. She said Resident #213 was originally planned to have been admitted to a private room and she was not sure why that plan had changed prior to admission. She said prior to admission the Infection Control Preventionist had not been informed Resident #213 was receiving nebulizer treatments. She said when she became aware on Monday 7/12/21, she had determined since the roommate was often out of the room, there were no concerns with having a roommate. The surveyor inquired what PPE would be utilized for staff entering the room during the aerosol-generating procedure and the Infection Preventionist said the staff was to don an N95 mask, gown, gloves and eye protection to enter the room during the treatment and for one hour post treatment. The surveyor inquired what was required of the roommate during and post aerosol-generating procedure and the Infection Control Preventionist said the expectation would be for the staff to pull the curtain between the resident beds. The Infection Control Preventionist said she was not sure what kind of protection this would offer the roommate. During an interview on 7/13/21 at 3:34 P.M., the Infection Control Preventionist said she was not sure what time the roommate of Resident #213 went to bed or if the roommate was in the room when Resident #213 received an 8:00 P.M. nebulizer treatment or the one hour post nebulizer treatment. During an interview on 7/15/21 at 11:45 A.M., the Medical Director said the expectation was for newly admitted , unvaccinated from COVID-19 residents be placed in a private room. He also indicated that if that resident was also on a nebulizer treatment, then that resident should be in a private room because of the aerosol generating procedure.

Based on policy review, interviews, and record reviews, the facility failed to ensure monthly medication regimen reviews were maintained as part of the permanent medical record and failed to follow the facility's policy to ensure the consultant pharmacist had access to the entire medical record for 5 out of 5 Residents (#51, #19, #10, #3 and #84) selected for an unnecessary medication review. In addition, the facility failed to ensure recommendations made by the pharmacy consultant were addressed timely for 2 out of 5 Residents (#51 and #19). Findings include: Review of the facility's policy for medication regimen review, updated 6/11/21, indicated the facility should ensure the consultant pharmacist has access to the following: - the resident's complete health record - the resident's laboratory tests - physician/prescriber progress notes, nurses notes, and other documents which may assist the consultant pharmacist in making professional judgement as to whether or not irregularities exist in the medication regimen. If an irregularity does not require urgent action but should be addressed before the consultant pharmacist's next monthly medication regimen review, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician responses to identify irregularities based on the specific resident's clinical condition. The facility should maintain readily available copies of the medication regimen review on file, in the facility as part of the resident's permanent health record. 1. For Resident #51 the facility failed to ensure the entire medical record was reviewed by the pharmacy consultant for the monthly medication regimen review and failed to ensure a recommendation made by the pharmacist was addressed timely. Resident #51 was admitted to the facility in November 2020. Review of Resident #51's hybrid medical record (includes electronic and paper records) failed to include documentation that a monthly medication regimen review was completed by a pharmacist for the following months: November 2020, December 2020, January 2021, March 2021, and April 2021. During an interview on 7/15/21 at 2:26 P.M., the Director of Nurses (DON) said that the pharmacist started coming in to the facility two months ago and she did not have access during the COVID-19 restrictions to write pharmacy progress notes in the electronic medical record. The DON said the pharmacist e-mailed any recommendations and a list of the residents she reviewed. During an interview on 7/15/21 at 4:05 P.M., the pharmacist confirmed she did not come to the facility from March 2020 through April 2021. She said the monthly medication regimen reviews were not documented in the residents' records until the last two months (May 2021 and June 2021). On 7/16/21 at 8:46 A.M., the DON was asked to provide the monthly pharmacy recommendations she received from the pharmacist for the period of time the pharmacist was doing virtual monthly medication regimen reviews. For Resident #51, the DON provided a pharmacy recommendation dated 12/10/20, which was not included in the Resident's hybrid medical record. Review of the pharmacist consultation report, dated 12/10/20, recommended a monitoring plan for use of the medication hydroxychloroquine which included obtaining laboratory tests (complete blood count and liver function test) every six months, to monitor for muscle weakness, blood glucose levels for hypoglycemia, and an annual ophthalmologic exam. The report provided by the DON had no physician response. At that time, the pharmacist review did not include access to facility laboratory test results. Although laboratory reports dated 1/15/21, 3/17/21, and 4/12/21 were in the paper medical record, there was no documentation that the pharmacist review was aware of the results. During an interview on 7/16/21 at 1:30 P.M., Unit Manager #3 said she had not seen the 12/10/20 recommendation. Upon further review, Unit Manager #3 said Resident #51 had resided on another unit at the time of the pharmacy recommendation and therefore would not have reviewed or filed it the medical record. Unit Manager #3 said medical records may have it in overflow. On 7/20/21 at 10:55 A.M., the Medical Records staff looked in Resident #51's overflow record with the surveyor for the completed pharmacy consultation report dated 12/10/20, and there was not one available. On 7/20/21 at 11:00 A.M., the DON was asked if she had the completed recommendation with the physician's response, and as of 1:00 P.M. had nothing further. 2. For Resident #19 the facility failed to ensure monthly pharmacy recommendations were addressed and completed timely, resulting in missed Abnormal Involuntary Movement Scale (AIMS) testing and the gradual dose reduction (GDR) of Seroquel, an antipsychotic medication. Resident #19 was admitted to the facility in December 2018 with diagnoses including psychosis, manic depression, and seizure disorder. Review of the paper and electronic medical records for Resident #19 did not indicate a monthly medication regimen review was completed from April 2020 through April 2021. Upon request, the Director of Nurses provided the surveyors with copies of the monthly medication regimen reviews and consultation summary reports, which were located in her e-mail and not part of the Resident's permanent medical record. Review of the medical record for Resident #19 included a pharmacy recommendation made on 8/12/20, for the Resident to undergo an AIMS test related to his/her use of Seroquel an antipsychotic medication which may cause involuntary movements including Tardive Dyskinesia (a potentially irreversible extrapyramidal disorder causing involuntary movements). Review of the monthly consultation summary report indicated the recommendation was not addressed and a repeat recommendation was made for the testing again on 10/20/20 before testing was completed on 10/27/20. An additional pharmacy recommendation made on 9/19/2020 requested a GDR to the Resident's Seroquel decreasing the current dose to 12.5 milligrams (mg). The recommendation indicated the Resident had been on the antipsychotic medication at the same dose of 25 mg since September 2019. The recommendation had a handwritten response by the practitioner dated 12/7/20 (almost three months later) agreeing to the recommendation for a decrease in the antipsychotic dosage. During an interview on 7/20/21 at 8:21 A.M., Unit Manager #3 said the process for pharmacy recommendations included the recommendation being flagged in the resident's medical record for the physician or nurse practitioners to address at their next visit. She said pharmacy recommendations should be completed within the month. She had no explanation as to why the pharmacy recommendations for Resident #19 were not addressed timely. 3. For Resident #10 the facility failed to ensure the pharmacist was able to access the entire medical, including responses to previous pharmacy recommendations and failed to maintain copies of the monthly medication regimen review as part of the permanent medical record. Resident #10 was admitted to the facility in September 2020 with a diagnosis of end-stage renal disease and started on dialysis in November 2020. Review of the paper and electronic medical record for Resident #10 did not include a medication regimen review for October 2020 through April 2021. During an interview on 7/15/21 at 2:28 P.M., the Director of Nurses said the pharmacy consultant had not been in the facility between the periods of March 2020 until May 2021. She said the pharmacy consultant had been reviewing the electronic medical records from off-site and had recently obtained access to documenting the medication regimen in the electronic medical record in May 2021. She confirmed the pharmacy consultant had not been able to access any documentation in the paper medical record, unless she called the facility and requested the documentation. The Director of Nurses provided the surveyors with copies of the monthly medication regimen reviews and consultation summary reports, which were located in her e-mail and not part of the Resident's permanent medical record. Review of the pharmacist consultation report, dated 12/10/20 indicated Resident #10 was receiving Fenofibrate, which should be avoided in individuals receiving dialysis. The form indicated it was signed by the physician on 1/15/21, declining the recommendation. Review of the pharmacist consultation report, dated 1/23/21 indicated this was a repeated recommendation from 12/10/20 for Resident #10. The recommendation indicated the use of Fenofibrate should be avoided in individuals receiving dialysis. The form was signed and accepted by the physician to discontinue the Fenofibrate on 1/27/21. Review of the pharmacy consultation summary report for 12/1/20 through 12/31/20 indicated there was no response to the recommendation made on 12/10/20 for Resident #10, with a repeat recommendation on 1/23/21. During an interview on 7/15/21 at 4:10 P.M., the consultant pharmacist said she had remote access to the electronic medical record since she was not coming to the facility. She said she did not have access to the paper record and would not know if a physician responded to a pharmacy recommendation, unless there was a change in the medication. She said if she was unable to make a determination as to what happened with a recommendation she would make the recommendation again. During an interview on 7/16/21 at 2:00 P.M., the Medical Director said, for Resident #10, he had originally declined the recommendation for the Fenofibrate, on 1/15/21, because the Resident was stable. He said he then accepted the repeated recommendation, dated 1/23/21, because he felt the pharmacist was being persistent with their recommendation. He said he was unaware that the pharmacist had not been coming to the facility at that time and did not have access to the paper record, which is where the declined recommendation had been kept. He said he was unaware the pharmacist would then repeat a recommendation based on not having access to the paper medical record. 4. For Resident #3, the facility failed to ensure the pharmacy consultant was able to access the entire medical record to complete a thorough medication regime review and failed to maintain copies of the monthly medication regimen review as part of the permanent medical record. Resident #3 was admitted to the facility in March 2021 with diagnoses which included dementia with behavioral disturbances, psychotic disorder, insulin dependent diabetes mellitus, and atrial fibrillation. Review of Resident #3's hybrid medical record failed to include a documented medication regimen review by the pharmacist consultant for the month of April 2021. During an interview on 7/15/21 at 2:28 P.M., the Director of Nurses said the pharmacy consultant had not been in the facility between the periods of March 2020 until May 2021. She said the pharmacy consultant had been reviewing the electronic medical records from off-site and had just gotten access to documenting the medication regimen in the electronic medical record in May 2021. She confirmed the pharmacy consultant had not been able to access any documentation in the paper medical record, unless she called the facility and requested the documentation. The Director of Nurses provided the surveyors with copies of the monthly medication regimen reviews and consultation summary reports, which were located in her e-mail and not part of the Resident's permanent medical record. During an interview on 7/15/21 at 4:06 P.M., the pharmacy consultant said she began remote access chart review in March 2020 due to the public health emergency. The consultant said she did not have the ability to remotely document monthly medication regimen reviews in the electronic medical record until two months ago. 5. For Resident #84, the facility failed to ensure the pharmacy consultant was able to access the entire medical record to complete a thorough medication regimen review and failed to maintain copies of the monthly medication regimen review as part of the permanent medical record. Resident #84 was admitted to the facility in February 2021. Review of Resident #84's hybrid medical record failed to include a documented medication regimen review by the pharmacist consultant for the month of March 2021. During an interview on 7/15/21 at 2:28 P.M., the Director of Nurses said the pharmacy consultant had not been in the facility between the periods of March 2020 until May 2021. She said the pharmacy consultant had been reviewing the electronic medical records from off-site and had just gotten access to documenting the medication regimen in the electronic medical record in May 2021. She confirmed the pharmacy consultant had not been able to access any documentation in the paper medical record, unless she called the facility and requested the documentation. The Director of Nurses provided the surveyors with copies of the monthly medication regimen reviews and consultation summary reports, which were located in her e-mail and not part of the Resident's permanent medical record. During an interview on 7/15/21 at 4:06 P.M., the pharmacy consultant said she began remote access chart review in March 2020 due to the public health emergency. The consultant said she did not have the ability to remotely document monthly medication regimen reviews in the electronic medical record until two months ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and 4 out of 4 test trays, the facility failed to ensure foods provided to residents on 3 out of 3 units were appetizing and served at palatable temperatures. Findings include: On 7/14/21 at 2:00 P.M., the surveyor held a Resident Council Group Meeting. The residents expressed concerns of cold food temperatures, such as eggs and soup, with no ability to reheat foods, and missing tray items. Review of the Resident Council meeting minutes indicated that residents identified food concerns at the monthly meetings on 2/7/21, 3/15/21, 4/7/21, 5/6/21, 6/2/21, and 7/6/21. During an interview on 7/14/21 at 2:10 P.M., the Ombudsman said residents have complained of food issues and temperatures and no one is allowed to use the microwaves to reheat foods. On 7/14/21 at 12:55 P.M. the surveyor observed the three resident unit nourishment kitchenettes which included a sign on top of the microwave: For Resident Safety, DO NOT re-heat coffee, hot water, any hot beverages, or meals in the microwave. Call the kitchen and they will resend a hot beverage or meal at the proper temperature. During an interview on 7/14/21 at 2:20 P.M., the Registered Dietitian (RD) said that the facility banned staff from using and reheating resident food in a microwave at least six months ago. The RD said that she only heard about it from nursing staff when a resident returned from dialysis and wanted soup from a meal tray left in the kitchenette and found out nursing staff was not allowed to reheat. The RD said it has been a problem. During an interview on 7/14/21 at 2:30 P.M., the Cook, filling in for the food service supervisor, Director of Nurses, RD, and Administrator were not able to produce a policy regarding microwave use or the prohibition of the microwave. The new Administrator said she was unfamiliar with the practice and the Director of Nurses said it has been in place for months, related to a resident incident of a burn. On 7/14/21, 7/15/21, and 7/20/21, the surveyor conducted test trays. The results validated some of the residents' voiced concerns of cold food and incorrect items as follows: Test Tray #1 on 7/14/21 at 12:24 P.M. on the [NAME] unit registered the following temperatures in degrees Fahrenheit (F): - soup at 133 degrees F; - chicken with sauce at 136 degrees F; - carrots at 131 degrees F; - mashed potato at 138 degrees F; - milk at 51 degrees F. The hot foods, specifically the soup broth could have been hotter for improved palatability. The milk tasted warm. Test Tray #2 on 7/15/21 at 8:43 A.M. on the [NAME] unit was checked for accuracy and registered the following temperatures in degrees Fahrenheit: - Although the meal tray card listed cream of wheat cereal, the item served was oatmeal. The oatmeal registered 135 degrees F and could have been hotter; - pureed scrambled egg at 104-108 degrees F, and tasted pasty and cool, not hot; - orange juice at 39 degrees F, - coffee at 138 degrees F and tepid (lukewarm) to taste; - pureed banana at 89 degrees F and was warm. Test Tray #3 on 7/15/21 at 12:29 P.M. on the Life Care Plus unit registered the following temperatures in degrees Fahrenheit: - a carton of milk contained ice inside at 38 degrees F; - turkey with gravy (sliced thin, deli style) at 114 degrees F; - mashed potato registered at 124 degrees F; and - the wax beans at 110 degrees F. The hot foods tasted cool and not hot. Test Tray #4 on 7/20/21 at 7:47 A.M. on the [NAME] unit, registered the following temperatures in degrees Fahrenheit: - milk at 55-58 degrees F; -juice at 60 degrees F; -tea water at 130 degrees F; -cream of wheat at 128 degrees F; - French toast at 100 degrees F; and - ground sausage at 120 degrees F. The hot food items tasted tepid. The milk and juice tasted warm and not chilled. During an interview on 7/14/21 at 10:00 A.M., the Head Cook, filling in for the Food Service Supervisor (FSS), was asked how resident meal preferences are obtained to assure meals are appetizing. The [NAME] said that the FSS or assistant, who were both out this week, visit with residents when admitted for food/meal likes and dislikes. There was no system that she was aware of on how often the preferences are updated. The Head [NAME] went on to say that known food dislikes, along with diet and allergies are entered into the menu system and based on diet restriction, allergies and preferences, the system selects and prints the resident's menu tray card. The Head [NAME] said some residents participate and receive a packet of menus for the week from activities and will call the kitchen or have staff call to tell what their choice is for that meal. However, this alternate list is not known by all residents that there are other foods they can ask for at the lunch and supper meals. During an interview on 7/14/21 at 1:00 P.M., a Resident, who did not want to be identified, said he/she did not like the noon meal served today. The Resident said he/she was not aware they could ask for something else, like a salad instead of a sandwich. The Resident said someone dropped off a packet of menus but did not know what to do with them or how to request something else. During an interview on 7/20/21 at 8:30 A.M., another Resident said at times it is frustrating, and is not sure if they (kitchen) receive my meal preference as no one picked up my menu packet. The Resident said he/she often has food brought in or delivered. For example the other evening the Resident said he/she ordered the Beef stew for the supper meal but received the alternate cottage cheese and fruit plate with no explanation. The Resident said he/she could not eat it. Or if you want something else you have to call and wait, and it is too frustrating.