Based on observation, interview and record review, the facility failed to provide the necessary respiratory care and services for two Residents (#86 and #11), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #86, to ensure nasal cannula (device that delivers extra oxygen (O2) through a tube into the nose) tubing and nebulizer mask/tubing (device that delivers aerosolized medication through tubing into the mouth and nose) was maintained to ensure sanitary conditions and decrease the risk of potential contamination by germs; and 2. For Resident #11, to maintain sanitary conditions of nasal cannula tubing and O2 equipment to help decrease the risk of potential contamination and exposure of infection to the Resident. Findings include: Review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, indicated but was not limited to the following: - The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. - Infection Control Considerations Related to Oxygen Administration: 7. Change the oxygen cannula and tubing every seven (7) days, or as needed, 8. Keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use. - Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses, 9. Discard the administration set-up every seven (7) days. Review of the facility's policy titled Nebulizer/Care and Use Of, dated 3/1/24, indicated but was not limited to the following: - Nursing will replace tubing, mask/mouthpiece weekly. - Tubing will be dated and replacement documented in resident record. - Equipment will be stored in a loosely covered plastic bag. 1. Resident #86 was admitted to the facility in October 2023 with diagnoses including Post-Polio Syndrome, disorders of diaphragm, and asthma. Review of the Minimum Data Set (MDS) assessment, dated 7/16/24, indicated Resident #86 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS assessment also indicated Resident #86 did not use continuous oxygen and required substantial or maximal assistance with activities of daily living. Furthermore, the MDS assessment indicated Resident #86 had shortness of breath (SOB) with exertion, SOB sitting at rest, and SOB lying flat. Review of Resident #86's current Physician's Orders indicated but was not limited to: - 11/15/23: Oxygen at two liters per minute (LPM) via nasal cannula (NC) PRN. - 11/23/23: Albuterol Sulfate Inhalation Nebulization Solution (25 milligrams (MG)/3 milliliters (mL)) 0.083%, one vial inhale orally via nebulizer every four hours as needed for SOB/wheeze. - 6/18/24: Change and date nebulizer tubing and storage bag once weekly, every night shift every Sunday. On 9/26/24 at 9:35 A.M., the surveyor observed the following: - Nebulizer mask/tubing was attached to the concentrator on a nightstand next to the Resident's bed. - The nebulizer mask/tubing was dated 9/30/24 and not covered or contained within a bag. During an observation with interview on 9/26/24 at 2:50 P.M., the surveyor observed Resident #86 resting in bed. The nebulizer mask/tubing was attached to the concentrator on a nightstand next to his/her bed and not covered or contained in a bag. Resident #86 said he/she uses the nebulizer as needed when he/she is SOB. Resident #86 said the nursing staff administers the treatment to him/her and when the treatment has ended takes the nebulizer mask/tubing back to store it. On 9/30/24 at 9:58 A.M., the surveyor observed the following: - An oxygen concentrator (a piece of equipment used to deliver oxygen to a resident through tubing or mask) was noted next to the Resident's bed by the window. - The NC tubing, dated 9/30/24, was wrapped around the top of the oxygen concentrator not stored in a bag. On 9/30/24 at 2:53 P.M., the surveyor observed the following: - Resident #86 sleeping in bed with the NC tubing donned (on). - The NC tubing was dated 9/30/24. - The oxygen concentrator was set to 2-LPM of Oxygen. On 10/1/24 at 7:56 A.M., the surveyor observed Resident #86 eating breakfast while positioned upright. Resident #86 had oxygen donned via his/her NC tubing dated 9/30/24. Resident #86 said he/she was feeling SOB and nursing staff helped him/her put the oxygen tubing on yesterday. On 10/1/24 at 10:21 A.M., the surveyor observed the following: - The oxygen concentrator was positioned by the window, not running. - The NC tubing, dated 9/30/24, was wrapped around the top of the oxygen concentrator not stored in a bag. During an interview on 10/1/24 at 1:08 P.M., Nurse #4 said nebulizer mask/tubing along with NC tubing is changed weekly and dated by the nursing staff. Nurse #4 said at that time a bag is supplied to store the mask and/or tubing when not in use. Nurse #4 and the surveyor made an observation of Resident #86's oxygen concentrator and NC tubing. Nurse #4 said the NC tubing should not be wrapped around the concentrator when not in use. Nurse #4 said it should be stored in the bag attached to the concentrator. Nurse #4 and the surveyor also reviewed the observations made regarding the nebulizer mask/tubing. Nurse #4 said the nebulizer mask/tubing is cleaned after use and then should be stored in a bag. During an interview on 10/2/24 at 8:34 A.M., Unit Manager (UM) #3 said tubing for nebulizers and oxygen is changed weekly on Sunday nights. UM #3 said NC tubing and nebulizer masks/tubing should be stored in bags when not in use. 2. Resident #11 was admitted to the facility in May 2021 and had diagnoses including bronchiectasis (condition in which the lungs' airways become damaged, making it hard to clear mucous), asthma, and dementia. Review of the MDS assessment, dated 7/18/24, indicated Resident #11 was cognitively intact as evidenced by a BIMS score of 14 out of 15 and had a pulmonary condition. Review of current Physician's Orders indicated the following: -Oxygen via NC 1-3 Liters (L) as needed for shortness of breath/keep sats >92%, 6/20/23 -Oxygen equipment maintenance as needed for equipment maintenance. Change oxygen tubing (mask, nasal cannula) and storage bags as needed, 10/13/22 -Oxygen equipment maintenance as needed for equipment maintenance. Cleanse oxygen concentrator filter, 10/13/22 -Oxygen equipment maintenance every night shift, every 1 month starting on the 8th for 1 day for equipment maintenance. Wipe down oxygen concentrator with clean damp cloth once monthly, 11/8/22 -Oxygen equipment maintenance every night shift, every Monday for equipment maintenance. Change oxygen tubing mask, nasal cannula, humidifier bottle, and storage bags once weekly, 10/13/22 During an observation with interview on 9/26/24 at 9:36 A.M., the surveyor observed Resident #11 sitting in a chair in their room. His/her NC tubing was observed attached to an O2 concentrator (takes air from your surroundings, extracts and filters it into purified oxygen for you to breathe) which was in the off position. The exterior of the concentrator was laden with a white powdery substance and dust. Resident #11 said, Yeah, it needs to be cleaned and that he/she used the oxygen at night for his/her breathing and for asthma. On 9/30/24 at 12:00 P.M., the surveyor observed Resident #11 sitting in a chair in their room eating lunch. His/her NC tubing was observed inserted into the Resident's nostrils with the other end attached to an O2 concentrator which was delivering 2 L of Oxygen. The exterior of the concentrator was laden with a white powdery substance and dust. On 10/1/24 at 8:17 A.M., the surveyor observed Resident #11 sitting in a chair in their room eating breakfast. His/her NC tubing was observed attached to an O2 concentrator which was delivering 2 L of Oxygen. The other end of the tubing was observed resting on top of the Resident's mattress, partially underneath a pillow, and potentially exposed to environmental contaminants. The tubing was not stored in the protective bag when not in use which was observed hanging from the concentrator. The tubing was dated 9/23/24 indicating it had not been changed. The exterior of the concentrator was laden with a white powdery substance and dust. On 10/1/24 at 8:21 A.M., Unit Manager (UM) #2 said she was the Resident's assigned nurse that morning and entered the room with the surveyor to observe the oxygen equipment. UM #2 said the oxygen tubing should have been changed and dated weekly on Sundays, but it was not, and should be stored in a plastic bag when not in use. UM #2 removed the concentrator's internal filter and said it needed to be changed and was not clean. She said the oxygen concentrator should be sanitized every week and as needed and the Resident needed a whole new concentrator. During an interview on 10/1/24 at 8:24 A.M., the surveyor reviewed the medical record with UM #2 who said, per physician's orders, the concentrator should be wiped down monthly and as needed, the tubing changed weekly on Mondays during the night shift, and the filter cleansed as needed but this was not done as ordered. During an interview on 10/1/24 at 3:37 P.M., the Director of Nursing (DON) said O2 concentrators should be wiped down as needed and the tubing should be changed weekly on the overnight shift on Monday. She said oxygen tubing should be labeled with the date when changed and initials of the nurse. She said this verifies how old the tubing is. The DON said maintenance oversees the external components, filters, and cleaning of the external parts and was frustrated this was missed. She said the oxygen tubing should be stored in a plastic bag when not in use and if it's a prn (as needed) thing, then it should be stored in a bag when not in use.

Based on observation, document review, and interview, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to store drugs and biologicals in accordance with accepted professional standards of practice until time of disposal, on one of three units. Findings include: Review of the facility's policy titled Administering Medications, dated as last revised April 2019, indicated but was not limited to the following: - Medications are administered in a safe and timely manner, and as prescribed Review of the facility's policy titled Storage of Medications, dated as last revised January 2018, indicated but was not limited to the following: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner - Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. On 10/1/24, the surveyor observed the following during the morning medication pass at 8:18 A.M.: - Nurse #3 poured the scheduled 8:00 A.M. medications for Resident #370 into one small, clear plastic medication cup which included: a. Loratadine (antihistamine) 10 milligrams (mg) one tablet for allergies b. Oxycodone (opioid for pain) 5 mg one tablet for pain management c. Zofran (antiemetic) 4 mg one tablet for nausea/vomiting - Resident #370 was sitting upright in his/her bed, with a pink basin on his/her lap. Resident #370 told the nurse he/she was nauseous and only wanted his/her medication for nausea and would take the rest of his/her medications, when he/she felt better. Nurse #1 administered only the Zofran 4 mg to Resident #370. - Nurse #3 returned to the medication cart in the hallway, opened the narcotic drawer, and put the clear, plastic medication cup including the Loratadine and Oxycodone (unlabeled) in the bottom of the narcotic drawer, surrounded by other resident medications, and locked the top of the narcotic drawer. - Nurse #3 then proceeded to medicate one other resident with their scheduled morning medications (the clear plastic medication cup unlabeled remained in the narcotic drawer of the medication cart). - At 8:40 A.M., Nurse #3 returned to the mediation cart with Unit Manager (UM) #1 and unlocked it and then unlocked the narcotic drawer, retrieved the clear plastic cup of pills, and handed the clear plastic cup of pills to the UM. The UM placed the two tablets into a clear pouch and placed the clear plastic pouch into the pill crushing machine crushed and disposed of the pills. During an interview on 10/1/24 at 8:43 A.M., Nurse #3 said she did not know what to do with the medications after she poured them for Resident #370, and was unable to administer them, so she locked them in the narcotic box. She said she went to ask her UM what to do with the medications. During an interview on 10/1/24 at 8:45 A.M., UM #1 said no medications should be stored in the medication cart, unlabeled, they should have been destroyed, and that is why she was destroying and disposing of the medications with Nurse #1. During an interview on 10/1/24 at 4:01 P.M., the Director of Nursing (DON) said the cup of pills should not have been put back in the medication cart without the proper packaging. She said they should have been disposed of when Resident #370 refused them.

Based on document review and interview, the facility failed to maintain complete medical records to accurately reflect the care of one Resident (#111), out of a total sample of 23 residents. Specifically, the facility failed to: 1. Document an administered dose of intravenous antibiotics (IV ANTBX) on the medication administration record (MAR) to reflect the date and time it was received; and 2. Ensure the medical record reflected physician notification of an acute change in potential medication side effects and the physicians follow up assessment to the presence of the condition. Findings include: Review of the facility's policy titled Charting and Documentation, dated as revised July 2017, indicated but was not limited to the following: - all services provided to the resident, progress towards goals or any changes in the resident's condition shall be documented in the medical record - the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care - the following information must be documented in the medical record: objective observations, treatments and services, medications administered - documentation of procedures and treatments will include: date and time the treatment/procedure was provided, notification of physician or other staff, and assessment data Review of the facility's policy titled Acute Condition Changes, revised March 2018, indicated but was not limited to the following: - the attending physician or nurse practitioner will respond in a timely manner to notification of problems or changes in condition and status Resident #111 was admitted to the facility in June 2024 with diagnoses including: malignant neoplasm of the bone (cancer), obsessive compulsive disorder and agoraphobia (intense fear of being in places or situations in which it may be difficult to escape or help is not available) with panic disorder. Review of the Brief Interview for Mental Status, dated 9/8/24, indicated Resident #111 was cognitively intact with a score of 15 out of 15. 1. During an observation with interviews on 9/26/24 at 9:40 A.M., the surveyor observed Resident #111 with a Contact precautions sign posted outside of his/her bedroom door and a dual lumen peripherally inserted central line (PICC) in their right arm. There was an intravenous (IV) pump and pole in the room, but no tubing or bag of medication was observed. Resident #111 said he/she is receiving medicine through he PICC for an infection on their leg. Nurse #2 said the Resident had methicillin resistant staph aureus (MRSA) as their infection germ and reason for IV antibiotics. Review of the current Physician's Orders as of 9/26/24 indicated but were not limited to the following: - Vancomycin IV solution 750 milligrams (mgs) in 150 milliliters of solution two times a day for infection until 10/3/24 at 8:00 A.M., and 8:00 P.M. Review of the progress notes for Resident #111 indicated but was not limited to the following: 9/25/24 at 10:46 P.M., PICC line blocked, MD notified and gave orders to contact IV support to have line unblocked or changed; Vancomycin on hold Review of the September MAR on 9/26/24 for Resident #111 indicated the IV Vancomycin was on hold for the 8:00 P.M. dose on 9/25/24 and 9/26/24 and the 8:00 A.M. dose on 9/26/24. During an observation with interview on 9/27/24 at 8:41 A.M., Resident #111 was lying in bed, beside the bed on the IV pole the surveyor observed a bag of IV Vancomycin not infusing. The Resident said he/she believes he/she received the IV medication the night prior at around 10:00 P.M. but was unsure of the exact time. During an interview on 9/27/24 at 9:25 A.M., Nurse #6 said she was the nurse for Resident #111 this morning and had just hung the IV ANTBX a few moments ago and took down the previous bag and replaced all the tubing. She said the bag that was hanging on the IV pole this morning was from the evening shift the night prior and was in place when she arrived at 11:00 P.M. the previous night and the medication must have been administered on 9/26/24 on the evening shift. During an interview on 9/27/24 at 9:31 A.M., Nurse #1 reviewed the MAR for 9/26/24 and said the MAR was documented as having the IV ANTBX on hold, as indicated by the H, for the evening shift on 9/26/24 and she could not explain how or why the IV medication was in the room this morning and not signed off as administered last evening if it was. During an interview on 9/27/24 at 9:32 A.M., Unit Manager #1 said she was having the Director of Nurses (DON) look into what may have occurred with the IV ANTBX last evening since the medication was documented on the MAR as being on hold and not signed off as administered on the 9/26/24 evening shift. Unit Manager #1 said she was in the room numerous times yesterday and never saw an IV bag or tubing in the room so the medication must have been administered in the evening after she had left for the day. Review of the progress notes for Resident #111 from 9/26/24 and 9/27/24 indicated but were not limited to the following: 9/26/24 at 10:29 A.M., Infectious disease called and said rash is not related to IV ANTBX and medication may continue 9/27/24 at 1:30 A.M., IV team fixed occluded line, MD aware of missed doses and gave order to resume Vancomycin at current dose; IV patent and flushing; Vanco running at scheduled time During an interview on 9/27/24 at 9:53 A.M., the DON said she reviewed the medical record and spoke to the Nurse who worked on 9/26/24 in the evening and the Nurse informed her she did administer the IV ANTBX but did not sign the administration off on the MAR and therefore the medical record is inaccurate and it appears the Resident had missed three doses of the IV ANTBX when they would have only missed two doses. During an interview on 9/27/24 at 10:43 A.M., Nurse #2 said she worked on the evening shift on 9/26/24 and the IV team attended to Resident #111 and unblocked the IV line. She said once the line was clear, she contacted the MD and received orders to resume the IV ANTBX administration. She said she thought she clicked the electronic medical record correctly to unhold the medication and administer the dose but she did not. She said she administered the IV ANTBX at approximately 10:00 P.M. but could not recall the exact time on 9/26/24. She said she did not document the administration of the medication on the MAR as she should have and she did not document the date and time of the IV ANTBX being administered in her progress note as she should have and that was an error on her part. During an interview on 9/27/24 at 11:55 A.M., the DON said the MAR does not accurately reflect the administration of the IV ANTBX on 9/26/24 as it should and the expectation is that medications are administered and documented at the time they are administered on the MAR to ensure the medical record is accurate and complete. She said the inaccurate record, if unnoticed, could result in inaccurate information being communicated to providers who make medical decisions on the Resident's care and accuracy of the MAR was important for these situations. 2. During an interview on 9/26/24 at 9:40 A.M., Resident #111 said he/she is on medications to manage his/her psychiatric conditions and has his/her own psychiatric provider in the community that they continue to have virtual therapy sessions with. He/She said it is important that they stay on their medications. Review of the current Physician's Orders for Resident #111 indicated but were not limited to the following: - Aripiprazole (antipsychotic) 5 mg oral tablet give one tablet by mouth at bedtime for mood stability - obsessive compulsive disorder (6/20/24) - Monitor for side effects of antipsychotic use: dry mouth, constipation, blurred vision, changes in urination, jerky movements in face tongue and jaw, swelling in hands ankles or feet, drooling, disturbed gait, or restlessness; every shift for surveillance. If side effect observed, document in progress note and notify practitioner. (6/18/24) Review of the MAR for Resident #111 for September 2024 indicated but was not limited to the following: - Aripiprazole was administered as ordered throughout the month daily at bedtime - Yes, side effects of the antipsychotic medication were identified on: 9/13, 9/14, 9/15, 9/17, and 9/18 Review of the progress notes for Resident #111 for 9/12/24 through 10/2/24 indicated but were not limited to the following: 9/13/24 at 7:15 P.M., Resident noted with increased movement of tongue, medicated as ordered, will continue to monitor 9/14/24 at 9:22 P.M., Resident noted with increased movement of tongue, medicated as ordered, will continue to monitor Further review of the notes failed to indicate what side effects of the antipsychotic were identified on 9/15, 9/17 and 9/18/24 or that the MD or Nurse Practitioner (NP) were ever notified of the new onset of symptoms. During an interview on 10/2/24 at 8:45 A.M., Nurse #1 reviewed the medical record of Resident #111 and said she could not find any evidence that the MD was aware of the new onset of symptoms from the antipsychotic or that the MD or NP evaluated the Resident's new symptoms once they were identified. She did however say the Nurse who documented the symptoms was currently in the facility. During an interview on 10/2/24 at 8:59 A.M., Nurse #3 said residents are monitored for signs and symptoms (s/s) of side effects for antipsychotic medications and the information is then documented on the medication administration record (MAR). She said she would also write a progress note indicating what s/s were observed and notify the Unit Manager (UM). She said she may or may not notify the physician, but if she did, she would document it in the progress notes. She said she does not know why she did not document that the physician was notified for Resident #111 or why there were no documented symptoms in the progress notes on 9/15, 9/17, and 9/18 as there should be. During an interview on 10/2/24 at 9:03 A.M., UM #1 said she was aware of the situation with Resident #111 intermittently being observed to have new symptoms of side effects from his/her antipsychotic and said she believes she notified the physician and he came and evaluated the Resident himself. She said she cannot be sure what exact date she notified the physician, since there is no documentation of that, and she is also unsure of the exact date the physician saw the Resident or what the outcome was since there was no progress note available from the MD that addresses the situation. She said the physician would typically write a note after seeing the Resident and then fax it to the facility so it could be placed in the medical record but there is no documentation available from the physician at this time. During an interview on 10/2/24 at 9:14 A.M., Physician #1 said he was made aware that Resident #111 was having an increase in mouth and tongue movements but couldn't recall the exact date of that indicating it was a few weeks ago. He said he examined the Resident himself and did not observe any of the reported s/s and since the Resident is on the lowest dose, he felt the medication remained appropriate. He said he had not provided a note of that visit to the facility as of this time and that is his error. He said he had not yet sent his notes for the visit to the facility and that is why the medical record is incomplete and does not reflect his evaluation of the Resident and follow up to the new identified change. During an interview on 10/2/24 at 9:27 A.M., the DON said the expectation is that the medical record is complete and accurate and the nurses document the s/s they observe in the progress notes along with notification to the MD as the order directs to ensure the record is complete and tells a story. She said the MD should have documented his follow-up visit to the Resident and that note should be available to the facility within a day or so to ensure the medical record reflects the follow up and resolution of a situation and is accurate and complete. She said at this time the medical record lacks the information that the MD was notified or visited the Resident to assess him/her and what was done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to ensure staff rapid antigen COVID-19 testing (CorDx) was conducted in a manner that is consistent with current standards of practice and manufacturer's instructions for use for two of three staff members observed. Findings include: During an interview upon entrance to the facility on 9/26/24 at 7:57 A.M., the Director of Nursing (DON) said the facility was experiencing a COVID-19 outbreak with 13 current positive residents residing on the Pottersville Unit (long-term care). During an interview on 9/30/24 at 3:42 P.M., the Infection Preventionist (IP) said staff were currently testing daily prior to their shift in the main lobby and that the facility followed Centers for Disease Control and Prevention (CDC), Massachusetts Department of Public Health (DPH), and Centers for Medicare and Medicaid Services (CMS) guidance for testing, whichever was the more stringent. Review of the 2024 staff and resident COVID-19 Positive Logs provided by the IP indicated there were currently 13 residents residing on the Pottersville Unit and three staff members who were positive for COVID-19. The [NAME] Unit (short-term rehab) became an affected unit on 9/4/24 and cleared on 9/28/24. The Pottersville Unit was affected on 9/12/24 to current. Review of the Massachusetts 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 10, 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 the DPH epidemiologist directs otherwise. - Residents and staff who are recovered from COVID-19 in the last 30 days can be excluded from this testing. Review of the CorDX rapid COVID-19 Ag Test manufacturer's product insert, revised September 2023, indicated but was not limited to the following: - A false result may occur if all the test steps are not followed as indicated below. If you skipped or incorrectly performed one or more steps, repeat the test with a new sample and cassette. Step 1: Collect Sample - Carefully insert the swab tip into one nostril about ½ to ¾ inch. Firmly and slowly rotate the swab 5 times, brushing against the inside walls of the nostril to ensure both mucous and cells are collected. - Using the same swab, repeat this process for the other nostril to ensure an adequate sample is collected from both nostrils. Failure to swab properly may cause incorrect results. Step 2: Process Sample - Insert the swab in tube to the bottom. - Rotate the swab at least 10 times while pressing the swab head against the bottom and side of the tube. Step 4: Read Result - Wait 10 minutes. Read the result at 10 minutes. - The result is valid when read at 10-30 minutes. If a positive result is obtained within 10 minutes, it should also be considered valid. On 10/1/24 at 6:35 A.M., the surveyor observed Rehabilitation Services Staff (RSS) #1 perform COVID-19 outbreak testing prior to his shift at the testing station in the main lobby of the facility. RSS #1 inserted the swab into each nostril rotating the swab only three times, not five. RSS #1 then inserted the swab into the tube to the bottom rotating the swab only four times, not 10, per manufacturer's instructions for use. During an interview on 10/1/24 at 1:05 P.M., RSS #1 said he should have swabbed each nostril five times and swirled the swab in the solution 10 times. On 10/1/24 at 6:38 A.M., the surveyor observed Nurse #4 perform COVID-19 outbreak testing prior to her shift at the testing station in the main lobby of the facility. Nurse #4 inserted the swab into each nostril rotating the swab only three times, not five. Nurse #4 inserted the swab into the tube to the bottom rotating the swab only four times, not 10. At 6:39 A.M., Nurse #4 applied three drops of the solution into the sample well. At 6:47 A.M., eight minutes later, Nurse #4 returned to the testing station to interpret her results then disposed of the testing cassette. Nurse #4 did not wait 10 minutes to read the result. During an interview on 10/1/24 at 10:34 A.M., Nurse #4 said the expectation was to swab each nostril five times, swirl the swab in the testing solution only four times, then wait 10 minutes for the result. Nurse #4 said she did not know she was supposed to swirl the swab in the solution 10 times. During an interview on 10/1/24 at 2:58 P.M., the surveyor reviewed the staff testing observations with the IP who said staff should have swabbed each nostril five times then put the swab in the vial of solution twisting it 10 times while pinching it to try and get the most sample out of there. She said staff are to wait 10 minutes for their test results and are expected to follow manufacturer's recommendations. The IP said if the sample is not collected properly it could lead to false results and staff are to retest.

Based on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for one Resident (#61), out of a total sample of 23 residents. Specifically, the facility failed to ensure a schedule II-controlled substance (hydrocodone-acetaminophen, high potential for abuse) medication to treat pain was administered to the Resident within parameters as ordered by the physician. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised 4/11/18, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. Review of the facility's policy titled Administering Medications, revised April 2019, indicated but was not limited to the following: - Medications are administered in accordance with prescriber orders, including any required timeframe. -The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #61 was admitted to the facility in December 2023 and had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, osteomyelitis, and post procedural pain. Review of the Minimum Data Set (MDS) assessment, dated 6/26/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and was on a scheduled and as needed pain medication regimen. Review of current Physician's Orders indicated the following: -hydrocodone-acetaminophen (Norco) oral tablet 5-325 milligrams (mg), give 1 tablet by mouth every 8 hours as needed for pain 7-10, 7/1/24 Review of the September 2024 Medication Administration Record (MAR) indicated the Norco was administered outside of physician prescribed parameters (pain scale documented as less than 7-10) (the pain scale is a tool that helps people measure their pain so that doctors can plan how to treat it with 0 indicating no pain and 10 the worst) on the following days: -9/2/24, 5:05 A.M., pain level 6 -9/3/24, 12:05 P.M., pain level 6 -9/3/24, 8:07 P.M., pain level 6 -9/4/24, 11:20 P.M., pain level 6 -9/6/24, 5:16 A.M., pain level 6 -9/11/24, 4:41 A.M., pain level 5 -9/13/24, 5:02 A.M., pain level 6 -9/13/24, 10:38 P.M., pain level 6 -9/15/24, 10:26 P.M., pain level 6 -9/16/24, 5:24 A.M., pain level 6 -9/17/24, 9:01 P.M., pain level 5 -9/24/24, 8:30 A.M., pain level 2 -9/25/24, 5:04 A.M., pain level 6 -9/27/24, 5:20 A.M., pain level 5 -9/29/24, 8:45 A.M., pain level 6 Review of the October 2024 MAR indicated the Norco was administered outside of physician prescribed parameters on the following days: -10/1/24, 8:25 A.M., pain level 5 During an interview on 10/1/24 at 11:30 A.M., Resident #61 said he/she had frequent pain in his/her mouth, upper back, neck, and right middle finger status post a partial amputation about a month ago and took Tylenol and Norco for it. During an interview on 10/1/24 at 11:52 A.M., the surveyor reviewed the medical record with Nurse #5 who said the physician's order indicated to give the Norco as needed for a pain scale rating of 7-10. She said she gave it this morning for a pain scale rating of 5; it was not given per physician's orders as it was below the parameter. During an interview on 10/1/24 at 3:44 P.M., the surveyor reviewed the medical record with the Director of Nursing (DON). The DON said the Norco should be given per physician's orders due to the risk of dependence, respiratory depression, lethargy, and constipation if not given as indicated.

Based on record review and interview, the facility failed to monitor for signs and symptoms of adverse consequences (i.e., side effects) of medications for one Resident (#61), out of 23 sampled residents. Specifically, the facility failed to monitor for signs and symptoms of hypoglycemia and hyperglycemia (low and high blood sugars) with the administration of insulin (anti-diabetic injectable medication). Findings include: Review of the facility's policy titled Diabetes-Clinical Protocol, revised December 2020, indicated but was not limited to the following: - Risk of hypoglycemia should be considered in any treatment plan, as it is a significant and high-risk complication of treatment. - The physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. - The physician will order desired parameters for monitoring and reporting information related to blood sugar management. - The staff will incorporate such parameters into the Medication Administration Record and care plan. - An example of appropriate treatment of hypoglycemia for a responsive individual would be 15 grams (g) to 20 g of carbohydrates in the form of glucose, sucrose tablets, or juice, combined with a sandwich, crackers, or other light snack containing protein. Resident #61 was admitted to the facility in December 2023 and had diagnoses including type 2 diabetes mellitus (DM) with diabetic neuropathy, end stage renal disease, and dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 6/26/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and received insulin injections. Review of current Physician's Orders indicated the following: - Insulin glargine subcutaneous solution 100 units/milliliter (ml), inject 10 units subcutaneously at bedtime for DM, 8/29/24 - Novalog FlexPen subcutaneous solution pen-injector 100 units/ml (insulin aspart), inject 5 units subcutaneously with meal for diabetes, hold for CBG (capillary blood glucose) less than 120, 5/11/24 - Novolog injection solution 100 units/ml (insulin aspart), inject per sliding scale: if 0-250=0 units; 251-300=2 units; 301-350=4 units; 351-400=6 units; 401-450=6 units, subcutaneously with meals for diabetes. If blood sugar is less than 70 or greater than 400 notify MD, 4/3/24 Review of Resident #61's Blood Sugar Vitals Record indicated the following values documented as being less than 70: 9/3/24 - 9:17 A.M., 60.0 mg/deciliter (dL) 9/4/24 - 10:21 A.M., 64.0 mg/dL 9/5/24 - 8:01 A.M., 69.0 mg/dL 9/11/24 - 11:36 A.M. and 11:39 A.M., 69.0 mg/dL 9/13/24 - 10:39 A.M., 68.0 mg/dL 9/14/24 - 9:09 A.M., 68.0 mg/dL 9/15/24 - 8:27 A.M., 68.0 mg/dL 9/18/24 - 10:25 A.M., 63.0 mg/dL Review of the September 2024 Medication Administration Record (MAR) indicated the insulin was held for the above below range blood sugar readings as ordered per sliding scale parameters. Further review of the September 2024 MAR and review of the September 2024 Treatment Administration Record (TAR) did not indicate documentation of monitoring of adverse consequences related to insulin medications. Further review of the medical record failed to indicate documentation that the above below range CBGs were reported to the physician to obtain potential treatment orders, if the Resident was experiencing signs and symptoms of hypoglycemia such as sweating, chills, confusion, anxiety, shakiness dizziness, or blurred vision, or follow up monitoring of the Resident's blood glucose level. During an interview on 10/1/24 at 11:30 A.M., Resident #61 said he/she was on insulin and his/her blood sugars could run low. The Resident said he/she was on dialysis so they could not have orange juice for it, but had food brought in by the family that he/she would eat. During an interview on 10/1/24 at 11:41 A.M., the surveyor reviewed the medical record with Nurse #5 who said there should be an order for hypo/hyperglycemia monitoring and treatment but there wasn't. She said there was no sign off on the MAR or TAR for it. Nurse #5 said the order is to call the physician if the blood sugar is less than 70 or greater than 400 and, if out of range, the nurse should document in a progress note. She said she could not locate documentation that this was done. She said the Resident should be monitored, but she has not had to personally treat him/her for low blood sugars. During an interview on 10/1/24 at 4:07 P.M., the Director of Nursing (DON) said the batch orders for diabetes management for Resident #61 were not entered which would have included: may obtain blood glucose as needed for symptoms of hypo/hyperglycemia, offer diabetic snack at bedtime, glucose gel (treats severe low blood sugar), Glucagon (treats severe low blood sugar) emergency medication, and diabetic hypo/hyperglycemia monitoring. She said the batch order is prepopulated and would have included everything. The DON said the orders should have been placed but weren't. She said if the blood sugar is less than 70 then the nurse should be notifying the physician even if the resident isn't symptomatic to let them know what the blood sugar was and to get a recommendation or order for treatment. She said the nurse would then document this in the medical record and go through the protocol. She said she couldn't determine if the Resident was symptomatic or not if it was not documented and would continue to look for the documentation and get back to the surveyor. During an interview on 10/2/24 at 7:16 A.M., the DON said she could not locate any documentation to support whether or not the Resident had signs and symptoms of hypoglycemia, if the physician was notified, or if recommendations or treatment orders were obtained for the below range blood sugar readings. During a telephone interview on 10/2/24 at 10:39 A.M., Physician #2 said he was covering for the attending physician but was familiar with the Resident. He said the Resident's blood sugars seemed to be stable with the highest recent daily reading being 155 and the lowest 74 with an order to notify the physician if the blood sugars were less than 70 or greater than 400. He said he would follow up with those readings and tell staff to hold the insulin if below range and said maybe the Resident just hadn't eaten. He said nurses would call and he would give a verbal telephone order for treatment. The surveyor reviewed the September 2024 blood sugar readings with Physician #2 that were below 70. Physician #2 said yes, he saw them in the electronic record and was somewhat familiar with them but said he couldn't locate any documentation about them or if the Resident had experienced any symptoms. He said typically he does not document in the record when on call but said the Resident usually did not have symptoms of hypoglycemia. He said typically there is an order for monitoring for hypo/hyperglycemia and treatment orders.

Based on observation, interview, and policy review, the facility failed to follow professional standards of nursing practice for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to allow adequate time for absorption of eye medication, when administering two eye medications. Findings include: Review of the facility's policy titled Instillation of Eye Drops, dated as revised January 2014, indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. -When administering two or more different eye drops allow three to five minutes between each application. Resident #6 was admitted to the facility in November 2021 with diagnoses including dry eyes and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 5/7/24, indicated Resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the current Physician's Orders indicated the following: -Restasis Ophthalmic Emulsion 0.05% (eye drop to increase tear production) instill one drop in both eyes two times a day for prevention -Artificial Tear Solution Instill one drop in both eyes two times a day for dry eyes During an observation on 6/3/24 at 8:41 A.M., Nurse #3 instilled one drop of Restasis into Resident #6's left eye, and one drop into his/her right eye. Nurse #3 then immediately picked up the container of Artificial tears and instilled one drop into Resident #6's left eye, and one drop into his/her right eye. During an interview on 6/3/24 at 2:45 P.M., Nurse #3 said she is not sure of the time frame needed to wait in between eye drops. She said she just administers them together. During an interview on 6/3/24 at 4:44 P.M., the Director of Nursing (DON) said when administering more than one eye drop, the nurse must wait a minimum of three to five minutes before administering another eye drop. She said if eye drops are given to close together, they do not have time to absorb, and are ineffective.

Based on interviews and record reviews, the facility failed to ensure a monthly medication regimen review was completed once per month for one Resident (#52), out of a total of five residents selected for unnecessary medication review. Findings include: Resident #52 was admitted to the facility in December 2023. Review of the medical record for Resident #52 included monthly medication regimen reviews for February 2024, April 2024 and May 2024. The record failed to indicate a medication regimen review was completed in March 2024. During an interview on 5/31/24 at 10:30 A.M., the Director of Nurses said she reviewed the March 2024 pharmacy reports and Resident #52 did not have a recommendation and was also not on the list of residents reviewed who did not have recommendations. During an interview on 5/31/24 at 10:57 A.M., the consultant Pharmacist said he had reviewed the information and found that Resident #52 had switched units on the day the Pharmacist was at the facility doing monthly reviews and the Resident had not been reviewed in March 2024.

Based on observation, interview, and policy review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were administered under direct supervision and not left at the bedside for one Resident (#6), out of a total sample of 24 residents. Findings include: Review of the facility's policy titled Administering Oral Medications, dated as revised October 2010, indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medications. -Remain with the resident until all medications have been taken. Review of the facility's policy titled Storage of Medications dated as revised November 2020, indicated but was not limited to the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -The nursing staff is responsible for maintaining medication storage. Resident #6 was admitted to the facility in November 2021 with diagnoses including hyperlipidemia (high cholesterol). Review of the Minimum Data Set (MDS) assessment, dated 5/7/24, indicated the Resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the June 2024 Medication Administration Record (MAR) indicated the following medication was scheduled for 8:00 A.M. and signed off as administered by the nurse: -Cholestyramine Light Oral Powder (used to treat high cholesterol) 4 grams (gm) On 6/3/24 at 8:41 A.M., the surveyor observed Nurse #3 prepare Resident #6's 8:00 A.M. medications. The following was observed: -Nurse #3 took one scoop of Cholestyramine Light Powder and mixed it with 4 ounces of water and placed it on top of the medication cart. -Nurse #3 placed the Cholestyramine mixed with water on Resident #6 bedside table -Nurse #3 instructed Resident #6 to drink the medication and exited the room -Nurse #3 left the Cholestyramine on the bedside table, unattended, and unlocked Review of the Care Plan failed to indicate Resident #6 self-administered medications. Review of the Physician's Orders failed to indicate an order to self-administer medications. During an interview on 6/3/24 at 8:52 A.M., Nurse #3 said Resident #6 does not have an order to self-administer medications. During an observation with interview on 6/3/24 at 9:02 A.M., Resident #6 said the nursing staff leaves the medication with him/her alone every day. The Resident said he/she usually doesn't drink it all because he/she does not like the taste. The surveyor observed the Cholestyramine mixed with water on Resident #6's bedside table. During an interview on 6/3/24 at 4:44 P.M., the Director of Nursing (DON) said medications should not be left at the bedside unattended, and the nurse should remain with the resident until all medications have been administered. She said Resident #6 does not have an order to self-administer medications and the medication should not have been left unattended and unsecured at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to develop and implement comprehensive person-centered care plans for three Residents (#84, #107, and #77), out of a sample of 24 residents. Specifically, the facility failed to: 1. For Resident #84, to develop and implement a care plan for resident safety with smoking; 2. For Resident #107, to develop and implement a person-centered care plan to address the use of antidepressant medication and behaviors; and 3. For Resident #77, to implement the plan of care for supervision while eating. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated but was not limited to the following: - a comprehensive person-centered care plan is developed and implemented to meet the resident's physical, psychosocial and functional needs - care plan interventions are derived from a thorough analysis of the information gathered as part of the assessment - the comprehensive person-centered care plan includes measurable objectives, describes services to be furnished and reflects current standards of practice - assessments of residents are ongoing and care plans are revised as information about the residents and their condition changes 1. Review of the facility's policy titled Smoking Policy - Residents, dated as revised July 2022, indicated but was not limited to the following: - a resident will be evaluated upon admission to determine if they are a smoker and their ability to safely smoke - a resident's ability to smoke safely will be re-evaluated quarterly, upon significant change and as determined by staff - any smoking related privileges, restrictions, and concerns shall be noted on the care plan and all personnel caring for the resident will be alerted Resident #84 was admitted to the facility in December 2023 with diagnoses including: cerebral palsy and muscle weakness. The most recent Brief Interview for Mental Status (BIMS), dated 3/20/24, indicated the Resident was cognitively intact with a score of 15 out of 15. Review of the medical record indicated Resident #84 had a smoking assessment completed upon admission and again on 3/21/24. The 3/21/24 smoking assessment indicated but was not limited to the following: - Yes, the Resident is a smoker and smokes cigarettes - There are no cognitive loss, visual deficit, or dexterity problems - Smoking occurs 1-2 times a day and the Resident can light their own cigarette and use an ashtray properly - the Resident does not express a desire to quit smoking - Resident is independent and does not require assistance to smoke - The care plan has been updated to assure the Resident is safe with smoking Review of the current active care plans for Resident #84 as of 5/31/24 failed to indicate a care plan had been developed for smoking. Review of the Resident's care [NAME] (nursing reference with resident-specific care information), dated 5/31/24, failed to indicate Resident #84 was a smoker. During an interview on 5/31/24 at 9:11 A.M., Activity Assistant #1 said Resident #84 is an active smoker and joins the smoking group daily at approximately 9:00 A.M. and 3:30 P.M. She said the Resident does not require any safety devices and is handed his/her cigarette and lighter and can independently light their cigarette, manage the ashes and extinguish the cigarette. She said cigarettes and lighting materials are kept locked up in the staff's possession and all smoking residents come to the smoking area at the designated times and a staff member is present. During an interview on 5/31/24 at 9:24 A.M., Nurse #1 said Resident #84 is an active smoker and is assessed quarterly. She said the process is to assess residents who smoke upon admission and quarterly and then an individualized care plan is developed for the Resident. She reviewed the medical record and care plans for Resident #84 and said there was not a care plan in place for smoking. During an interview on 5/31/24 at 9:34 A.M., Unit Manager #1 said Resident #84 was a smoker and should have a care plan for smoking safety. She reviewed the medical record and care plans for Resident #84 and said there was no care plan in place and it must have been missed in error. During an interview on 5/31/24 at 10:54 A.M., the Director of Nurses (DON) said all residents who smoke are required to have a care plan for smoking as part of the smoking assessment and care planning process. She reviewed the care plans for Resident #84 and said a care plan was not in place for smoking. 2. Resident #107 was admitted to the facility in April 2024 with diagnoses including dislocation of left hip prosthesis and metabolic encephalopathy. Review of the BIMS for Resident #107, dated 5/22/24, indicated the Resident was cognitively intact with a score of 14 out of 15. Review of the active orders for Resident #107, as of 5/31/24, indicated but were not limited to the following: - Trazodone (an antidepressant) 0.5 milligrams every eight hours as needed for agitation to be re-evaluated in 14 days (5/22/24) Review of the current care plans for Resident #107 failed to indicate a care plan had been developed for management of the perceived agitation or use of the antidepressant medication. Review of the current care [NAME], dated 5/31/24, failed to indicate the Resident had any agitation behaviors. During an interview on 6/4/24 at 9:51 A.M., Unit Manager #1 said the Resident does exhibit some minor agitated behaviors at times, but it is infrequent. She reviewed the care plans for Resident #107 and said the Resident does not have a care plan developed for the agitated behavior or the trialing of an antidepressant at this time. She said there should be care plans in place for the use of the antidepressant and the management of the Resident's agitation and there are not. During an interview on 6/4/24 at 10:02 A.M., the DON said the process is for residents on antidepressant medications or who demonstrate behaviors is to have specific care plans to address the need for those medications and to assist staff in managing any potential behaviors. She reviewed the medical record and care plans for Resident #107 and said there were no care plans in place to address the Resident's behavior of agitation or the antidepressant use as there should be in accordance with the care plan policy. 3. Resident #77 was admitted to the facility in September 2020 with a diagnosis of dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 4/11/24, indicated Resident #77 needed supervision (helper provides verbal cues or touching/steadying as resident completes activity) with eating. Review of the care plans indicated Resident #77 required assistance with activities of daily living including continual supervision while eating. Review of the Physician's Orders indicated that effective 6/9/23 Resident #77 had a mechanical soft diet, nectar thick liquids, one to one (1:1) supervision and aspiration precautions for aspiration pneumonia. Review of the Speech Therapy Discharge summary, dated [DATE], indicated Resident #77 needed 1:1 supervision and to be cued to cough to clear penetration and minimize aspiration. During an interview on 5/30/24 at 8:55 A.M., the family member of Resident #77 said he visits Resident #77 twice per day, for breakfast and dinner. He said Resident #77 does not get out of bed and eats all meals in bed. On 5/30/24 at 12:00 P.M., the surveyor observed Resident #77 in his/her room alone, self-feeding. At 12:02 P.M., the surveyor observed a nurse enter the room and leave at 12:04 P.M. No staff were observed to be with the Resident during lunch. On 5/31/24 at 11:43 A.M., the surveyor observed Certified Nurses Assistant (CNA) #2 bring the lunch tray to Resident #77, thicken the Resident's juice and attempt to wake the Resident up to eat, then leave the room. On 5/31/24 at 11:54 A.M. and 12:05 P.M., the surveyor observed Resident #77 in bed with his/her eyes closed and the lunch tray in front of them. During an interview on 5/31/24 at 12:19 P.M., CNA #2 said she occasionally works on this unit and was told when she was passing trays that Resident #77 needed to be set up for meals and that the Resident can feed him/herself and did not need any assistance after set-up. On 5/31/24 at 12:32 P.M., the surveyor observed Resident #77 to be awake and attempting to eat a piece of cauliflower (with two heads) from a spoon. The Resident was not able to open his/her mouth wide enough for the piece of cauliflower. During an interview with observation on 5/31/24 at 12:33 P.M., Nurse #2 said she was helping on the unit and could not speak to the Resident's supervision level. She said the cauliflower should have been cut up for the Resident when the meal tray was set-up. During an interview on 5/31/24 at 12:38 P.M., CNA #3 said she was familiar with Resident #77. She said the Resident did not like to get out of bed and that the Resident did not like to be fed and did well feeding his/herself once they woke up. She said the staff set up the meals and then leave the Resident to self-feed. During an interview on 5/31/24 at 12:45 P.M., the DON said she was not sure of the supervision status of Resident #77 and thought the Resident's family member was at the facility for every meal. During an interview on 5/31/24 at 1:25 P.M., the DON said Resident #77 should be supervised for all meals and staff should be assisting in cutting up food as needed.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had severe cognitive impairment, but could make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 01/19/24, Certified Nurse Aide (CNA) #1 spoke to Resident #1 in a loud, tough, degrading and inappropriate manner during care. Findings include: Review of the Facility's Resident Rights Policy, dated as revised February 2021, indicated federal and state laws guarantee certain basic rights to all residents of this facility. The Policy indicated these rights include the resident's right to a dignified existence, and to be treated with respect, kindness, and dignity. Resident #1 was admitted to the Facility in April 2015, diagnoses included: vascular dementia, myocardial infarction, major depressive disorder and anxiety disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 11/09/23, indicated he/she had severe cognitive impairment and had verbal and physical behaviors directed at others. Review of the Facility's Internal Investigation Summary, dated 1/19/24, indicated that at 12:45 P.M. on 1/19/24, a staff CNA (later identified as CNA #2) and an agency CNA (later identified as CNA #1) were providing care to Resident #1, when Resident #1 became combative towards CNA #1. The Summary indicated that CNA #1 verbally threatened Resident #1 and spoke abusively towards Resident #1. The Summary indicated that CNA #1 stated to Resident #1, If you're going to be mean, I'll be mean right back, I'll f*** you up, you got the wrong girl. The Summary indicated that CNA #1 was asked to provide a statement, refused to provide a statement and was asked to leave the facility immediately. Review of CNA #2's Written Witness Statement, undated, indicated that she was helping CNA #1 provide care to Resident #1 when CNA #1 said to Resident #1, If you touch me, I'll F--- you up, today you have the wrong girl. During an interview on 01/30/24 at 3:30 P.M., CNA #2 said that she was helping CNA #1 provide care to Resident #1 and said Resident #1 began throwing food at her (CNA #2) and became feisty with CNA #1 and said he/she verbally told CNA #1 to get out of his/her room. CNA #2 said that CNA #1 stated to Resident #1, If you touch me, I'm going to F--- you up and beat the crap out of you. CNA #2 said she immediately called out for a nurse and Nurse #1 came into the room immediately. Review of Nurse #1's Written Witness Statement, dated 1/19/24, indicated that a CNA (later identified as CNA #2) called her into Resident #1's room and an agency CNA (later identified as CNA #1) was being verbally abusive to Resident #1. The Statement indicated that CNA #1 said, If you're going to be mean to me, I will be mean to you. During an interview on 01/30/24 at 1:02 P.M., Nurse #1 said that she was at her medication cart when she heard CNA #2 yell out for a nurse. Nurse #1 said that when she entered Resident #1's room, CNA #1 was in the room and she heard CNA #1 state to Resident #1, If you're going to do that to me, I'm going to do that to you. Nurse #1 said that Resident #1 was going to scratch CNA #1 when she said that to Resident #1. Nurse #1 said that CNA #1 was sent home after the incident. During a telephone interview on 01/31/24 at 8:12 A.M., CNA #1 said she and CNA #2 were providing care to Resident #1 when he/she became combative and threw food at CNA #2. CNA #1 said that she told Resident #1 in a loud and tough voice that he/she needed to stop throwing food and stop doing that. CNA #1 said she was tough and loud with Resident #1 but denied swearing at him/her, denied that she said she was going to be mean to Resident #1 and denied that she said she was going to scratch Resident #1. During a telephone interview on 01/31/24 at 8:57 A.M., the Director of Nurses (DON) said that CNA #1 should not have talked to Resident #1 in the manner that she did. The DON said that it was her expectation that staff treat all residents with dignity and respect and not speak to residents in a loud and tough voice. The DON said that CNA #1 is not allowed back in the facility to provide care to any of the residents. On 01/30/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction that addressed the area(s) of concern as evidenced by: A) On 01/19/24, Resident #1 was immediately assessed by Nursing for any injuries. B) On 01/19/24, CNA #1 was sent home during the Facility's internal investigation, the Agency was notified of the incident and CNA #1 was not allowed to return to the Facility. C) On 01/19/24, the Director of Social Services provided a supportive visit and interviewed Resident #1. D) On 01/19/24, other residents on CNA #1's assignment were interviewed by the Director of Social Services, to identify any additional issues. E) On 01/19/24, the Local Police were notified of the incident and investigated the incident. F) On 01/19/24, Resident #1's Care Plan was updated by the Unit Manager to indicate that he/she was at increased risk for abuse related to aggressive behaviors. G) On 01/19/24, Abuse Prohibition and Resident Rights education was initiated for all staff, by the Staff Development Coordinator. H) On 01/29/24, Resident #1 was assessed by Behavioral Health Services. I) On 01/29/24, random Resident Interviews/Audits were completed by the Director of Social Services. The Director of Social Services will conduct weekly random resident interviews/audits twice a week for two weeks, then weekly for one month, then monthly for three months. J) The Director of Social Services/designee will meet with Resident #1 weekly for three months. K) Results of the random Resident Interviews/Audits will be discussed and reviewed monthly at the Quality Assurance and Performance Improvement (QAPI) Committee meeting for three months or until substantial compliance is met. L) The Director of Nurses/designee is responsible for overall compliance.

Based on interview and record review, the facility failed to notify the physician of a consulting physician's recommendation for one Resident (#95), out of a total sample of 26 residents. Specifically, the facility failed to notify the physician of the need to have a specialized diet to manage Resident #95's diagnosis of gastroparesis (weak muscle contractions of the stomach, resulting in food and liquid remaining in the stomach for prolonged periods of time). Findings include: Resident #95 was admitted to the facility in February 2023 with a diagnosis of peptic ulcer disease (break of the inner lining of the stomach). Review of the Minimum Data Set (MDS) assessment, dated 10/26/23, indicated Resident #95 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #95 was cognitively intact. Review of the medical record included a Report of Consultation, dated 9/21/23, completed by a Gastroenterologist indicating Resident #95 had a diagnosis of Gastroparesis. Recommendations listed included the following: -Need Gastroparesis diet: Low fat, low fiber, 6 small meals per day, no intake 3 hours before bed, limit narcotics and downgrade to full liquids if nausea/vomiting. Review of the Physician's Orders indicated a diet order active as of 6/8/23 for regular diet texture, low residue (limit high-fiber foods), low fat. The diet order failed to include any further instructions. Review of the progress notes failed to indicate the physician had been made aware of the Report of Consultation including diagnosis and treatment recommendations. Review of the care plan failed to indicate documentation of the gastroparesis diagnosis and diet treatment recommendations. During an interview on 1/9/24 at 10:38 A.M., Resident #95 said he/she remembered going to see the Gastroenterologist for bleeding in his/her stomach and gave the paperwork to the nurse upon return. He/she just assumed the facility was unable to provide 6 small meals per day. During an interview on 1/9/24 at 1:29 P.M., Unit Manager #3 said she was not familiar with this consultation and had never seen it before. She said she would notify the physician today. She said her expectation was for the nurse on duty to review the report and notify the physician with any new recommendations, then to note the recommendations and physician's response in the progress notes and file the report.

2. Resident #64 was admitted to the facility in September 2023 with diagnoses of cognitive communication deficit and other symptoms and signs involving cognitive functions following cerebral infarction (stroke). Review of the facility's policy titled Wandering and Elopement, dated March 2022, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm. Review of Resident #64's current care plans indicated but were not limited to the following: Focus: Elopement related to impaired safety awareness, date initiated 11/30/2023 Goal: Resident is an elopement risk related to impaired safety awareness with a goal of maintaining resident safety (11/30/23) Interventions: Wander guard bracelet (device used to trigger alarm at exit doors) to his/her right ankle (11/30/23) The surveyor made the following observations of Resident #64: -1/4/24 at 9:19 A.M., Resident self-propelling in wheelchair in the hallway. -1/4/24 at 3:04 P.M., Resident self-propelling in wheelchair wandering on the unit. When a staff member asked the Resident where he/she was going, the Resident responded: I don't know. -1/4/24 at 3:04 P.M., Resident self-propelling out of his/her room in wheelchair down the hall looking in other residents' rooms. -1/8/24 at 11:37 A.M., Resident self-propelling in his/her wheelchair out the doors of the unit activating the alarm on the unit as he/she attempted to leave the unit unsupervised. During an interview on 1/4/24 at 3:14 P.M., Nurse #3 said the Resident wanders quite a bit and he/she goes into other rooms at times and will try to get off the unit to get to the front door. During an interview on 1/4/24 at 4:14 P.M., Unit Manager #2 said residents at risk for elopement and with wander guards in use should be identified in the facility elopement books at each unit nurses' station and at the reception desk. She reviewed the elopement book at the nurses' station on the unit and said the information was not in the elopement book nor could she find the information in the elopement book at the reception desk. She said she was unsure of how information would be relayed to emergency services to prevent an unsafe situation if the Resident were to wander off the unit or out of the facility and the process was not in place as it should be. During an interview on 1/4/24 at 4:31 P.M., the Receptionist said that she would not know who is in danger of eloping if their information were not in the Elopement Binder left at the receptionist desk and therefore, would not be able to identify a missing resident to emergency services. She reviewed the elopement book at the receptionist desk and said the information for Resident #64 was not in the book. Based on observation, interviews, and records reviewed, for two Residents (#80 and #64) of 26 sampled residents, the facility failed to provide adequate supervision to prevent accidents. Specifically, the facility failed: 1. For Resident #80, to provide adequate supervision through fall prevention interventions. Resident #80 had a significant history of falls including two prior falls out of bed in the month of October 2023; and 2. For Resident #64, to implement the elopement binder safety system in use by the facility for a resident at risk for elopement. Findings include: 1. Review of the facility's policy titled Falls and Fall Risk, Managing, dated as revised in March 2022, indicated: - Staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) for each resident at risk or with a history of falls. Resident #80 was admitted to the facility in July 2020 with a diagnosis of dementia with behaviors. Review of the Minimum Data Set (MDS) assessment, dated 12/14/23, indicated Resident #80 needed substantial/maximal assistance to get on and off the toilet. Review of the care plans indicated Resident #80 was at risk for falls related to poor safety awareness and impaired mobility. The interventions included but were not limited to: - Bed sensor to alert staff of unassisted transfer attempts to decrease risk of falls and injury, - Frequent safety checks when in room, and - Monitor and assist with toileting needs; offer to bring to bathroom before/after meals, upon waking and prior to going to bed. Review of the medical record indicated Resident #80 had a history of falling out of bed including 10/2/23, 10/3/23, and 10/21/23. Review of the facility's Fall Investigation indicated Resident #80 fell out of bed on to a floor mat on 10/21/23 at 1:20 P.M. The statement from the nurse indicated the following: - The wall sensor alarm for Resident #80 sounded and Nurse #7 responded to the alarm to find Resident #80 attempting to get out of bed. Resident #80 had stated that he/she needed to get up and get changed. The nurse put the Resident's legs back in bed and told the Resident that she would get help. - The nurse left the Resident unattended to go ask for assistance from a Certified Nursing Assistant (CNA). - Two CNAs told the nurse they were not assigned to provide care for Resident #80 and did not go to assist Resident #80. - Resident fell out of bed four to five minutes later. During an interview on 1/9/24 at 11:10 A.M., the Director of Nurses said Resident #80 should have received assistance to avoid the fall. She said the CNAs should not have told the nurse they were not assigned to the help the Resident. The Director of Nurses said staff are to provide care to all residents.

Based on observation, interview, and policy review, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line device (inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava which is one of the central venous system veins that carries blood to the heart) was provided in accordance with professional standards of practice for one Resident #224, out of a total sample of 26 residents. Specifically, the facility failed to: -Ensure staff labeled and changed the PICC dressing to prevent the risk of germs entering the bloodstream when the dressing was compromised, and -Ensure the insertion site was visible for routine assessment by the licensed nurses. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, dated as revised March 2022, indicated but was not limited to the following: - the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. - perform site care and dressing changes at established intervals or immediately if the integrity of the dressing is compromised (damp, loose, or visibly soiled) - change the dressing if it becomes damp, loosened, or soiled immediately or the site appears compromised - assess the central venous access device with each infusion and at least daily - observe the insertion site and surrounding area for complications Resident #224 was admitted to the facility in December 2023, following an acute hospital stay with a PICC line for intravenous (IV) antibiotics to treat his/her diagnosed septic prepatellar bursitis of the left knee and cellulitis of the left lower extremity. Review of the most recent Brief Interview for Mental Status (BIMS) score indicated the Resident was cognitively intact with a score of 14 out of 15. Review of the PICC line insertion information in the Resident's medical record indicated the following: - Resident had a dual lumen (two access ports) PICC line inserted into his/her right basilic vein in his/her right arm on 12/22/23 while at the hospital. - PICC line total length is 32 centimeters (cm) - Baseline right arm circumference was 25 cm - Zero cm of catheter length was exposed externally from the insertion site Review of the admission assessment for the Resident, signed as completed, failed to indicate the Resident had a PICC line in place. Review of the admission Progress Note for Resident #224 by Nurse #4 indicated the Resident had a PICC line placed at the hospital. The note failed to indicate an assessment of the PICC line at the time the Resident was admitted . Review of the IV medication orders in place upon admission, 12/2023, for Resident #224 indicated the following: - Vancomycin hydrochloride (an antibiotic) 1000 milligrams (mg) intravenously two times a day for cellulitis/septic prepatellar bursitis until 12/30/23 - Ampicillin (an antibiotic) 3 grams (gm) intravenously three times a day for cellulitis until 12/30/23 Review of the December 2023 Medication Administration Record (MAR) for Resident #224 indicated the Resident received his/her IV antibiotics as ordered until the completion date. During an interview with observation on 1/3/24 at 8:56 A.M., the surveyor observed Resident #224 in bed with a dual lumen PICC in his/her right arm. The Resident said they were receiving antibiotics through the IV until recently. When he/she gestured to the IV pole at the head of his/her bed, the IV dressing protecting the IV site was observed to be loose and lifting significantly on the top right corner and bottom left corner. There was a thick opaque type of dressing approximately 2 cm long by 1 cm wide covering the insertion site of the IV making observation of the insertion site not visible for assessment. The dressing in place to the PICC line was unlabeled with no date of dressing change. The Resident said he/she could not recall the staff at the facility changing the dressing or thick opaque dressing over the insertion site of the IV and said the line was placed in his/her arm at the hospital about a week ago. Review of the current Physician's Orders (on 1/3/24) for Resident #224 indicated but were not limited to the following: - PICC site: observe the extremity and catheter for changes in skin, tissue and catheter integrity and monitor for redness, warmth, edema, dressing placement and catheter integrity - record observations two times a day (12/26/23) - Change PICC right arm transparent dressing, extension set, and cap on admission, weekly and as needed (PRN) for dressing change for IV maintenance - date and label dressing (12/29/23) On 1/3/24 at 11:42 A.M., the surveyor observed Resident #224 in bed with a PICC line in the right arm, the dressing integrity was compromised (loose) and peeling back in the corners and there was a thick opaque dressing covering the insertion site making the insertion site not visible for observations and assessment. During an observation with interview on 1/3/24 at 12:08 P.M., Nurse #7 observed the Resident's right arm PICC line site with the surveyor. She said the dressing was falling off and that could create the possibility of germs getting under the dressing and was an infection control concern. She viewed the dressing and said the dressing was not labeled or dated and the insertion site was not visible for an assessment of the insertion site. She said she can see that there are problems with the state of the PICC line and the dressing should have been changed or reinforced. She said the assessments of the line and insertion site do not occur on her shift and she did not notice the issue but believed the PICC was being removed shortly since the Resident had finished his/her antibiotics. During an observation with interview on 1/3/24 at 12:21 P.M., the Director of Nurses (DON) observed the Resident's PICC line and dressing. She said the dressing was loose and falling off and needed to be changed, but the staff were coming in to discontinue to line, in accordance with the MD order. She said the dressing was not dated and labeled as it should be and the insertion site was not visible for assessment and it was not good and the situation should have been taken care of when the issue was identified and it should not have been left like that. Review of the MAR and Treatment Administration Record (TAR) for December 2023 for Resident #224 indicated the following: - Change PICC right arm transparent dressing, extension set, and cap on admission, weekly and as needed (PRN) for dressing change for IV maintenance - date and label dressing was documented as completed on 12/23/23 and 12/29/23 - PICC site: observe the extremity and catheter for changes in skin, tissue and catheter integrity and monitor for redness, warmth, edema, dressing placement and catheter integrity - record observations two times a day were documented as completed twice daily from 12/26/23 through 12/31/23 Review of the MAR and TAR for January 2024 for Resident #224 indicated the following: - PICC site: observe the extremity and catheter for changes in skin, tissue and catheter integrity and monitor for redness, warmth, edema, dressing placement and catheter integrity - record observations two times a day were completed from 1/1/24 through 1/3/24 at 6:00 A.M. and 6:00 P.M. The January MAR and TAR failed to indicate the Resident had a dressing change completed to the PICC in the right arm. During an interview on 1/10/24 at 2:34 P.M., Nurse #4 said an assessment of the PICC line should be completed upon admission, which would be the first 48 hours of entering the facility. She said she could not find any information on the nursing admission assessment indicating the Resident's PICC line was assessed by anyone in nursing, but she did see that the orders for line assessment and measurements were put in place and signed off. She said the PICC observation site order was not put in place until 12/26/23 (more than 48 hours after admission). She reviewed the progress note she wrote at the time of the Resident's admission and said it did not include an assessment of the PICC line. During an interview on 1/10/24 at 3:14 P.M., the Director of Nursing (DON) said the expectations for PICC line assessment and dressing change are that the standard of care was met. She said the loose dressing should have been changed when it was identified as being compromised and was not. She said the opaque dressing over the insertion site would make a visual inspection of the insertion site for assessment of potential complications not possible and the dressing also not being labeled was a problem. She said the dressing was signed off as changed timely but the observation assessments were not and the facility needed to look into some additional education regarding the PICC line process.

Based on interviews and record review, the facility failed to ensure the plan of care was followed for one Resident (#83), in a total sample of 26 residents. Specifically, the facility failed to refer Resident #83 to Physical Therapy (PT) as recommended by the physician. Findings include: Resident #83 was admitted to the facility in March 2022 with a diagnosis of multiple myeloma (cancer of the plasma cells). During an interview on 1/3/24 at 4:10 P.M., Resident #83 said he/she was previously able to walk with a rolling walker but had become weaker. The Resident said he/she had been told about a week or two prior that he/she could work with PT on standing, but he/she had not seen a Physical Therapist. Review of the medical record indicated Resident #83 was seen by the physician on 12/20/23 and the physician recommended Resident #83 be referred to PT for ambulation and a referral was placed. Review of the Physician's Progress Note, dated 12/20/23, indicated Resident #83 had weakness in both lower extremities and the Resident agreed to PT for ambulation. During an interview on 1/5/24 at 1:26 P.M., Unit Manager #3 said Resident #83 was not on PT at this time and she would have to review when the referral was made to the rehabilitation department. During an interview on 1/5/24 at 2:10 P.M., Unit Manager #3 said the referral for Resident #83 had not been sent down to the rehabilitation department when the physician had recommended the services, 16 days prior. During an interview on 1/9/24 at 8:05 A.M., Resident #83 said he/she had not been seen by PT yet, 21 days after the physician had recommended the services. During an interview on 1/9/24 at 8:07 A.M., Unit Manager #3 said Resident #83 had not been seen by the rehabilitation department for evaluation yet.

Based on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#368), out of a total sample of 26 residents, hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to ensure a signed certification statement for hospice eligibility and hospice election forms were in the medical record to ensure prompt, effective communication and continuity of care for the Resident. Findings include: Review of the facility Hospice agreement, dated 1/7/2021, indicated but was not limited to the following: - Facility and Hospice shall prepare and maintain complete medical records for Hospice Patients receiving facility services in accordance with this agreement and shall include all treatment, progress notes, authorizations, physician orders, and other pertinent information. - Hospice will maintain a complete and timely clinical record on each Hospice Patient relating to all services rendered. - Hospice will provide the most recent hospice plan of care, election form; advanced directives; physician certification and recertification of terminal illness. Resident #368 was admitted to the facility in December 2023 with diagnoses which included cerebrovascular disease (stroke), acute ischemic heart disease, malignant neoplasm of colon, muscle wasting, and atrophy. Review of the Physician's Orders indicated Resident #368 was recommended for hospice on 12/27/23 and the Resident's representative elected hospice on 12/27/23. Review of the medical record for Resident #368 failed to indicate a physician certification for hospice services and consents for hospice services were in place and completed. During an interview on 1/4/24 at 3:30 P.M., Unit Manager #2 said that the hospice consents and physician certification should be located in the hospice binder assigned to the Resident. She reviewed the medical record and was unable to locate either the completed consent forms for hospice or the physician's signed certification for hospice services. During an interview on 1/10/24 at 3:02 P.M., the Hospice Nurse said the expectation is the physician certification and hospice consents should be in the facility in the medical record. She said the liaison and case manager are responsible for ensuring this is maintained and she wasn't aware they were not in the Resident's medical record as they should be.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding long call light wait times were acted upon to resolve the issue. Findings include: Review of the facility's policy titled Resident/Family Council, dated 12/19/22, indicated residents may voice grievances to the Resident Service Coordinator, Performance Improvement Coordinator, Social Services designee or Charge Nurse. The management team shall investigate any grievance. Review of the Resident Council Minutes, dated 9/7/23, indicated call light response time continued to be an issue, there was a QAPI (Quality Assurance and Performance Improvement) plan in place for call lights, nursing would continue to monitor, and the Resident Council requested the Director of Nurses attend the next meeting. Review of the follow up provided by the facility indicated a call light audit was conducted in September 2023 with call light wait times ranging from 4 minutes to 15 minutes. No other information was provided in response to the September Resident Council concern of long call light wait times. Review of the Resident Council Minutes, dated 10/5/23, indicated call lights continued to be an issue. The Director of Nurses was in attendance and addressed call light concerns stating the unit managers would conduct audits and there was an ongoing QAPI plan in place. Review of the follow up provided by the facility indicated a call light audit was conducted in October 2023 with call light wait times ranging from 2 minutes to 15 minutes and staff education to answer call lights was conducted on 10/23/23. Review of the Resident Council Minutes, dated 11/2/23, indicated call lights continued to be an issue, that Unit Managers had completed call light audits, and there was a QAPI plan in place for call lights and nursing would continue to monitor. Review of the follow up provided by the facility indicated a call light audit was conducted in November 2023 with call light wait times ranging from 4 minutes to 13 minutes. No other information was provided in response to the November Resident Council concern of long call light wait times. On 1/4/24 at 10:30 A.M., the surveyor held a group meeting with 10 residents in attendance. The residents said every month they bring up the concerns of the call lights and discuss waiting anywhere from 30 to 60 minutes for their call lights to be answered. Eight out of 10 residents said they have waited over a half hour for a call light to be answered. They said a facility representative at Resident Council discusses every month that the call light concern will be looked into, but the Resident Council was never told what the facility was going to do to fix the concern. During an interview on 1/4/24 at 11:40 A.M., the Ombudsman said he attends Resident Council every month. He said there were consistent and constant concerns with call lights not being answered and has brought this to the attention of management with no improvement. The Ombudsman said he has observed call lights on and multiple staff members sitting at a nurses' station and not responding to the call lights. During an interview on 1/5/24 at 11:40 A.M., the Activity Director said the residents voice concerns about long call light wait times every month at Resident Council. She said the residents voice waiting 30 minutes to an hour for call lights to be answered and this usually occurs in the evening hours. She said she reports the concerns to the Director of Nurses who also attended one of the Resident Council meetings. During an interview on 1/5/24 at 12:04 P.M., the Director of Nurses said she and other management staff have been conducting call light audits and if any call light is on for 10 to 15 minutes they will intervene and pull the staff together for an ad hoc education on answering call lights timely. During an interview on 1/9/24 at 9:20 A.M., Unit Manager #3 said she conducts call light audits sporadically during the month, during the weekdays. She said when doing the audits, she waits about 10-15 minutes and then gets the staff to remind them to answer call lights. During an interview on 1/9/24 at 3:17 P.M., the Director of Nurses said the call light audits were conducted by management staff discreetly going to a unit and pulling a call light. She said the audits are conducted between 8:00 A.M. and 5:00 P.M. and the management staff wait 10-15 minutes and will notify staff if the call light has not been answered. She said the management staff are not waiting to see the full response time. The Director of Nurses said the residents had concerns regarding evening call light wait times but no audits had been conducted during that time. She said there was a QAPI plan for call light response time which included conducting audits and the QAPI plan had not been re-evaluated for the effectiveness of doing audits.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#5), out of a total sample of 26 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to obtain a physician's order for Ankle Foot Orthotics (AFO) and to monitor skin surrounding/under the braces daily. Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized 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. Review of the facility's policy titled Orthotic and Assistive Devices, dated as last revised February 2022, indicated but was not limited to the following: -An assistive device is any piece of equipment that assists a resident in coping with the effects of his/her disability/limited range of motion due to medical condition. -Determining the best type of device stabilization for the resident includes assessment of skin integrity, rehab screen and recommendation. -Assistive devices are assessed during activities of daily living (ADL), prior to application and after removal. -Skin is assessed during ADL, prior to application and after removal. Report abnormalities to the provider. -Update care plan as needed. -The device is removed regularly, and the resident is assessed for circulation, skin integrity and range of motion. -The reason for the use of the joint stabilization device is documented in the medical record. Resident #5 was admitted to the facility in November 2020 and re-admitted after a brief hospitalization in December 2023 with diagnoses that included: hemiplegia and hemiparesis following a cerebral infarction (partial paralysis and weakness after a stroke) affecting right dominant side, difficulty walking, muscle wasting and atrophy and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 10/24/23, indicated Resident #5 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and needed assistance with activities of daily living (ADLs). The surveyor made the following observations: -1/3/24 at 10:06 A.M., Resident #5 was sitting in his/her wheelchair in his/her room with bilateral AFO braces on. -1/4/24 at 7:52 A.M., Resident #5 was sitting in his/her wheelchair in his/her room with bilateral AFO braces on. -1/5/24 at 11:06 A.M., Resident #5 was sitting in his/her wheelchair in the day room with bilateral AFO braces on. -1/8/24 at 9:40 A.M., Resident #5 was sitting in his/her wheelchair in his/her room with bilateral AFO braces on. -1/9/24 at 11:23 A.M., Resident #5 was sitting in his/her wheelchair in day room with bilateral AFO braces on. Review of the current Physician's Orders for Resident #5 failed to indicate an order for bilateral AFO braces or an order to check the skin surrounding/under the braces daily. Review of the Care Plan failed to indicate Resident #5 wore AFO braces daily. During an interview on 1/4/24 at 7:52 A.M., Resident #5 said he/she wears the AFO braces every day. During an interview on 1/4/24 at 9:36 A.M, Nurse #1 said Resident #5 wears the AFOs every day. During an interview on 1/8/24 at 2:34 P.M., the Director of Nurses (DON) said Resident #5 has bilateral AFO braces and wears them daily. Additionally, she said there is no order for them and there should be. She said there should be an order to put them on and take them off and an order to monitor the Resident's skin daily. She said a care plan for the use of the AFO's should be in place and there is not one. During an interview on 1/9/24 at 11:30 A.M., Nurse #8 said Resident #5 wears the AFOs every day. During an interview on 1/9/24 at 12:16 P.M., Unit Manager #1 said Resident #5 has had the AFO braces for years and there should have been orders in place for them, specifically to put them on, take them off, and for skin checks daily. During an interview on 1/9/24 at 4:05 P.M., Nurse #6 said Resident #5 has had the AFO braces forever, and she did not realize there were no orders for them but there should have been orders in place for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident was assisted with toileting to maintain continence of bowels and to prevent urinary tract infections. Specifically, the facility failed: 1. For Resident #99, to provide toileting assistance every two hours as recommended by a Urologist for assistance with recurrent urinary tract infections (UTIs); 2. For Resident #23, to provide toileting assistance timely to maintain continence of bowels; and 3. For Resident #96, to provide toileting assistance timely to maintain continence of bowels. Findings include: Review of the facility's policy titled Urinary Incontinence-Clinical Protocol, dated as revised in April 2022, indicated but was not limited to the following: - As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. 1. Resident #99 was admitted to the facility in July 2023 with diagnoses including dementia, UTIs, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 10/26/23, indicated Resident #99 was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Review of the care plans indicated Resident #99 had a history of frequent UTIs with interventions including being followed by a Urologist and assistance with hand hygiene following toileting. During an interview on 1/3/24 at 12:25 P.M., the Family Member of Resident #99 said she visited the Resident daily. She said her biggest concern was Resident #99 had multiple UTIs since being admitted to the facility. She said the Resident was to be toileted every two hours per the physician and the staff were not toileting the Resident every two hours. She said Resident #99 needed to be reminded to go to the bathroom to avoid holding in urine which could decrease the UTIs. Review of the Physician's Progress Note, dated 10/3/23, indicated Resident #99 was hospitalized from [DATE] through 9/1/23 for urosepsis (septic response to UTI) with a plan to follow up with Urology as scheduled. Review of the Physician's Progress Note, dated 11/28/23, indicated Resident #99 was seen for frequent UTIs, noting four UTIs in the past five months, with a plan to wait for the Urology recommendations from 12/19/23. Review of the Report of Consultation from the Urologist, dated 12/19/23, indicated Resident #99 had incontinence and to toilet the Resident every two hours during the daytime. Review of the Care Plans and Care Cards (information provided to the Certified Nursing Assistants (CNA) on how to care for the Resident) failed to include any information regarding toileting Resident #99 every two hours. During an interview on 1/4/24 at 4:17 P.M., CNA #11 said Resident #99 was continent 50% of the time and would get toileted approximately three times between 3:00 P.M. and when the Resident went to bed around 8:00 P.M. On 1/5/24 from 7:35 A.M. until 11:10 A.M., the surveyor observed the following for Resident #99: 7:35 A.M., up in wheelchair going to dining room for breakfast 8:03 A.M., finished breakfast, leaving the unit dining and staff brought the Resident to the end of the hallway. Resident #99 was observed by the surveyor every five minutes to be seated in a wheelchair at the end of the hallway until 9:41 A.M. 9:41 A.M., brought to unit day room. Resident was observed in line of site of the surveyor from 9:41 A.M. through 11:10 A.M. 11:10 A.M., CNA #4 approaches Resident and offers to take him/her to the bathroom and change his/her brief. 3 hours and 35 minutes after the observation initiated. During an interview on 1/5/24 at 1:02 P.M., CNA #4 said she had taken Resident #99 to the bathroom at 11:00 A.M. and the Resident was continent of bladder. She said she was not the assigned CNA to care for Resident #99 on this day, but knows the Resident and the schedule for the Resident was for the Resident to get up out of bed (get toileted and dressed) prior to 7:00 A.M. (with the previous shift) and to be toileted again around 10:00 A.M., then again around lunch time (11:30 A.M.-12:00 P.M.) and then before the second shift starts (around 3:00 P.M.). During an interview on 1/5/24 at 1:06 P.M., CNA #5 said she was assigned to care for Resident #99 on this day, but the Resident had been washed, dressed, and toileted by the previous shift. She said she had not toileted Resident #99 at any point during the day as of this time. She said there was no specific plan for toileting Resident #99 and if the Resident needed to go to the bathroom the Resident could ring their call light. During an interview on 1/5/24 at 1:15 P.M., Unit Manager #3 said all residents on the unit were to be toileted every two hours as a part of the routine. She said the staff should be doing rounds to toilet residents every two hours including during care, after breakfast, before lunch, after lunch. She reviewed the care plan and care card for Resident #99 and said they did not include the recommendations from the Urologist to toilet the Resident every two hours. She said the staff should be following the Urologist's recommendation to toilet Resident #99 every two hours. She said there was no documentation to indicate the staff had been educated on the recommendation. 2. Resident #23 was admitted to the facility in October 2021. Review of the MDS assessment, dated 10/7/23, indicated Resident #23 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. The MDS indicated Resident #23 was occasionally incontinent (one episode of bowel incontinence) of bowel. During an interview on 1/9/24 at 8:33 A.M., Resident #23 said the call light wait times can be up to a half hour. The Resident said over the weekend he/she waited over a half hour for staff to answer the call light. The Resident said they have diverticulitis (inflammation of colon) resulting in increased urgency for bowel movements and being unable to wait half an hour to have a bowel movement. The Resident said the staff did not respond to the call light timely and he/she was incontinent of bowel. During an interview on 1/9/24 at 8:53 A.M., CNA #4 said she had worked at the facility on Saturday 1/6/24 and Resident #23 had informed her of the incontinent episode that occurred on Friday 1/5/24. She said the CNA assigned to Resident #23 on Friday evening had gone on a dinner break from 7:00 P.M. until 7:30 P.M. and then was assigned to supervise the unit day room from 7:30 P.M. until 8:00 P.M. She said the other staff members had not answered the Resident's call light and that was why Resident #23 was incontinent. She said residents can wait a long time for call lights to be answered. During an interview on 1/9/24 at 9:20 A.M., Unit Manager #3 said she had met with Resident #23 the previous day and was aware the Resident had been incontinent of bowel while waiting for a call light to be answered. She said Resident #23 had diverticulitis and the Resident should not wait that long to be assisted with care. 3. Resident #96 was admitted in March 2022. Review of the MDS assessment, dated 11/16/23, indicated Resident #96 scored a 15 out of 15 on the BIMS indicating the Resident was cognitively intact. The MDS indicated Resident #96 was always continent of bowel. During an interview on 1/3/24 at 4:10 P.M., Resident #96 said he/she waits a long time for call lights to be answered, usually between 30 to 60 minutes. The Resident said they have had to hold their bowels so much that they were holding their breath to keep it in. Resident #96 said he/she has had to have an incontinent bowel episode in their brief from waiting for the call lights to be answered. Review of the December 2023 Bowel Continence tracker indicated Resident #96 was incontinent of bowels on 12/4/23, 12/26/23, and 12/28/23. During an interview on 1/5/24 at 2:30 P.M., CNA #6 said Resident #96 was incontinent of urine, but was continent of bowels and could tell when he/she needed to have a bowel movement and would put on the call light. During an interview on 1/9/24 at 8:05 A.M., Resident #96 said he/she had not been incontinent of bowels over the weekend but did have to wait over an hour for the call light to be answered. During an interview on 1/9/24 at 1:18 P.M., CNA #7 said Resident #96 was continent of bowel but had previously had episodes of bowel movements in his/her brief from waiting for the call light to be answered. During an interview on 1/9/24 at 9:20 A.M., Unit Manager #3 said sporadic audits of call light wait times had been conducted by her and she would intervene after waiting 10 to 15 minutes and there was no way to tell how long residents were waiting for call lights. She said no resident should wait 30 to 60 minutes for a call light to be answered and residents should not be incontinent of bowel movements because of waiting for a call light.

3. Resident #45 was admitted to the facility in July 2023 and had diagnoses including: major depressive disorder, recurrent - mild and psychotic disorder with hallucinations due to unknown physiological condition. Review of the medical record indicated that Resident #45 had current Physician's Orders for: - Zoloft (an antidepressant) 150 mg at bedtime daily; and - Remeron 7.5 mg (an antidepressant) daily for his/her diagnosis of depression. Review of the current care plans for Resident #45 indicated but were not limited to the following: Focus: Resident is at risk for distressed/fluctuating mood symptoms related to history of anxiety and depression. Goal: Resident will demonstrate stable mood and remain free of fluctuations in mood state. Interventions: Monitor/record/report to MD PRN (as needed) mood patterns, signs and symptoms of depression, anxiety, and sad mood as per orders. Review of the current care plans failed to indicate the Resident had a care plan with targeted behaviors with psychotropic medication use. Review of the medical record failed to indicate any orders were in place for licensed staff to monitor/record/report to MD PRN mood changes, signs and symptoms of depression, anxiety, and sad mood as directed in the care plan. During an interview on 1/9/24 at 11:44 A.M., Nurse #4 said she was unable to locate any information for target behaviors for the use of the Resident's antidepressants. She said the Resident experiences periods of weepiness but there was no order to monitor that behavior to determine the effectiveness of the medication in use. During an interview on 1/9/24 at 1:33 P.M., the DON said she would expect to find information on monitoring target behaviors and medication side effects in the orders for each resident on psychotropic medications for the licensed nurses to complete at least daily. On review of the medical record, she confirmed those orders and that information could not be found in the medical record for Resident #45 prior to the surveyor inquiring. Based on interview, policy review, and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs for three Residents (#90, #108 and #45), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #90, to ensure he/she was monitored for potential side effects of psychotropic medications and the effectiveness of the ordered psychotropic medications with identified target behaviors for the use of the medications; 2. For Resident #108, to Identify target behaviors and monitor the effectiveness of the ordered psychotropic medications in an effort to identify the minimum dose necessary; and 3. For Resident #45, to ensure he/she was monitored for potential side effects of psychotropic medications and the effectiveness of the ordered psychotropic medications with identified target behaviors for the use of the medications. Findings include: Review of the facility's policy titled Use of Psychotropic Medications, undated, indicated but was not limited to the following: - Residents are not given psychotropic medications unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the residents' response to the medication(s); - Residents who use psychotropic medications shall also receive non-pharmacological interventions to facilitate the reduction or discontinuation of the drugs; - Residents who receive antipsychotics will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission and every six months; - The effects of the psychotropic medications on a resident's well-being will be evaluated on an ongoing basis such as: in accordance with nurse assessment, medication monitoring parameters consistent with clinical standards of practice and the resident's comprehensive plan of care; - The resident's response to the medication(s), including progress towards goals and the presence or absence of adverse consequences shall be documented in the medical record; and - For enduring conditions: the resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented. 1. Resident #90 was admitted to the facility in December 2023 and had diagnoses including: Parkinson's disease, major depressive disorder recurrent and severe with psychotic symptoms, and encephalopathy. Review of the Pre-admission Screening and Resident Review (PASRR) level one, completed on 12/15/23, failed to indicate Resident #90 had a documented diagnosis of a serious mental illness or disorder. Review of the most recent Minimum Data Set (MDS) assessment for Resident #90, dated 12/2023 indicated but was not limited to the following: - Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she is cognitively intact. - Section D, Mood: indicated by use of the PHQ-9 assessment (Resident mood interview) a score of zero, did not have symptoms of feeling down, depressed or hopeless, indicating the Resident did not have any problems with his/her mood. - Section E, Behaviors: no documented or exhibited behaviors. - Section N, Medications: Resident is taking both an antidepressant and antipsychotic medication on a routine basis. Review of the current Physician's Orders for Resident #90 included but were not limited to the following: - Remeron (an antidepressant) 15 milligrams (mg), one tab by mouth at bedtime daily for mood (started: 12/15/23) - Seroquel (an antipsychotic) 25 mg, one tab by mouth at bedtime daily for mood (started: 12/15/23) Review of the December 2023 and January 2024 Medication Administration Records (MAR) for Resident #90 indicated he/she was receiving his/her medications as ordered. During an interview on 1/3/24 at 2:32 P.M., the Resident and their spouse said the goal is for Resident #90 to continue to improve and return home. They said they are aware of the medications to help with mood, but Resident #90 is not having any issues with mood at this time. The Resident said he/she signed all the consents and paperwork the facility asked him/her to and he/she feels good and is eager to return home. Review of the current care plans for Resident #90 included but were not limited to the following: Focus: The resident uses psychotropic drugs: antidepressant and antipsychotic medication related to (r/t) diagnosis of depression/mood disorder. Goal: The resident will be free from discomfort or adverse reactions r/t psychotropic medication therapy through the review date. Interventions: Administer medications as ordered by physician, ensure consent is signed, psych evaluation as needed, monitor, document and report any side effects. Review of the medical record for Resident #90 failed to indicate any target behaviors were identified for the use of the psychotropic medications to determine their effectiveness or any documentation was in place to monitor side effects of the psychotropic medications. During an interview on 1/9/24 at 11:47 A.M., Nurse #4 said the certified nurse assistants (CNAs) document any behaviors in the medical record and report them to the nurse for all residents. She said if a resident is on a psychotropic medication they would have target behaviors identified and monitored by the licensed nurses in the nursing progress notes. She said in addition, residents on psychotropic medications are monitored for potential side effects of the medications and that monitoring is documented on the MAR. She reviewed the medical record, including the MAR for Resident #90, and said she does not know and does not see any information on what the Resident's targeted behaviors for the use of his/her psychotropic medications and there was no documentation for monitoring the Resident for potential symptoms of side effects to the psychotropic medications as there should be and the information was missing. Review of the CNA documentation for behaviors for Resident #90 indicated the Resident has not exhibited any behaviors in the last 31 days. During an interview on 1/9/24 at 12:03 P.M., Unit Manager (UM) #2 said all residents on psychotropic medications are supposed to have orders in place to monitor their target behaviors and monitor for potential side effects of the psychotropic medications every shift by the licensed nurses on the MAR. She reviewed the medical record for Resident #90 and said there was no documented behavior monitoring or orders in place for the Resident and no indication in the progress notes that the Resident is exhibiting any behaviors or has any known target behaviors to determine if the psychotropic medications are necessary or effective. She said there is also no documentation in place that indicates the Resident is being monitored for potential side effects of their prescribed psychotropic medications. She said she is not aware of any behaviors the Resident has had or that the Resident had a history of behaviors. During an interview on 1/9/24 at 1:23 P.M., the Director of Nurses (DON) said the expectation was for the licensed nurses to monitor and document the effectiveness of all psychotropic medications and monitor and document any potential side effects of psychotropic medications. She reviewed the medical record for Resident #90 and said the behavior and side effect monitoring was not in place as it should be and it must have been missed. She said the care plan is not individualized as to the need for the medications or what the medications are specifically being used for and therefore there is no way for the staff to determine if the medications are effective and necessary or not. She said it doesn't appear the policy was being followed. Further review of the medical record for Resident #90 failed to indicate an AIMS test had been completed for the Resident and his/her use of Seroquel upon admission to help determine whether or not the Resident is having any adverse effects from the use of the antipsychotic. During a follow up interview on 1/9/24 at 3:20 P.M., the DON reviewed the medical record and said Resident #90 did not have an AIMS test completed, as it should have been on admission in accordance with the facility policy, and it was completed only after the surveyor inquired. 2. Resident #108 was admitted to the facility in August 2023 and had diagnoses including: mood disorder with depressive features, insomnia, major depressive disorder - recurrent and moderate, and non-traumatic intercranial hemorrhage (bleeding in the brain). Review of the PASRR level one, completed on 8/18/23, indicated Resident #108 had a documented diagnosis of mood disorder and insomnia. Review of the most recent MDS assessment for Resident #108, dated 11/2023, indicated but was not limited to the following: - Resident had a BIMS score of 15 out of 15, indicating he/she is cognitively intact. - Section D, Mood: indicated by use of the PHQ-9 assessment (Resident mood interview) a score of zero, did not have symptoms of feeling down, depressed, or hopeless, indicating the Resident did not have any problems with his/her mood. - Section E, Behaviors: no documented or exhibited behaviors. - Section N, Medications: Resident is taking an antidepressant, an antianxiety, and antipsychotic medication on a routine basis. Review of the current Physician's Orders for Resident #108, dated 1/2/24, included but were not limited to the following: - Seroquel 50 mg by mouth daily at bedtime for insomnia (started: 8/23/23) - Zoloft (an antidepressant) 100 mg, give one and a half tablets to equal 150 mg dose once daily for depression (started: 11/14/23) - Trazodone (an antidepressant) 50 mg by mouth at bedtime daily for insomnia/depression (started: 9/14/23) - Bupropion hydrochloride (an antidepressant) 75 mg by mouth twice a day for depression (started: 8/23/23) Review of the current care plans for Resident #108 indicated but were not limited to the following: Focus: Insomnia - Resident has difficulty sleeping at times (9/21/23). Goal: The resident will have no complaints of insomnia through the next review date (9/21/23). Interventions: Determine usual bedtime, dim lights at bedtime, ensure quiet environment, encourage resident to refrain from daytime napping, administer sleep medications as ordered (9/21/23). Focus: Resident is at risk for distressed/fluctuating mood symptoms r/t admission, recent stroke, history of mood disorder/insomnia, Healthdrive behavioral health (8/25/23). Goal: Resident will remain free of fluctuations in mood state through review date (8/25/23) Interventions: Assist resident to identify strengths and positive coping skills; Monitor/report/record nighttime (PM) mood patterns, signs and symptoms of depression, anxiety, sad mood, per orders to MD (8/25/23). Focus: Psychotropic medications: the resident uses psychotropic drug medications r/t mood disorder with depression (9/21/23). Goal: The resident will be free from discomfort or adverse reactions r/t psychotropic medication therapy through the review date (9/21/23). Interventions: Psych evaluation as needed; monitor for signs and symptoms of mood disorder and any behavior problems and report to social services (SS); consult with pharmacy - MD to consider dosage reduction when clinically appropriate at least quarterly; review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy; monitor/document/report side effects to MD per order; administer medications as ordered by physician; document and report observances of target behaviors per MD order (including interventions used and outcomes) (9/21/23). Review of the care plans failed to indicate what the target behaviors were for the prescribed psychotropic medications. Review of the December 2023 and January 2024 MARs for Resident #108 indicated he/she was receiving his/her psychotropic medications as ordered, but failed to include any documentation on the Resident's targeted behaviors for the use of the psychotropic medications and whether or not they were effective. During an interview on 1/4/24 at 3:00 P.M., CNA #7 said she knows Resident #108 and although she believes the Resident can be needy, she is not aware of or ever witnessed any other behaviors. During an interview on 1/4/24 at 3:06 P.M., CNA #1 said she knows the Resident well and he/she can be short-tempered when they don't feel well, but otherwise does not have any behaviors that she is aware of or has ever observed. During an interview on 1/4/24 at 4:01 P.M., CNA #9 said she knows the Resident well and the Resident will yell out or bang on their overbed table at times in the evening when the staff do not respond quickly, and that is the only behavior she is aware of for the Resident. During an interview on 1/4/24 at 4:04 P.M., Nurse #4 said the Resident exhibited some behaviors r/t anxiousness and not getting things done in a time frame they want. She said the Resident will ring the call bell excessively, yell out and bang on his/her overbed table when they feel things aren't done quickly enough. She said she does not know if that information is in the medical record or care plan, but any resident who exhibits a behavior should typically be verbally redirected by staff at the time the behavior is occurring. Review of the progress notes for Resident #108 from December to current (1/4/24) failed to indicate the Resident had any behavioral episodes. Review of the CNA documentation for behaviors for Resident #108 indicated the Resident has not exhibited any behaviors in the last 31 days. During an interview on 1/9/24 at 11:43 A.M., Nurse #4 said residents should have targeted behaviors monitored every shift on their MAR or in the nursing progress notes at least daily to indicate whether or not there are any behaviors or symptoms of depression present like weepiness and that is how they know if a psychotropic medication is effective to manage the resident. She reviewed the medical record for Resident #108 and said there were no nursing progress notes to indicate behavior monitoring was occurring or the Resident had any behaviors and the MAR did not have any documentation on it to indicate behavior monitoring was occurring. She said she knew the Resident had a history of insomnia and was on medication for that but she was not sure what specific targeted behaviors the other psychotropic medications prescribed to the Resident were managing. During an interview on 1/9/24 at 12:03 P.M., UM #2 said there should be orders in place for the staff to document every shift on potential behaviors for all residents who are on psychotropic medications. She reviewed the medical record for Resident #108 and said she could not find any evidence of behavior monitoring to determine if the psychotropic medications prescribed to the Resident were effective. She said the Resident is followed by Healthdrive behavioral and was last seen on 9/18/23 by the behavioral health nurse practitioner and the note from that visit indicated the staff should monitor the Resident for mood and behaviors, but she could not find any documentation of that occurring in the medical record. She said she was not aware that this Resident had any behaviors and she has not ever witnessed any behaviors for this Resident and there are no targeted behaviors documented in the medical record or on the Resident's care plans. During an interview on 1/9/24 at 1:21 P.M., the DON reviewed the medical record for Resident #108 and said she did not see any targeted behaviors or behavior monitoring in place or find any evidence that this Resident had any behaviors. She said the care plan is not individualized to target behaviors for the psychotropic medication use or how to determine if the psychotropic medications are necessary and effective. She said the policy and expectation for the use of psychotropic medications was not followed at this time.

Based on observation, record review, and interview, the facility failed to ensure that it was free of a medication error rate of five percent or greater. Specifically, the medication error rate was 5.56% with two errors observed of 36 opportunities. Findings include: Review of the facility's policy titled Administering Medications, dated as last revised April 2022, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. Review of the facility's policy titled Adverse Consequences and Medication Errors, dated as last revised in April 2014, indicated but was not limited to the following: -A medication error is defined as the preparation or administration of drug or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles do the professional(s) providing services. -Examples of medication errors include: a. omission; b. unauthorized drug; c. wrong dose; d. wrong route; e. wrong dose form; f. wrong drug; g. wrong time; h. failure to follow manufacturer instructions and/or accepted professional standards. Resident #66 was admitted to the facility in November 2019 with diagnoses which included muscle weakness, multiple sclerosis, and muscle spasms. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/16/23, indicated Resident #66 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the current Physician's Order indicated but was not limited to the following: -Calcium-Vitamin D Tablet 500-400 milligram (mg)-unit Give one tablet by mouth one time a day for supplementation. (6/21/2022) During the medication pass on 1/8/24 at 10:00 A.M., on Unit Potterville with Nurse #5, the surveyor observed the following: -Nurse #5 poured Calcium Carbonate 500 mg (chewable generic TUMS tablet containing 500 mg of Calcium) into the medication cup with the rest of Resident #66's morning medications. -Nurse #5 then signed off the Calcium-Vitamin D 500-400 mg-unit on the Medication Administration Record (MAR). -Nurse #5 then administered the cup of medications to Resident #66. Resident #59 was admitted to the facility in December 2018 with diagnoses which included adjustment disorder with anxiety, depression, and vascular dementia, severe with behavioral disturbances. Review of the MDS assessment, dated 11/9/23, indicated Resident #59 had severe cognitive impairment as evidenced by a score of 6 out of 15 on the BIMS. Review of the current Physician's Order indicated but was not limited to the following: -Senna tablet 8.6 mg Give 8.6 mg by mouth once a day for constipation (8/10/17). During the medication pass on 1/8/24 at 10:05 A.M., on Unit Potterville with Nurse #5 the surveyor observed the following: -Nurse #5 poured Senna-S also called Senna Plus (a tablet containing Senna 8.6 mg and docusate sodium or Colace 50 mg) into the medication cup with the rest of Resident #59's morning medications. -Nurse #5 then signed off the Senna on the Medication Administration Record (MAR). -Nurse #5 then attempted x3 to administer the cup of medications to Resident #59. -Resident #59 refused to take any of his/her morning medications. -Nurse #5 went back into MAR and marked the medications refused. During an interview on 1/8/24 at 1:33 P.M., Nurse #5 said, The Calcium Carbonate 500 mg (generic TUMS) contains the same 500 mg of Calcium so that's what I gave; it's not the same but it is what I usually give. Additionally, Nurse #5 said Senna is the same as Senna Plus, stating that they both have Senna 8.6 mg in them. The surveyor pointed out the Senna-S or Senna Plus also had docusate sodium 50 mg in it, a stool softener. Nurse #5 said, Oh, but it has Senna in it and that is what I always give. During an interview on 1/8/24 at 2:18 P.M., Nurse #4 said Calcium Carbonate 500 mg is not the same at Calcium-Vitamin D 500-400 mg-units and Senna is not the same as Senna S or Senna Plus. She said Calcium Carbonate 500 mg does not have any Vitamin D in it and Senna is just Senna, Senna Plus has Colace in it too and would have a different order. During an interview on 1/8/24 at 2:24 P.M., the Director of Nurses (DON) said Calcium Carbonate is not the same as Calcium with Vitamin D, the generic TUMS does not have Vitamin D in them. The DON also said Senna and Senna-S or Senna Plus are not interchangeable. The DON said the nurse needs education on both of those medications and although Resident #59 refused his/her meds he/she would have gotten the wrong medication because the pills were all poured and the nurse attempted to administer them. The DON stated Resident #59 can be difficult and sometimes refuses medications and luckily, he/she refused them today.

Based on observations and interviews, the facility failed to provide food that accommodated the preferences of one Resident (#23), in a total sample of 26 residents. Findings include: Resident #23 was admitted to the facility in October 2021. Review of the Minimum Data Set assessment, dated 12/28/23, indicated Resident #23 scored a 15 out of 15 on the Brief Interview for Mental Status, was cognitively intact and was their own healthcare decision maker. During an interview on 1/3/24 at 9:43 A.M., Resident #23 said he/she was unable to digest hard-boiled eggs and continued to receive a hard-boiled egg and toast every day for breakfast. During an interview on 1/5/24 at 8:25 A.M., Resident #23 said he/she got a hard-boiled egg again and he/she threw it right in the trash. He/she said they believed the Unit Manager had told the kitchen multiple times that the Resident no longer wanted to get hard-boiled eggs for breakfast. During an interview on 1/5/24 at 8:33 A.M., Certified Nursing Assistant (CNA) #4 said Resident #23 does not want hard-boiled eggs and the staff continue to tell the kitchen. During an interview on 1/5/24 at 1:31 P.M., the Food Service Director said he keeps a folder of food preferences and updates the preferences for each resident in the electronic system that prints the individual meal tickets. He said if the preferences for Resident #23 changed then the floor staff should have called the Food Service Director directly or should have written out a diet slip for a change. He said he had not received any changes for Resident #23 and would meet with the Resident. During an interview on 1/5/24 at 2:33 P.M., CNA #3 said the floor staff had previously notified the kitchen staff regarding the change in preference for Resident #23. She said Resident #23 no longer wants to get hard-boiled eggs and she was not sure why the kitchen continued to send them. During an interview on 1/9/24 at 8:33 A.M., Resident #23 said he/she had received a hard-boiled egg for breakfast on Saturday 1/6/24, after he/she had talked to the kitchen. When the staff had requested a new breakfast of fried eggs, he/she was provided with a cold smashed egg and cold toast and ultimately ended up eating cookies for breakfast. During an interview on 1/9/24 at 8:53 A.M., CNA #4 said she had worked on 1/6/24 and Resident #23 had received a hard-boiled egg for breakfast and had personally called the kitchen to order fried eggs for Resident #23. She said when the breakfast came up it was a mashed egg, not scrambled and was not fried. She said Resident #23 was not happy. During an interview on 1/9/24 at 10:00 A.M., the Food Service Director said the printed slip for meal tickets for the weekend had not been updated to reflect the preferences of Resident #23 that were reviewed on 1/5/24.

Based on observation, policy review, 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 ensure food was stored properly, discarded prior to use by dates, and to maintain safe and clean equipment in three out of three kitchenettes. Findings include: Review of the facility's policy titled Unit Par-List 2 x per day, undated, indicated but was not limited to the following: - Please ensure we are following our use by guideline and are cleaning fridges, microwaves, ice bins and ice scoops - Please note no personal belongings belong in our kitchenette Review of the facility's policy titled Food and Nutrition Services Use by dating guidelines, dated as revised 12/1/15, indicated but was not limited to the following: - The following is a guide to use when establishing a use by date for food items - Area: Freezer: frozen foods stored in the freezer - Use by date of 45 days after opening and properly closed. On 1/4/24 at 3:46 P.M., the surveyor observed the following on the Baypoint unit kitchenette: - Inside the microwave there were brown stains and food particle spatter on the top, bottom right corner and microwave plate, and exposed metal on the inside top; - On the door inside the refrigerator there was an iced coffee with no label or date; - The top cabinet had an iced coffee cup, which was warm to touch, with a small amount of thick brown substance with white flecks floating on top of the substance; and - Ice scoop holder had a brown, slimy substance on the bottom. On 1/4/24 at 3:57 P.M., the surveyor observed the following on the Cedarville unit kitchenette: - Inside the top and bottom of the microwave there were food particle spatter and brown stains; and - Ice scoop holder had a brown, slimy substance on the bottom. On 1/4/24 at 4:14 P.M., the surveyor observed the following on the Pottersville unit kitchenette: - Carton of ice cream in freezer dated 4/7 (no year); - Carton of ice cream in freezer dated 6/7 (no year); and - Box of popsicles in freezer dated 1/12/23 During an interview on 1/4/24 at 4:16 P.M., Unit Manager #3 said the ice cream and popsicles are expired and should not be there and threw them in the trash. She said the kitchen staff were responsible for cleaning and maintaining the kitchenette. During an interview with observation of the Baypoint kitchenette on 1/5/24 at 1:30 P.M., the Food Service Director said the microwaves were cleaned daily. The surveyor and the Food Service Director observed the microwave on the Baypoint Unit to continue to have a brown substance on the microwave plate and the bottom right corner of the microwave and to continue to have splatter and exposed metal on the inside top of the microwave. He said none of the microwaves should have exposed metal on the top and it would need to be replaced. He said the kitchen staff clean the ice scoop holders, which come off the wall, twice per day. The surveyor and the Food Service Director observed the Baypoint ice scoop holder to continue to have a brown, slimy substance on the bottom of the holder. He said the ice scoop holder bottom was removable and should be kept clean so as not to have a residue. The Food Service Director said staff should not be keeping unlabeled, undated coffees in the resident refrigerator or in the cabinets. In addition, he said the frozen items in the Pottersville unit freezer should have been disposed of prior to the surveyor observation and he was not sure how they could have been in the freezer that long.

Based on document review and interview, the facility failed to ensure the Arbitration agreement, in use by the facility, fully informed residents of their rights prior to entering into an arbitration agreement for three Residents (#68, #95, and #45), out of three residents reviewed. Findings include: During an interview on 1/4/24 at 5:07 P.M., the Administrator provided the survey team with a list of 26 residents who had entered into an Arbitration agreement with the facility. He said none of the residents who have signed the agreement have had any disputes resolved through the arbitration process. Review of the Arbitration agreement in use by the facility (undated) failed to indicate the Residents or their representatives had the right to a neutral arbitrator agreed upon by both parties, or the right to continue to communicate with federal, state or local officials including state surveyors, state health department employees, and the office of the Ombudsman. Review of the signed Arbitration agreement for Residents #68, #95, or #45 also failed to notify the Residents or their representatives of their right to choose a neutral arbitrator agreed upon by both parties and the right to continue to communicate with federal, state, or local officials including state surveyors, state health department employees and the office of the Ombudsman. During an interview on 1/9/24 at 4:09 P.M., the Administrator reviewed the Arbitration agreement in use by the facility and said he could not find any language in the agreement that reflects the selection of a neutral arbitrator to be agreed upon by both parties, or that the residents are not restricted from communicating with federal, state or local officials including state surveyors, state health department employees, and the office of the Ombudsman.

Based on observation, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to: 1. Implement outbreak testing for residents in accordance with their policy, state, and national standards, when the facility was experiencing an outbreak of COVID-19 infections; and 2. Ensure staff adhered to infection control protocols for personal protective equipment (PPE) use when providing care and services to residents requiring precautions to prevent the possible spread of germs and illnesses. Findings include: During an interview on 1/4/24 at 11:31 A.M., the Infection Preventionist (IP) said the facility was currently in a COVID-19 outbreak. She said the first resident tested positive for COVID-19 on 11/26/23 and was exposed on 11/22/23 and they have not been able to sustain a seven-day period with no COVID-19 positive cases since this date. Review of the facility's policy titled Coronavirus Disease (COVID-19)- Testing Residents, dated 4/1/2023, indicated but was not limited to the following: -Testing of all residents is conducted if there is an outbreak in the facility. -Following the requisite outbreak testing, long-term care facilities should test exposed residents and staff every 48 hours on the affected unit until the facility sustains seven days without a new case. -All tests for residents, including results, are documented. During an interview on 1/04/24 at 9:11 A.M., the IP said she started outbreak testing using the contact tracing method until 11/29/23 and then began broad-based testing. She said residents were being tested on Monday, Wednesday, and Friday to adhere to the 48-hour testing guideline. She said she realized those days did not meet the testing requirements once identified by surveyor. Review of resident records including but not limited to physician's orders, medication administration record, and progress notes for Resident #24 indicated: - Due to exposure to COVID-19 on 11/22/23, Resident #24 was to be tested for the next three days and then every 48 hours in accordance with his/her physician's orders. - Resident #24 was initially tested for COVID-19, as part of his/her exposure/outbreak testing on 11/23/23, 11/24/23, and 11/26/23. - COVID-19 testing was missed on 11/25/23 per MD order and nursing progress note dated 11/23/23. Resident #24 was tested for COVID-19, as part of the continued outbreak testing, on 12/1/23, indicating greater than 48 hours have passed, since the last test on 11/23/23, 8 days prior. Resident #24 was not COVID-19 tested again until 1/5/24, as a late entry note, 35 days after his/her prior COVID-19 test on 12/1/23. Resident #24 tested again for COVID-19, as part of an ongoing COVID-19 outbreak testing, on 1/9/24, four days after his/her previous test on 1/5/24. Record review for Resident #64 including but not limited to physician's orders, medication administration record, and progress notes, indicated: - Resident #64 was not tested for COVID-19 until 12/8/23, 9 days after broad-based outbreak testing was initiated in the facility on 11/29/23. During an interview on 1/04/24 at 12:34 P.M., the Director of Nursing (DON) said she is aware the facility is out of compliance with testing requirements. 2. Review of the facility's policy titled Isolation - Transmission-Based Precautions, dated as revised 10/2018, indicated but was not limited to: - Transmission-based precautions (TBP) are initiated when a resident develops signs and symptoms of a transmittable infection and is at risk of transmitting an infection to other residents - When a resident is placed on TBP, notification is placed on the room door so personnel and visitors are aware of the type of precaution - Signage informs the staff of the type of CDC precautions, instructions for personal protective equipment (PPE) use and the instruction to see the nurse before entering the room During an interview on 1/03/24 at 8:09 A.M., the DON said the PPE expectations in the facility are that staff follow the posted signs outside of each resident's room for any transmission-based precautions. She said the staff are wearing N-95 facemasks as source control on each nursing unit. On 1/3/24 at 11:34 A.M., the surveyor observed Certified Nurse Assistant (CNA) #1 approach Resident #110's room to deliver a lunch tray, the sign posted outside of the Resident's room indicated: Isolation: Droplet/Contact precautions. The CNA performed hand hygiene (HH) and donned (put on) a gown, face shield, and gloves. The CNA already had an N-95 respirator mask in place since the facility was using them as source control for their staff. CNA #1 knocked and entered the room delivering the lunch tray to the Resident in the room. Prior to exiting the room, the CNA was observed in the doorway of the room doffing (removing) her gloves, face shield, and gown, and then performing HH. She was not observed removing or changing her N-95 mask. She walked down the hall to Resident #221's room, which also had a sign on the door which indicated Isolation: Droplet/Contact precautions. CNA #1 performed HH and then donned a gown, face shield and gloves. She was not observed changing her dirty N-95. She entered the room and delivered a lunch tray. Upon exiting the room, the surveyor observed CNA #1 doff her gloves, face shield and gown and perform HH. She was not observed changing her N-95 mask. She continued down the hall to the opposite end of the unit to continue to pass lunch trays. At no time was CNA #1 observed to change her N-95 mask. Review of the sign in use by the facility and posted outside of Resident #110's room indicated but was not limited to the following: Isolation: Droplet/Contact precautions In addition to standard precautions staff and providers must: Clean hands when entering and exiting and: Wear gown and change in between residents N-95 respirator Eye protection (face shield or goggles) Gloves and change in between residents During an interview on 1/3/24 at 12:04 P.M., CNA #1 said she did not change her N-95 mask after leaving either isolation room as she should have; she made a mistake. She said since they wear the N-95 masks all day long as source control she must have forgotten but realizes the N-95 is dirty once it is in a positive isolation room and it should have been changed when leaving the room and was not. She said it was a mistake on her part and the processes for changing PPE was not followed. On 1/3/24 at 11:43 A.M., the surveyor observed Unit Manager (UM) #2 provide a report to two Emergency Medical Technicians (EMT) who arrived to the facility to transport Resident #221. The UM was heard informing the two EMTs that Resident #221 was on isolation precautions and required full PPE for direct contact. The two EMTs were observed to make their way to the room with a sign posted outside of the Resident's door indicating Isolation: Droplet/Contact precautions. The EMTs waited outside of the room while the Resident finished his/her lunch prior to entering. At 11:50 A.M., both EMTs were observed to perform HH and don gloves (they already had N-95 masks in place) and enter the room of Resident #221. Neither EMT were observed to don a gown upon entering the room or prior to physically touching the Resident to place him/her on the stretcher for transport. UM #2 was alerted to the situation and approached the doorway of Resident #221's room and asked the EMTs why they did not follow her report or the posted sign and don a gown prior to entering the room and physically transferring the Resident to the stretcher. The EMTs replied, Did you want us to do that too? to which the UM replied, Yes, you need to follow the protocols for infection control with a positive COVID-19 Resident. They exited the room with the Resident on the stretcher, doffed their gloves and masks at the bedroom door and performed HH prior to exiting the facility with the Resident. During an interview on 1/3/24 at 11:51 A.M., UM #2 said the transport of Resident #221 was not urgent and she had informed the EMTs about the required precautions prior to them going to the Resident's room. She said there is no reason why the EMTs shouldn't have followed the PPE use guidelines and infection control guidance as they were informed and it was a breech in infection control for them to not wear the necessary PPE prior to entering the room and handling the Resident. During an interview on 1/4/23 at 11:19 A.M., the IP was made aware of the surveyor's observations from 1/3/24 regarding posted signs and PPE use. She said although the facility is using N-95 masks as source control staff should be donning all required PPE prior to entering the room of an Isolation resident and doffing all the PPE upon exiting. She said the N-95 face mask should have been changed once it entered an Isolation room, as it would be considered dirty. She said there was no reason for the EMTs to not follow the posted Isolation signs and follow the PPE requirements and the expectations for using PPE in the isolation rooms were not met in these instances. Review of the sign in use by the facility and posted outside of the room of both Resident #90 and Resident #111 indicated, but was not limited to, the following: Enhanced Barrier Precautions - Everyone must clean their hands before entering and when leaving the room Providers and staff must also: Wear gloves and gown for the following high contact care resident activities: Transferring, changing linens, device care or use (urinary catheter) During an observation with interview on 1/4/24 at 3:54 P.M., the surveyor observed CNA #10 enter the room of Resident #90. There was a sign posted on the door of the room indicating Enhanced Barrier Precautions (EBP). CNA #10 performed HH prior to entering the room and donned gloves but was not observed to don a gown. CNA #10 was observed to adjust Resident #10's clothing, place shoes on the Resident, move the Resident to the edge of the bed and move the Resident's urinary catheter drainage bag while in the room, but was not observed with a gown on for protection throughout this entire process. The CNA said she thought the Resident was on EBP since he/she has a urinary catheter and she should have put a gown on before providing any care to him/her but she did not. She said she did not follow the posted sign or guidelines for PPE use with a Resident on EBP. During an observation with interview on 1/4/23 at 3:56 P.M., the surveyor observed CNA #9 and CNA #8 both enter the room of Resident #111. There was a sign posted on the door of the room indicating Enhanced Barrier Precautions. Both CNAs were observed to perform HH and don gloves but were not observed to don a gown. The two CNAs were observed to perform a mechanical lift transfer with Resident #111 and roll the Resident in the bed from side to side to remove the mechanical lift sling, neither CNA were observed to be wearing a gown throughout this process. CNA #9 said she believed the Resident has wounds on his/her bilateral legs and is on EBP for the open areas. She said they should have both put on gowns prior to providing care to the Resident and did not. CNA #8 said they messed up and did not follow the posted sign outside the Resident's room as they should have for PPE use with a Resident on EBP. During an interview on 1/4/24 at 3:58 P.M., the Staff Development Coordinator (SDC) was made aware of the surveyor's observations for both Resident #90 and Resident #111. She said the staff should have been wearing gowns as part of their PPE use with any resident on EBP and that is how they are trained. She said the guidelines for PPE use for a Resident with EBP were not followed in these instances. During an interview on 1/9/24 at 11:09 A.M., the surveyor made the DON aware of their PPE and infection control concerns. The DON said the PPE breeches should not have occurred and the expectation is that the signs posted outside of the Resident's room are followed. She said the staff may be experiencing some PPE fatigue but should be following the guidelines and using their PPE in accordance with guidance and in these circumstances they had not.

Based on interview, policy review, and document review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that had a systematic analysis and action plan to rectify identified issues. Specifically, after implementing actions to improve call light response time the facility failed to measure the success and track the performance to ensure improvements were sustained. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated as revised in February 2020, indicated the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: -tracking and measuring performance; -establishing goals and thresholds for performance measurements; -identifying and prioritizing quality deficiencies; -systematically analyzing underlying causes of systemic quality deficiencies; -developing and implementing corrective action or performance improvement activities; and -monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Review of the Resident Council Meeting Minutes indicated concerns with call light response times in the months of September 2023, October 2023, and November 2023. The Resident Council Minutes indicated the facility had initiated a QAPI project to improve call light response time. On 1/4/24 at 10:30 A.M., the surveyor held a group meeting with 10 residents in attendance. The residents said every month they bring up the concerns of the call lights and discuss waiting anywhere from 30 to 60 minutes for their call lights to be answered. Eight out of 10 residents said they have waited over a half hour for a call light to be answered. They said a facility representative at Resident Council discusses every month that the call light concern will be looked in to, but the Resident Council was never told what the facility was going to do to fix the concern. During an interview on 1/4/24 at 11:40 A.M., the Ombudsman said he attends Resident Council every month. He said there were consistent and constant concerns with call lights not being answered and has brought this to the attention of management with no improvement. During an interview on 1/5/24 at 11:40 A.M., the Activity Director said the residents voice concerns about long call light wait times every month at Resident Council. She said the residents voice waiting 30 minutes to an hour for call lights to be answered and this usually occurs in the evening hours. She said she reports the concerns to the Director of Nurses who also attended one of the Resident Council meetings and there was a QAPI in place. During an interview on 1/9/24 at 9:20 A.M., Unit Manager #3 said she conducts call light audits sporadically during the month, during the weekdays. She said when doing the audits, she waits about 10-15 minutes and then gets the staff to remind them to answer call lights. Review of the QAPI minutes provided by the facility indicated the facility had been conducting call light audits since March 2023. Review of the July 2023 QAPI projects indicated the facility identified a concern through Resident Council for call light response time. Review of an ad hoc QAPI project, dated 10/12/23, indicated a topic of Customer Service/Fall Prevention, with a Goal of Safety/Fall Prevention and an Objective of Staff education on customer service related to answering call lights/fall prevention for every resident. The project indicated the following: -Problems: staff indicating it's not my resident, increase risk of falls -Action: education provided to staff on expectation of answering call lights, rounding, and random call light audits -When: immediate education initiated as a result of a resident falling when a nurse asked for assistance, education monthly at each meeting -Follow-up: Administrator will continue to follow up with staff to ensure understanding of responsibilities to respond to call lights to decrease risk of falls and ensure resident needs are met timely. Review of the Quarterly QAPI Agenda, dated 10/26/23, indicated the following projects: Administrator: Answering call lights Nursing: Fall prevention During an interview on 1/9/24 at 3:17 P.M., the Director of Nurses said the call light audits were conducted by management staff discreetly going to a unit and pulling a call light. She said the audits are conducted between 8:00 A.M. and 5:00 P.M. and the management staff wait 10-15 minutes and will notify staff if the call light has not been answered. She said the management staff are not waiting to see the full response time. The Director of Nurses said the residents had concerns regarding evening call light wait times but no audits had been conducted during that time. She said there was a QAPI plan for call light response time which included conducting audits and the QAPI plan had not been re-evaluated for the effectiveness of doing audits. During an interview on 1/10/24 at 4:00 P.M., the Administrator said the most recent QAPI meeting was held on 10/26/23. He said there was no project in the QAPI binder for October 2023 that was specifically for call light response time, as there had been at the previous quarterly meeting in July 2023. He said there had been a customer service QAPI that included call light response time related to falls. He said the Resident Council continued to identify concerns with call light response time. He said the QAPI project for call lights had not been evaluated for the effectiveness of the program. He said the call light audits provided information but he was not sure what the facility was doing with the information. He said the staff have been educated on answering call lights but this had not changed the concern with call light response time. He said the facility was able to identify the concerns but had not taken the projects further to ensure improvement.