**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one Resident (#14) out of a total sample of 12 residents, with limited range of motion (ROM) received appropriate care and services to maintain and/or improve their mobility function. Specifically, the facility failed to implement an Occupational Therapy (OT) recommendation for a carrot device (an assistive or orthotic device used in a hand with a contracture, or permanent tightening of muscles, tendons or ligaments that limits movement of a joint or body part) for Resident #14 to prevent further loss of range of motion and skin breakdown. Findings include: Review of the facility policy titled Assistive Devices and Equipment, dated January 2020, indicated the following: -our facility maintains and supervises the use of assistive devices and equipment for residents. -recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. Resident #14 was admitted to the facility in May 2023, with diagnoses including Parkinsonism (a group of brain conditions that cause slowed movements, rigidity, and tremors), and Contracture of the left hand. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] indicated the following: -the Resident has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of a possible score of 15. -the Resident has functional limitation in range of motion (ROM) to both upper extremities. -the Resident required substantial/maximal (helper does more than half the effort) assistance to complete Activities of Daily Living (ADLs) including dressing. Review of Resident #14's Occupational Therapy Evaluation and Plan of Treatment for the certification period of 1/9/24 through 2/6/24 indicated the following: -New goal: Resident will wear carrot in left hand, times 2 hours, without signs or symptoms of skin breakdown or irritation to reduce the risk of further contracture and maintain current functional use. >Initiate wearing schedule dated 1/9/24 Review of Resident #14's Activities of Daily Living (ADL) Care Plan included the following intervention with a start date of 10/21/24: -Blue [Carrot] #10 to left hand as tolerated when out of bed. Remove for meals, transfers and tabletop tasks where he/she uses bilateral hands. The surveyor observed Resident #14 sitting up in his/her Broda wheelchair (a specific type of wheelchair that provides positioning support) with no carrot device in place to the Resident's left hand on the following dates and times: -11/13/24 at 3:05 P.M. -11/15/24 at 8:30 A.M. During an interview on 11/15/24 at 9:00 A.M., Certified Nurses Aide (CNA) #1 said she worked at the facility routinely and was familiar with Resident #14's care. CNA #1 said she remembered the Resident using a carrot device at one time but that he/she was no longer using the device. During an interview on 11/15/24 at 9:55 A.M., the Occupational Therapist (OT) said that she had implemented use of a carrot device when she saw Resident #14 in January 2024 and the carrot device treatment had not been discontinued by OT and should still be in use. During an interview on 11/15/24 at 11:16 A.M., the Corporate Nurse said that the carrot device should have been in place. The Corporate Nurse further said that she was unable to find any documentation that indicated the carrot device had been discontinued. The facility did not provide any additional documentation related to the Resident's use of the carrot device prior to the survey exit.

Based on record review, and interview, the facility failed to maintain complete and accurate medical records for one Resident (#34) out of a total sample of 12 residents. Specifically, the facility failed to ensure that complete and accurate documentation of neurological assessments were completed as required after Resident #34 sustained a fall, striking his/her head. Findings include: Review of the facility policy titled Fall Management Program dated 5/27/21 indicated the following: e. Any fall that involves a potential/actual head injury will include neurological checks. Neurological checks will be documented on the Neurological Assessment Flowsheet. Review of a blank facility Neurological Assessment Flowsheet indicated Neurological (Neuro) and vital signs (VS) to be completed as follows: -Every 15 minutes times four -Every 30 minutes times four -Every hour for the next four hours -Every four hours for the next 20 hours Resident #34 was admitted to the facility in May 2024 with diagnoses including lack of coordination, Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), repeated falls, and difficulty walking. Review of Resident #34's Nursing Progress Note dated 9/11/24, indicated the following: -At 7:30 PM this writer just turn [sic] away from Resident and heard a loud noise coming from his/her direction, saw Resident falling onto the floor, hit his/her head on the foot of the computer stand, roll to his/her right side . did sustain . a bump on top toward the back of his/her left head slightly pink, cold pad applied. Review of Resident #34's Nursing Progress Note dated 9/12/24 indicated the following: - .up in wheelchair, denies pain, neuro intact. Further review of Resident #34's medical record indicated no documented evidence that a Neurological Assessment Flowsheet had been completed that included neuro checks being done as follows: -Every 15 minutes times four -Every 30 minutes times four -Every hour for the next four hours -Every four hours for the next 20 hours During an interview on 11/18/24 at 9:08 A.M., the Assistant Director of Nursing (ADON) said when a Resident hits their head either witnessed or unwitnessed, the staff follow a protocol that included neuro checks being completed as outlined on the facility Neurological Assessment Flowsheet for 24 hours. The ADON said staff document the neuro checks and VS's on the Neurological Assessment Flowsheet that is scanned into the electronic medical record (EMR). During a follow-up interview on 11/18/24 at 9:50 A.M., the ADON said that she was unable to locate documentation that Resident #34's neuro checks and VS's had been completed on the Neurological Assessment Flowsheet as required, after Resident #34 sustained a fall, striking his/her head on 9/11/24. The ADON said that there were notes in the nursing progress notes on 9/11/24 and 9/12/24 that indicated Neuro intact, VS's, but the neuro checks and VS's had not been completed on the Neurological Assessment Flowsheet. The ADON said that the Resident did not have any changes neurologically, and the neuro checks were just not documented per the facility protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adhere to infection control practice standards to prevent the development and transmission of communicable diseases and infections in the facility, and for one Resident (#7) out of a total sample of 12 residents. Specifically, the facility failed to: 1) Develop and implement a Water Management Program to reduce the risk of Legionella growth and spread in the facility. 2) Ensure that infection control practices were adhered to during the removal of Personal Protective Equipment (PPE: equipment, such as a gown, gloves, mask, etc., that is worn to protect from the spread of infection) during observation of a medication administration process with Nurse #1. 3) For Resident #7, ensure that staff adhered to Enhanced Barrier Precautions (EBP- protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care) during the care of an indwelling urinary catheter (a device inserted into the bladder to drain urine outside of the body). Findings include: 1) Review of the Centers for Medicare and Medicaid Services (CMS) Memo titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD), reference QSO-17-30, revised 7/6/18, indicated the following: -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. -This policy memorandum applies to . Long-Term Care -Facilities must have water management plans and documentation that, at a minimum ensure each facility: >develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit. During an interview on 11/15/24 at 2:29 P.M., the Maintenance Director provided the surveyor with the CDC toolkit Version 1.1 assessment, dated June 5, 2017. The Maintenance Director said the facility did not have a Water Management Plan since there were no stagnant water sources in the facility. The Maintenance Director said the facility water source was supplied by the city of [NAME]. Review of the facility's CDC toolkit assessment Version 1.1, dated June 5, 2017, titled: Identifying Buildings at Increased Risk, indicated the following: -If you answer yes to any of the questions 1 through 4, you should have a water management program for that building's hot and cold water distribution system. -The facility answered yes to questions number 1 through 3 on the assessment. The facility did not provide any additional documentation related to a facility water treatment plan to the survey team prior to or at the survey exit. 2) Review of the facility policy titled Handwashing/Hand Hygiene, dated 3/5/20, indicated the following: -The facility considers hand hygiene the primary means to prevent the spread of infections. -Use of alcohol-based hand rub containing at least > 60% ethanol or >70% isopropyl alcohol; or, alternatively, soap and water for the following situations: >After removing gloves. On 11/14/24 at 7:50 A.M., during a medication administration process completed by Nurse #1, the surveyor observed the following: -Nurse #1 donned (put on) gloves at the medication cart to open a medication capsule added into yogurt for administration. -Nurse #1 doffed (take off) gloves and continued the medication preparation without performing hand hygiene. -Nurse #1 went into a resident's room to administer medications and donned gloves without performing hand hygiene. -Nurse #1 administered eye drops to the resident and doffed gloves without performing hand hygiene. -Nurse #1 donned new gloves, completed a fingerstick (when a finger is pricked with a lancet [small single use needle] to obtain blood for testing) blood glucose test, administer a medication injection and then doffed gloves and performed hand hygiene. During an interview on 11/14/24 at 8:05 A.M., Nurse #1 said she should have performed hand hygiene each time she removed her gloves. During an interview on 11/15/24 at 3:27 P.M., the surveyor reviewed the medication administration observation of Nurse #1 removing gloves without performing hand hygiene with the Infection Control Preventionist (ICP). The ICP said the first thing staff should do when removing gloves is perform hand hygiene. The ICP further said that not performing hand hygiene after removing gloves is an infection control concern. 3) Resident #7 was admitted to the facility in January 2024 with diagnoses including Chronic Kidney Disease (CKD- when the kidneys are damaged and cannot filter blood the way that it should) and absence of right leg below the knee. Review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/24 indicated the following: 1. Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms (MDROs) to residents. 2. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include . device care or use (central line, urinary catheter, feeding tube, tracheostomy ventilator, etc.) Review of Resident #7's October 2024 Physician order's indicated the following urinary catheter orders: -Foley (type of urinary catheter) catheter output document every shift, start date 11/3/24 -Foley catheter French (French scale or system used to size catheters) 18 with 10 cubic centimeter (cc) balloon(retention balloon - a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body) to gravity drain every shift, clarity and odor and color, start date 11/1/24 -Change as needed for leakage, start date 11/1/24 -Catheter care every shift, start date 11/1/24 -Catheter irrigation as needed with 60 cc normal saline (ns), start date 11/1/24 On 11/14/24 at 9:54 A.M., the surveyor observed the following: -EBP signage posted outside of Resident #7's room indicating to wear PPE when performing high contact care. -Three drawer bin containing PPE items. -Nurse #1 was observed at Resident #7's bedside, holding the tubing of Resident #7's urinary catheter in her ungloved hands. -While the surveyor spoke to the Resident, Nurse #1 lowered the urinary catheter tubing, excused herself, performed hand hygiene and exited the room. During an interview on 11/14/24 at 11:05 A.M., the Unit Manager (UM) said that she would expect gloves to be worn by staff when touching the tubing of the urinary catheter. During an interview on 11/18/24 at 11:30 A.M., the ICP said at every encounter with a urinary catheter or any part of the urinary catheter, including the tubing, gloves should be worn to prevent the spread of germs.

Based on interview and record review, the facility failed to follow Physician's orders for one Resident (#14) out of a total sample of 12 residents. Specifically, 1. For Resident #14, the facility staff failed to refer the Resident to a Urology Consultant for evaluation and management, as ordered by the Physician. Findings include: 1. Resident #14 was admitted to the facility in May 2023 with diagnoses including: Neurogenic Bladder (refers to what happens when the relationship between the nervous system and bladder function is disrupted by injury or disease), and recurring Urinary Tract Infections (UTIs). According to a Cleveland Clinic article titled Neurogenic Bladder, reviewed on 2/15/2022 (https://my.clevelandclinic.org), indicated that people who have Neurogenic Bladder are at higher risk for other urological problems, including repeated infections, kidney damage, vesicoureteral reflux and stones that form in the urinary tract. Review of the August 2023 Physician's orders indicated the following: -Refer to Nurse Practitioner ([NP] specialist for urology) evaluation and management, dated 5/26/23 -Straight catheterize every six hours for neurogenic bladder, dated 5/29/23 Review of the History and Physical (H&P) completed on 5/30/23, indicated the following: -Resident is high risk of UTI due to frequent self-catheterization. -Will refer to NP for urologic evaluation and management. Review of Resident #14's medical record indicated his/her most recent UTI was 5/27/23. During an interview on 8/2/23 at 9:58 A.M., the Unit Manager (UM) was unable to confirm if the referral had been made to the NP Consultant and if the Resident had been seen by the Urology Consultant. During a follow-up interview, the UM said the referral was made back in May 2023, and that it should have been followed through on, as it was a Physician's order and because the Resident is at high risk for UTIs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to practice acceptable standards of infection control and prevention for two Residents (#1 and #37) out of three applicable residents, out of a total sample of 12 residents. Specifically, the facility failed to: 1. Ensure that staff handled linens in such a manner to prevent contamination. 2. For Resident #1, ensure a Foley catheter (a thin, flexible tube placed through the urethra into the bladder to drain urine from the body) drainage bag was placed properly to prevent contamination. 3. For Resident #37, ensure that staff utilized personal protective equipment (PPE) while providing care to the Resident who was on Enhanced Barrier Precautions. Findings include: 1. On 8/1/23 at 9:49 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 remove clean linens from the linen cart. While she removed what she needed, other clean linens fell from the cart on the floor. The surveyor then observed CNA #1 pick up the contaminated linens from the floor and place them back into the clean linen cart and proceed into a resident's room. The surveyor further observed CNA #1 remove soiled linens from a resident's bed, carry them with her ungloved hands and place the soiled linens into a pile on the floor of the resident's room. CNA #1 was then observed to leave the resident's room without washing or sanitizing her hands and go into another room in search of the soiled linen cart. During an interview on 8/1/23 at 9:55 A.M., the surveyor informed CNA #1 of her observations. CNA #1 removed the contaminated linens from the clean linen cart and added the removed linens to the pile of soiled linens in the resident's room. CNA #1 said she had worn gloves when changing the resident's bedding but removed her gloves prior to carrying the soiled linens to the corner of the room and dropping them on the floor. CNA #1 then asked the surveyor, should I wash my hands now? CNA #1 then said she placed the soiled linens on the floor because she could not find the soiled linen cart, that the soiled linens did not belong on the floor, but she did not know what to do with them. During an interview on 8/1/23 at 10:05 A.M., the Assistant Director of Nursing (ADON) said CNA #1 should not have placed the contaminated linens back into the clean linen cart, should not have handled soiled linens with her bare hands, should not have placed the soiled linens on the floor and should have cleaned her hands immediately after handling the soiled linens. The ADON further said that soiled linens should have been bagged and placed into the soiled linen cart. 2. Resident #1 was admitted to the facility in June 2023 with a diagnosis of recurrent Urinary Tract Infections (UTIs). Review of Clinical Nursing Skills, 9th Edition copyrighted 2018 by [NAME] and [NAME], Chapter 34, page 877 indicated the following: - An indwelling catheter is attached to a urinary drainage bag to collect the continuous flow of urine. -Always hang the bag below the level of the bladder on the bed frame or chair so urine drains down, out of the bladder. -The bag should never touch the floor. Review of a Physician's Progress Note dated 6/10/23, indicated the Resident had recurrent UTIs and was prescribed Bactrim (an antibiotic) twice daily as well as Methenamine (an antibiotic that eliminates bacteria that cause urinary tract infections) twice daily. Review of a Urinalysis Report dated 7/18/23, indicated the following: Method of collection: Urinary Catheter Bacteria: Heavy (sign of infection) White Blood Cells: Too many to count (sign of an infection) Nitrite (chemical compound containing nitrogen and oxygen): Positive (sign of infection) Review of a Urine Culture Final Report dated 7/22/23, indicated the following: -Organism 1: Klebsiella Pneumoniae (a type of bacteria), greater than 100,000 colony forming units per milliliter (CFU/ml) -Organism 2: Proteus Mirabilis (a type of bacteria), 50,000-99,000 CFU/ml -Drug Resistant Organism: Klebsiella Pneumoniae ESBL (a type of bacteria) - testing indicated presence of extended spectrum beta lactamase (ESBL) which should be considered to be resistant to all Penicillins, Cephalosporins, and Aztreonam (types of antibiotics). Review of the July 2023 Physician's orders indicated the Resident was prescribed Augmentin (an antibiotic) 875 milligrams (mg) twice per day for seven days to treat his/her antibiotic-resistant UTI. During an observation and interview on 8/1/23 at 10:11 A.M., the surveyor observed the Resident lying in his/her bed with his/her Foley catheter's urine collection bag laying on the floor. As the surveyor was observing the catheter bag on the floor, the Assistant Director of Nursing (ADON) arrived in the Resident's room to update the surveyor that the Resident did not speak English. The surveyor then pointed out the collection bag laying on the floor. At that time, the ADON said the urinary drainage bag should not be on the floor due to the risk of causing infection. 3. Resident #37 was admitted to the facility in December 2022 with diagnoses including: Stage 3 Pressure Ulcer (full-thickness skin loss), Osteomyelitis (an infection of the bone) and a urinary catheter. On 8/1/23 at 9:15 A.M., the surveyor observed an Enhanced Barrier Precaution sign located at the entrance to the Resident's room (on the outside of the door at eye level) indicating that all providers and staff must .wear gloves and gown for the following high-contact areas: -Dressing -Bathing/showering -Transferring -Changing linens -Changing briefs or assisting with toileting -Device care or use (i.e.: central line, urinary catheter, feeding tube, tracheostomy -Wound care: any skin opening requiring a dressing Upon entering the room, the surveyor observed Resident #37 to be in bed receiving therapy. Therapist #1 had both hands under the top sheet providing direct contact care to the Resident. Therapist #1 was not wearing a gown. On 8/3/23 at 11:23 A.M., the surveyor observed Therapist #1 providing therapy at the Resident's bedside with her ungloved hand on the Resident's bare knee. Therapist #1 was not wearing a gown and gloves. Therapist #1 and the surveyor together observed the signage on the door outside of the Resident's room. Therapist #1 said that she was unaware that she was required to wear a gown and gloves when providing rehabilitation services to the Resident. During an interview following the observation, the Unit Manager (UM) said that staff are required to wear PPE (personal protective equipment) per the Enhanced Barrier Precaution sign for all direct, hands-on care.

Based on interview and record review, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccination per the Centers for Disease Control and Prevention (CDC) recommendations for two Residents (#14 and #31) out of a sample of five residents. Specifically, 1. For Resident #14, the facility staff failed to offer 20-Valent Pneumococcal Conjugate Vaccine (PCV20). 2. For Resident #31, the facility staff failed to offer either PCV20 or Pneumococcal Conjugate Vaccine 15 (PCV15). Findings include: Review of the facility policy titled Pneumococcal Vaccination - Residents, dated 6/11/19, indicated the following: -To provide each resident with a Pneumococcal Vaccination on admission, unless there is documentation that the resident had received these vaccinations prior to admission. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/15/23 indicated the following: -For adults 65 and over who have had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23), and it has been 5 years or greater since the last Pneumococcal vaccination then the patient and the vaccine provider may choose to administer the PCV20. -For adults 65 and over who have had PPSV23 only, and it has been 1 year or greater, then the patient and the vaccine provider may choose to administer PCV20 or PCV15. 1. Resident #14 was admitted to the facility in May 2023 and was over the age of 65. Review of the facility Vaccination Tracking Form indicated that Resident #14 had received the PCV23 vaccine on 12/29/03 and the PCV13 vaccine on 3/18/15. Further review of Resident #14's clinical record indicated no documented evidence that he/she had been educated, assessed for eligibility, and offered any additional Pneumococcal Vaccinations per the facility policy and CDC recommendations. 2. Resident #31 was admitted to the facility in April 2023 and was over the age of 65. Review of the facility Vaccination Tracking Form indicated that Resident #31 had received the PPSV23 vaccine on 6/21/21. Further review of Resident #31's clinical record indicated no documented evidence that he/she had been educated, assessed for eligibility, and offered any additional Pneumococcal Vaccinations per the facility policy and CDC recommendations. During an interview on 8/3/23 at 9:14 A.M., the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said that the Resident's Pneumococcal Vaccination status should have been reviewed upon admission and offered to the Resident/Resident Representative per the facility policy and had not been as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #3 was admitted to the facility in April 2021 with diagnoses including: Diabetes, chronic lower extremity edema (swelling caused by too much fluid trapped in the body's tissues), chronic lower extremity wounds, and xerosis (abnormally dry skin). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15. Review of the Resident's medical record indicated that due to the Resident's chronic wounds, he/she was under the care of a Wound Care Specialist contracted with the facility. Review of the August 2023 Physician's orders indicated an order to apply Lac-Hydrin (Ammonium Lactate, a medicated, topical cream used to treat xerosis) once daily to bilateral lower extremities, initiated 11/17/22. Review of the Wound Care NP progress notes indicated to apply Lac-Hydrin twice daily to Resident #3's bilateral lower extremities for xerosis twice per day, but first wrap with warm towels for 10 minutes, pat dry and remove lifting scales (loose areas of dry skin) on the following dates: -3/9/23 and 3/23/23 -4/6/23, 4/13/23, 4/20/23, and 4/27/23 -5/4/23, 5/11/23, 5/18/23, and 5/25/23 -6/2/23, 6/8/23, 6/15/23, and 6/22/23 -7/6/23, 7/13/23, and 7/20/23 Review of the Resident's medical record indicated no evidence these recommendations were ever implemented, nor was there evidence the Resident refused these recommendations. During an interview on 8/3/23 at 9:11 A.M., the surveyor asked the Resident if the facility staff ever wrapped his/her legs in warm towels and removed his/her dry scales prior to applying the Lac-Hydrin lotion. The Resident said, Oh I loved that! The Nurse did that for me once before. Resident #3 further said that the warm towel treatment had only been performed one time that he/she could recall. During an interview on 8/3/23 at 1:09 P.M., the Assistant Director of Nursing (ADON) said that after the Wound Specialist NP visited the residents, the ADON and another facility Nurse received an email from the Consultant Wound Care agency listing all the residents visited and recommendations made as a result of those visits. The ADON then presented said recommendations to the facility NP to review and write orders, if warranted. She further said if the NP ordered any of the recommendations and the Resident subsequently continued to refuse those interventions, it was possible the orders had been discontinued. During an interview on 8/3/23 at 2:08 P.M., the MDS Nurse said he was able to locate an order for the Lac-Hydrin cream dating back to 11/17/22, and upon reviewing the Wound Care NP progress notes, he learned she had been recommending the warm towel wraps as far back as December 2022. The MDS Nurse further said there was never an order for the warm towel wraps at any point, and the recommendation was never addressed as required. Based on interviews and records review, the facility failed to develop and implement a comprehensive person-centered care plan for four Residents (#14, #16, #37 and #3) out of a total sample of 12 residents. Specifically, 1. For Resident #14, the facility failed to implement a care plan relative to falls for a Resident who was considered high risk for falls and injury by: a) not following a wheelchair recommendation, and b) not following the care plan pertaining to falls assessments. 2. For Resident's #16, #37, the facility failed to implement a care plan relative to skin assessments for individuals who were considered high risk for skin breakdown. 3. For Resident #3, the facility failed to implement recommendations made by the Wound Specialist Nurse Practitioner (NP). Findings include: 1. Resident #14 was admitted to the facility in May 2023 with diagnoses including: weakness, lack of coordination, repeated falls, and Dementia. Review of the facility policy titled Fall Management Program, dated 5/27/21, indicated Fall Risk Assessment scores of 10 or above represents a high risk for falls and will require the development of a care plan with interventions implemented designed to minimize the potential for falls. Review of the Fall Risk assessment dated [DATE], indicated a total score of 14 for Resident #14 (indicating high risk for falls). Review of the History and Physical (H&P) completed on 5/30/23, indicated the following: -The Resident had sustained a fall while trying to self-transfer from the wheelchair to the bed without assistance. -The Resident forgot to lock the wheelchair and fell. a) Review of the Interdisciplinary Care Plan Meeting note dated 6/7/23, indicated the following: -Recent fall during transfer from wheelchair since wheelchair was not locked. -Will add anti-rollback (prevents a wheelchair from rolling backward) to wheelchair. On 8/2/23 at 8:58 A.M., the Rehabilitation Director and surveyor observed Resident #14 to not have the anti-rollback mechanism installed on his/her wheelchair. The Rehabilitation Director said that the maintenance department would install the anti-rollback mechanism if it was recommended, and she was unable to verify if that recommendation had been made. During an interview on 8/2/23 at 9:17 A.M., the Director of Maintenance said that the team meets every morning providing an opportunity for verbal communication and to follow up on any recommendations needed. Additionally, they utilize a computer-based program for all staff to submit work orders through, including recommendations for wheelchair changes. During a follow-up interview on 8/2/23 at 11:58 A.M., the Director of Maintenance said that he reviewed his records and did not have a record of a submitted request to install the anti-rollback mechanism to Resident #14's wheelchair. b) Review of Falls Care Plan, initiated on 5/24/23 indicated the following: -fall assessment on admission, quarterly and PRN (as needed)/Fall Review of the Interdisciplinary Notes indicated the Resident sustained a fall on the following dates: 6/8/23, 6/18/23 and 7/25/23. Review of the medical record indicated a fall assessment was completed on 5/24/23. No additional fall assessments were completed. During an interview on 8/2/23 at 10:48 A.M., the Unit Manager (UM) said that the only fall assessment available to review was dated 5/24/23. She said that based on the Resident's care plan, a fall assessment should be completed PRN and/or when the Resident experienced a fall. The UM said a fall assessment had not been completed as required after the Resident fell on 6/8/23, 6/18/23 and 7/25/23. Review of the Facility policy titled Skin Protocol dated 9/1/16, indicated to document condition of skin (risk areas) weekly. 2a. Resident #16 was admitted to the facility in February 2023 with diagnoses including: Type II Diabetes (when the body does not produce enough insulin to function properly, resulting in high blood sugar levels) and hemiplegia (paralysis of one side of the body) following a CVA (Cerebrovascular Accident). Review of skin integrity care plan initiated 7/13/23, indicated the following: -Resident is at risk for impaired skin integrity due to impaired mobility, Type II Diabetes, incontinence, decreased sensation and history of CVA. -Weekly skin check by licensed nurse. Review of the medical record indicated skin assessments were completed on 2/17/23 and 7/16/23. Further review of the record indicated no additional evidence that weekly skin assessments were completed per the Resident's care plan. During an interview on 8/2/23 at 1:28 P.M., the Assistant Director of Nursing (ADON) said that she found no evidence in the Resident's medical record that the facility staff had completed weekly head to toe skin assessments. She further said that the assessments should have been completed per the facility policy and the Resident's care plan, and was not completed as required. 2b. Resident #37 was admitted to the facility in December 2022 with diagnoses including: Stage 3 Pressure Ulcer (full-thickness skin loss), Paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs) and Osteomyelitis (an infection of the bone). Review of the Skin Integrity Care Plan updated on 2/21/23, indicated the following: -Weekly skin check by licensed nurse During an interview on 8/3/23 at 9:24 A.M., the ADON said there was no documented evidence of weekly skin checks being completed. She said that typically there will be an order, which will carry over onto the Treatment Administration Record (TAR). The Nurse will then check off that the skin assessment had been completed, and if there are any newly identified areas the Nurse would then proceed to completing a skin assessment. The ADON said that the order was placed yesterday (8/2/23) as it had not been there. [sic]

Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary environment in the kitchen and adhere to safe food practices relative to labeling, dating and removal of expired food. Specifically, the facility staff failed to ensure that: a) food items for resident consumption were stored, labeled, dated, and not expired. b) kitchen equipment was properly cleaned and sanitized. c) staff wore proper hair restraints. Findings include: Review of the facility policy titled Food Safety Management System revised on 4/1/22, indicated the following: -B-8 Employee Uniforms, Hair Restraints and Personal Items >Food employees shall wear hair restraints such as hats hair covers or nets, beard restraints, and clothing that covers body hair. -D-9 Cleaning and Sanitizing Frequency >Every 24 hours for: *Cooking and baking equipment *Non-food contact surfaces must be cleaned at a frequency necessary to preclude the accumulation of soil residue On 8/1/23 at 7:57 A.M., the surveyor conducted an initial walk through of the kitchen with Dietary Staff #1. The following was observed: a)-A box of corn meal: opened and undated -A bag of brown sugar: opened and undated -A bag of sliced almonds: opened and undated -Four trays of ribs stored on a tall tray cart, uncovered in the open kitchen. -Three uncovered containers of cooled soup. During an interview at the time, Dietary Staff #1 said that those items (corn meal, brown sugar and sliced almonds) were opened last night, and should have been labeled with the date they were opened. Dietary Staff #1 said that ribs were cooked last night, and then placed in the walk-in refrigerator as they cooled. He said he was educated to not cover foods that were still hot to avoid any type of condensation and potential bacterial growth. Dietary Staff #1 further said that the three uncovered containers of soup were from dinner last night and were placed in the walk-in refrigerator to be cooled down. -Walk in refrigerator >One container of gelatin dessert: undated >One container of potato salad: undated >One container of pasta salad: undated >One large container of fruit salad: undated >Two large containers of cooked pasta not completely covered >One container of expired pizza sauce, dated 7/21/23 Dietary Staff #1 said that the pizza sauce should have been thrown away. b)-The backsplash behind the cooking and baking equipment, in multiple areas contained food particles splattered throughout. -The left side of the ovens were laden with thick grease and food residue. -One of the three hoods contained a brownish orange dust debris built up in the left corner. -The sides of the flat cook-top were laden with thick grease and food residue. c) During a follow-up visit to the kitchen and interview on 8/3/23 at 11:01 A.M., the Food Service Director (FSD) and the surveyor observed one kitchen staff with a large beard prepping food. The kitchen staff was not wearing a beard protector (hair restraint). The FSD said that the kitchen staff should be wearing a hair restraint while prepping food. The surveyor and the FSD reviewed the concerns that had been noted during the initial walk-through. The FSD said that the kitchen appliances including the hood had not been cleaned in a timely manner or per the cleaning schedule and therefore had more build up than normal. He said the company that cleans the hoods comes in quarterly, however had missed the last scheduled cleaning, therefore had not been in since January. The FSD said that the uncovered ribs and soups that were observed in the kitchen and stored on the tall tray cart, should have been covered when in the open kitchen.

Based on interview, record review, and policy review, the facility failed to ensure staff provided a Notice of Transfer and Discharge to the Resident and/or the Resident's Representative in writing upon transfer to the hospital for one Resident (#30) out of a total of 12 residents sampled. Findings Include: Review of the facility policy titled Admission, Transfer & Discharge, dated 8/24/17, indicated the following: Notice before transfer: Before the facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing . Resident #30 was admitted to the facility in April 2021. Review of the Nursing Home to Hospital Transfer Form dated 1/21/22 indicated Resident #30 was sent to the hospital on 1/21/22. Further review of the Resident's medical record did not indicate that Resident #30 and/or his/her representative received a Notice of Transfer and Discharge form at the time of hospitalization. During an interview on 5/23/22 at 2:49 P.M., the Director of Nursing said she was unable to provide a Notice of Transfer or Discharge for the Resident's transfer on 1/21/22. She further said the nurse who worked on the unit should have completed the form at the time of transfer and sent the Resident with a copy and that was not done as required.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#14) out of a total of 12 sampled residents was free from a significant medication error, putting him/her at risk for seizure activity. Findings include: Resident #14 was admitted to the facility in November 2021 with a diagnosis of seizure disorder. Review of Lippincott Nursing Procedures - 8th Ed. (2019), Safe Medication Administration Practices, included the following: -To promote a culture of safety and to prevent medication errors, nurses must avoid distractions and interruptions when preparing and administering medications and adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. Review of Wolters Kluwer Nursing 2022 Drug Handbook - 42nd Ed. (2022), included the following: - Monitor drug level. Therapeutic level of total Phenytoin (a medication used to manage seizures) is 10-20 micrograms per milliliter (mcg/ml) in adults. Review of the clinical record indicated laboratory results measuring the amount of Phenytoin level in the Resident's blood was 5.5 mcg/ml (below established therapeutic range) on 1/11/22. There was no evidence in the clinical record that the Phenytoin levels were obtained after 1/11/22. Review of the May 2022 Physician's Orders included the following medication order: - Phenytoin Sodium Extended Release, 100 milligram (mg) capsule, give four capsules by mouth daily, initiated 2/1/22. On 5/20/22 at 8:03 A.M., during a medication pass, the surveyor observed Nurse #1 administer one Phenytoin 100 mg capsule to Resident #14 instead of the four capsules per the Physician's order. On 5/20/22 at 8:46 A.M., Nurse #1 said he gave Resident #14 one Phenytoin capsule and he should have given a total of four as ordered.

Based on observation and interview, the facility failed to ensure the resident environment remained free of accident hazards by failing to to clean the lint filter for two of two clothing dryers in the laundry room presenting a potential fire risk. Findings include: On 5/23/22 at 4:05 P.M., the surveyor and the Facilities Director observed the lint filters on the dryers in the laundry- room, a coating of lint in the lint filters. The staff working in the laundry had left for the the day. The Facilities Director said that there was approximately a one day build up of lint and staff should have cleaned the lint filters prior to leaving for the day. The Facilities Director was unable to locate the schedule logs for the lint filter cleaning.

Based on observation, interview, and policy review, the facility failed to ensure that a.) Food items for resident consumption were stored, labeled, dated, and not expired for three out of three kitchen areas observed and b.) Kitchen equipment was properly cleaned and sanitized for one out of three kitchen areas observed. Findings include: Review of the facility policy titled, Sanitation and Infection Control Labeling and Dating, undated, indicated that all foods will be appropriately wrapped, labeled and dated based on food storage guidelines. It further stated that all foods are labeled, dated and securely covered and use-by dates are monitored and followed. On 5/19/22 at 7:15 A.M., during a walk through of the kitchen with the Executive Chef, the following was observed: In the side by side refrigerator: -eight salad dressing containers were open with no open date and no expiration/use by date. In the walk in refrigerator: -an employee lunch was stored on the shelf in plastic bags. -uncovered/ undated flan dessert in a large sheet pan. -metal containers filled with tomatoes, cucumbers and cabbage were undated. In the food prep area: -the microwave had multiple cooked potatoes in it, as well as other food particles splattered throughout. -sandwich/salad topping containers with cut chicken, tomato, onions, pickles, and lettuce were undated. In the one door salad fridge: -a tray containing small ramekins filled with cut fruit were undated. In the wait staff refrigerator: -two opened Lactaid containers had an expiration date of 5/10/22. The Executive Chef said that the salad dressing containers should have been labeled with the date they were opened as well as a use by date. He said the employee lunch should not be stored in the walk in refrigerator. He also said that the flan dessert should have been covered and dated. He further said that the potatoes were from last night and that the microwave is usually cleaned out every night and should have been. Lastly, he said that the toppings and cut fruit should be labeled and were not as required. On 5/23/22 at 3:49 P.M., the surveyor and Dietary Aide #1, observed in the Point of Service Kitchen refrigerator on the unit, four open containers of Lactaid with an expiration date of 5/10/22. Dietary Aide #1 said the expired Lactaid should not be in the refrigerator and should have been disposed as they were expired.

4. Resident #2 was admitted to the facility in October 2019. Review of the medical record included a MOLST signed by the Resident and the Physician on 11/19/21 that indicated the following preferences: attempt resuscitation, Do Not Intubate and ventilate, use Non-Invasive Ventilation, transfer to hospital, use dialysis short term only, use artificial nutrition and use artificial hydration. Review of the Advanced Directive Care Plan, with a start date of 4/27/22, indicated the Resident had formulated an advanced directive that reflected his/her wishes to be: Do Not Resuscitate, Do Not Intubate and ventilate, do not use Non-Invasive Ventilation, transfer to hospital, no dialysis, no artificial nutrition, no artificial hydration. 5. Resident #15 was admitted to the facility in December 2021 Review of medical record indicated a MOLST signed by the Resident's Representative and Nurse Practitioner on 12/13/21 that indicated he/she requested: Use of Non-Invasive Ventilation and use of artificial hydration. Review of the Advanced Directive Care Plan, with a start date of 12/06/21, indicated the Resident had formulated an advanced directive that reflected his/her wishes to be: do not use Non-Invasive Ventilation and no artificial hydration. Review of Resident #15's Resident Weight Tracking System Report indicated the following weights: 4/19/22 105.2 pounds (lbs.) 4/26/22 101.6 lbs. 5/3/22 99.8 lbs. 5/12/22 100.6 lbs. 5/18/22 99.4 lbs. indicating a 5% or greater weight loss within a month During an interview on 5/23/22 at 2:46 P.M., the Director of Nursing (DON) said Resident #15 should have had a reweigh done on 5/18/22. During an interview on 5/23/22 at 3:21 P.M., the DON said the Resident was reweighed 5/23/22 and was 104 lbs. The wheelchair weight that the staff had been using of 39 lbs. was incorrect and the wheelchair actually weighed 35 lbs. She further said there was clearly an issue with the weight documentation due to inaccurate wheelchair weight, and they will need to reestablish a baseline weight for the Resident. 6. Resident #30 was admitted to the facility in April 2021. Review of the medical record indicated a MOLST signed by the Resident and Nurse Practitioner on 4/29/21 that indicated the following preferences: use of Non-Invasive Ventilation and use of artificial hydration. Review of the Advanced Directive care plan, with a start date of 1/30/22, indicated the Resident had formulated an advanced directive that reflected his/her wishes to be: do not use Non-Invasive Ventilation and no artificial hydration. During an interview on 5/20/22 at 12:51 P.M., the MDS Nurse said the MOLSTs and Care Plans should match and if a staff member uses a default care plan (a care plan already typed in the facility's electronic medical record) they should update the care plan to match the residents MOLST. The MDS Nurse said that upon admission and during the resident's care plan meeting the care plans should be updated. He further said for Resident's #2, #3, #15, #30, #33, and #37 the care plans and the MOLST did not match, the care plans should have been updated to match the MOLSTs, and they were not as required. Based on record review and interview, the facility failed to ensure its staff maintained complete and accurate medical records relative to advanced directives for six Resident's (#2, #3, #15, #30 ,#33 and #37) out of a total sample of 12 residents. For Resident #15 the facility also failed to ensure staff accurately maintained an accurate weight record. Findings include: 1. Resident #3 was admitted to the facility in January 2022. Review of the medical record indicated a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), signed by the Resident and Nurse Practitioner on 1/26/22, and reflected the Resident's wishes to be a full code (attempt resuscitation, intubate [insertion of a tube either through the mouth or nose and into the airway to aid with breathing] and ventilate [use of a machine or device to support or replace the breathing]), transfer to the hospital, use dialysis (A blood purifying treatment), use artificial nutrition, and use artificial hydration. Review of the Advanced Directive Care Plan, with a start date of 1/25/22, indicated the Resident had formulated an advanced directive that reflected his/her wishes to be: Do Not Resuscitate, Do Not Intubate and ventilate, do not use Non-Invasive Ventilation (e.g. continuous positive airway pressure [CPAP] ), transfer to the hospital, no dialysis, no artificial nutrition, and no artificial hydration 2. Resident #33 was admitted to the facility in April 2022. Review of the medical record indicated a MOLST, signed by the Resident (4/12/22) and Nurse Practitioner (4/13/22), and reflected the Resident's wishes to be a full code, with no artificial nutrition. Review of the Advanced Directive Care Plan, with a start date of 4/12/22, indicated the Resident had formulated an advanced directive that reflected his/her wishes to be: Do Not Resuscitate, Do Not Intubate and ventilate, do not use Non-Invasive Ventilation (e.g.CPAP), transfer to the hospital, no dialysis, no artificial nutrition, and no artificial hydration. 3. Resident # 37 was admitted to the facility in April 2022. Review of the medical record indicated a MOLST, signed by the Resident and provider on 2/24/20, and reflected the Resident's wishes to be a full code, with no artificial nutrition. Review of the Advanced Directive Care Plan, with a start date of 4/14/22, indicated the Resident had formulated an advanced directive that reflected his/her wishes to be: Do Not Resuscitate, Do Not Intubate and ventilate, do not use Non-Invasive Ventilation (e.g.CPAP), transfer to the hospital, no dialysis, no artificial nutrition, and no artificial hydration.