**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing staff notified his/her Health Care Agent (HCA), that he/she had changes in his/her condition which also included the need for new Physician's orders.Findings include:Review of the Facility's Policy titled Change in a Resident's Condition or Status, dated May 2023, indicated the following:-our facility shall promptly notify the resident's representative of change in the resident's medical/mental condition and/or status.-the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During an interview on 09/09/25 at 10:42 A.M., Family Member #1 (who was Resident #1's HCA) said Resident #1 was re-admitted to the facility on [DATE], after a hospitalization. Family Member #1 said she called the facility on 07/04/25 to see how Resident #1 was doing and said she was told everything was fine, that he/she was doing okay. Family Member #1 said she was not notified by nursing that he/she required a diet change or that Resident #1 had a blister on his/her right heel.Family Member #1 said she also found out that Resident #1 had a vasovagal episode on 07/23/25 while working with therapy, that he/she became unresponsive for a period of time and said the facility had also not notified her of that event.Family Member #1 said it was not until after she had requested and reviewed a copy of Resident #1's medical record (sometime around the end of July 2025), that she became aware the incidents or/and changes that had occurred.Resident #1 was admitted to the Facility in January 2024, diagnoses included Dementia, bipolar disorder, type II diabetes mellitus, Parkinson's disease, hypertension, and hyperlipidemia (high cholesterol).Review of Resident #1's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, dated 02/01/24, indicated that Resident #1's Health Care Proxy (HCP) was permanently invoked.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/24/25, indicated that he/she had moderate impaired cognition.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 was evaluated by Speech Pathology, he/she was determined to be at risk for aspiration (inhalation of food, fluid or other foreign material into the lungs) and received a Dysphagia (difficulty swallowing foods or liquids) Carbohydrate (CHO) Consistent soft/easy to chew with thin liquids diet during his/her hospitalization. The Summary indicated that Resident #1's discharge diet instructions were for a Dysphagia Carbohydrate Consistent 1600-2000 calories (60-75 grams (g) CHO), soft/easy to chew with thin liquids.Review of Resident #1's Nurse Progress Note, dated 07/04/25 (written by Nurse #1), indicated that Resident had an empty fluid blister on his/her right heel, orders were confirmed with the Nurse Practitioner who gave a new order for skin prep three times a day and to offload his/her right heel on pillow while in bed.Review of Resident #1's medical record indicated there was no documentation to support his/her HCA was notified.During an interview on 09/10/25 at 2:23 P.M., Nurse #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25, was assigned to Resident #1 and he/she had returned from the hospital that afternoon. Nurse #1 said she reviewed Resident #1's Hospital Discharge paperwork including all medication, treatments and diet orders. Nurse #1 said she was not aware that Resident #1 had a new order for a Dysphagia diet and thought she had reviewed all his/her orders but must have overlooked the new diet order.However, review of Resident #1's Diet Requisition Form indicated it was not completed until 07/07/25 and included that he/she was a re-admission with a diet change. The Form indicated the diet order was for a Dysphagia Advanced texture diet.Nurse #1 also said upon Resident #1's return to the facility that day, he/she had a fluid blister on his/her right heel, and the NP gave an order for skin prep and to offload his/her right heel on a pillow while in bed. Nurse #1 said she did not notify Resident #1's HCA of his/her return from the hospital, or that he/she had a new treatment order to his/her right heel and said she should have.Review of Resident #1's Nurse Progress Note, dated 07/23/25 (written by Former Unit Manager), indicated that Resident #1 became unresponsive to verbal and tactile stimuli while with Rehabilitation. The Note indicated that he/she was put into bed, his/her vitals and blood sugar were taken, legs were elevated, and he/she became responsive to tactile stimuli. The Note further indicated that the NP was notified and ordered STAT (immediately) bloodwork, a urinalysis (UA) and a culture and sensitivity (C&S).Review of Resident #1's Physician Progress Note, dated 07/24/25, indicated that Resident #1 was evaluated after an episode of unresponsiveness, likely vasovagal in origin.During an interview on 09/15/25 at 4:48 P.M., the Former Unit Manager said Resident #1 became unresponsive while working with therapy (could not recall exact date) and she notified the NP and obtained new orders for lab work, UA and C&S. The Former Unit Manager said she could not recall if she notified Resident #1's HCA that day of his/her episode.Further review of Resident #1's medical record indicated there was no documentation to support that the facility ever notified Family Member #1 (HCA) related to Resident #1's new diet order, new treatment order to his/her right heel, and that he/she had experienced a vasovagal event and Physician orders for lab work were obtained.During an interview on 09/16/25 at 1:42 P.M., the Former Director of Nursing (DON) said she was not aware that Resident #1's HCA had not been notified of his/her changes and said all nurses should have followed the facility's policy.During an in-person interview on 09/10/25 at 4:06 P.M and a telephone interview on 09/16/25 at 2:46 P.M., the Director of Nursing (DON) said it is her expectation that all nurses should notify resident's family, responsible person, or HCA of changes in their status or condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), whose hospital discharge summary indicated he/she required an altered textured diet (dysphagia diet), the Facility failed to ensure meals prepared and served to him/her met his/her individual need, when his/her new diet orders were not transcribed by nursing, and he/she received the incorrect diet for two days. Findings Include: Review of the Facility's Policy tilted Therapeutic Diet Orders Policy, dated as reviewed/revised March 2025, indicated the following: -the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician.-a Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake.-all diet orders are to be communicated to the dietary department in accordance with facility procedures.-dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of the Facility's Policy titled Charting and Documentation, dated May 2023, indicated the following: -all services provided to the resident to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.-documentation in the medical record will be complete and accurate.Resident #1 was admitted to the Facility in January 2024, diagnoses included Dementia, bipolar disorder, type II diabetes mellitus, Parkinson's disease, hypertension, and hyperlipidemia (high cholesterol).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 was evaluated by Speech Pathology, he/she was determined a risk for aspiration (inhalation of foods, fluids, or other foreign objects into the lungs) and received a Dysphagia (difficulty swallowing or chewing) Carbohydrate (CHO) Consistent soft/easy to chew with thin liquids diet during his/her hospitalization. The Summary indicated that Resident #1's discharge diet instructions were for a Dysphagia Carbohydrate Consistent 1600-2000 calories (60-75 grams (g) CHO), soft/easy to chew with thin liquids.Review of Resident #1's previous Physician's Orders, dated as initiated 03/31/25, indicated his/her diet orders were for a Carbohydrate Consistent Diet (CCD) Regular texture with thin liquids consistency and upon re-admission on [DATE], he/she continued to receive that same diet. Further review of the Physician orders indicated that he/she was started on a CCD Dysphagia Advanced texture diet with thin liquids on 07/07/25, three days after being re-admitted .Review of Resident #1's Nurse Progress Note, dated 07/04/25 (written by Nurse #1), indicated that Resident #1 was readmitted to the facility and the kitchen was notified to resume his/her previous diet (CCD Regular texture).During an interview on 09/10/25 at 2:23 P.M., Nurse #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25, was assigned to Resident #1 and that he/she had returned from the hospital that afternoon. Nurse #1 said she reviewed Resident #1's Hospital Discharge paperwork including all medication, treatments and diet orders, verified all orders with the Nurse Practitioner and entered the orders into Point Click Care (PCC) computer system. Nurse #1 said she notified the kitchen to resume Resident #1's previous diet order which was a CCD Regular texture thin liquids diet. Nurse #1 said she was not aware that Resident #1 had a new order for a Dysphagia diet and thought she had reviewed all his/her orders but must have overlooked the new diet order.During an interview on 09/15/25 at 4:48 P.M., Nurse #4 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25 and was assigned to Resident #1. Nurse #4 said during change of shift report the 11:00 P.M. to 7:00 A.M. Nurse told her that Resident #1 was on a modified ground diet. Nurse #4 said she did not recall that Resident #1 was on a ground diet, and said she checked Resident #1's tray and the kitchen had sent him/her a regular texture diet.Nurse #4 said she reviewed Resident #1's Hospital Discharge paperwork and saw that he/she diet was supposed to be on a Dysphagia Advanced diet. Nurse #4 said she filled out a diet requisition form for Resident #1's new textured diet order and said she gave the form to the Food Service Director and waited for Resident #1's breakfast tray with the correct diet order.However, review of Resident #1's Diet Requisition Form, which was completed and dated 07/07/25, indicated that he/she was a re-admission with a diet change. The Form indicated the diet order was for a Dysphagia Advanced texture diet.During an interview on 09/17/25 at 11:19 A.M., the Food Service Director (FSD) said on 07/07/25 she received a diet requisition form for Resident #1's new diet order for a Dysphagia Advanced diet that morning from one of the nurses. The FSD said Resident #1 received a Regular texture diet on 07/05/25 and 07/06/25 because the kitchen had not been informed of his/her new diet order until the morning of 07/07/25.During an interview on 09/16/25 at 1:42 P.M., the Former Director of Nursing (DON) said she was not aware that Resident #1 had a new diet order when he/she returned from the hospital on [DATE] and that he/she had not received the correct diet for two days. The Former DON said two nurses should have reviewed all of Resident #1's orders on his/her Hospital Discharge Summary to ensure that there were no errors made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had new diet order instructions, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing staff failed to transcribe his/her new diet order onto Resident #1's Physician orders.Findings Include:Review of the Facility's Policy titled Charting and Documentation, dated May 2023, indicated the following:-all services provided to the resident to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.-documentation in the medical record will be complete and accurate.Resident #1 was admitted to the Facility in January 2024, diagnoses included Dementia, bipolar disorder, type II diabetes mellitus, Parkinson's disease, hypertension, and hyperlipidemia (high cholesterol).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1's discharge diet instructions were for a Dysphagia Carbohydrate Consistent 1600-2000 calories (60-75 grams (g) CHO), soft/easy to chew with thin liquids.Review of Resident #1's Physician's Orders, dated 07/04/25 through 07/07/25, indicated that he/she had orders for a Carbohydrate Consistent Diet (CCD) Regular texture with thin liquidsReview of Resident #1's Nurse Progress Note, dated 07/04/25 (written by Nurse #1), indicated that Resident #1 was readmitted to the facility and the kitchen was notified to resume his/her previous diet (CCD Regular texture).During an interview on 09/10/25 at 2:23 P.M., Nurse #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25, was assigned to Resident #1 and that he/she had returned from the hospital that afternoon. Nurse #1 said she reviewed Resident #1's Hospital Discharge paperwork including all medication, treatments and diet orders, and said that she verified all orders with the Nurse Practitioner and entered the orders into Point Click Care (PCC) computer system. Nurse #1 said she notified the kitchen to resume Resident #1's previous diet order which was a CCD Regular texture thin liquids diet. Nurse #1 said she was not aware that Resident #1 had a new order for a Dysphagia diet and thought she had reviewed all his/her orders but must have overlooked the new diet order.During an interview on 09/16/25 at 1:42 P.M., the Former Director of Nursing (DON) said she was not aware that Resident #1 had a new diet order when he/she returned from the hospital on [DATE] and that Nurse #1 had not transcribed his/her new diet order. The Former DON said two nurses should have reviewed all of Resident #1's orders on his/her Hospital Discharge Summary to ensure that there were no errors made.During an in-person interview on 09/10/25 at 4:06 P.M and a telephone interview on 09/16/25 at 2:46 P.M., the Director of Nursing (DON) said it is her expectation that all nurses should be reviewing all orders on resident's discharge paperwork to ensure no orders are missed.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#168), out of a total sample of 17 residents, was treated with respect and dignity. Specifically, the facility failed to ensure Resident #168's Foley catheter (tube inserted into the bladder to drain urine) drainage bag was consistently covered with a privacy shield and/or positioned away from the doorway. Findings include: Review of the facility's policy titled Promoting/Maintaining Resident Dignity, last revised March 2025, indicated but was not limited to: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. -All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights. -Maintain resident privacy. Resident #168 was admitted to the facility in May 2025 and had diagnoses including neurogenic bladder (a condition where the bladder muscles contract involuntarily, causing frequent and urgent urination). Review of the Minimum Data Set assessment, dated 6/3/25, indicated Resident #168 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and had an indwelling urinary catheter. Review of Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 30 cubic centimeter (cc) balloon (6/1/25) -Foley catheter care daily as well as needed (PRN) and every shift (5/31/25) -Empty Foley drainage bag every shift and record output, monitor urine for any abnormalities and notify MD/NP every shift for Foley output (5/31/25) On 6/17/25 at 9:01 A.M., the surveyor observed Resident #168 lying in bed watching television. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. On 6/17/25 at 9:47 A.M., the surveyor observed Resident #168 lying in bed asleep. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. On 6/23/25 at 8:07 A.M., the surveyor observed Resident #168 lying in bed asleep. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. During an observation with interview on 6/23/25 at 8:10 A.M., Unit Manager #1 and the surveyor observed Resident #168 lying in bed asleep. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. Unit Manager #1 said the Resident's catheter bag should be covered for privacy.

Based on observations and interviews, the facility failed to ensure the privacy and confidentiality of resident information was maintained on one of two nursing units. Specifically, the facility failed to ensure residents' private health information and Activity of Daily Living (ADL) schedule was secure and not accessible to be viewed by anyone walking by the East unit nurses' station. Findings include: Review of the facility's policy titled Promoting/Maintaining Resident Dignity, last revised March 2025, indicated but was not limited to: - Maintain resident privacy - Random observations and/or verifications are conducted by the Director of Nurses or designee to ensure compliance On 6/20/25 at 10:22 A.M., the surveyor observed a multi-page resident information flip chart open on top of the East unit desk, standing up and facing outward towards the hallways. The information that was available for review to people walking by included: four resident's names who were to be gotten up on the 11:00 P.M. to 7:00 A.M. shift and the opposite page included a list for showers and skin checks. On 6/20/25 from 10:22 A.M. to 10:47 A.M., the surveyor observed staff walking past the resident information that was in clear view at the nurses' station 20 separate times. Staff, including the Maintenance director, Maintenance assistant, Director of Nurses, Infection Preventionist, Nurse assigned to the unit, Administrator, Laundry Aide, Regional Food Service Manager, Regional Director of Operations, and Rehab staff all passed the resident specific available information without identifying that it may be a privacy concern. At 10:38 A.M., the Administrator assisted a resident in a wheelchair past the information and at 10:40 A.M., a different resident was observed to self-propel past the information. The information was observed to be available for a total of 37 minutes. During an observation with interview on 6/20/25 at 10:59 A.M., the surveyor observed the Administrator walk past the information again, at which point the surveyor stopped the Administrator and asked him about the information that was on the top of the East nurses' station facing out towards the hallway. He said it is a quick flip chart of information for the Certified Nurse Aides (CNAs) to know which residents need to get up or have showers and includes information on residents who wear splints and have any special needs. He said the flip chart was not supposed to be standing up on the outer perimeter of the nurses' station or facing the hallway and was supposed to be left behind the desk and facing inward towards the nurses' station to keep the residents' information secure. He said the manner in which the information was displayed, facing the hallway and open on the outer perimeter of the top of the nurses' station, was a potential issue for residents' privacy being violated and the flip chart should not be left where any passerby could see it.

Based on interview, observation, and document review, the facility failed to ensure residents/resident representatives had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance for one Resident (#51), out of a total sample of 17 residents. Specifically, the facility failed to ensure staff followed their policy and procedure when Resident #51's Health Care Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) notified staff that the Resident's denture (partial plate) was missing. Findings include: Review of the facility's policy titled Complaint/Grievance Policy and Procedure, dated September 2023, indicated but was not limited to: Policy: -All residents and their responsible representative will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter. -Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. Procedure: -Staff shall complete a grievance form when residents or responsible representatives make verbal complaints, if not completed by the complainant. -Completed forms should be forwarded to the Grievance Official and notify the Executive Director. -The Grievance Official, or designee in his/her absence, will review the grievance within 24-48 business hours of receipt. -The Grievance Official will oversee the process, track grievances through the conclusion, lead investigations, issue written decisions to residents if requested, and coordinate with State and Federal agencies if necessary. -The Grievance Official will complete the Complaint/Grievance form and submit to the Social Service Department and Administrator (if not the Grievance Official). -The Grievance Official will complete the Grievance form to include date received, summary statement, steps taken to investigate, summary of findings, confirmation or no confirmation of grievance, corrective action taken or to be taken, and date written resolution was issued if requested. Resident #51 was admitted to the facility in August 2024 and had diagnoses including dementia. Review of the Minimum Data Set assessment, dated 4/22/25, indicated Resident #51 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, was edentulous and received Hospice services. The assessment indicated Resident #51 had an activated HCP. Review of the medical record indicated a Hospice communication note, dated 6/7/25, indicating the Hospice Aide reported to the staff nurse that Resident #51 was missing his/her denture. Review of a Hospice communication note written by the Hospice Aide, dated 6/16/25, indicated Resident #51's denture was still missing. Review of the facility's grievance book failed to indicate a grievance form was completed for Resident #51's missing denture. Further review of the medical record failed to indicate any documentation regarding the Resident's denture was missing and any efforts to attempt a resolution. During an interview on 6/23/25 at 8:28 A.M., Nurse #5 said she let administration know that the Resident's denture was missing and gave the Resident's HCP a grievance form to complete. She said she is not sure if the HCP ever filled out the papers. The Nurse said she could not recall which staff member in administration she reported the missing denture to. During an interview on 6/23/25 at 9:35 A.M., Unit Manager #1 and the Social Worker reviewed Resident #51's Hospice note dated 6/7/25. The Social Worker said she did not know if a grievance form was completed when the missing denture was reported on 6/7/25. Unit Manager #1 said Resident #51's HCP called her on 6/18/25 and asked that the Resident be seen by the facility's dental provider to get a new denture. She said she faxed a request to the dentist on 6/18/25 and is still waiting to hear back when the Resident can be seen. During a telephonic interview on 6/23/25 at 11:03 A.M., Resident #51's HCP said she discovered that his/her upper denture was missing when she came to visit on 6/7/25. The HCP said she looked everywhere in the Resident's room and was unable to find it. She said staff told her the denture had been missing for a few days, and they were unable to find it either. The HCP said she told Nurse #1 on 6/7/25 that Resident #51's denture was missing and the nurse gave her a grievance form to fill out. The HCP said she did her best to fill out the grievance form and brought it into the facility the following week. She said she did not hear back from the facility and then called the Administrator and Unit Manager #1 on 6/18/25 and was told Resident #51 can be placed on a list to see the dentist the next time he comes in. During an interview on 6/23/25 at 11:50 P.M., the Administrator said he was not aware of Resident #51's missing denture until he received a grievance form completed by his/her HCP on 6/13/25. Review of the grievance form, dated 6/13, indicated that on 6/7/25, the HCP went to get the Resident's denture from its storage cup, and it was empty. She reported the missing denture to the nurse and was told that the denture had been missing for a few days. Staff then came into the Resident's room and searched everywhere but were unable to find the denture. The Administrator said at the time when staff discovered that Resident #51's denture was missing, they should have completed a grievance form and documented the lost dentures so it could be followed through timely, but they did not.

Based on record review and interview, the facility failed to ensure nursing staff developed and provided the resident with a summary of the baseline or comprehensive care plan within 48 hours of admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for one Resident (#168), of a total sample of 17 residents. Specifically, the facility failed to ensure a baseline care plan was developed and a summary provided to the Resident for the use of an indwelling urinary catheter. Findings include: Review of the facility's policy titled, Baseline Care Plan, last revised May 2025, indicated but was not limited to: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. -The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social Services. vi. PASARR recommendations, if applicable. -A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. -A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. -A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by the completion of the comprehensive care plan. -The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided. b. Make a copy of the summary for the medical record. Resident #168 was admitted to the facility in May 2025 and had diagnoses including neurogenic bladder (a condition where the bladder muscles contract involuntarily, causing frequent and urgent urination). Review of the Minimum Data Set (MDS) assessment, dated 6/3/25, indicated Resident #168 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and had an indwelling urinary catheter. Review of the Admission/readmission Nursing Assessment V3, dated 5/31/25, indicated Resident #168 had a urinary catheter. Review of Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 10 cubic centimeter (cc) balloon (5/31/25, discontinued 6/1/25) -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 30 cc balloon (6/1/25) -Foley catheter care daily as well as needed (PRN) and every shift (5/31/25) -Empty Foley drainage bag every shift and record output, monitor urine for any abnormalities and notify MD/NP every shift for Foley output (5/31/25) On 6/17/25 at 9:01 A.M., the surveyor observed Resident #168 lying in bed watching television. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. Review of the entire medical record failed to indicate a baseline or comprehensive care plan for the use of an indwelling urinary catheter was developed within 48 hours of Resident #168's admission. During an interview on 6/23/25 at 2:25 P.M., Resident #168 said he/she was admitted to the facility with a urinary catheter. The Resident said he/she was not provided with or asked to sign a summary of a baseline care plan. During an interview on 6/23/25 at 2:30 P.M., Consulting Staff #3 said she is covering for the MDS Coordinator while she is on vacation this week. She said the MDS Coordinator is responsible for completion of MDS assessments and care plan development for triggered care areas, but nursing staff can also develop care plans. Consulting Staff #3 reviewed Resident #168's MDS assessment, dated 6/3/25, and the entire medical record and said the MDS triggered a care area for urinary catheter and a baseline or comprehensive care plan should have been developed within 48 hours but it was not.

Based on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for one Resident (#168), out of a total sample of 17 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the Resident's indwelling catheter. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised May 2025, included but was not limited to: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. -The comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS) assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #168 was admitted to the facility in May 2025 and had diagnoses including uninhibited neurogenic bladder (a condition where the bladder muscles contract involuntarily, causing frequent and urgent urination). Review of the comprehensive MDS assessment, dated 6/3/25, indicated Resident #168 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and had an indwelling urinary catheter. Review of the Admission/readmission Nursing Assessment V3, dated 5/31/25, indicated Resident #168 had a urinary catheter. Review of Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 10 cubic centimeter (cc) balloon (5/31/25, discontinued 6/1/25) -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 30 cc balloon (6/1/25) -Foley catheter care daily as well as needed (PRN) and every shift (5/31/25) -Empty Foley drainage bag every shift and record output, monitor urine for any abnormalities and notify MD/NP every shift for Foley output (5/31/25) On 6/17/25 at 9:01 A.M., the surveyor observed Resident #168 lying in bed watching television. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. Review of comprehensive care plans failed to indicate a care plan had been developed to address the Resident's use of an indwelling urinary catheter. During an interview on 6/23/25 at 2:30 P.M., Consulting Staff #3 said she is covering for the MDS Coordinator while she is on vacation this week. She said the MDS Coordinator is responsible for completion of MDS assessments and care plan development for triggered care areas, but nursing staff can also develop care plans. Consulting Staff #3 reviewed Resident #168's MDS assessment, dated 6/3/25, and the Resident's comprehensive care plans. She said the MDS triggered a care area for urinary catheter and a care plan should have been developed but it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one Resident (#21), out of a total sample of 17 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically, the facility failed to reposition Resident #21 when he/she was identified to be a very high risk of developing a pressure area resulting in the development of a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue resulting from intense and/or prolonged pressure) to his/her left heel. Findings include: Review of the facility's policy titled Skin Integrity Management, undated, indicated but was not limited to: -Residents with pressure ulcer risk factors are identified, assessed, and provided treatment according to standards of practice. -Residents with actual skin breakdown are identified, assessed and provided treatment according to standards of practice. -Resident's skin integrity status and need for prevention intervention or treatment modalities is identified through review of assessment information. -Identify residents risk level -Care Plan for residents at high risk for skin breakdown -Perform and document skin inspection on admission and weekly Review of the facility's policy titled Pressure Injury Risk Assessment, last revised March 2025, indicated but was not limited to: - It is our policy to perform a pressure injury risk assessment as part of our systemic approach to pressure injury prevention. A risk assessment does not always identify who will develop a pressure injury but will determine which residents are more likely to develop a pressure injury. - Resident determined as at risk for developing pressure injuries will have interventions documented in a plan of care based on specific factors identified in the risk assessment. Resident #21 was admitted to the facility in May 2025 with diagnoses of left femur fracture, diabetes mellitus, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 5/23/25, indicated Resident #21 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated Resident #21 was dependent on staff to roll from side to side and he/she was at risk of developing a pressure ulcer. Review of Resident #21's Admission/readmission Nursing Assessment indicated but was not limited to: -Skin Integrity: -Is Skin intact: No -Classify any wounds: Surgical -Site: Left hip status post left hip hemiarthroplasty (a surgical procedure that replaces only half of a joint) Review of Resident #21's Care Plans indicated but was not limited to: -Focus: Impaired skin integrity as evidenced by/related to: Diabetic, impaired mobility, occasional incontinence of bowel and bladder, anticoagulant/antiplatelet medications, use of splints, braces, immobilizers, status post surgery, left hip and left elbow fracture, diagnosis of diabetes mellitus (initiated 5/5/2025, revised: 6/11/25) -Goal: Skin will remain intact through next review period (initiated 5/5/2025, revised: 5/6/25), Free from additional skin breakdown through next review (initiated 5/5/2025, revised: 6/11/25), Wound/ulcer will show signs of improvement by next review (signs and symptoms of infection, decreased in size) (initiated 5/5/2025, revised: 6/11/25) -Interventions: Pressure redistributing mattress (initiated 5/5/25), Report changes in skin integrity promptly (redness, change in temperature, blisters, etc.) (initiated 5/5/25), Observe for changes in skin integrity related to splints, braces, tubing, positioning tendencies (initiated 5/5/25), Weekly skin checks per protocol (initiated 5/5/25), Barrier cream between incontinent episodes as indicated (initiated 5/6/25) Review of Resident #21's Care Plans indicated but was not limited to: -Focus: I am at risk of skin breakdown related to deconditioning/decreased mobility and incontinence, Surgical wound on left hip, deep tissue injury left heel (initiated 5/12/25, revised 6/13/25) -Goal: The remainder of my skin will be without breakdown through review date (initiated 5/12/25, revised 6/11/25) -Interventions: Identify/document potential causative factors and eliminate/resolve where possible (initiated: 5/12/25), Keep skin clean and dry. Use lotions on dry skin. Provide barrier cream to protect skin. Weekly body audit (initiated: 5/12/25) Review of Resident #21's Care Plans indicated but was not limited to: -Focus: I require assistance with activities of daily living care related to limited mobility, fracture to left upper extremity and left lower extremity (initiated 5/6/2025, revised: 5/8/25) -Goal: I will be assisted with activities of daily living care to be clean, dry, and well-groomed. I will assist as able with activities of daily living care daily (initiated 5/6/2025, revised: 6/11/25) -Interventions: Bed mobility: Dependent (initiated 5/6/2025, revised: 5/8/25) Review of Resident #21's admission Norton Scale for predicting Risk of Pressure Ulcer Assessment (a tool used to assess the risk of a patient developing a pressure injury), dated 5/5/25, indicated but was not limited to: - Physical Condition: Fair - Mental Condition: Alert - Activity: Walks with help - Mobility: Very Limited - Incontinent: Occasional - Deductions: No deductions listed/identified - Score: 15 (Medium Risk) Review of Resident #21's Norton Scale for predicting Risk of Pressure Ulcer Assessment, dated 5/13/25, indicated but was not limited to: - Physical Condition: Poor - Mental Condition: Confused - Activity: Chair Bound - Mobility: Very Limited - Incontinent: Urine and Feces - Deductions: Diagnosis of Diabetes, Hematocrit (the ratio of the volume of red blood cells to the total volume of blood) less than 41%, Hemoglobin (a protein found in red blood cells that is responsible for transporting oxygen throughout the body) less than 14 grams (g)/ deciliter (dL), Albumin level less than 3.3 g/dL, and he/she is on 5 or more medications. -Score: 4 (Very High Risk) During an interview on 6/23/25 at 3:12 P.M., the Director of Nursing (DON) said Resident #21's initial Norton Assessment, dated 5/5/25, was not fully completed by the admitting Nurse. She said Resident #21 was considered high risk for developing a pressure area and no care plan interventions were revised or implemented after the 5/13/25 Norton Assessment which indicated Resident #21 was very high risk for developing a pressure area. Review of Resident #21's Physical Therapy Evaluation, dated 5/6/25, indicated but was not limited to: -Resident #21 required Maximum Assistance (requires substantial help from another person to perform a task, typically 75% or more of the effort) for bed mobility. -Resident #21 had impaired range of motion in his left leg at his/her hip and knee. Review of Resident #21's Physical Therapy Discharge summary, dated [DATE], indicated he/she required Maximum Assistance for bed mobility. Review of Resident #21's Physician Orders indicated but were not limited to: -Skin prep apply to bilateral heels topically two times daily (5/8/25) -Elevated feet on pillows as tolerated while in bed every shift to prevent pressure heels (start 5/6/25 discontinued 5/19/25) -Elevated feet on pillows as tolerated while in bed every shift to prevent pressure heels (5/20/25) -Elevate heels every shift (start 5/8/25, discontinued 5/19/25) -Norton Assessment (used to assess the risk for pressure ulcer in adult patients), (5/5/25) -Hip precautions: Left posterior hip (limiting hip flexion (bending the hip past 90 degrees), avoid crossing the legs or ankles, and preventing internal rotation (turning the left leg inward) every shift (5/7/25) -Weekly skin check every week on Friday, (start 5/5/25, discontinued 6/23/25) Review of Resident #21's positioning documentation from 5/5/25 to 5/18/25 indicated he/she had not been repositioned on 15 out of 36 opportunities (42% of the time) as follows: -36 total opportunities (not including one hospital visit of less than 24 hours) -7 of the 36 opportunities were coded as Not Applicable -3 of the 36 opportunities were left blank -5 out of 36 opportunities were coded as No During an interview on 6/23/25 at 3:12 P.M., the DON said the CNAs should not have left Resident #21's position sheet with blanks areas or marked them as not applicable because that indicated Resident #21 was not repositioned. Review of Resident #21's Nursing Notes indicated but was not limited to: -Date: 5/17/25 at 4:13 P.M., General: Resident #21 has open areas or marks on skin. Worsened areas: No, areas have not worsened. New Areas No new areas. Wound team: notified. -Date: 5/19/25 at 10:52 A.M. During care noted a deep tissue injury dark black 2.5-centimeter (cm) area hard intact cleansed patted dry, skin prep applied followed by abdominal pad and Kling. Nurse Practitioner and Healthcare proxy aware. Review of the Wound Physician's Initial Evaluation, dated 5/22/25, indicated but was not limited to the following: -Unstageable Deep Tissue Injury of the Left Heel -Etiology: Pressure -Size: 4 cm x 3.5 cm, depth is unmeasurable due to the presence of tissue overgrowth, Drainage: None During an interview on 6/20/25 at 1:40 P.M., Certified Nursing Assistant (CNA) #3 said Resident #21 did not have any pressure area and needed to be repositioned every two hours. During an interview on 6/20/25 at 2:05 P.M., CNA #2 said Resident #21 had an open area on their heel and needed to be repositioned every two hours. CNA #2 said she was unaware if Resident #21 was supposed to have his/her heels offloaded. During an interview on 6/23/25 at 8:37 A.M., CNA #4 said she would help with providing care for Resident #21. She said Resident #21 was supposed to be repositioned every two hours and the CNAs should have documented this in Resident #21's positioning sheets. During an interview on 6/23/25 at 8:13 A.M., Nurse #5 said when Resident #21 was admitted his/her skin was intact, and he/she only had a surgical incision. Nurse #5 said Resident #21 had impaired mobility because of a left hip fracture and had interventions in place to offload his/her heels on a pillow, apply skin prep to heels, and to turn and reposition every two hours. Nurse #5 said these were generic interventions for every resident who was considered high risk. During an interview on 6/23/25 at 3:12 P.M., the DON said Resident #21 did not receive their air mattress until 5/19/25 when the pressure area on his/her heel had developed. She said Resident #21 was incredibly high risk for developing a pressure area due to their immobility, comorbidities, and left hip fracture. During a telephonic interview on 6/23/25 at 4:10 P.M., Physician #3 said Resident #21 had a history of a previous healed left heel ulcer and when he/she was admitted to the facility his/her left heel was intact until 5/19/25. During a telephonic interview on 6/25/25 at 3:06 P.M., Physician #2 said when he initially evaluated Resident #21's left heel pressure area it was his evaluation this wound was caused by pressure related to immobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure staff provided residents with an environment free from accidents and hazards. Specifically, the facility failed to ensure medications were disposed of on the [NAME] Unit in a secure manner to prevent access to those medications on one of two nursing units. Findings include: Review of the facility's policy titled Destruction of Unused Drugs, last revised [DATE], indicated but was not limited to: -All unused, contaminated, or expired prescription and non-prescription drugs shall be disposed of per facility policy. -Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. Review of the facility Matrix (used to identify pertinent care categories for residents) provided to surveyors by the Director of Nursing on [DATE] indicated the [NAME] Unit had 37 out of 39 residents with diagnoses of Alzheimer's disease/Dementia. On [DATE] at 8:25 A.M., the surveyor observed Nurse #4 drop two medications on the floor: - Gabapentin (used to treat seizures and for nerve pain) - Sucralfate (to treat and prevent duodenal ulcer) The surveyor then observed Nurse #4 pick the medications up of the floor and dispose of them into an uncovered trash bin on the side of the medication cart. During an interview on [DATE] at 12:33 P.M., Nurse #4 said she should not have disposed of the medication in the trash on her medication cart. During an interview on [DATE] at 4:25 P.M., the Director of Nursing (DON) said the [NAME] Unit has a large population of residents with Alzheimer's Disease and Dementia. The DON said Nurse #4 should not have thrown the medications into the trash on the side of her cart but disposed of them in the medication disposal area for resident safety.

Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed during a medication pass made three errors out of 28 opportunities, resulting in a medication error rate of 10.71%. Those errors impacted two Residents (#11 and #18), out of four residents observed. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: - Medications shall be administered in a safe and timely manner, and as prescribed. - Medications must be administered in accordance with the orders. 1. For Resident #18, Nurse #4 administered: - the incorrect formula of a probiotic (live microorganisms that provide health benefits when consumed, generally by improving or restoring the microbiota in the gut). On 6/18/25 at 8:25 A.M., the surveyor observed Nurse #4 prepare and administer medications to Resident #18 including: -Acidophilus (a bacteria-based probiotic) 1 capsule Review of Resident #27's Physician's Orders indicated but was not limited to: -Saccharomyces boulardii (a yeast-based probiotic), give one capsule by mouth two times daily for 14 days, dated 6/5/25 During an interview on 6/18/25 at 12:33 P.M., Nurse #4 said the facility had usually used Acidophilus as a probiotic because it was house stock. Nurse #4 said she had not administered the correct probiotic to Resident #27, and she should have followed the physician's order. 2. For Resident #11, Nurse #2 administered -the incorrect formula of Calcium (supplement used for bone health) -the incorrect formula of Multivitamin with Minerals On 6/18/25 at 8:16 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #11 including: -Oyster Shell Calcium 500 milligrams (mg) plus Vitamin D, 5 micrograms (mcg) -Multivitamin with Minerals (provides a broad range of vitamins and minerals for overall health and well-being) Review of Resident #11's Physician's Orders indicated but was not limited to: -Calcium 500 mg, give one tablet by mouth one time a day, dated 6/30/21 -PreserVision AREDS Tablet (a vitamin and mineral supplement, designed to support eye health), give one tablet by mouth two times a day, dated 4/27/21 During an interview on 6/18/25 at 10:44 A.M., Nurse #2 said she had administered the incorrect formula of Calcium and had administered a Multivitamin with Minerals instead of PreserVision AREDS Tablet to Resident #11. During an interview on 6/18/25 at 4:25 P.M., the Director of Nursing said the expectation was for nurses to administer medications per physician's orders.

4. Resident #8 was admitted to the facility in January 2024 with diagnoses including migraine (a neurological condition that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head, accompanied by nausea, vomiting, and extreme sensitivity to light and sound) and restless leg syndrome (a neurological disorder characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations). Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: -The individual administering the medication must initial the resident's Electronic Medical Administration Record (EMAR) in the appropriate field after giving each medication and before administering the next ones. -As required or indicated for a medication, the individual administering the medication will record in the resident's electronic medical record: -the date and time the medication was administered. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: -When administering an as needed medication: -Document the time of administration. Review of the Minimum Data Set assessment, dated 4/24/25, indicated Resident #8 had received an opioid (a strong prescription pain reliever) medication during the review period. Review of Resident #8's Physician's Orders indicated but was not limited to: - Hydrocodone-Acetaminophen (opioid pain reliever) 7.5-325 milligrams (mg), give 1 tablet by mouth every 6 hours as needed for pain, (start date: 4/4/2025, discontinued: 5/16/2025) - Hydrocodone-Acetaminophen 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (5/16/2025) Review of the EMAR indicated Resident #8 received Hydrocodone-Acetaminophen 41 times from 5/3/25 to 6/18/25. Review of the Narcotic Book (a record book used in healthcare settings to track and document the administration and handling of controlled substances) indicated Resident #8 had received his/her Hydrocodone-Acetaminophen 58 times. Further of Resident #8's EMAR indicated the use of his/her Hydrocodone-Acetaminophen had not been documented 17 out of 58 times (29% of the time). During an interview on 6/18/25 at 12:33 P.M., Nurse #4 said when a resident receives a PRN (as needed) medication, especially if it is an opioid, it should be documented in the EMAR and in the Narcotic Book. The EMAR and Narcotic Book documentation should match. During an interview on 6/18/25 at 3:57 P.M., Nurse #3 said when he administers a PRN medication, he checks the EMAR to see when a PRN medication dose had last been administered to ensure enough time had passed. Nurse #3 said documentation of the time, name, and amount of medication that was administered should match in both the EMAR and Narcotic Book. Nurse #3 said he should have documented in the EMAR but sometimes he would get busy and forget. During an interview on 6/18/25 at 4:25 P.M., the DON said it was her expectation for nurses to follow the standards of practice and the facility's policy and document the use of a PRN medication in the narcotic book and the EMAR. Based on record review and interviews, the facility failed to ensure staff maintained accurate medical records for four Residents (58, #40, #31, and #8), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #58, to ensure the Nurse Practitioner was accurately documenting advance directives as indicated on the Resident's Massachusetts Medical Orders for Life Sustaining Treatment form (MOLST); 2. For Resident #40, to ensure the Resident's active Physician's Orders accurately reflected the Resident's advance directives as indicated on the Resident's MOLST; 3. For Resident #31, to ensure the Resident's active Physician's Orders and Care Plans accurately reflected the Resident's advance directives as indicated on the Resident's MOLST; and 4. For Resident #8, to ensure nursing staff accurately documented the use of an as needed (PRN) medication on the medication administration record (MAR). Findings include: 1. Resident #58 was admitted to the facility in January 2025 with diagnoses including non-traumatic brain dysfunction. Review of the medical record indicated the Resident's Health Care Proxy (HCP) and Nurse Practitioner #1 initiated a new MOLST on 4/3/25. The MOLST reflected the following advance directives: Do not resuscitate (DNR), Do not intubate and ventilate (DNI), do not transfer to hospital (DNH) (unless needed for comfort). Review of Nurse Practitioner #1's 16 progress notes from 4/3/25 to her most recent visit on 6/19/25, indicated -Code Status: Full Code During an interview on 6/23/25 at 10:19 A.M., Nurse Practitioner #1 said her notes and the MOLST form should match. She said all her notes indicated the Resident was a Full Code. She said her notes are incorrect and the MOLST is the most accurate indicator of the advanced directives. She said her notes auto populate from each visit and it must have been an error that the Full Code status was carried over to each visit. She said she expected her documentation in a Resident's medical record to be accurate. During an interview on 6/23/25 at 10:25 A.M., the Director of Nursing (DON) said the information in the medical record should be accurate and complete. She said she expected the nurse practitioner's documentation to be accurate and reflect the Resident's advance directives. She said the nurse practitioner's notes are inaccurate and the Resident's advance directives/code status is DNR/DNI/DNH according to his/her MOLST. 2. Resident #40 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of the medical record indicated the Resident's HCP and Attending Physician initiated a new MOLST on 6/13/25. The MOLST reflected the following advance directives: Do Not Resuscitate (DNR); Intubate and Ventilate, but Short Term Only; Use Non-invasive Ventilation, but Short Term Only; Transfer to Hospital; No Dialysis; Use Artificial Nutrition, but Short Term Only; and Use Artificial Hydration, but Short Term Only. Review of Resident #40's current Physician's Orders indicated, but was not limited to, the following: -Code Status: (DNR/DNI) Refer to MOLST dated: (5/21/25) Do Not Resuscitate, Do Not Intubate and Ventilate, Use Non-Invasive Ventilation (e.g. CPAP), Transfer to Hospital, No dialysis, Use Artificial nutrition, but short term only, Use artificial Hydration, but short term only [order date: 5/21/25] Review of Resident #40's Physician's Progress Note for a visit on 5/21/25 indicated the Resident's MOLST form was reviewed and the Resident continued as a full code. During an interview on 6/23/25 at 10:25 A.M., the DON said the information in the medical record should be accurate and complete. 3. Resident #31 was admitted to the facility in July 2022 with diagnoses including Alzheimer's disease. Review of the medical record indicated the Resident's HCP and Nurse Practitioner #2 initiated a new MOLST effective 4/18/25. The MOLST reflected the following advance directives: Do Not Resuscitate (DNR); Do Not Intubate and Ventilate (DNI); Do Not Use Non-Invasive Ventilation; Do Not Transfer to Hospital (unless needed for comfort); No Dialysis; No Artificial Nutrition; and No Artificial Hydration. Review of Resident #31's current Physician's Orders indicated, but was not limited to, the following: -Attempt resuscitation, Do no [sic] intubate and ventilate, use non-invasive ventilation, transfer to Hospital, Use dialysis, use artificial nutrition, use artificial hydration [order date: 7/17/24] Review of Resident #31's Care Plans indicated, but was not limited to, the following: -Focus: ADVANCE DIRECTIVES: are as follows: Full Code. Established HCP is invoked. During an interview on 6/23/25 at 10:25 A.M., the DON said the information in the medical record should be accurate and complete.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) policy, and interview, the facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee developed, implemented and maintained a comprehensive QAPI program with projects that were data driven and had metrics that benchmarked their current status, established goals and defined measurements for improvement for outcomes that were sustainable. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement Program, last dated, January 2025, included but was not limited to the following: - Our QAPI program will be ongoing and comprehensive and includes all employees, all departments, and all services provided. - QAPI will utilize best available evidence (data, benchmarks, published best practice, clinical guidelines) to define and measure goals. - Data to be monitored includes, but is not limited to: quality measures, previous survey deficiencies, complaints or facility monitored incidents, ombudsman concerns, resident/family input - grievance log/resident council, adverse events and med errors. - Evidence and data will be used to benchmark, establish goals and define measures for improvement - The facility Administrator is responsible and accountable for developing, leading, and closely monitoring the QAPI program - QAPI activities are governed and monitored by the QAA committee, which includes the Medical director, Director of Nurses (DON), Administrator, Infection Preventionist (IP) and two additional staff members. - Our organization will conduct Performance Improvement Projects (PIPs) that are designed to take a systematic approach to review and improve care or services in areas that we identify as needing attention; an important aspect of our PIPs is to determine the effectiveness of our performance improvement activities and whether improvement is sustained. - The QAA committee will prioritize topics for PIPs and provide guidance on how to address issues that arise and need corrective action and designate a PIP team - The PIP team will: consider each PIP as a learning process, follow steps for any quality improvement project, determine information needed, determine a timeline for the project, request supplies, staff and equipment as needed, use systematic analysis and systematic actions to identify and implement change. Systematic Analysis and Action: - a systematic approach is used to determine when in-depth analysis is needed to fully understand identified problems, causes of the problems, and implications of a change; to get to the underlying cause of the issue teams work together to identify the root cause and contributing factors using tools such as the five whys. - To prevent future events and promote sustained improvement the organization uses Plan-Do-Study-Act cycles to test actions and recognize and address unintended consequences of planned changes - To ensure planned changes are implemented and effective in making a sustained change the organization uses measure that tie directly to the new action and conducts ongoing periodic measurements and review to ensure the new action has been adopted and performance is consistent. During an interview on 6/23/25 at 1:30 P.M., the Administrator said he is in charge of QAPI and all QAA activities. He said he was involved himself in a project to improve the number of grievances that were communicated accurately using the grievance process. He said he identified that the facility had very few grievances brought forth and it didn't seem the process was being used correctly and he wanted to increase the number to ensure things were not being missed. He said he did not complete a data driven analysis or use a benchmark for the starting point of his project and did not have any measurable data to show an improvement had been made, except that he felt people better understood the grievance process as it is defined within the facility and he felt more grievances had been filed. He said he considered the project recently completed with sustainable results. He said he was aware that a grievance that was recently missed and brought to his attention by the survey team and was a concern. On 6/23/25 at 1:48 P.M., the DON joined the Administrator during the QAPI interview. She said she is currently working on a project to improve the completion of resident incident reports within the facility. She said the regional team identified an issue during a recent audit indicating not all the steps in the incident report and follow up process were being completed. She said the goal is 100% completion but did not know what her starting point was and had no data driven metric to determine how many incident reports were reviewed during the audit or how many were complete versus incomplete. She said she was not measuring improvement periodically and would just consider the project completed once the goal of 100% incident report follow up was met. Throughout the interview both the Administrator and DON said that they are not fully trained or educated on how the process works for determining if a QAPI project is a facility wide QAA project or a PIP and could not indicate what method or cycles of activity the facility and organization used to move throughout the identification, analysis, implementation and measurement checks needed to identify improvement. The Administrator and DON said they had not previously heard of Plan-Do-Study-Act and were unaware of the tools in use by their organization to systematically manage and sustain improvement. The Administrator and DON said they identify a problem, provide education and then monitor the issue, sometimes daily, until they reach their goal of 100% and then consider the project completed. They said they do not seek feedback from their line staff to determine if the education completed for their projects is effective at that level. The DON discussed a project the facility had the previous year for weekly skin checks not being completed as ordered/required. She said the project was initiated off a deficiency from their survey results. She said today she started the project again when a surveyor had brought some concerns regarding skin and the missing skin checks to her attention. She said she was not aware the change had not been sustained. Both the Administrator and the DON said they felt they needed more resources and training on the process of QAA and improvement projects for the program to be fully implemented. During an interview on 6/23/25 at 3:27 P.M., the Director of Operations said the expectation is for the facility leadership to use data-based evidence and metrics to help sustain improvements in identified areas. He said the process would involve a root cause analysis of the situation to identify necessary change and measurable goals and outcomes to determine if the project is effective in creating the desired change or if it would require adjustment for the desired outcomes that could be measured and sustained. He said the facility leadership should be using the organizational process and based on the information provided to the surveyor it seemed that the process for QAA and improvement projects was not in place as it should be. He said that the current process was not comprehensive or inclusive of the organizational requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and interview, the facility failed to ensure the new hire employee records contained evidence of the 2024-2025 COVID-19 vaccination for four of five newly hired employees. Specifically, the facility failed to ensure the employee record contained evidence of the 2024-2025 COVID-19 vaccination or proof the newly hired employees were offered an updated COVID-19 vaccine when he/she was eligible. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance, Staying up to date with COVID-19 vaccinations, dated as revised June 6, 2025, indicated but was not limited to the following: - CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 years and older. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID. Importance of staying up to date: - Getting the 2024-2025 COVID-19 vaccine is important because protection from the COVID-19 vaccine decreases with time; Immunity after COVID-19 infection decreases with time; COVID-19 vaccines are updated to give you the best protection from the currently circulating strains. - Administer recommended vaccines if vaccination history is incomplete or unknown. - Routine vaccination: age [AGE]-64 years: a. Unvaccinated: 1 dose 2024-25 Moderna or Pfizer-BioNTech; 2 doses 2024-25 Novavax at 0, 3-8 weeks b. Previously vaccinated before 2024-25 vaccine with: 1 or more doses Moderna or Pfizer-BioNTech: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 dose Novavax: 1 dose 2024-25 Novavax 3-8 weeks after most recent dose. If more than 8 weeks after most recent dose, administer 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech. 2 or more doses Novavax: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 or more doses [NAME]: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech. - Routine Vaccination: age [AGE] years and older: a. Unvaccinated: follow recommendations above for unvaccinated persons ages 19-64 years and administer dose 2 of 2024-25 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months). b. Previously vaccinated before 2024-25 vaccine: follow recommendations above for previously vaccinated persons ages 19-64 years and administer dose 2 of 2024-25 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months). - Unvaccinated persons have never received any COVID-19 vaccine doses. There is no preferential recommendation for the use of one COVID-19 vaccine over another when more than one recommended age-appropriate vaccine is available. Administer an age-appropriate COVID-19 vaccine product for each dose. Staff member #1 was hired on 6/3/25 as a Nurse. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Staff member #3 was hired on 2/19/25 as an Activity assistant. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Staff member #4 was hired on 5/6/25 as a Nurse. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Staff member #5 was hired on 3/19//25 as a Maintenance assistant. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Review of the employee timecards indicated that the four new hires, who had not been offered the most recent COVID-19 vaccination, had been actively working in the facility. During an interview on 6/23/25 at 8:32 A.M., the Human Resource (HR) staff at the facility said he provides a list to new employees prior to hire of items they need to bring in with them at the time of orientation, including current vaccination with the COVID-19 vaccine. He said he does not confirm whether or not the files contain an offer of the current COVID-19 vaccination once he receives the information back from the Infection Preventionist (IP) because he was unaware that the facility was required to offer its staff the most recent COVID-19 vaccination. During an interview on 6/23/25 at 9:03 A.M., the IP said the facility has newly hired staff bring a copy of their vaccine history with them at the time of hire, which includes the COVID-19 vaccination and information should be in the employee files. She said the staff should have a signed declination or consent on file if they choose to receive the newest vaccine. During an interview on 06/23/25 at 2:41 P.M., the IP said the facility does not offer COVID-19 vaccination or boosters to new staff upon hire and that is why no documentation could be located in the employee files.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 -March 31) in accordance with the schedule specified by CMS. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility triggered for: -Failed to Submit Data for the Quarter (No Data Submitted for Quarter) -One Star Staffing Rating (Staff Staffing Rating Equals 1) During an interview on 6/18/25 at 9:37 A.M., the Director of Operations said the company had a change in the corporate Human resource position at the time of PBJ submission for Quarter 2 and they were unaware that the submission had not taken place. He said he attempted to reach out to CMS so they could submit the data after the fact but was informed that wouldn't be possible. He said the PBJ information should have been submitted as required and was not.

3. Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: -Staff shall follow established facility infection control procedures for the administration of medications. On 6/16/25 at 8:25 A.M., the surveyor observed Nurse #4 prepare 10 medications for Resident #8. Nurse #4 dropped one pill on to the top of the medication cart, picked up the pill, placed it into the medication cup and administered it to Resident #8. During an interview on 6/16/25 at 8:43 A.M., Nurse #4 said she had cleaned the top the of the medication cart at the beginning of her shift at 7:00 A.M. and the pill had not fallen on the floor but on top of the medication cart. During an interview on 6/16/25 at 4:25 P.M., the Director of Nursing said Nurse #2 should not have administered the medication after it fell on top of the medication cart. The Director of Nursing said the top of the medication is not considered a clean surface and if a medication falls on top of the medication cart it should be disposed of and a new pill should have been administered as it is an infection control concern. 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. Specifically, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. Ensure contact tracing and outbreak testing were completed on two occurrences in February 2025; and 3. Ensure that sanitary practices were used by nursing while preparing and administering medications. Findings include: 1. Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated, but was not limited to, the following: -An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. -Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness. -Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. -Outbreak management is a process that consists of: 1) determining the presence of an outbreak; 2) managing the affected residents; 3) preventing the spread to other residents; 4) documenting information about the outbreak 5) reporting the information to appropriate public health authorities; 6) educating the staff and the public; 7) monitoring for recurrences; 8) reviewing the care after the outbreak has subsided; 9) recommending new or revised policies to handle similar events in the future. -Specific criteria will be used to help differentiate sporadic cases from true outbreaks or epidemics. Review of an untitled and undated facility policy indicated, but was not limited to, the following: -It is the policy of this facility to complete Infection Control Line Listings each month. The data on the line listings will be used to identify improvement opportunities. These line listings will be utilized to produce a roll up of data that will be reviewed for improvement opportunities. -Line Listing will include - *Resident Name or Identifier *Room # *Category of Infection *Date of Onset *Symptoms *Date of Culture *Site of Infection *Results of Culture *Treatment - including name of ABX (antibiotic) used *Date Infection cleared *Final Status - HAI (healthcare-acquired infection) or CAI (community-acquired infection) -These listing [sic] will be entered into a standardized spreadsheet that will provide a breakdown and comparison of data. The report will look at Infection trends over a period of time. Review of the facility's infection surveillance line listings indicated, but was not limited to, the following: July 2024 -8 out of 8 resident infections had no documented signs and symptoms of an illness or date of symptom onset -1 out of 1 blood infections failed to include culture results identifying the organism/bacteria -Review of the Infection Control Report provided by the facility's consultant laboratory indicated that a urine specimen collected from a resident on 7/27/24 resulted positive for ESBL (extended-spectrum beta-lactamase producing bacteria - bacteria that produce enzymes that break down certain antibiotics, making them ineffective). This culture result was not included on the facility's July 2024 line listing document. August 2024 -9 out of 9 resident infections had no documented signs and symptoms of an illness or date of symptom onset -1 out of 2 urinary tract infections failed to include culture results identifying the organism/bacteria September 2024 -2 out of 7 resident infections had no documented site/type of infection -7 out of 7 resident infections had no documented signs and symptoms of an illness or date of symptom onset October 2024 -6 out of 6 resident infections had no documented signs and symptoms of an illness or date of symptom onset -Review of the Infection Control Report provided by the facility's consultant laboratory indicated that a urine specimen collected from a resident on 10/3/24 resulted positive for Proteus penneri (a type of bacteria associated with healthcare-acquired infections). This culture result was not included on the facility's October 2024 line listing document. November 2024 -10 out of 10 resident infections had no documented signs and symptoms of an illness or date of symptom onset December 2024 -11 out of 11 resident infections had no documented signs and symptoms of an illness or date of symptom onset -1 out of 6 urinary tract infections failed to include culture results identifying the organism/bacteria No facility surveillance line listings were provided to the surveyor for the months of January 2025 through May 2025. The facility's Infection Prevention Nurse provided the surveyor with Infection Control Reports from the consultant laboratory with resident culture results and monthly Order Listing Reports from the facility's electronic health record (EHR) with a list of antibiotics prescribed each month. The Order Listing Reports and Infection Control Reports failed to include dates of symptom onset and signs and symptoms of infection present. Additionally, the reports failed to include laboratory results from specimens collected outside of the facility. Further review of the Infection Control Reports provided by the facility's consultant laboratory indicated the Reports for July 2024 through February 2025 were not generated until April 2025. Further review of the facility's line listings failed to indicate that suspected infections that were not treated with antibiotics, such as suspected gastrointestinal or urinary tract infections with negative culture results, were included on the facility's infection surveillance line listings. During an interview on 6/18/25 at 2:04 P.M., the Infection Prevention Nurse said she uses the facility's EHR generated report of residents that have been prescribed antibiotics each month and the Infection Control Report generated by the facility's consultant laboratory as her monthly infection surveillance logs. The Infection Prevention Nurse said the EHR and laboratory reports do not include a description of symptoms, symptom onset date, tracking of suspected infections not treated with antibiotics, or culture results from laboratories outside of the facility's consultant laboratory. The Infection Prevention Nurse said she had used a handwritten line listing tool through December 2024 and tried an electronic spreadsheet for infection surveillance before switching to the EHR and laboratory reports. The Infection Prevention Nurse said symptoms and laboratory results should be included as part of the infection surveillance program. During an interview on 6/23/25 at 7:39 A.M., the Director of Nursing said the facility's line listings should include date of onset and signs and symptoms of infection. 2. Review of the facility's policy titled Infection Prevention and Control COVID-19, revised 6/30/23, indicated, but was not limited to, the following: -An outbreak investigation is initiated when a new nursing home onset of COVID-19 occurs (i.e., a new COVID-19 case among residents or staff). -The Infection Preventionist will conduct ongoing surveillance for all Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections such as COVID-19 that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. -The Infection Preventionist, or designee, will be responsible for the following protocols for contact tracing: *Identify residents, employees, and visitors who the confirmed positive case had contact with the 48 hours prior or 10 days following the positive test or symptoms. -Outbreak Testing *Document the date the case was identified, the date that other residents and staff are tested, the date that all residents and staff who tested negative are retested, and results of all tests. *Staff test results may be maintained on a log in a secure location. Review of the facility's line listings indicated that a resident on the [NAME] unit tested positive for COVID-19 on 9/28/24. Subsequently, 14 additional residents on the [NAME] unit tested positive for COVID-19 between 10/1/24 and 10/25/24. The surveyor requested documentation of the facility's outbreak investigation, including contact tracing and outbreak testing logs for staff and residents. The Infection Prevention Nurse provided the surveyor with a line listing of COVID-19 positive residents. The line listing failed to include information on the residents' signs/symptoms of COVID-19 and date of symptom onset. The facility failed to provide the surveyor with a list of who had been exposed to COVID-19 positive residents and when they were tested. During an interview on 6/18/25 at 2:04 P.M., the Infection Prevention Nurse said the facility had no infectious disease outbreaks since the previous survey in July 2024. During an interview on 6/23/25 at 12:20 P.M., the Infection Prevention Nurse said the facility did have an outbreak of COVID-19 in October 2024. The Infection Prevention Nurse said she had no additional outbreak investigation documentation other than what was included on the line listing of COVID-19 positive residents provided to the surveyor. The Infection Prevention Nurse said residents on the [NAME] unit were tested every 48 hours until seven days passed with no new cases of COVID-19 identified and results were documented in each resident's medical record. The Infection Prevention Nurse said staff were tested before reporting to the unit for their shift during the outbreak period, but the facility did not keep documentation of staff testing dates and/or test results. The Infection Prevention Nurse said she kept a list of the COVID-19 positive residents, but did not maintain documentation of any contact tracing or additional outbreak investigation information.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was alert and oriented and required substantial assistance from staff members when bathing, the Facility failed to ensure that staff treated him/her is a dignified and respectful manner, when related to his/her right to personal privacy when, on 4/03/25 while assisting him/her in the shower, Certified Nurse Aide (CNA) #1 conducted a telephone call using Face Time. Findings include: Review of the Facility Personal Cell Phone Policy, dated as reviewed/revised during January 2025, indicated the Facility prohibited employees from using personal cell phones for any reason on the nursing units. Review of the Facility Resident Rights Policy, dated as reviewed/revised during October 2024, indicated the resident had the right to personal privacy. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during January 2025 and his/her diagnoses included multiple sclerosis. Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 4/05/25, indicated that Resident #1's cognitive patterns were intact and he/she required substantial assistance from staff members when bathing and showering. During an interview on 4/22/25 at 11:50 A.M., Resident #1 said that on 4/03/25, CNA #1 assisted him/her during a shower. Resident #1 said that during the shower, CNA #1 was on her cell phone. Resident #1 said that the cell phone was on speaker and he/she could hear the conversation between the caller and CNA #1. Resident #1 said that the caller was telling CNA #1 about a relationship break up. Resident #1 said that at some point while he/she was naked and covered in soap, CNA #1 knelt in front of him/her to wash his/her legs and feet. Resident #1 said that when CNA #1 knelt down, the cell phone slid out of his/her scrub top pocket. Resident #1 said that he/she could clearly see the face of the male caller on the cell phone and realized that the call was a Face Time call. Resident #1 was able to describe the physical appearance of the man's face on CNA #1's cell phone. Resident #1 said that he/she made eye contact with the caller and said nice hoodie and the caller replied thanks. Resident #1 said that CNA #1 said oopsie and slid the cell phone back deeper into his/her pocket. Resident #1 said that CNA #1 continued the cell phone conversation throughout his/her shower and only ended the call to dress him/her. Resident #1 said that he/she was shocked, embarrassed and humiliated when he/she realized that CNA #1 was using the cell phone on Face Time and wondered if he/she could be seen by the caller while naked in the shower. During a telephone interview on 4/25/25 at 12:00 P.M., CNA #1 said that she answered a telephone call with her cell phone during Resident #1's shower on 4/03/25. CNA #1 said that she was on the call briefly while she arranged to return the call at another time, that she ended the call and placed the cell phone back into her scrub top pocket. CNA #1 said that at one point after the call, her cell phone fell out of her pocket. CNA #1 said that she thought that Resident #1 mistook a photograph on her telephone screen as a Face Time call. Review of CNA #2 and the Director of Nursing Written Statements, dated 4/04/25, indicated that during a telephone interview of CNA #1 on 4/04/25 conducted by the Director of Nursing during which CNA #2 acted as witness, CNA #1 stated that she was on a Face Time phone call during Resident #1's shower on 4/03/25. Although CNA #1 told the Surveyor that she did not use Face Time when she used the telephone during Resident #1's shower, her statement seems suspect given Resident #1's consistent statements regarding the incident and the corroboratory statements CNA #1 gave during a 4/04/25 telephone interview conducted by the Director of Nursing, as witnessed by CNA #2. During an interview on 4/22/25 at 12:55 P.M., the Director of Nursing said that on 4/04/25, Resident #1 reported that, on 4/03/25, CNA #1 was on a Face Time cell phone call throughout his/her shower. The Director of Nursing said that she called CNA #1 and suspended her. The Director of Nursing said that during the phone call, CNA #1 told her that she had been on a Face Time phone call on 4/03/25 while showering Resident #1. The Director of Nursing said that CNA #1 was terminated as a result of the incident. On 4/22/25 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. The Facility suspended CNA #1 on 4/04/25 and subsequently terminated her. B. Resident #1 was seen by the Facility Social Worker on 407/25, the Psychiatric Service Provider on 4/08/25 and the Nurse Practitioner on 4/09/25 for on-going support related to the incident. C. The Director of Nursing, Administrator and Staff Development Coordinator initiated reinforced training of all staff on the Facility Abuse, Social Media and Cell Phone policies on 4/04/25 and training is on-going. D. On 4/04/25, the Facility initiated random weekly rounds by the Administrator, the Director of Nursing or designee for personal cell phone use by staff members on resident units. E. On 4/07/25, the Facility initiated random interviews of 5 residents weekly to ensure that any potential violations are identified, investigated and reported. F. On 4/04/25, the Facility initiated a Quality Assurance Action Plan for the resident rights violation and the progress was reviewed on 4/16/25 by the QA Committee. G. The Administrator and/or designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Physician/Practitioner was notified of a change in treatment for one Resident (#44), out of a total sample of 14 residents. Specifically, the facility failed to ensure the Physician/Practitioner was notified when a prescribed anticoagulant (blood thinner) was not available from the pharmacy and administered as ordered. Findings include: Resident #44 was originally admitted to the facility in June 2022 and had diagnoses including dementia. Review of the medical record indicated Resident #44 was admitted to the hospital on [DATE] after sustaining a right hip fracture following a fall. The hospital Discharge summary, dated [DATE], indicated Resident #44 underwent an open reduction internal fixation (surgery to re-align and stabilize serious fractures) on 8/15/24. The summary and discharge medications indicated the Resident was to receive enoxaparin (anticoagulant) 40 milligrams/0.4 mL injection every 24 hours starting on 8/19/24 for Deep Vein Thrombosis (DVT) prophylaxis postoperatively. Review of August 2024 physician's orders indicated, but was not limited to: -Enoxaparin Sodium Injection Solution, Prefilled syringe 40 mg/0.4 mL, inject 40 mg subcutaneously (under the skin) one time a day until 9/20/24 (8/19/24) Review of the August 2024 Medication Administration Record (MAR) indicated the number 9 and initials in the box corresponding to the order for enoxaparin on 8/19/24. Review of the legend on the MAR identified the code 9 was other/See Nurse Notes. A medication administration note, dated 8/19/24, indicated a notation of n/a next to the order for enoxaparin 40 mg/0.4 mL with no other documentation. Further review of the medical record failed to indicate the Physician/Nurse Practitioner was notified that enoxaparin was not administered on 8/19/24 as ordered. During an interview on 8/20/24 at 3:04 P.M., Nurse #3 said she documented the code 9 on the MAR and n/a in a note for not available because the Resident did not get the enoxaparin as it had not been delivered by the pharmacy yet. She said it was delivered the next day. Nurse #3 said she did not notify the Physician or Nurse Practitioner that the enoxaparin was not administered on 8/19/24 as ordered. During an interview on 8/20/24 at 3:25 P.M., Unit Manager #1 reviewed Resident #44's medical record and said Nurse #3 should have notified the Physician or Nurse Practitioner, but did not. See F760

Based on record review and interview, the facility failed to ensure staff developed a baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care for two Residents (#20 and #74), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #20, to develop a baseline care plan for the Resident's diagnosis of diabetes mellitus; and 2. For Resident #74, to develop a baseline care plan for the Resident's diagnosis of endocarditis (infection of the heart's inner lining, usually involving the heart valves), presence of a Peripherally Inserted Central Catheter (PICC: a thin, flexible tube inserted into a vein in the upper arm then guided (threaded) into a large vein above the right side of the heart called the superior vena cava), and administration of intravenous antibiotic therapy. Findings include: Review of the facility's Baseline Care Plan policy, last revised 3/4/24, indicated but was not limited to: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. -The baseline care plan will be developed within 48 hours of a resident's admission. -Include minimum healthcare information necessary to properly care for a resident including, but not limited to: -Initial goals based on admission orders. -Physician orders. -Dietary orders. -The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. -Once gathered, initial goals shall be established that reflect the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such as for IV therapy, dialysis, or wound care. 1. Resident #20 was admitted to the facility in April 2024 with diagnoses including diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 4/19/24, indicated Resident #20 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, was diabetic, required a therapeutic diet and received insulin injections. Review of the medical record indicated Physician's Orders for the following anti-diabetic medications: -Glipizide ER 2.5 milligrams (mg), give one tablet one time a day for type 2 diabetes mellitus (4/16/24) -Humalog Injection Solution 100 unit/milliliters (mL), inject per sliding scale for type 2 diabetes mellitus (4/16/24) -Metformin HCI 500 mg, give one tablet two times a day for type 2 diabetes mellitus (4/16/24) -Ozempic Subcutaneous Solution Pen Injector 4 mg/3 mL, inject 1 mg subcutaneously (under the skin) one time a day for type 2 diabetes mellitus (4/16/24) Further review of Resident #20's medical record failed to indicate a baseline or comprehensive care plan was developed within 48 hours of admission to address the Resident's diagnosis, treatment and monitoring of diabetes mellitus. During an interview on 6/25/24 at 11:29 A.M., Unit Manager #1 reviewed Resident #20's medical record and said a baseline or comprehensive care plan should have been developed within 48 hours for the Resident's diagnosis and treatment plan for diabetes mellitus and it was not. 2. Resident #74 was admitted to the facility in May 2024 with diagnoses including endocarditis and had a PICC line for infusion of antibiotic medication. Review of the MDS assessment, dated 6/2/24, indicated Resident #74 was cognitively intact as evidenced by a BIMS score of 14 out of 15 and received intravenous antibiotic medication. Review of the medical record indicated that Resident #74 had a PICC line placed to the left antecubital (inner surface of the forearm) for infusion of antibiotic medication during a recent hospitalization. Review of Physician's Orders indicated but was not limited to: -Change Cap and Extensions set on PICC/ Midline catheter 24 hours after insertion or on admission, then weekly with dressing change, and as needed (prn) for PICC/ Midline Protocol (5/29/24) -Change PICC/ Midline dressing on admission, weekly, Thursday and as needed for Dressing Change (5/29/24) -Measure external catheter on admission, and with dressing change (5/29/24) -Ampicillin Sodium Injection Solution (antibiotic) Reconstituted 2 grams (gm), use 2 gm intravenously every 4 hours related to acute and subacute endocarditis for 6 Weeks (5/29/24) -Ceftriaxone Sodium Injection Solution (antibiotic) Reconstituted 2 gm, use 2 gm intravenously every 12 hours related to acute and subacute endocarditis for 6 Weeks (5/29/24) Further review of Resident #74's medical record failed to indicate a baseline or comprehensive care plan was developed within 48 hours of admission to address the Resident's diagnosis and treatment of endocarditis utilizing a PICC line. During an interview on 6/27/24 at 2:21 P.M., Nurse #8 reviewed Resident #74's medical record and said there were no baseline or comprehensive care plans for the Resident's admission diagnosis of endocarditis, the use of antibiotic therapy, and a PICC line. She said a baseline care plan should have been developed for these care needs and were not.

Based on record review and staff interview, the facility failed to document the recapitulation (a summary) of the Resident's stay from the facility for one Resident (#80), out of two closed records reviewed. Findings include: Review of the facility's policy titled Transfer Discharge (including AMA), last Reviewed/Revised 3/4/24, indicated but was not limited to: Policy: Anticipated Transfers or Discharges - resident-initiated discharges. - A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to the following: - i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. - ii. A final summary of the residents' status. - iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). - iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative (s) which will assist the resident to adjust to his or her new living environment. Resident #80 was admitted to the facility in May 2024 with diagnoses including metabolic encephalopathy, urinary tract infection, hypertension, diabetes mellitus, chronic kidney disease stage three, muscle weakness and displaced bimalleolar fracture (involve both the lateral and medial malleoli at the distal ends of the fibula and tibia, respectively) of left lower leg, hyperlipidemia, and anxiety disorder. Review of the medical record indicated the Resident was discharged home on 5/10/24. Review of the Minimum Data Set (MDS) assessment, dated 5/25/24, indicated Discharge return not anticipated. Review of the Discharge Review Form indicated discharge home with services. Review of the Patient Care Referral Form indicated the sections Physician's orders and Physician's Signature were not completed. Review of the medical record failed to include a physician's recapitulation of stay. During an interview on 06/27/24 at 3:45 P.M., the Director of Nursing reviewed the electronic record and said she did not retrieve the recapitulation note. During an interview on 06/28/24 at 9:34 A.M., the Administrator said they do not have a medical record person. He thought the recapitulation was in the medical record office and had not yet been uploaded into the system. He would look. During an interview on 06/28/24 at 2:50 P.M., the Administrator said the Physician did not write a recapitulation note. During an interview on 6/28/24 at 2:55 P.M., the Social Worker reviewed her file and said she could not find a completed discharge summary for Resident #80.

Based on record review and interviews, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for one Resident (#32), out of a total sample of 19 residents. Specifically, the facility failed to ensure a Certified Nursing Assistant (CNA) did not move a resident off the floor after the Resident sustained an unwitnessed fall with a head strike, prior to having a nurse assess the Resident. Findings include: Review of the facility's Fall Reduction policy, last reviewed 6/22/22, included but was not limited to: In the event a resident falls, the following measures will be instituted: -Conduct a physical assessment to determine if there are any injuries. Notify the nursing supervisor/Director of Nursing Services immediately. Administer appropriate first aid. -If the resident fall was unwitnessed or if a head injury is suspected, monitor neurological signs. Resident #32 was admitted to the facility in January 2024 with diagnoses including dementia, abnormalities of gait and mobility, and unsteadiness on his/her feet. Review of the Minimum Data Set (MDS) assessment, dated 4/13/24, indicated Resident #32's cognitive status was not assessed, required maximum assistance for toileting, maximum assistance to get on and off the toilet and maximum assistance to walk 10 feet. Review of a Brief Interview for Mental Status (BIMS) assessment, conducted on 3/5/24, indicated Resident #32 had moderate cognitive impairment as evidenced by a score of 11 out of 15. Review of a Nursing Progress note, dated 5/10/24, indicated Nurse #3 was seated at the Nurses' station at 10:40 A.M. when Certified Nursing Assistant (CNA) #9 brought Resident #32 out to the common area in a wheelchair. The CNA told the Nurse the Resident was standing in the bathroom while she left the room to bring dirty clothes to the bin in the hallway. When she returned to the bathroom, she found the Resident lying on the floor on his/her left side. The CNA assisted the Resident off the floor and put him/her in a wheelchair and brought the Resident out to the common area. The note indicated the Resident stated he/she was standing near the toilet and fell and hit his/her head on the floor. Review of the Incident Report indicated Resident #32 had an unwitnessed fall in the bathroom in his/her room on 5/10/24 while the CNA left the room to put dirty clothing in a bin in the hallway. The Resident was put in a wheelchair and brought out to the common area by a CNA and then assessed by Nurse #3. Review of a statement from Nurse #3 indicated the Nurse was seated at the nurses' station when CNA #9 brought Resident #32 out to the common area in a wheelchair at approximately 10:40 A.M. and informed the nurse that the Resident was standing in the bathroom and the CNA had gone out of the room to put dirty clothes in a bin, and when she came back, the Resident was lying on the floor on his/her left side. The CNA assisted the Resident off the floor and put him/her in a wheelchair and brought the Resident to the common area. The Resident stated he/she struck the left side of his/her head on the floor. Family, doctor, Director of Nursing (DON) and Unit Manager were informed and neurological checks were initiated. Review of a statement from CNA #9 indicated when she was done washing Resident #32, she stepped out of the room to throw away dirty linens and came back and found the Resident lying on the floor. Review of a statement from Nurse #1 indicated she was at the medication cart when a CNA told her that the Resident was on the floor. Review of statements from CNAs #4 and #8 indicated they did not know about the incident. During an interview on 6/28/24 at 12:20 P.M., CNA #8 said Resident #32 was on her assignment the day he/she fell in the bathroom. She said she was helping the Resident in the bathroom and left the room to put dirty laundry in a bin in the hallway. When she returned to the bathroom, she found the Resident on the floor. She said she picked up the Resident and put him/her onto the toilet, then left the room and got Nurse #1. When asked if it was routine practice to pick residents up off the floor when they have had a fall, then tell the nurse, CNA #8 said it depends on the fall. She said if they slide onto the floor, she can pick them up, but if they have a bigger fall (she gave an example of another resident that fell with blood coming from his/her head), then everyone comes to help. During an interview on 6/28/24 at 12:25 P.M., the DON and Chief Nursing Officer (CNO) said the CNA should not have moved the Resident after finding him/her on the floor after having a fall. She said she should have notified the Nurse right away so she could assess the Resident.

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 to deliver medications and other treatments directly to the large central veins near your heart) was provided in accordance with professional standards of practice for one Resident (#74), out of a total sample of 19 residents. Specifically, the facility failed to ensure: -nursing staff measured the external length of the PICC line catheter as ordered by the Physician to ensure the catheter had not migrated (moved) out of place, and -the insertion site was visible for routine assessment by the licensed nurses. Findings include: Review of the Peripherally Inserted Central Catheter/Midline/Central Venous Access Device (CVAD) Dressing Change policy and Documentation Guidelines, last revised 3/4/24, included but was not limited to: -It is the policy of this facility to change PICC, midline or CVAD dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. -Inspect the catheter-skin junction and surrounding area, palpating through the intact dressing for redness, tenderness, swelling and drainage. -Documenting Infusion Therapy -Document every shift if resident has an infusion catheter in place, or whenever an infusion treatment is given. The shift note should include the following information: a. location and objective description of insertion site b. patency and/or functionality of the device. c. type, rate and length of infusions. d. any complications, interventions. e. resident education, questions. f. a statement from the resident how they are tolerating treatment. If the resident is non-verbal, describe any objective signs/symptoms of problems. g. date, time, signature and title. -Additional Documentation for Midline Catheters and PICCs: -At established intervals, document the external length of the catheter and the original length of the catheter inserted. Review of the Administration Set/Tubing Changes policy, dated 1/1/21, indicated but was not limited to: -Primary or secondary intermittent infusion administration sets: change every 24 hours. -Assessment: Inspect intravenous catheter for any signs/symptoms of IV related complications at scheduled intervals. -Label administration set and tubing with date, time and initials. -Documentation: The following information should be recorded in the resident's medical record: 1. The date and time of the administration set change. 2. The type of flow-control device. 3. The type of solution or medical infusing. 4. The amount of solution or medication to be infused. 5. The rate of infusion. 6. The condition of the IV site. 7. Notification of the provider of any intravenous complications. 8. Resident's response to treatment. 9. The signature and title of the person recording the data. Resident #74 was admitted to the facility in May 2024 with diagnoses including endocarditis (infection of the heart's inner lining, usually involving the heart valves) and had a PICC line for infusion of antibiotic medication. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/2/24, indicated Resident #74 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and received intravenous (IV) antibiotic medication. Review of the medical record indicated that on 5/25/24, Resident #74 had a double lumen PICC line placed in the left basilic vein at the antecubital region (inner surface of the forearm) for infusion of antibiotic medication during a recent hospitalization. A chlorhexidine gluconate dressing (CHG-also known as Tegaderm) was applied to the PICC line site. According to the National Institute of Health (2016), a chlorhexidine gluconate dressing is a transparent securement dressing that covers and protects catheter sites and secures devices to the skin. It comprises a transparent adhesive dressing to act as a barrier against external contamination and an integrated gel pad containing an antiseptic agent. According to the manufacturer's website (2024), transparent dressing and CHG gel pad allow continuous site visibility to easily assess for early signs of infection. Review of the Physician's Orders indicated but was not limited to: -Change Cap and Extensions set on PICC/ Midline catheter 24 hours after insertion or on admission, then weekly with dressing change, and as needed (prn) (5/29/24) -Change PICC/ Midline dressing on admission, weekly, Thursday and as needed (5/29/24) -Measure external catheter on admission, and with dressing change (5/29/24) -Ampicillin Sodium Injection Solution Reconstituted 2 gram (gm), use 2 gm intravenously every 4 hours for 6 weeks (5/29/24) -Normal Saline Flush Solution, use 10 milliliters (ml) intravenously as needed for IV antibiotics. Flush each IV catheter lumen with 10 ml normal saline after each intermittent IV administration. AND Use 10 ml intravenously every shift for IV infusion. Flush each IV catheter lumen with 10 ml normal saline before and after each intermittent IV administration (5/29/24) -ceftriaxone Sodium Injection Solution Reconstituted 2 gm, use 2 gm intravenously every 12 hours for 6 weeks (5/29/24) Review of a Clinical Nurse's Note, dated 5/29/24, indicated the PICC line dressing was changed upon admission to the facility, the lumen length (external catheter length) was 11 centimeters (cm) and showed no signs or symptoms of infection. Review of the June 2024 Medication/Treatment Administration Record (MAR/TAR) indicated Resident #74's PICC line dressing was changed on 6/6/24, 6/12/24, 6/19/24 and 6/26/24. Review of the medical record, including Nursing Notes and the MAR/TAR, failed to indicate the external catheter length was measured with each dressing change as ordered by the physician. During an interview with observation on 6/24/24 at 9:00 A.M., Nurse #1 flushed Resident #74's PICC line upon conclusion of the antibiotic infusion. A dressing was in place on the Resident's left antecubital area. The PICC line insertion site was not visible as it was covered by a 2 inch X 2 inch opaque pad and a transparent covering over the pad. On 6/24/24 at 12:20 P.M., the surveyor observed Nurse #1 enter Resident #74's room and hook up the antibiotic medication to the Resident's PICC line. The Nurse said the Resident receives this antibiotic every four hours. The insertion site was not visible as it was covered by a 2 inch X 2 inch opaque pad and a transparent covering over the pad. Review of the medical record, from 5/29/24 through 6/24/24, failed to indicate nursing staff assessed the Resident's insertion site and documented the information in a shift note for 64 shifts out of a total of 81 shifts from 5/29/24 through 6/24/24. During an interview on 6/25/24 at 11:29 A.M., Unit Manager (UM) #1 said the pharmacy sends a standard dressing kit weekly for the Resident's PICC line. When asked if it was routine to cover the insertion site with an opaque pad making the insertion site not visible for assessment, UM #1 said she likes to visualize the site to see if it's red or swollen and if an opaque pad is there, you can't see the site to assess it. She said the insertion site should be assessed and documented in the medical record every shift either on the MAR/TAR or in a note. She reviewed the medical record and said there was no documentation to indicate the insertion site had been assessed every shift. She said the antibiotic is hung every four hours and nursing looks at the site at this time and they should document their assessment in the medical record. UM #1 reviewed the medical record and said there were no measurements of the external catheter since the first dressing change upon admission to the facility and there was no way to tell if the line had migrated or not. During interviews on 6/28/24 at 10:48 A.M. and 7/1/24 at 8:05 A.M., the Staff Development Coordinator (SDC) reviewed Resident #74's medical record and said she could not find any documentation to indicate the external length of the catheter had been measured since the first dressing change upon admission to the facility. She said the nurse is supposed to measure the external length of the catheter with every dressing change, assess the insertion site and document it in the medical record. The SDC said when residents are admitted from the hospital, a lot of orders are incomplete and need to be clarified with the Physician. She said the orders for the PICC line dressing should have identified the type of dressings to be used and allowed for the insertion site to be visible for assessment. Refer to F726

Based on observation, interviews, and record review, the facility failed to maintain respiratory equipment according to professional standards of practice for one Resident (#78), out of a total sample of 19 residents. Specifically, the facility failed to obtain a physician's order for the use of a continuous positive airway pressure machine (CPAP, machine used to treat sleep apnea). Findings include: Review of the facility's policy titled Continuous Positive Airway Pressure (CPAP), undated, indicated but was not limited to: - Policy: The operation of the CPAP machine is the responsibility of licensed staff. - Procedure: 1. Check physician orders. They should include the level of CPAP pressure and the oxygen liter flow if required. - Documentation: 1. Date and Time 2. CPAP mode 3. CPAP pressure 5. Patient's tolerance of procedure Resident #78 was admitted to the facility in April 2024 with diagnoses including hypertension and hyperlipidemia (high cholesterol). Review of Resident #78's Brief Interview for Mental Status (BIMS) assessment, dated 4/4/24, indicated Resident #78 was cognitively intact as evidenced by a score of 15 out of 15. During an interview with observation on 6/24/24 at 9:10 A.M., Resident #78 said he/she brought the CPAP from home and that he/she manages the CPAP themselves. The surveyor observed a CPAP machine on Resident #78's nightstand with the CPAP mask in the top drawer, a one-gallon distilled water jug was noted next to his/her nightstand. Review of Resident #78's medical record failed to indicate Resident #78 had an order for their CPAP. During an interview on 6/25/24 at 8:50 A.M., Resident #78 said he/she would wear their CPAP sometimes. Resident #78 said the nurses would fill the water reservoir with distilled water and turn the machine on for him/her. During an interview on 6/26/24 at 4:34 P.M., Unit Manager #1 said any Resident with a CPAP machine should have an order for settings, cleaning schedule, when to apply the CPAP mask and when to take it off. Unit Manager #1 reviewed Resident #78's medical record and said Resident #78 should have an order for the CPAP but he/she does not. During an interview on 6/27/24 at 7:51 A.M., Nurse #7 said she was not sure if Resident #78 wears his/her CPAP machine, but she is aware that Resident #78 has a CPAP machine at his/her bedside. Nurse #7 said Resident #78 should have an order for his/her CPAP machine including pressure settings, cleaning schedules, and when to apply the CPAP. Nurse #7 reviewed #78's medical record and said Resident #78 did not have any orders for their CPAP machine but should have orders. On 7/1/24 at 8:08 A.M., the surveyor observed Resident #78 in bed with his/her CPAP on. During an interview on 7/1/24 at 8:12 A.M., Nurse #9 said Resident #78 should have an order for his/her CPAP but does not. During an interview on 7/1/24 at 10:04 A.M., the Director of Nursing (DON) and Chief Nursing Officer (CNO) said Resident #78 should have an order for his/her CPAP.

Based on observation, interviews, and record review, the facility failed to ensure staff had the skills necessary to meet the behavioral needs of one Resident (#10), out of a sample of 19 residents. Specifically, the facility failed to ensure staff had training in areas such as mental health needs and care of cognitively impaired residents. Findings include: Review of the Facility Assessment, updated 6/1/24, indicated but was not limited to the following: - To achieve strong clinical out-comes, we continue to strive to develop skill set/competency of associates. We recognize the resident population we serve is affected by multiple co-morbidities requiring a well-rounded clinical team. - Category: Psychiatric/Mood Disorders; Common Diagnoses or Conditions: Impaired cognition, depression, anxiety disorder, Schizophrenia, Bipolar Disorder, Dementia - Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. Resident #10 was admitted to the facility in January 2024 with diagnoses including dementia, anxiety disorder, major depressive disorder, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 5/8/24, indicated Resident #10 had moderate cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). Review of Resident #10's care plans indicated but was not limited to the following: - Focus: I am taking an antipsychotic, antidepressant medication r/t (related to) agitation, mood, and behaviors. My behaviors include: calling out for attention repeatedly. Anxiousness where his/her room is. [sic] Goal: My doctors will monitor my medications and attempt to reduce the use of psychotropic (medications that affect behavior, mood, thoughts, or perception) through the review date. Interventions: Assure that the RN, Social Worker, MD, and family are aware of my behaviors; I will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date; Reassure and redirect me when I am behavioral. - Focus: I have behaviors like constant request for attention, crying at times and repetitive questions and sentences. I frequently ask for the same things (water, heating up coffee) multiple times even when staff has assisted me. 5/18/24 I attempted to use my cane as a weapon, unable to be redirected. I am intrusive at times, wander into other peoples space, come in the hallway disrobed and yell and swear at staff. - Goal: I will have fewer behaviors through next review date. - Interventions: s/p (status post) fall 4/18/2024. Resident slowly placed his/herself on the floor; PT screen; Staff to encourage resident to discuss his/her needs and will assist with needs in a timely manner; Staff will assist me when I ask for things in a timely manner; transfer out to Outside Hospital for geri (geriatric) psych 5/18/24; Follow by psych as needed. Review of a Clinical Nurse's Note, written by Nurse #12 and dated 5/18/2024, indicated Resident #10 was verbally abusive to staff and physically abusive several times, using his/her cane as a weapon. Further review of the Clinical Nurse's Note indicated that the Resident was warned multiple times to stop with the aggression and cane use as a weapon or he/she would be sent to the hospital. The Resident stated he/she wanted to go and 911 was called to transport the Resident to the hospital for further evaluation. On 6/24/24 at 9:15 A.M., the surveyor observed Resident #10 standing in his/her room, crying and unable to answer questions. Certified Nursing Assistant (CNA) #1 entered the room to assist the Resident and stated he/she was always like this and assisted the resident back to bed. Review of employee education documents provided failed to indicate that CNA #1 had in-servicing and/or training on caring for residents with mental and psychosocial disorders. Review of employee education documents provided failed to indicate that Nurse #12 had in-servicing and/or training on caring for residents with mental and psychosocial disorders. During an interview on 7/1/24 at 10:00 A.M., the Staff Development Coordinator (SDC) said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training on written standards, policies, and procedures for behavioral health should be completed upon hire and then annually. Refer to F949

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one Resident (#44) out of a total sample of 14 residents, was free from significant medication error when an anticoagulant (blood thinner) medication was not administered according to physician's orders Findings include: Review of the facility policy, Unavailable Medications, last revised 2/2024, indicated, but was not limited to: -The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (prn), and emergency medication. -An urgent (STAT) supply of commonly used medications is maintained in-house for timely initiation of medications. -Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: -Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. -If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication error, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Resident #44 was originally admitted to the facility in June 2022 and had diagnoses including dementia. Review of the medical record indicated Resident #44 was admitted to the hospital on [DATE] after sustaining a right hip fracture following a fall. The hospital Discharge summary, dated [DATE], indicated Resident #44 underwent an open reduction internal fixation (surgery to re-align and stabilize serious fractures) on 8/15/24. The discharge medication list indicated the Resident was to receive enoxaparin (anticoagulant) 40 milligrams(mg)/0.4 milliliters (mL) injection every 24 hours starting on 8/19/24 for Deep Vein Thrombosis (DVT) prophylaxis. According to the National Institute of Health (2023), the interruption of anticoagulant therapy can increase the risk of thrombotic events during and after surgery. Review of August 2024 physician's orders indicated, but was not limited to: -Enoxaparin Sodium Injection Solution, Prefilled syringe 40 mg/0.4 mL, inject 40 mg subcutaneously (under the skin) one time a day until 9/20/24 (8/19/24) Review of the August 2024 Medication Administration Record (MAR) indicated the number 9 and initials in the box corresponding to the order for enoxaparin on 8/19/24. Review of the legend on the MAR identified the code 9 was other/See Nurse Notes. A medication administration note, dated 8/19/24, indicated a notation of n/a next to the order for enoxaparin 40 mg/0.4 mL with no other documentation. Further review of the medical record failed to indicate the Physician/Nurse Practitioner was notified that enoxaparin was not administered on 8/19/24 as ordered. During an interview on 8/20/24 at 3:04 P.M., Nurse #3 said she documented the code 9 on the MAR and n/a in a note for not available because the Resident did not get the enoxaparin as it had not been delivered by the pharmacy yet. She said it was delivered the next day. Nurse #3 said she did not notify the Physician or Nurse Practitioner that the enoxaparin was not available and not administered on 8/19/24 as ordered. Nurse #3 and the surveyor inspected the emergency kits (e-kits) in the medication room. An e-kit labeled #31 was noted to have an inventory list of contents that included enoxaparin 100 milligrams/milliliters. Nurse #3 said she could have used it for Resident #44, but didn't even think of accessing the e-kit for the medication. During an interview on 8/20/24 at 3:25 P.M., Unit Manager #1 reviewed Resident #44's medical record and said Nurse #3 should have notified the Physician or Nurse Practitioner and accessed the e-kit to obtain and administer enoxaparin, but did not.

Based on interviews and staff education records reviewed for two direct care staff employees (Nurse #1 and Nurse #9) of eight employees reviewed, the facility failed to ensure that training on abuse, neglect, and exploitation prevention was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: h. Abuse, neglect, and exploitation prevention -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of the training on abuse, neglect, and exploitation prevention. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training for abuse, neglect, and exploitation prevention should be completed upon hire and then annually. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response. Findings include: Review of the facility's policy titled Resident Council, dated 3/2/24, indicated but was not limited to: -The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. -The group may appoint a resident to take notes/maintain meeting minutes, or may elect that the Activity Director/designated liaison to take notes/maintain minutes. -The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the Resident Council Minutes, dated 3/21/24, indicated eight residents participated in the meeting, and brought forward the following grievance: -One resident complained that lettuce is shredded and does not like it; prefers chopped lettuce. Review of the Resident Council Minutes for April 2024 indicated the residents refused to attend or participate in resident council meeting due to the Activities Director being out on leave. Review of the Resident Council Minutes, dated 5/23/24, indicated eight residents participated in the meeting, and brought forward the following grievance: -Food was uneatable (sic) on the weekend. Dietary Manager notified. On 6/25/24 at 1:00 P.M., the surveyor held a Resident Group meeting with five residents in attendance. The surveyor reviewed Resident Council Minutes from 3/21/24 through 5/23/24 with the residents. The Resident Council President said the minutes do not reflect the meetings at all. He/she said every month they talk about problems with the food and missing and damaged laundry. He/she said no one has followed up or attempted to make it better. They said the Activity Director was out for a long time and Activity Assistant #3 ran the Resident Council Meetings. During an interview on 6/25/24 at 2:25 P.M., Activity Assistant #3 said she ran the Resident Council Meetings while the Activity Director was out on leave. She said she doesn't take minutes or notes about anything discussed during the meetings. Activity Assistant #3 and the surveyor reviewed the March and May 2024 meeting minutes and said she did not write them and doesn't know who did. She said she did not remember if any residents brought up concerns during the meetings. During an interview on 6/27/24 at 9:35 A.M., the Activity Director said Activity Assistant #3 has been running the Resident Council meetings in her absence. The Activity Director said, although she was not working in the facility during the times the meetings were held, she typed up March and May 2024 meeting minutes because she does not think Activity Assistant #3 knows how to document the meetings. The Activity Director said she is aware that food and laundry complaints have been ongoing and the Resident Council bring it up at every meeting she has attended. She said the complaints should be documented on a grievance form so it can be addressed and resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure the privacy and confidentiality of resident records were maintained. Specifically, the facility failed to ensure residents' private health information was securely stored and not accessible in the facility's copy room and Staff Development Coordinator's (SDC) office, which were located on the main hallway on the first floor of the facility. Findings include: Review of the facility's policy titled Safeguarding of Resident Identifiable Information, last revised 3/4/24, indicated but was not limited to the following: -Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records. -Policy Explanation and Compliance Guidelines: 1. The facility may not release information that is resident-identifiable to the public. 4. Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information. On 6/26/24 at 4:24 P.M., the surveyor observed the door to the copy room of the main hallway with the door open and unattended with two boxes labeled medical records visible from the hallway and physician notes which included medical diagnoses and resident face sheets on the fax machine. Upon further investigation, the boxes labeled medical records contained but were not limited to hospital discharge summaries and resident diagnoses. During an interview on 6/26/24 at 4:27 P.M., the Administrator said the doctors and nurse practitioners would fax their notes to the fax machine and the two boxes of medical records were waiting to be filed. The Administrator said the door to the copy room should be locked to protect resident information because it is accessible to anyone walking by. On 6/26/24 at 4:51 P.M., the surveyor observed the door to the copy room of the main hallway with the door open and unattended with two boxes labeled medical records visible from the hallway and physician notes which included medical diagnoses and resident face sheets on the fax machine. Upon further investigation, the boxes labeled medical records contained but were not limited to hospital discharge summaries and resident diagnoses. During an interview on 6/26/24 at 4:55 P.M., the Chief Nursing Officer (CNO) said the door to copy room should have been closed and locked because the room contains residents' personal medical information but it was not. On 6/27/24 at 8:19 A.M., the surveyor observed the SDC's office door wide open with no staff inside the office. Two large piles of residents' physician's orders were on a table. The physician's orders contained private health information including but not limited to residents' name, date of birth , allergies, diagnoses, diet orders, treatment orders, and medication orders. A large box containing three, 3-ring binders were on a chair. The binders contained resident specific information on [NAME] cards (card that identifies residents and their care needs), Activity of Daily Living Flow sheets (includes bowel and bladder information) and daily census listings. A purple binder was on a desk and was labeled Infection Control Line Listings for 2024. The binder contained pages of information including, but not limited to resident's names, infections, signs and symptoms of infection experienced by the residents and treatments. During an interview on 6/27/24 at 8:52 A.M., the surveyor alerted the Director of Nursing (DON) that the SDC's office door was wide open and resident's private health information was not secured and accessible to anyone. The DON said it should be closed at all times when no one is in the office. On 7/1/24 at 8:02 A.M., the surveyor observed the SDC's office door wide open with no staff inside the office. Two large piles of residents' physician's orders were on a table. The physician's orders contained private health information including but not limited to residents' name, date of birth , allergies, diagnoses, diet orders, treatment orders, and medication orders. On 7/1/24 at 9:13 A.M., the surveyor observed the SDC's office door wide open with no staff inside the office. Two large piles of residents' physician's orders were on a table. The physician's orders contained private health information including but not limited to residents' name, date of birth , allergies, diagnoses, diet orders, treatment orders, and medication orders. On 7/1/24 at 9:22 A.M., the surveyor observed the SDC's office door wide open with no staff inside the office. Two large piles of residents' physician's orders were on a table. The physician's orders contained private health information including but not limited to residents' name, date of birth , allergies, diagnoses, diet orders, treatment orders, and medication orders. During an interview on 7/1/24 at 10:04 A.M., the CNO said the door to the SDC office should never be left open and unattended because there are resident records in there and accessible to anyone.

7. Resident #72 was admitted to the facility in May 2024 with the following diagnoses: sepsis (an infection of the bloodstream) and Methicillin-Susceptible Staphylococcus aureus (MSSA) infection (a bacterial infection that can be treated by antibiotics). Review of the MDS assessment, dated 5/21/24, indicated Resident #72 was cognitively intact as evidenced by a BIMS score of 15 out of 15, and had diagnoses including a multi-drug resistant organism infection, septicemia, and wound infection. Further review of the MDS indicated he/she received application of dressings to his/her feet and received IV (intravenous) antibiotic therapy. Review of Resident #72's Order Summary Report indicated but was not limited to the following: -Clean area to Left Great Toe with normal saline, pat dry. Apply protective dressing every evening shift (order date 5/17/24); -Clean area to Right Ankle with normal saline. Pat dry. Apply dry protective dressing every evening shift (order date 5/17/24); -D/C (discontinue) midline after abx (antibiotic) therapy is completed on 6/26/24 (order date 6/19/24); -Enhance Barrier Precautions and Contact Precautions every shift (order date 5/17/24); -Patient has a implantable cardioverter defibrillator [sic] (order date 5/17/24). Review of Resident #72's May and June 2024 MAR and TAR indicated but was not limited to: -Resident #72 was administered IV Cefazolin (an antibiotic) 5/18/24 through 5/31/24 and 6/1/24 through 6/26/24. -Resident #72 received treatment, including cleansing area with normal saline and application of a dry protective dressing, to left great toe and right ankle areas every evening shift 6/1/24 through 6/19/24 and 6/21/24 through 6/25/24. Review of Resident #72's comprehensive care plans failed to indicate that a person-centered care plan had been developed to specify the goals or interventions for Resident #72's IV therapy, wound assessment and care, enhanced barrier and transmission-based precautions, and implantable cardioverter defibrillator. During an interview on 6/27/24 at 12:55 P.M., the CNO said that care plans should be individualized for each resident. 8. Resident #30 was admitted to the facility in March 2024 with diagnoses including presence of cardiac pacemaker, sick sinus syndrome (a disease in which the heart's natural pacemaker is no longer able to generate normal heartbeats at the normal rate), atrial fibrillation, and dementia. Review of the MDS assessment, dated 4/3/24, indicated for Resident #30 that no BIMS assessment was conducted. Further review of the MDS indicated the presence of a cardiac pacemaker. Review of Resident #30's active Physician's Orders indicated but were not limited to: - Resident has pacemaker left chest wall (LCW), every shift. Active 3/5/24. Further review of Resident #30's Medical Record included but was not limited to: - Clinical Nurses Note, dated 3/4/24: dual pacemaker LCW family contacted for further details [sic]. - Outside record, dated 1/27/23, indicating the brand of pacemaker and pacemaker testing results. Review of Resident #30's active care plan did not include a cardiac pacemaker. During an interview on 6/27/24 at 11:10 A.M., Nurse #3 said Resident #30's cardiac pacemaker was still in use despite the Resident being admitted to hospice on 3/22/24. Nurse #3 and the surveyor reviewed Resident #30's medical record together. Nurse #3 said she had the name of the surgeon, name of the cardiologist, and where the cardiac pacemaker implant procedure was done, but she could not find the cardiac pacemaker setting information or monitoring schedule. Nurse #3 said she was unsure of the plan for Resident #30's pacemaker. During an interview on 7/1/24 at 9:42 A.M., the DON reviewed the Resident #30's care plan in the medical record and said there was no care plan for the Resident's cardiac pacemaker. The DON said there should be a care plan for Resident #30's cardiac pacemaker regardless of whether the pacemaker was being utilized. Based on observations, interviews, and records reviewed, for nine Residents (#55, #231, #48, #78, #74, #20, #72, #30 and #47), out of 19 sampled residents, the facility failed to develop and/or implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #55, a. to implement a care plan for an indwelling Foley catheter (tube placed in the body to drain and collect urine from the bladder), and b. to develop and implement a care plan for psychotropic medications; 2. For Resident #231, to develop and implement a care plan for an anticoagulant (blood thinning) medication; 3. For Resident #48, to implement a care plan for an anticoagulant medication; 4. For Resident #78, to implement a care plan for antidepressant medication; 5. For Resident #74, to develop a comprehensive care plan for the Resident's diagnosis of endocarditis (infection of the heart's inner lining, usually involving the heart valves), presence of a Peripherally Inserted Central Catheter (PICC: a thin, flexible tube inserted into a vein in the upper arm then guided (threaded) into a large vein above the right side of the heart called the superior vena cava), and administration of intravenous antibiotic therapy; 6. For Resident #20, to develop a comprehensive care plan for the diagnosis, treatment and monitoring of diabetes mellitus; 7. For Resident #72, to develop and implement a care plan for intravenous (IV) therapy, wound assessment and care, enhanced barrier and transmission-based precautions, and implantable cardioverter defibrillator (a battery-operated device used to correct abnormal heart rhythms); 8. For Resident #30, to develop and implement a care plan for a cardiac pacemaker; and 9. For Resident #47, to develop and implement a care plan for elopement risk. Findings include: Review of the facility's policy titled Comprehensive Care Plans, last reviewed/revised 3/4/24, indicated but was not limited to: - Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. - Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Resident #55 was admitted to the facility in October 2024 with diagnoses including retention of urine, anxiety, obsessive compulsive disorder, depression, and obstructive and reflux uropathy. Review of the Minimum Data Set (MDS) assessment, dated 3/5/24, indicated Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS indicated the Resident had an indwelling catheter, and received antipsychotic, antianxiety, and antidepressant medications. a. During an observation with interview on 6/24/24 at 9:37 A.M., the surveyor observed Resident #55 sitting in a chair with his/her Foley catheter in a privacy bag. Resident #55 said he/she has had the Foley catheter for a while now and it has been changed monthly. Review of Resident #55's current Physician's Orders indicated but was not limited to: - Intake and output every shift until Foley is discontinued (11/5/23) - Change Foley catheter as needed for leakage/blockage or dislodgement (11/6/23) - May irrigate Foley Catheter with 30 cc (cubic centimeter) or 60 cc of Normal Saline for blockage. Document amount used as needed for blockage (11/6/23) - Foley Catheter Size: 16 Fr (French) 5-10 cc (1/28/24) - Empty Foley drainage bag every shift and record output every shift (2/25/24) - Change Foley catheter monthly for care 16 Fr 5-10 cc every evening shift once monthly (3/4/24) Review of Resident #55's April, May, and June 2024 Treatment Administration Record (TAR) indicated Foley catheter care was performed as ordered by the Physician. Review of Resident #55's interdisciplinary care plan indicated but was not limited to the following: - Focus: I have a Foley catheter in place due to D/X (diagnosis) URINARY RETENTION and unsuccessful voiding trial and ongoing UTI (urinary tract infection) (Last revised 2/1/2024) -Goal: I will not present with any complications from my Foley Catheter. For example - I will not develop a urinary tract infection. (Dated 11/7/2023) -Interventions: Please empty my drainage bag each shift. Note the amount, color, consistency, and odor of my urine. (Dated 11/7/2023) Further review of Resident #55's Physician Orders failed to indicate an order to monitor for color, consistency, and odor of my urine. During an interview on 6/26/24 at 4:40 P.M., Unit Manager #1 said Resident #55 did not have a separate order to monitor color, consistency, and odor but should have. During an interview on 6/28/24 at 2:18 P.M., the Director of Nursing (DON) said Resident #55 should have had his/her urine monitored for color, consistency, and odor but it was not. b. Review of Resident #55's current Physician's Orders indicated but was not limited to: - Escitalopram (antidepressant) 20 milligrams (mg) tab by mouth one time a day (10/27/23) - Aripiprazole (antipsychotic) 2 mg tab by mouth one time a day (10/27/23) - Remeron (antidepressant) 7.5 mg by mouth one time a day (11/20/23) - Xanax (antianxiety) 0.5 mg by mouth three times a day (11/16/23) Review of Resident #55's April, May, and June 2024 Medication Administration Records (MAR) indicated he/she received Escitalopram, Aripiprazole, Remeron, and Xanax as ordered. During an interview on 6/25/24 at 12:40 P.M., Unit Manager #1 said any resident taking an antipsychotic, antianxiety, and antidepressant medication should have a care plan. Unit Manager #1 and surveyor reviewed resident #55's care plans. Unit Manager #1 said Resident #55 did not have a care plan for his/her antipsychotic, antianxiety, and antidepressant medications but should have. During an interview on 6/27/24 at 12:55 P.M., the DON said residents who are receiving antidepressant, antianxiety, and antipsychotic medications should have a care plan for the medications. The DON said the care plans should be developed and implemented for Resident #55 but were not. 2. Resident #231 was admitted to the facility in June 2024 with diagnoses including hypertension and alcohol abuse. Review of Resident #231's MDS assessment, dated 6/8/24, indicated that Resident #231 had a moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15. Further review of the MDS indicated that Resident #231 received anticoagulant medication. Review of Resident #231's current Physician's Orders indicated but was not limited to: - Enoxaparin Sodium (anticoagulant) 40 mg/0.4 milliliter (ml); Inject subcutaneously (under the skin) one time a day (6/5/24) Review of Resident #231's June 2024 MAR indicated he/she received Enoxaparin Sodium as ordered. Review of Resident #231's care plan failed to indicate that a care plan for the use of anticoagulant medication had been developed. During an interview on 6/26/24 at 4:49 P.M., Nurse #5 reviewed Resident #231's physician's orders, MAR, and care plans. Nurse #5 said Resident #231 received anticoagulant medication and should have had a care plan in place but did not. During an interview on 6/27/24 at 12:55 P.M., the DON said residents who are receiving anticoagulant medications should have a care plan for the medications. The DON said the care plan for Resident #231 should be developed and implemented but was not. 3. Resident #48 was admitted to the facility in April 2024 with diagnoses including atrial fibrillation and muscle wasting and atrophy. Review of Resident #48's MDS assessment, dated 4/11/24, indicated Resident #48 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated Resident # 48 received anticoagulant medication. Review of Resident #48's current Physician's Orders indicated but was not limited to: - Apixaban (anticoagulant) 5 mg give 1 tablet two times a day (4/8/24) Review of Resident #48's April, May, and June 2024 MARs indicated he/she received Apixaban as ordered. Review of Resident #48's care plan failed to indicate that a care plan for the use of anticoagulant medication had been developed. During an interview on 6/26/24 at 4:49 P.M., Nurse #5 reviewed Resident #48's physician's orders, MAR, and care plans. Nurse #5 said Resident #231 received anticoagulant medication and should have had a care plan in place but did not. During an interview on 6/27/24 at 12:55 P.M., the DON said residents who are receiving an anticoagulant medication should have a care plan. The DON said the care plan for Resident #48 should have been developed and implemented but was not. 4. Resident #78 was admitted to the facility in April 2024 with diagnoses including major depressive disorder. Review of Resident #78's BIMS assessment, dated 4/4/24, indicated Resident #78 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of Resident #78's MDS assessment, dated 4/12/24, indicated that Resident #78 received antidepressant medication. Review of Resident #78's current Physician's Orders indicated but were not limited to: - Citalopram (antidepressant) 20 mg give one tab daily (5/17/24) - Sertraline (antidepressant) 25 mg give one tab daily (4/4/24) Review of Resident #78's April, May, and June 2024 MARs indicated he/she received Citalopram and Sertraline as ordered. Review of Resident #78's care plan included but was not limited to: -Focus: I uses [SIC] antidepressant medication Sertraline and Citalopram r/t (related to) Depression (date initiated 5/13/24) -Goal: I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (date initiated 5/13/24) -Interventions: -Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift) (date initiated 5/13/24) -Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy (date initiated 5/13/24) Further review of Resident #78's medical record indicated the facility failed to implement Resident #78's care plan to monitor potential side effects of antidepressant medications. During an interview on 6/27/24 at 12:55 P.M., the DON said residents who are receiving antidepressant medications should have a care plan for monitoring potential side effects of the medications. The DON said the care plan for Resident #78 should have been implemented but was not. During an interview on 7/1/24 at 10:04 A.M., the Chief Nursing Officer (CNO) said that if a care plan indicated to monitor side effects of antidepressant medications, then staff should have asked the physician to write an order so the intervention could be implemented. 5. Resident #74 was admitted to the facility in May 2024 with diagnoses including endocarditis and had a PICC line for infusion of antibiotic medication. Review of the MDS assessment, dated 6/2/24, indicated Resident #74 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15 and received intravenous antibiotic medication. Review of the medical record indicated that Resident #74 had a PICC line placed to the left antecubital (inner surface of the forearm) for infusion of antibiotic medication during a recent hospitalization. Review of Physician's orders indicated, but was not limited to: -Change Cap and Extensions set on PICC/ Midline catheter 24 hours after insertion or on admission, then weekly with dressing change, and as needed (prn) for PICC/ Midline Protocol (5/29/24) -Change PICC/ Midline dressing on admission, weekly, Thursday and as needed for Dressing Change (5/29/24) -Measure external catheter on admission, and with dressing change (5/29/24) -Ampicillin Sodium Injection Solution (antibiotic) Reconstituted 2 grams (gm), use 2 gm intravenously every 4 hours related to acute and subacute endocarditis for 6 Weeks (5/29/24) -Ceftriaxone Sodium Injection Solution (antibiotic) Reconstituted 2 gm, use 2 gm intravenously every 12 hours related to acute and subacute endocarditis for 6 Weeks (5/29/24) Further review of Resident #74's medical record failed to indicate a comprehensive care plan was developed to address the Resident's care needs related to his/her diagnosis and treatment of endocarditis utilizing a PICC line. During an interview on 6/27/24 at 2:21 P.M., Nurse #8 reviewed Resident #74's medical record and said a comprehensive care plan had not been developed for the Resident's diagnosis of endocarditis, the use of antibiotic therapy, and a PICC line but should have been. 6. Resident #20 was admitted to the facility in April 2024 with diagnoses including diabetes mellitus. Review of the MDS assessment, dated 4/19/24, indicated Resident #20 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, was diabetic, required a therapeutic diet, and received insulin injections. Review of the medical record indicated Physician's Orders for the following anti-diabetic medications: -Glipizide ER 2.5 milligrams (mg), give one tablet one time a day for type 2 diabetes mellitus (4/16/24) -Humalog Injection Solution 100 unit/milliliters (mL), inject per sliding scale for type 2 diabetes mellitus (4/16/24) -Metformin HCI 500 mg, give one tablet two times a day for type 2 diabetes mellitus (4/16/24) -Ozempic Subcutaneous Solution Pen Injector 4 mg/3 mL, inject 1 mg subcutaneously (under the skin) one time a day for type 2 diabetes mellitus (4/16/24) Further review of Resident #20's medical record failed to indicate a comprehensive care plan was developed to address the Resident's diagnosis, treatment, and monitoring of diabetes mellitus. During an interview on 6/25/24 at 11:29 A.M., Unit Manager #1 reviewed Resident #20's medical record and said comprehensive care plan should have been developed for the Resident's diagnosis and treatment plan for diabetes mellitus and it was not. 9. Resident #47 was admitted to the facility in December 2023 with diagnoses which included Alzheimer's disease. Review of the facility's policy titled Elopements and Wandering Residents, dated as revised 3/4/24, indicated but was not limited to: - the facility ensures that residents who exhibit wandering behavior and/or risk for elopement recieve adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Review of the MDS assessment indicated Resident #47 was severely impaired as evidenced by a BIMS score of 2 out of 15 and was able to ambulate independently. Review of the Elopement Risk Screen, dated 3/5/24, indicated Resident #47: - Scored 2 and was a moderate actual risk for elopement - a. Wandering is not easily ended or diverted and/or - b. Resident is responding negatively to being contained within boundaries set by other and/or - c. Infrequent and unsuccessful attempts to transgress boundaries set by others. Further review of Resident #47's medical record failed to indicate a comprehensive care plan was developed to address the Resident's care needs related to risk for elopement. During an interview on 6/28/24 at 10:50 A.M., Nurse #8 said Resident #47 had the potential to be an elopement risk especially after visits from family members. Nurse #8 reviewed the Resident's medical record and said a comprehensive care plan for elopement risk had not been developed but should have. During an interview on 6/28/24 at 12:50 P.M., the CNO said it was the expectation that residents who are assessed as an elopement risk have a comprehensive care plan developed and in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility's policy titled Skin Assessment, dated 3/4/24, indicated but was not limited to: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. -Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in the wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate. Review of the facility's policy titled Wound Treatment Management, dated 3/4/24, indicated but was not limited to: - The effectiveness of treatments will be monitored through ongoing assessment of the wound. Resident #72 was admitted to the facility in May 2024 with the following diagnoses: sepsis (an infection of the bloodstream) and Methicillin-Susceptible Staphylococcus aureus (MSSA) infection (a bacterial infection that can be treated by antibiotics). Review of the MDS assessment, dated 5/21/24, indicated Resident #72 was cognitively intact as evidenced by a BIMS score of score of 15 out of 15, and had diagnoses including a multi-drug resistant organism infection, septicemia, and wound infection. Further review of the MDS indicated he/she received application of dressings to his/her feet and received IV (intravenous) antibiotic therapy. Review of Resident #72's Hospital Discharge summary, dated [DATE], indicated that he/she had a left leg wound with purulent discharge that grew MSSA and was likely the source of the Resident's bacteremia (bacteria in the bloodstream). Review of Resident #72's Order Summary Report indicated but was not limited to: - Clean area to Left Great Toe with normal saline, pat dry. Apply protective dressing every evening shift (order date 5/17/24); - Clean area to Right Ankle with normal saline. Pat dry. Apply dry protective dressing every evening shift (order date 5/17/24); - Weekly skin check with shower Thursday 7-3 (order date 5/17/24) Review of Resident #72's May and June 2024 MARs and June 2024 TARs indicated but was not limited to: - Resident #72 received treatment, including cleansing area with normal saline and application of a dry protective dressing, to left great toe and right ankle areas every evening shift 6/1/24 through 6/19/24 and 6/21/24 through 6/25/24. - Resident #72 received weekly skin check with shower 6/6/24, 6/13/24, and 6/20/24. Review of Resident #72's Weekly Skin Assessment tools indicated but was not limited to: - 6/7/24: Yes, has open areas or marks on skin. - 6/8/24: Yes, has open areas or marks on skin. - 6/13/24: right elbow: superficial healing moist area; right ankle: superficial area with moist base; other: left foot open area with sm amt drg [sic]. Further review of Resident #72's Weekly Skin Assessment tools failed to indicate the size and/or a description of the open areas. During an interview on 6/27/24 at 10:15 A.M., Nurse #4 said that Resident #72 had a wound and that the last time she saw the wound, it was small. During an interview on 6/27/24 at 9:54 A.M., Unit Manager (UM) #1 said that Resident #72 was admitted with a wound on his/her toe that she had only seen once but was nearly healed when she saw it. UM #1 said that Resident #72 was not followed on wound rounds but should have weekly skin checks documenting the measurements/condition of any wounds. Based on observation, interview, and record review, the facility failed to follow professional standards of practice for four Residents (#28, #20, #48, and #72), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #28, to notify the Physician that the Resident's oxygen saturation levels trended above the range specified in the Physician's orders; 2. For Resident #20, a. to ensure physician's orders were in place for fingerstick blood sugars (FSBS) in order to implement the Physician's order for sliding scale insulin (medication used in the treatment and management of diabetes mellitus), to monitor for symptoms of hyper/hypoglycemia (high/low blood sugar) and treatment interventions to address the potential for hypoglycemia, and b. to ensure physician's orders for a change in treatment with psychotropic medication was accurately documented and implemented, and to inform the Physician when the Resident was not administered medication as ordered for 10 days; 3. For Resident #48, to obtain an order for care and treatment of a [NAME] drain (a piece of surgical thread that's left in an anal fistula (an abnormal tunnel under the skin that connects the anal canal in the colon to the skin of the buttocks) for several weeks to keep it open; and 4. For Resident #72, to document weekly comprehensive skin assessments. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Review of the facility's policy titled Oxygen Administration, dated as reviewed/revised on 3/4/24, indicated but was not limited to: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. - Oxygen is administered under orders of a physician. - Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. - Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. Resident #28 was admitted to the facility in November 2018 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), major depressive disorder, and general anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 3/27/24, indicated Resident #28 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Further review of the MDS indicated Resident #28 was receiving oxygen therapy. Review of Resident #28's current Physician's Orders included but was not limited to: - Goal oxygen (O2) saturation (sat) for COPD patient is between 88-92%. It should not be any higher. Please monitor O2 sats every 4 hours for COPD. Active 5/13/2024. - Check O2 sat at every shift, maintain O2 between 88-92% every shift for prevention. Active 5/13/24. - Oxygen at 1-3 Liters (L) per minute continuous to maintain O2 sat 88-92% every shift for oxygen therapy AND as needed for shortness of breath (SOB). Active 5/14/24. Review of Resident #28's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May, June, and July 2024 indicated nursing was administering oxygen to the Resident and obtaining O2 sat levels per Physician's orders. Further review of Resident #28's medical record indicated but was not limited to: - Oxygen Saturation Values (oxygen via nasal cannula, a plastic cannula in the nostrils, unless otherwise noted): 7/1/24: 95% 6/30/24: 95%, 96%, 95% 6/29/24: 96%, 96% (room air), 96% 6/28/24: 96%, 97% (room air), 97% 6/27/24: 93% 6/26/24: 95%, 96%, 96%, 96% 6/25/24: 96% (room air), 89%, 90% 6/24/24: 94%, 93%, 93%, 94% (room air), 93% 6/23/24: 96%, 94%, 94% 6/22/24: 94%, 96% 6/21/24: 95%, 94%, 94% 6/20/24: 93%, 94%, 95% 6/19/24: 97%, 96%, 96% 6/18/24: 95%, 95%, 98% 6/17/24: 95% (room air), 95%, 98%, 98%, 98% 6/16/24: 95%, 94%, 95% 6/15/24: 95%, 95% 6/14/24: 95%, 94% 6/13/24: 95%, 95%, 96% (room air) 6/12/24: 95%. 96%, 95% 6/11/24: 92%, 92%, 92% 6/10/24: 96%, 95%, 94%, 96% (room air) 6/9/24: 94%, 95% 6/8/24: 95%, 96% (room air), 96% (room air) 6/7/24: 96% (room air), 96% (room air), 97% 6/6/24: 95%, 97%, 97% 6/5/24: 95%, 95% 6/4/24: 96%, 94%, 95% 6/3/24: 95%, 94% (room air), 92%, 93% 6/2/24: 93%, 92%, 92% 6/1/24: 96%, 88%, 91% 5/31/24: 95%, 95%, 95% 5/30/24: 96% (room air), 95%, 96% (room air) 5/29/24: 95%, 94% 5/28/24: 91%, 92%, 94% 5/27/24: 95%, 92%, 92%, 92%, 92%, 93% 5/26/24: 96% (room air), 95%, 96% 5/25/24: 96%, 96%, 95% 5/24/24: 97% (room air), 93% 5/23/24: 96% (continuous positive airway pressure, CPAP), 92%, 92% 5/22/24: 96%, 95% 5/21/24: 97%, 97% 5/20/24: 96%, 92%, 95%, 95%, 95%, 96% 5/19/24: 95%, 97%, 97% 5/18/24: 96% (room air), 93%, 93% 5/17/24: 99%, 97% 5/16/24: 92%, 98%, 95% 5/15/24: 96%, 96%, 96% 5/14/24: 93%, 93%, 94%, 90% Further review of the Resident's medical record indicated: - Clinical Nurse's Note, dated 6/24/24: Shows no signs or symptoms of respiratory distress as of this note. Continue with plan of care. - Progress Note, dated 6/6/24: Check O2 sat at every shift, maintain O2 between 88-92% every shift for prevention. Turned down to 1L. - Progress Note, dated 5/28/24: Check O2 sat at every shift, maintain O2 between 88-92% every shift for prevention. Turned down to 1L. - Clinical Nurse's Note, dated 5/20/24: No acute respiratory distress noted. Patient continues on 1.5L oxygen, O2 sats between 93-95%. No sign of discomfort. Plan of care continues. - Progress Note, dated 5/19/24: Check O2 sat at every shift, maintain O2 between 88-92% every shift for prevention. O2 turned down to 0.5L to maintain proper pulse oximeter oxygen saturation (SPO2). Will continue to monitor. - Clinical Nurse's Note, dated 5/18/24: No respiratory distress notes. 93% 1L via nasal cannula. - Clinical Nurse's Note, dated 5/17/24: Continue on azithromycin and prednisone taper for upper respiratory infection. No respiratory distress noted. Sat 94% on 1L O2. - Progress Note, dated 5/14/24: Check O2 sat at every shift, maintain O2 between 88-92% every shift for prevention. Patient was on 3L, turned patient down to 1L to maintain correct oxygenation. During an interview on 6/27/24 at 12:57 P.M., Nurse #3 reviewed Resident #28's physician's orders for oxygen therapy (including maintaining O2 sats between 88-92%) and monitoring. Nurse #3 reviewed the Resident's medical record and said Resident #28's O2 sats were quite often higher than 92%. Nurse #3 said the Resident was currently receiving 1L of oxygen, the lowest amount ordered by the Physician, but O2 sats remain above the Physician's ordered range. Nurse #3 said the Physician should be notified if the oxygen therapy regimen is not producing the intended outcome of an O2 sat range of 88-92% so the Physician can reassess the Resident and plan of care. During an interview on 6/27/24 at 4:20 P.M., the Director of Nursing (DON) said Resident #28 was experiencing a COPD exacerbation in mid-May. The DON reviewed the Resident's medical record, and said her expectation would be for nursing to notice Resident #28's O2 sats were consistently above the Physician's recommended parameters. The DON said she would then expect nursing to notify the Physician or Nurse Practitioner of the trend so the Practitioner can re-assess the oxygen therapy plan. 3. Resident #48 was admitted to the facility in April 2024 with diagnoses including rectal abscess (collection of pus in the tissue around the anus and rectum) and muscle wasting and atrophy (wasting away of a body part). Review of Resident #48's MDS assessment, dated 4/11/24, indicated Resident #48 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated Resident #48 received anticoagulant medication. Review of Resident #48's Hospital Discharge summary, dated [DATE], indicated but was not limited to: -CT scan showed large peri-rectal abscess up to 5.5 cm (centimeters) concerning for infectious source. Underwent I&D (incision and drainage) of abscess with packing placed by colorectal surgery on 2/6. During an interview on 6/24/24 at 11:25 A.M., Resident #48 said he/she had staples in his/her rectum that were causing him/her pain. Resident #48 said he/she was admitted with the staples and had an appointment scheduled to see the doctor tomorrow (6/25/24). On 6/24/24 at 1:00 P.M., the surveyor observed Unit Manager #1 perform a skin check of Resident #48's rectum. The surveyor observed that Resident #48 had four [NAME] drains in his/her rectum. Review of Resident #48's medical record failed to indicate orders for care and maintenance of the [NAME] drains. Review of the National Library of Medicine (NLM), dated 8/8/23, indicated but was not limited to: [NAME] drains have few complications. There is some leakage of stool with the [NAME], and instructions for cleaning should be given. There may be some bleeding from the raw tract, and this should be minor. Infections are uncommon, but if they occur, this should prompt either another exam under anesthesia or oral antibiotics if not severe, or IV (intravenous) antibiotics and exploration if severe such as a perineal necrotizing infection. Incontinence is rare with the [NAME] placement. (https://www.ncbi.nlm.nih.gov/books/NBK555998/) Review of Resident #48's GI (gastroenterology) consult, dated 6/25/24, indicated but was not limited to: - 3 Setons (skin bridging removed) - [NAME] connected anal canal remains During an interview on 6/25/24 at 1:30 P.M., Unit Manager #1 said Resident #48 should have an order to monitor for placement of the [NAME] drains and to monitor signs and symptoms of infection at a minimum. Unit Manager #1 reviewed Resident #48's medical record and said Resident #48 did not have orders for care and maintenance of the [NAME] drains but should. During an interview on 6/25/24 at 2:27 P.M., Resident #48 said he/she had a follow today with his/her gastroenterologist and they removed all but one of the drains in his/her rectum. Resident #48 said he/she has a follow-up in six months but the drain can fall out before then. During an interview on 6/26/24 at 12:34 P.M., the DON said Resident #48 was admitted to the facility with the [NAME] drains from the hospital. The DON said the hospital discharge paperwork did not include how to care for the [NAME] drain. The DON said Resident #48 should have had an order for care and treatment of the [NAME] drain including to monitor placement of the [NAME] drain and for signs and symptoms of infection but did not. 2. Resident #20 was admitted to the facility in April 2024 with diagnoses including diabetes mellitus. Review of the MDS assessment, dated 4/19/24, indicated Resident #20 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, was diabetic, required a therapeutic diet and received insulin injections. a. Review of Physician's Orders included, but was not limited to: - Glipizide ER 2.5 milligrams (mg) (insulin), give one tablet one time a day for type 2 diabetes mellitus (4/16/24) - Metformin HCI 500 mg (insulin), give one tablet two times a day for type 2 diabetes mellitus (4/16/24) - Ozempic Subcutaneous Solution Pen Injector 4mg/3mL (injectable treatment for type 2 diabetes mellitus similar to insulin), inject 1 mg subcutaneously (under the skin) one time a day for type 2 diabetes mellitus (4/16/24) - Humalog Injection Solution 100 unit/milliliters (mL) (insulin), inject per sliding scale for type 2 diabetes mellitus (4/16/24) - blood sugar levels less than 70 or greater than 300, call Physician/Nurse Practitioner; - If 0-149= 0 units; - 150-199=2 units; - 200-249=4 units; - 250-299=6 units; - 300-999=8 units. According to the Mayo Clinic (2023), hypoglycemia needs immediate treatment. Treatment involves quickly getting your blood sugar back to within the standard range either with a high-sugar food or drink or with medication. Signs and symptoms of hypoglycemia can include, but are not limited to: - Looking pale - Shakiness - Sweating - Headache - Hunger or nausea - An irregular or fast heartbeat - Fatigue - Irritability or anxiety - Difficulty concentrating - Dizziness or lightheadedness - Tingling or numbness of the lips, tongue or cheek Symptoms of hyperglycemia develop slowly over several days or weeks. Recognizing early symptoms of hyperglycemia can help identify and treat it right away. Watch for: - Frequent urination - Increased thirst - Blurred vision - Feeling weak or unusually tired The physician's orders failed to indicate an order to monitor for signs and symptoms of hyper/hypoglycemia, failed to include an order for fingerstick blood sugars (FSBS-a lancet used to prick the fingertip to obtain a blood sample) to obtain the capillary blood glucose level (CBG) to implement the order for sliding scale insulin administration, and failed to include interventions for the potential of hypoglycemia. Review of April, May and June 2024 Medication/Treatment Administration Records (MAR/TAR) indicated Resident #20's CBG level was obtained on 184 occasions without a Physician's order to do so. During an interview on 6/25/24 at 11:29 A.M., Unit Manager #1 said Resident #20 has his/her CBG checked utilizing a FSBS three times a day. She said all residents with diabetes mellitus should be monitored for signs/symptoms of hyper/hypoglycemia with interventions, and have orders in place for obtaining CBGs if there is a sliding scale. She reviewed the medical record and was unable to find a Physician's order to obtain the capillary blood glucose level or to monitor for signs/symptoms of hyper/hypoglycemia. She said there were no orders for interventions if the Resident experiences signs and symptoms of hypoglycemia but should be. b. Review of Physician's orders included, but was not limited to: -Klonopin (anticonvulsant used to treat anxiety) 1 mg, give 1 mg at bedtime (HS) (4/16/24) -Klonopin 1 mg, give 1mg every 12 hours as needed (prn) for anxiety for 90 Days (6/15/24) Review of the facility's Psychiatric Consultant Nurse Practitioner's note, dated 6/19/24, indicated a recommendation to discontinue Klonopin 1mg prn. A handwritten signature of Resident #20's Nurse Practitioner (NP) with the letters, OK and date 6/21/24 were noted in the lower left corner of the note. Review of a Nursing Progress Note, dated 6/21/24, indicated Klonopin 1mg every 12 hours prn was discontinued. Review of Physician's orders indicated the order for Klonopin 1 mg at HS was discontinued, and not Klonopin 1 mg every 12 hours prn as authorized by Resident #20's NP. During an interview on 6/25/24 at 11:29 A.M., Unit Manager #1 reviewed Resident #20's medical record including the consultant Psychiatric NP's note dated 6/19/24. She confirmed the initials on the lower left corner of the note indicated the NP approved the recommendation to discontinue Klonopin 1 mg every 12 hours prn. She reviewed Resident #20's medical record and said the incorrect Klonopin order was discontinued on 6/21/24. The Resident should still be receiving Klonopin 1 mg at bedtime and not Klonopin 1 mg every 12 hours prn. Review of the medical record on 7/1/24 indicated Resident #20 still had an active order for Klonopin 1 mg every 12 hours as needed and not Klonopin 1 mg at bedtime. The medical record failed to indicate that either the Resident's Physician or Nurse Practitioner were notified that the wrong order for Klonopin was discontinued and the Resident had not received Klonopin as ordered for 10 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents on one Unit (West Unit), out of two units observed. Specifically, the facility failed to ensure staff implemented facility sponsored group activities for all residents on the [NAME] Unit. Findings include: Review of the facility's policy titled Activities, last revised 3/4/24, indicated but was not limited to the following: -Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. -Activities will be conducted in different ways: a. One-to-One Programs. b. Person Appropriate-activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c. Program of Activities-to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. -Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. Review of the facility's June 2024 Activity Calendar posted on the [NAME] Unit indicated the following activities scheduled for 6/24/24: 9:00 A.M. Chronicles 10:00 A.M. Music trivia 11:15 A.M. Rosary 11:30 A.M. Lunch 2:00 P.M. Bingo On 6/24/24, the surveyor observed the following on the [NAME] Unit nursing unit in the large dining/dayroom: 9:19 A.M. -Seven residents seated in the unit dining/dayroom area at dining tables; three residents were seated in chairs in the vicinity of the television. -The television on with the volume low and inaudible to the surveyor. -No other activities taking place in the room. -The residents had no materials in front of them for self-directed activity. -No staff were observed in the dining/dayroom area. 9:30 A.M., the surveyor observed Daily Chronicles being distributed to residents in the dining/day room. 10:17 A.M. -13 residents seated in the unit dining/dayroom. -The television was on to a drama show. -No other activities taking place in the room. -The residents had no materials in front of them for self-directed activities. At 10:19 A.M., Activity Assistant #1 opened a supply drawer and began to take items out and bring them to residents seated in the room. During an interview on 6/24/24 at 10:35 A.M., Activity Assistant #1 said she is a Certified Nursing Assistant (CNA) but picked up some hours as an Activity Assistant. She said she usually comes to the [NAME] Unit in the morning to get everyone set up with something to do, then helps out with activities off of the [NAME] unit. The following activities were scheduled for 6/25/24: 9:00 A.M. Chronicles 10:00 A.M. Hairdresser 11:30 A.M. Lunch 2:00 P.M. [NAME] On 6/25/24, the surveyor observed the following on the [NAME] Unit nursing unit in the large dining/dayroom: 12:30 P.M. -Seven residents were seated in the unit dining/dayroom area. -The television was on with the volume low. -No other activities were taking place in the room. -The residents had no materials in front of them for self-directed activity. The following activities were scheduled for 6/25/24: 9:00 A.M. Chronicles 10:00 A.M. Trivia 10:30 A.M. Music 11:30 A.M. Lunch 2:00 P.M. Mass On 6/26/24, the surveyor observed the following on the [NAME] Unit nursing unit in the large dining/dayroom: 10:32 A.M. to 11:00 A.M. -Ten residents were seated in the dayroom/dining room: Four of which were seated at tables with a Chronicle newsletter in front of them as they slept; Six were seated in chairs near the television. -The television was on and set to a still picture with no audio. -No other activities were taking place in the room. -No staff were observed in the dining/dayroom area. During an interview on 6/27/24 at 9:35 A.M., the Activity Director said they used to have scheduled activities on the [NAME] Unit, but they don't anymore. She said staff were pulling the Activity Assistants to work as CNAs, so they stopped sending Activity Assistants to that unit.

Based on observation, record review, and interview, the facility failed to ensure licensed nursing staff possessed the appropriate competency and skills to care for one Resident (#74), who required intravenous (IV) administration of antibiotics through a Peripherally Inserted Central Catheter (PICC), out of a total sample of 19 residents. Specifically, the facility failed to ensure that nine Nursing staff (#1, #3, #5, #8, #10, #12, #13, Unit Manager #1, and the Director of Nursing ) had demonstrated necessary competencies to care for residents in the facility with specialized needs, inclusive of IV/PICC line care and treatment. Findings include: Review of the facility's policy titled Competency Evaluation, last revised 3/4/24, indicated but was not limited to: - Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. - Evaluating competency of staff is accomplished through the facility's training program. - Initial competency is evaluated during the orientation process. - Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. - Checklists are used to document training and competency evaluations. - Employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resource Director for placing into the employee's personnel file. Review of the Facility Assessment, updated 6/1/24, indicated the facility provided for medication administration via IV (peripheral or central line). Further review of the Facility Assessment indicated that the role of the Director of Staff Development is to provide on-going education to both licensed and non-licensed staff related to the provision of care to their residents. Together, with the respective Department Head, the Director of Staff Development monitors staff competency. The Facility Assessment indicated that all licensed nursing staff should complete IV medication administration competencies. Resident #74 was admitted to the facility in May 2024 with diagnoses including endocarditis (infection of the heart's inner lining, usually involving the heart valves) and had a PICC line for infusion of antibiotic medication. Review of the Minimum Data Set (MDS) assessment, dated 6/2/24, indicated Resident #74 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and received intravenous (IV) antibiotic medication. Review of the medical record indicated that on 5/25/24, Resident #74 had a double lumen PICC line placed in the left basilic vein at the antecubital region (inner surface of the forearm) for infusion of antibiotic medication during a recent hospitalization. A chlorhexidine gluconate dressing (CHG-also known as Tegaderm) was applied to the PICC line site. Review of the Physician's Orders indicated, but was not limited to: - Change Cap and Extensions set on PICC/ Midline catheter 24 hours after insertion or on admission, then weekly with dressing change, and as needed (prn) (5/29/24) - Change PICC/ Midline dressing on admission, weekly, Thursday and as needed (5/29/24) - Measure external catheter on admission, and with dressing change (5/29/24) - Ampicillin Sodium Injection Solution Reconstituted 2 grams (gm), use 2 gm intravenously every 4 hours for 6 weeks (5/29/24) - Normal Saline Flush Solution, use 10 milliliters (ml) intravenously as needed for IV antibiotics. Flush each IV catheter lumen with 10 ml normal saline after each intermittent IV administration. AND Use 10 ml intravenously every shift for IV infusion. Flush each IV catheter lumen with 10 ml normal saline before and after each intermittent IV administration (5/29/24) - Ceftriaxone Sodium Injection Solution Reconstituted 2 gm, use 2 gram intravenously every 12 hours for 6 weeks (5/29/24) Review of a Clinical Nurse's Note, dated 5/29/24, indicated the PICC line dressing was changed upon admission to the facility, the lumen length (external catheter length) was 11 centimeters (cm) and showed no signs or symptoms of infection. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for May 2024 and June 2024 indicated that Nurses #1, #3, #5, #8, #10, #12, #13, Unit Manager #1 and the Director of Nursing had all provided care and/or administered medication through Resident #74's IV line. Review of the June 2024 MARs and TARs indicated Resident #74's PICC line dressing was changed on 6/6/24, 6/12/24, 6/19/24 and 6/26/24. Review of the medical record, including Nursing Notes and the MARs and TARs, failed to indicate the external catheter length was measured with each dressing change as ordered by the physician. During interviews on 6/27/24 at 11:00 A.M. and 6/28/24 at 10:48 A.M., the Staff Development Coordinator (SDC) reviewed Resident #74's medical record and said she could not find any documentation to indicate the external length of the catheter had been measured since the first dressing change upon admission to the facility. She said the nurse is supposed to measure the external length of the catheter with every dressing change and document it in the medical record. She said when she started in March 2024, she realized there was a need for staff education and competencies to be done. She provided the surveyor with a sign-in sheet for PICC line and Midline education provided to 16 nurses on 3/18/24, only four of which provided care to Resident #74. However, she was unable to provide evidence of completed competency checklists for any nursing staff. She said there was no system in place to determine if all of the Nurses who have provided IV care and services to Resident #74 had the required training and competencies.

2. Review of the facility's policy titled Hypoglycemia Management, dated 3/4/24, indicated but was not limited to the following: -The facility will identify residents that are at risk for hypoglycemia (low blood sugar) and observe them for signs and symptoms of low blood glucose. -Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner. Resident #10 was admitted to the facility in January 2024 with diagnoses including diabetes mellitus. Review of the MDS assessment, dated 5/8/24, indicated Resident #10 had moderate cognitive impairment as evidenced by a BIMS score of 8 out of 15. Review of Resident #10's care plans indicated but was not limited to the following: Focus: I have nutritional [sic] problem or potential nutritional problem r/t (related to) therapeutic diet, obesity Interventions: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Review of Resident #10's current Physician's Orders indicated but was not limited to: - Farxiga (prescription pill to help lower blood sugar) Oral Tablet 10 mg. Give 10 mg by mouth one time a day, dated 6/17/24 - Glipizide (prescription pill to help lower blood sugar) Oral Tablet 10 mg. Give 10 mg by mouth two times a day, dated 6/10/24 - Humalog (fast acting insulin, used to lower blood sugar) injection solution 100 unit/milliliter (ml) (Insulin Lispro) Inject 12 units subcutaneously before meals, dated 1/31/24 - Humalog injection solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: if 150-199 = 2 units; 200-249 = 4 units; 250-299 = 6 units; 300-349 = 8 units Notify MD is [sic] BS (blood sugar) is above 350 or less than 70 subcutaneously before meals, dated 1/31/24 - Insulin Glargine (long-acting insulin, used to lower blood sugar) Solution 100 unit/ml Inject 14 unit subcutaneously at bedtime, dated 6/12/24 - CBG (capillary blood glucose) 4x day before meals and at bedtime, dated 1/31/24 Review of Resident #10's May and June 2024 MARs indicated he/she was administered insulin and hypoglycemic medications as ordered. Further review of the May and June 2024 MARs and Treatment Administration Records (TARs) indicated the monitoring of adverse consequences to insulin and hypoglycemic medications was not being documented. During an interview on 6/28/24 at 12:50 P.M., the CNO said the expectation was for all residents who were administered medications to alter their blood sugar should be monitored for potential adverse reactions and/or side effects. Based on record review, policy review, and interview, the facility failed to monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting, a blood thinner) and anti-hypoglycemic medications (used to lower blood sugar) prescribed for three Residents (#231, #48, and #10), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Residents #231 and #48, to monitor for side effects of anticoagulant medication; and 2. For Resident #10, to monitor for side effects of hypoglycemic medications. Findings include: 1. Review of the facility's policy titled High Risk, dated 3/4/24, indicated but was not limited to the following: - Policy: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systemic approach to managing anticoagulant therapy for efficacy and safety. Policy Explanation and Compliance Guidelines: - The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine and stool) b. Fall in hematocrit or blood pressure c. Thromboembolism (a dangerous condition that occurs when a blood clot breaks free) A. Resident #231 was admitted to the facility in June 2024 with diagnoses including hypertension and alcohol abuse. Review of Resident #231's Minimum Data Set (MDS) assessment, dated 6/8/24, indicated Resident #231 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Further review of the MDS indicated that Resident #231 received anticoagulant medication. Review of Resident #231's current Physician's Orders indicated but was not limited to: - Enoxaparin Sodium (anticoagulant) 40 milligrams (mg)/0.4 milliliter (ml) Inject subcutaneously (under the skin) one time a day (6/5/24) Review of Resident #231's June 2024 Medication Administration Record (MAR) indicated he/she received Enoxaparin Sodium as ordered. Further review of Resident #231's medical record failed to indicate Resident #231 was monitored for adverse consequences of anticoagulant medication. During an interview with a record review on 6/26/24 at 4:49 P.M., Nurse #5 and the surveyor reviewed Resident #231's MAR. Nurse #5 said Resident #231 received anticoagulant medication as ordered and should have had an order to monitor adverse consequences but did not. B. Resident #48 was admitted to the facility in April 2024 with diagnoses including atrial fibrillation. Review of Resident #48's MDS assessment, dated 4/11/24, indicated Resident #48 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated Resident #48 received anticoagulant medication. Review of Resident #48's current Physician's Orders indicated but was not limited to: - Apixaban (anticoagulant) 5 mg give 1 tablet two times a day (4/8/24) Review of Resident #48's April, May, and June 2024 MARs indicated he/she received Apixaban as ordered. Further review of Resident #48's medical record failed to indicate Resident #48 was monitored for adverse consequences of anticoagulant medication. During an interview on 6/26/24 at 4:49 P.M., Nurse #5 reviewed Resident #48's care plans and MAR. Nurse #5 said Resident #48 received anticoagulant medication as ordered and should have had an order to monitor adverse consequences but did not. During an interview on 6/27/24 at 12:55 P.M., the Director of Nursing (DON) said all residents who received anticoagulant medications should have an order to monitor for adverse consequences. During an interview on 6/28/24 at 12:50 P.M., the Chief Nursing Officer (CNO) said the expectation was for all residents who were administered anticoagulants be monitored for potential symptoms or side effects.

4. Resident #10 was admitted to the facility in January 2024 with diagnoses including dementia, anxiety disorder, major depressive disorder, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 5/8/24, indicated Resident #10 had moderate cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). Review of Resident #10's care plans indicated but was not limited to: - Focus: I am taking an antipsychotic, antidepressant medication r/t (related to) agitation, mood, and behaviors. My behaviors include: calling out for attention repeatedly. Anxiousness where her room is. [sic] - Goal: My doctors will monitor my medications and attempt to reduce the use of psychotropic (medications that affect behavior, mood, thoughts, or perception) through the review date. - Interventions: I will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Review of the Physician's Orders indicated but was not limited to the following: - Ativan (anti-anxiety) Oral Tablet 0.5 mg (Lorazepam) Give 1 mg by mouth every 24 hours as needed for agitation at HS (bedtime), dated 6/5/24 - Ativan Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth two times a day, dated 6/5/24 - Latuda (antipsychotic) Oral Tablet 80 mg (Lurasidone HCl) Give 80 mg by mouth one time a day, dated 6/17/24 - Trazodone HCl Oral Tablet Give 25 mg by mouth two times a day, dated 6/5/24 - Trazodone HCl Oral Tablet 100 mg Give 2 tablet [sic] by mouth one time a day, dated 6/10/24 Further review of the as needed Ativan order failed to indicate a stop date or re-evaluation date as required. Review of the June 2024 MAR indicated that Resident #10 was administered the as needed dose of Ativan on 6/6/24 and 6/20/24. Further review of Resident #10's May and June 2024 MARs and Treatment Administration Records (TARs) indicated the monitoring of adverse consequences to psychotropic medications were not being documented. During an interview on 6/27/24 at 12:55 P.M., the DON said all residents who are receiving antidepressant, antianxiety and antipsychotic medications should have orders to monitor for potential adverse consequences. 3. Resident #30 was admitted to the facility in March 2024 with diagnoses which included anxiety disorder and dementia. Review of the MDS assessment, dated 4/3/24, indicated that Resident #30 received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #30's active Physician's Orders indicated but were not limited to: - Trazodone (antidepressant) tablet, 50 mg. Give 25mg by mouth two times a day for agitation related to unspecified dementia, moderate with other behavioral disturbance. Give one half tab (25mg) by mouth twice daily. Active 3/8/24. Revised 5/23/24. - Trazodone tablet, 50mg. Give 25mg by mouth every 8 hours as needed for agitation for 90 days. Active 4/5/24. - Seroquel (antipsychotic) tablet, 50mg. Give 50mg by mouth two times a day for dementia. Active 3/4/24. - Xanax (antianxiety) tablet 0.25mg. Give 0.25mg by mouth every 24 hours as needed for anxiety/agitation for 90 AND give 0.25mg by mouth one time a day for anxiety/agitation. Active 4/5/24. Review of Resident #30's MAR for May and June 2024 indicated the Resident received Trazodone, Seroquel, and Xanax medications per physician's orders. Review of Resident #30's active care plan indicated but was not limited to: - I use antidepressant medication and antianxiety medications related to depression and anxiety. - I will be free from discomfort or adverse reactions related to antidepressant/antianxiety therapy through the review date. - Administer antidepressant/antianxiety medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Further review of Resident #30's medical record failed to indicate physician's order for or documentation of side effects and effectiveness every shift for Trazodone, Seroquel, or Xanax medications. During an interview on 6/27/24 at 4:46 P.M., the DON and Chief Nursing Officer (CNO) reviewed Resident #30's medical record. The DON said the Resident should have physician's orders to monitor side effects of Trazodone, Seroquel, and Xanax. During an interview on 7/1/24 at 10:31 A.M., Nurse Practitioner #2 said an order should exist to monitor side effects of Trazodone, Seroquel, and Xanax for Resident #30.Based on record review and interview, the facility failed to ensure each Resident's drug regimen was free from unnecessary psychotropic medications for five Residents (#55, #78, #30, #32, and #10), out of a total sample of 19 residents. Specifically, the facility failed to ensure psychotropic medications were monitored for adverse consequences (side effects) of their use. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, dated 3/4/24, indicated but was not limited to: - Policy: Residents are not given psychotropic drugs 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 resident's response to the medication(s). Policy Explanation and Compliance Guidelines: - The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 1. Resident #55 was admitted to the facility in October 2024 with diagnoses including anxiety, obsessive compulsive disorder, and depression. Review of the Minimum Data Set (MDS) assessment, dated 3/5/24, indicated Resident #55 had received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #55's current Physician's Orders indicated but was not limited to: - Escitalopram (antidepressant) 20 milligrams (mg) tab by mouth one time a day (10/27/23) - Aripiprazole (antipsychotic) 2 mg tab by mouth one time a day (10/27/23) - Remeron (antidepressant) 7.5 mg by mouth one time a day (11/20/23) - Xanax (antianxiety) 0.5 mg by mouth three times a day (11/16/23) Review of Resident #55's April, May, and June 2024 Medication Administration Records (MAR) indicated he/she received Escitalopram, Aripiprazole, Remeron, and Xanax as ordered. Further review of Resident #55's medical record failed to indicate Resident #55 was monitored for potential adverse consequences of antipsychotic, antianxiety, and antidepressant medications. During an interview on 6/25/24 at 12:40 P.M., Unit Manager #1 said any resident taking an antipsychotic, antianxiety, and antidepressant medication should be monitored for side effects of the medications. Unit Manager #1 reviewed Resident #55's physician orders and said Resident #55 did not have an order to monitor for potential adverse consequences of his/her antipsychotic, antianxiety, and antidepressant medications but should have one. During an interview on 6/27/24 at 12:55 P.M., the Director of Nursing (DON) said residents who are receiving antidepressant, antianxiety, and antipsychotic medications should have order to monitor for potential adverse consequences. 2. Resident #78 was admitted to the facility in April 2024 with diagnoses including major depressive disorder. Review of Resident #78's MDS assessment, dated 4/12/24, indicated that Resident #78 received antidepressant medication. Review of Resident #78's current Physician's Orders indicated but were not limited to: - Citalopram (antidepressant) 20 mg give one tab daily (5/17/24) - Sertraline (antidepressant) 25 mg give one tab daily (4/4/24) Review of Resident #78's April, May, and June 2024 MARs indicated he/she received Citalopram and Sertraline as ordered. Review of Resident #78's care plan failed to indicate but was not limited to: - Focus: I uses [SIC] antidepressant medication Sertraline and Citalopram r/t (related to) Depression (date initiated 5/13/24) - Goal: I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (dated initiated 5/13/24) - Interventions: - Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift) (date initiated 5/13/24) - Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy (date initiated 5/13/24) Further review of Resident #78's medical record failed to indicate Resident #78 was monitored for potential adverse consequences of antidepressant medications. During an interview on 6/27/24 at 7:51 A.M., Nurse #7 said residents who take antidepressant medications should be monitored for potential adverse consequences. Nurse #7 reviewed Resident #78's medical record and said Resident #78 was administered antidepressant medications per physician's orders. Nurse #7 said the Resident did not have an order to monitor for potential adverse consequences of antidepressant medications but should have one. During an interview on 6/27/24 at 12:55 P.M., the DON said residents who are receiving antidepressant should have order to monitor for potential adverse consequences. 5. Resident #32 was admitted to the facility in January 2024 with diagnoses including dementia, abnormalities of gait and mobility, and unsteadiness on his/her feet. Review of the MDS assessment, dated 4/13/24, indicated Resident #32's received psychotropic medication daily. Review of Resident #32's current Physician's Orders indicated but was not limited to: - Ativan 0.5mg one time a day (4/25/24) - Depakote Sprinkles (anticonvulsant used for behaviors) 125mg, give 2 capsules one time a day (5/1/24) - Seroquel 25mg, give 12.5mg two times a day (6/18/24) - Trazodone 50mg, give 25mg every 12 hours as needed for anxiety (6/7/24) - Trazodone 50mg at bedtime (4/25/24) Review of Resident #32's April 2024 through June 2024 MAR indicated the Resident received Ativan, Depakote, Seroquel and Trazodone as ordered by the Physician. Further review of the entire medical record failed to indicate Resident #32 was monitored for potential adverse consequences of antianxiety, antipsychotic and antidepressant medications. During an interview on 6/25/24 at 11:29 A.M., Unit Manager #1 said residents on psychotropic medications should be monitored for side effects. She reviewed Resident #32's medical record and said they were not monitoring him/her for adverse consequences of psychotropic medication use.

Based on observations, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles prior to administration and in 1 of 4 medication carts and 1 of 2 medication rooms. Specifically, the facility failed to ensure: - For Resident #74, Intravenous (IV) medication was stored in the medication cart and not left at the bedside; - Schedule II-V controlled substance medications were maintained in a separately locked, permanently affixed compartment; - Loose pills were properly discarded; and - A multi-dose vial of Tuberculin (used to perform a skin test to diagnose Tuberculosis) which had been opened/accessed was dated and discarded within 30 days. Findings include: Review of the facility's policy titled Medication Storage, dated 3/4/24, indicated but was not limited to the following: - It is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations; - Schedule II drugs and back-up stock of Schedule III, IV, and V medications are stored under double-lock and key; - The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. On 6/25/24 at 11:32 A.M., the surveyor observed an Intravenous (IV) bag containing Ampicillin (antibiotic) 2 grams/100 milliliters (ml) along with a 10 ml saline flush, unattended on the overbed table in Resident #74's room. During an interview on 6/25/24 at 11:42 A.M., Nurse #1 stated she left the IV medication in Resident #74's room because he/she was not in the room and she had gone to look for him/her. Nurse #1 stated that she should not have left the medication there and it was not her usual practice. During an interview on 7/1/24 at 10:04 A.M., the Chief Nursing Officer (CNO) and Director of Nursing (DON) said that IV antibiotics should not have been left in the Resident's room unattended and should have been stored either in the medication room or medication cart. During review of the East Unit A-Side medication cart, on 6/27/24 at 12:30 P.M., with Nurse #7, the surveyor observed: - Multiple loose pills in the top drawer of the medication cart where over-the-counter medications were stored - Four unlabeled inhaler devices not stored in boxes; - Numerous schedule II-V controlled substances were not maintained within a separately locked, permanently affixed compartment. During an interview on 6/27/24 at 12:30 P.M., Nurse #7 said that that loose pills should have been discarded and not left in the drawer of the medication cart. Nurse #7 said that inhaler devices should be labeled and stored in boxes marked with the residents' names and prescription information. Nurse #7 said that the lock on the separately locked compartment in the medication cart, where schedule II-V controlled substances were usually stored, had been broken for a few weeks and that the pharmacy had been contacted for repair. Nurse #7 did not know when the pharmacy had been contacted or when the lock was scheduled to be repaired. Nurse #7 said that the Director of Nursing (DON) was aware that the lock was broken. During an interview on 6/27/24 at 12:30 P.M., the DON said she was aware the lock was broken and that the pharmacy had been contacted. The DON said that schedule II-V controlled substances should be stored under double-lock and key. During an interview on 6/27/24 at 12:30 P.M., the CNO said that she was not aware that the drawer lock was broken and that controlled substances should be stored in a double-locked permanently affixed compartment. During review of the East Unit medication room, on 6/27/24 at 12:38 P.M., with Nurse #7, the surveyor observed a multi-dose vial of Tuberculin, which had been opened/accessed, was not labeled with the opened date and expiration date stored in the medication room refrigerator. Review of the manufacturer's guide for Tuberculin indicated that once opened/accessed, multiple dose vials should be discarded after 30 days. During an interview on 6/27/24 at 12:38 P.M., Nurse #7 said that the Tuberculin vial should have been labeled with the opened date and expiration date.

3. Review of the facility's policy titled Skin Assessment, dated 3/4/24, indicated but was not limited to: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. -Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in the wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate. A. Resident #6 was admitted to the facility in April 2024 with diagnoses which included diabetes mellitus, pressure ulcer of the sacral region, and pressure ulcer of the right hip. Review of Resident #6's current Physician's Orders indicated but was not limited to: -Weekly skin check with shower Fridays 3-11 every evening shift every Friday *Complete Weekly Skin Check UDA (user-defined assessment)* (4/10/24) Review of Resident #6's April, May, and June 2024 Treatment Administration Records (TAR) indicated a nurse had signed off weekly skin checks as being completed on 4/12/24, 4/19/24, 4/26/24, 5/3/24, 5/10/24, 5/17/24, 5/24/24, 5/31/24, 6/7/24, 6/14/24, 6/21/24, and 6/28/24. Further review of Resident #6's medical record failed to indicate a weekly skin check assessment form had been filled out on the following days: - 4/12/24 - 5/10/24 - 5/17/24 - 6/28/24 B. Resident #231 was admitted to the facility in June 2024, with diagnoses including hypertension and alcohol abuse. Review of Resident #231's current Physician's Orders indicated but was not limited to: - Weekly skin check with shower Monday PM every evening shift every Monday *Complete Weekly Skin Check UDA* (dated 6/5/24) Review of Resident #231's June TAR indicated a nurse had signed off weekly skin checks as being completed on 6/10/24, 6/17/24, and 6/24/24. Further review of Resident #231's medical record failed to indicate a weekly skin check assessment form had been filled out on the following days: - 6/10/24 - 6/17/24 - 6/24/24 C. Resident #48 was admitted to the facility in April 2024 with diagnoses including rectal abscess and muscle wasting and atrophy. Review of Resident #48's current Physician's Orders indicated but was not limited to: - Weekly skin check with shower Fridays 3-11 every evening shift every Friday *Complete Weekly Skin Check UDA* (dated 4/8/24) Review of Resident #48's April and May 2024 TAR indicated a nurse had signed off weekly skin checks as being completed on 4/12/24, 4/19/24, 4/26/24, 5/3/24, and 5/10/24. Further review of Resident #48's medical record failed to indicate a weekly skin check assessment form had been filled out on the following days: - 4/12/24 - 4/19/24 - 4/26/24 - 5/3/24 - 5/10/24 During an interview on 7/1/24 at 10:04 A.M. the DON said skin checks are completed on shower days and should be signed off on the TAR and a UDA completed. The DON said Residents #6, #231, and #48 all had skin checks signed off on the TAR but all three residents were missing UDAs and should not have been. Based on observation, record review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for five Residents (#74, #20, #6, #231, and #48), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #74, to accurately document the recommendations from the consultant infectious disease Physician regarding the plan of care for a peripherally inserted central catheter (PICC); 2. For Resident #20, to ensure his/her electronic medical record contained scanned documents pertaining only to Resident #20; and 3. For Residents #6, #231, and #48, to document weekly comprehensive skin assessment per physician orders. Findings include: Review of the facility's Confidentiality of Personal and Medical Records policy and Safeguarding of Resident Identifiable Information, both dated 3/4/24, indicated but was not limited to: - This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. - Personal and medical records include all types of records the facility might keep on a resident, whether they are medical, social, funds accounts, automated, or other. - Keep confidential is defined as safeguarding the content of information including written documentation, video, audio or other computer stored information from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative. - It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records. 1. Resident #74 was admitted to the facility in May 2024 with diagnoses including endocarditis (infection of the heart's inner lining, usually involving the heart valves) and had a Peripherally Inserted Central Catheter (PICC) for infusion of antibiotic medication. Review of the Minimum Data Set (MDS) assessment, dated 6/2/24, indicated Resident #74 had received intravenous (IV) antibiotic medication. Review of an outpatient infectious disease progress note, dated 6/25/24, indicated Resident #74 was seen on 6/25/24 for a follow-up appointment. The note indicated the Resident was getting Ceftriaxone (antibiotic) 2 grams (gm) every 12 hours and Ampicillin (antibiotic) 2 gm every 4 hours to treat endocarditis. Treatment recommendation included, but was not limited to: - Continue IV Ampicillin 2 mg every 4 hours and IV Ceftriaxone 2 gm over 12 hours. - Anticipate 6 week course of IV antibiotic therapy (end date 7/4/24), to be followed by indefinite oral antibiotic suppression with oral Amoxicillin 500 mg three times a day. Review of a nursing progress note, dated 6/25/24, indicated Resident #74's PICC line was to be pulled on 7/15, and would start amoxicillin 500 mg three times a day indefinitely. Further review of the medical record indicated a Physician's order, entered on 6/25/24, for an RN (Registered Nurse) to remove PICC line on 7/15/24. During an interview on 6/28/24 at 2:00 P.M., the Staff Development Coordinator (SDC) reviewed Resident #74's medical record and said she would call the infectious disease physician to clarify the recommendations. During an interview on 7/1/24 at 8:05 A.M., the SDC said she spoke with the infectious disease physician's office, and they said Resident #74's antibiotic treatment will end on 7/4/24 and will begin oral antibiotics as indicated in their note. She said the information documented in the medical record was inaccurate. 2. Resident #20 was admitted to the facility in April 2024. Review of the electronic medical record miscellaneous tab indicated but was not limited to the following: - Psychiatric Consultant Progress Notes, dated 4/17/24 for two residents who were not Resident #20; and - Psychiatric Consultant Progress Notes, dated 4/24/24 for seven residents who were not Resident #20. During an interview on 7/1/24 at 12:30 P.M., the Director of Nurses (DON) reviewed Resident #20's electronic medical record and said the documents should have been uploaded into each residents' medical record and not Resident #20's medical record.

Based on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections for five Residents (#72, #74, #17, #6, and #55) of 19 sampled residents. Specifically, the facility failed to: 1. For Resident #72, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) and Contact Precautions (infection control precautions used for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission); 2. For Resident #74, ensure staff wore PPE as required for EBP while providing care to a resident with a Peripherally Inserted Central Catheter (PICC); 3. For Resident #17, ensure staff wore PPE while in contact with the Resident's blood; 4. For Resident #6, ensure staff wore the appropriate PPE as required for EBP while providing direct care; 5. For Resident #55, ensure staff wore the appropriate PPE as required for EBP while providing direct care; and 6. Clean and sanitize tables before meals and perform hand hygiene for residents before meals on one of two units. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, dated 3/4/24, indicated but was not limited to: - Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. - Definitions: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and gloves use during high contact resident care activities. - Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical advices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubs, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubs, hemodialysis catheters, PICC lines, midline catheters h. Wound care: any skin opening requiring a dressing 10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's policy titled Transmission Based Precautions, dated 3/8/20, indicated but was not limited to the following: - In addition to Standard Precautions Contact Precautions will be implemented for residents with known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. - Wear a clean non-sterile gown for all interaction that may involve contact with the resident or potentially contaminated items in the resident's environment. Review of the Centers for Disease Control and Prevention (CDC) article titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, indicated that changing linen is considered a high contact resident care activity and gown and gloves should be worn by personnel if they are changing the linen of residents on Enhanced Barrier Precautions. 1. Resident #72 was admitted to the facility in May 2024 with the following diagnoses: sepsis (an infection of the bloodstream) and Methicillin-Susceptible Staphylococcus aureus (MSSA) infection (a bacterial infection that can be treated by antibiotics). Review of the Minimum Data Set (MDS) assessment, dated 5/21/24, indicated Resident #72 had diagnoses including a multi-drug resistant organism infection, septicemia, and wound infection. Further review of the MDS indicated he/she received application of dressings to his/her feet and received IV (intravenous) antibiotic therapy. Review of Resident #72's Order Summary Report indicated but was not limited to the following: - Enhance Barrier Precautions and Contact Precautions every shift (order date 5/17/24) On 6/24/24 at 9:26 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 in Resident #72's room handling the Resident's bed linen without a gown on. Signs posted outside the Resident's room indicated that staff were to follow EBP and Contact Precautions. A cart containing personal protective equipment was observed inside the doorway of the Resident's room. Review of the CDC Contact Precautions sign, undated, indicated but was not limited to: - Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Review of the CDC EBP sign, undated, indicated but was not limited to: - Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing During an interview on 6/24/24 at 9:26 A.M., CNA #1 said that Resident #72 was not on Contact Precautions. During an interview on 6/26/24 at 8:49 A.M., CNA #5 said that Resident #72 was on EBP due to the presence of a urinary catheter and that staff are to wear a gown and gloves when performing high-contact care activities. During an interview on 6/26/24 at 8:45 A.M., the Staff Development Coordinator (SDC)/Infection Preventionist (IP) said Resident #72 was on EBP but was not on Contact Precautions and that staff should be wearing a gown and gloves when changing his/her linen.6. On 6/25/24 at 11:37 A.M., the surveyor observed 17 residents in the [NAME] unit dining/activity area. The surveyor observed some of the residents handling blocks and playing cards. The surveyor observed staff clear the activities off the tables but did not clean the tabletops or perform hand hygiene for the residents prior to serving lunch. On 6/25/24 at 11:49 A.M., the surveyor observed one resident eating peas with their bare hands and another resident eating a roll with their bare hands. During an interview on 6/27/24 at 9:31 A.M., Resident #29 said they would like to have their hands cleaned and sanitized before meals. On 6/27/24 at 11:36 A.M., the surveyor observed in the [NAME] unit, residents sitting at tables with many residents doing activities such as building blocks, shuffling cards, and handling sensory items. The surveyor observed the lunch truck arrive at which time staff cleared activities off tables. The surveyor observed that staff did not clean any tabletops after the activities and prior to serving meals. The surveyor observed staff also did not perform hand hygiene for the residents prior to the lunch meal. The surveyor observed two residents eating sandwiches with their bare hands. During an interview on 6/27/24 at 3:30 P.M., CNA #4 said for the [NAME] unit there was no protocol in place to clean or sanitize tables before serving meals, nor for performing hand hygiene on resident's hands before meals. CNA #4 said staff cleaned tables and residents' hands prior to meals if they were noticeably dirty. 4. Resident #6 was admitted to the facility in April 2024 with diagnoses of diabetes mellitus, pressure ulcer of the sacral region, and pressure ulcer of the right hip. Review of Resident #6's MDS assessment, dated 5/13/24, indicated Resident #6 had three stage 4 (full thickness skin and tissue loss) pressure ulcers. Review of Resident #6's current Physician Orders indicated but was not limited to: -Enhanced Barrier Precautions. Please use enhanced barrier precautions (gloves, gown) during all close contact resident care. Every shift for infection control (Dated 5/13/24) Resident #6 had an EBP sign, undated, from the CDC outside his/her room, which indicated but was not limited to the following: - STOP ENHANCED BARRIER PRECAUTIONS - EVERYONE MUST: - Clean their hands, including before entering and when leaving the room. - PROVIDERS AND STAFF MUST ALSO: - Wear gloves and a gown for the following High-Contact Resident Care Activities. - Dressing - Bathing/Showering - Transferring - Changing Linens - Providing Hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound Care: any skin opening requiring a dressing On 6/24/24 at 1:17 P.M., the surveyor observed a nurse and a CNA assist Resident #6 with perineal care (washing of private parts). The surveyor observed the nurse and the CNA wearing only gloves. The nurse and the CNA failed to don (put on) a gown. During an interview on 7/1/24 at 10:35 A.M., Unit Manager #1 said Resident #6 is on EBP for multiple wounds. Unit Manager #1 said anyone providing perineal care to Resident #6 should have been wearing a gown and had gloves on. During an interview on 7/1/24 at 10:04 A.M., the DON said the expectation is for staff to wear the appropriate PPE when providing direct high contact care to residents on EBP. 5. Resident #55 was admitted to the facility in October 2024 with diagnoses including retention of urine and obstructive and reflux uropathy. Review of the MDS assessment, dated 3/5/24, indicated Resident #55 had an indwelling Foley catheter care. Review of Resident #55's current Physician Orders indicated but was not limited to: -Enhanced Barrier Precautions. Please use enhanced barrier precautions (gloves, gown) during all close contact resident care. Every shift for infection control (Dated 5/13/24) Resident #55 had an EBP sign, undated, from the CDC outside his/her room, which indicated but was not limited to the following: - STOP ENHANCED BARRIER PRECAUTIONS - EVERYONE MUST: - Clean their hands, including before entering and when leaving the room. - PROVIDERS AND STAFF MUST ALSO: - Wear gloves and a gown for the following High-Contact Resident Care Activities. - Dressing - Bathing/Showering - Transferring - Changing Linens - Providing Hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound Care: any skin opening requiring a dressing On 6/25/24 at 7:41 A.M., the surveyor observed CNA #6 transfer Resident #55 out of his/her bed and assist his/her to their chair. CNA #6 was wearing gloves. CNA #6 failed to don a gown on. During an interview on 6/25/24 at 12:27 P.M., CNA #6 said he did not put on a gown when transferring Resident #55 because he had not seen the sign for EBP outside of Resident #55's room. CNA #6 said had he seen the sign then he would have put on a gown when transferring Resident #55 as he was supposed to. On 6/26/24 the surveyor made the following observations: - At 8:45 A.M., CNA #1 entered Resident #55's room and assisted Resident #55 to the bathroom. CNA #1 did not perform hand hygiene or don a gown and gloves. - At 8:48 A.M., CNA #1 exited Resident #55's room without performing hand hygiene and walked over to the linen cart in the hall, CNA #1 returned to assist Resident #55 in the bathroom without performing hand hygiene and CNA #1 did not don a gown and gloves. - At 8:49 A.M., CNA #1 exited Resident #55's room without performing hand hygiene, went over to a linen cart in the hallway then CNA #1 entered another Resident's room, then exited the room without performing hand hygiene. - At 8:51 A.M., CNA #1 returned to Resident #55's room. CNA #1 failed to perform hand hygiene. CNA #1 donned gloves but failed to don a gown. CNA #1 assisted Resident #55 from the bathroom to his/her chair. CNA #1 doffed off the gloves. CNA #1 failed to perform hand hygiene and exited Resident #55's room. During an interview on 6/26/24 at 8:57 A.M., CNA #1 said Resident #55 is on EBP because he/she has a Foley catheter. CNA #1 said when providing care in the bathroom you have to wash your hands and put on a gown and gloves. CNA #1 said she should have put on a gown and gloves as well as perform hand hygiene. On 6/27/24 at 7:53 A.M., the surveyor observed CNA #1 making Resident #55's bed. CNA #1 failed to have a gown and gloves on. CNA #1 exited Resident #55's room and failed to perform hand hygiene. During an interview on 6/27/24 at 7:56 A.M., CNA #1 said she was not aware that she had to wear a gown and gloves while making Resident #55's bed because he/she was out at the hospital. During an interview on 6/27/24 at 8:40 A.M., the Administrator said CNA #1 should have worn a gown and gloves while making Resident #55's bed. During an interview on 7/1/24 at 10:04 A.M., the DON said the expectation was to wear the appropriate PPE and perform hand hygiene when providing direct high contact care and changing linens to residents on EBP. 2. Resident #74 was admitted to the facility in May 2024 with diagnoses including endocarditis (infection of the heart's inner lining, usually involving the heart valves) and had a Peripherally Inserted Central Catheter (PICC) line for infusion of antibiotic medication. Review of the most recent MDS assessment indicated Resident #74 received intravenous (IV) antibiotic medication. Review of the medical record indicated that on 5/25/24, Resident #74 had a double lumen PICC line placed in the left basilic vein at the antecubital region (inner surface of the forearm) for infusion of antibiotic medication during a recent hospitalization. Review of the Physician's Orders indicated, but was not limited to: -Enhanced Barrier Precautions every shift (5/29/24) On 6/24/24 at 8:59 A.M., the surveyor observed a sign posted outside the Resident's room that indicated staff were to follow EBP for high contact resident care activities including device care. A three-tiered precaution cart filled with PPE was noted outside the Resident's door. On 6/24/24 at 9:00 A.M., the surveyor observed Nurse #1 enter Resident #74's room, put on a pair of gloves, approach the intravenous pump at the Resident's bedside and disconnect the PICC line tubing. The Nurse failed to perform hand hygiene before applying the gloves and did not wear a gown as required. On 6/24/24 at 10:30 A.M., the surveyor observed Nurse #1 assist Resident #74 out of his/her wheelchair. Nurse #1 was not wearing any PPE while assisting the Resident. On 6/24/24 at 12:20 P.M., the surveyor observed Nurse #1 enter Resident #74's room, put on a pair of gloves and disconnect Resident #74's PICC line tubing. The Nurse failed to perform hand hygiene before applying the gloves and did not wear a gown as required. During an observation with interview on 6/24/24 at 4:44 P.M., the surveyor observed Nurse #1 perform hand hygiene, put on gloves, and enter Resident #74's room and administer medication through the PICC line. The Nurse failed to put on a gown. Nurse #1 said she didn't know she had to wear a gown when hanging IV (intravenous) medication. 3. Review of Standard Precautions for All Patient Care by the CDC, dated 4/3/24, indicated Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. Use personal protective equipment (PPE) whenever there is an expectation of possible exposure to an infectious material. Resident #17 was admitted to the facility in November 2019 with diagnoses including chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). Review of the MDS assessment, dated 6/21/24, indicated Resident #17 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15, was dependent on staff for all activities of daily living and utilized oxygen therapy. On 6/24/24 at 8:00 A.M., the surveyor observed Resident #17 seated in a recliner chair in the unit dayroom being fed by a CNA. A red substance, consistent with blood, was observed smeared from the Resident's left nostril to his/her left upper lip. On 6/24/24 at 8:22 A.M., Nurse #2 approached Resident #17 with ungloved hands, and used the Resident's clothing protector around his/her neck to wipe away the blood that was underneath his/her left nostril. The nurse left the clothing protector with blood on it in place around the Resident's neck and the CNA continued to feed him/her. On 6/24/24 at 8:30 A.M., Nurse #2, with ungloved hands, removed the clothing protector with blood on it from around the Resident's neck and told the surveyor that she was going to get an ice pack for the Resident.

Based on record review and interviews, the facility failed to implement and maintain an effective training program for all new and existing staff. Specifically, for eight direct care staff (Nurse #1, Nurse #9, Nurse #8, Certified Nursing Assistant (CNA) #1, CNA #7, CNA #4, CNA #11, and CNA #10), out of eight direct care staff education records reviewed, the facility failed to provide all of the required training necessary to meet the needs of each resident. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: a. Effective communication for direct care staff b. Resident rights and facility responsibilities for caring for residents c. Elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program d. Written standards, policies, and procedures for the facility's infection prevention and control program e. Written standards, policies, and procedures for the facility's compliance and ethics program f. Behavioral health g. Dementia management and care of the cognitively impaired h. Abuse, neglect, and exploitation prevention i. Safety and emergency procedures -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. Review of the staff education records indicated the following direct care staff had no documented evidence to indicate the completion of the facility's training requirements: -Nurse #1 and Nurse #9, had no education/training records -Nurse #8 and CNA #1, failed to complete compliance and ethics and behavioral health training, -CNA #7 failed to complete resident rights, QAPI, compliance and ethics, behavioral health, and infection prevention and control training -CNA #4 and CNA #11 failed to complete effective communication, resident rights, compliance and ethics, and behavioral health training -CNA # 10 failed to complete effective communication, resident rights, QAPI, compliance and ethics, infection control and prevention and behavioral health training. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of the mandatory trainings. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory and required trainings should be completed upon hire and then annually per the facility policy. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on interviews and staff education records reviewed for five direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistants (CNA) #4, CNA #11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on effective communications was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: a. Effective communication for direct care staff -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for CNAs #4, #11, and #10 failed to include mandatory training on effective communications. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of effective communication training. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training for effective communication should be completed upon hire and then annually. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on interviews and staff education records reviewed for five direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #4, CNA #11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on resident rights was included as mandatory training for direct care staff. Findings include: Review of the facility policy titled, Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: b. Resident rights and facility responsibilities for caring for residents -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for CNAs #4, #11, and #10 failed to include mandatory training on resident rights. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of the training on resident rights. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training for resident rights should be completed upon hire and then annually. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on interviews and staff education records reviewed for five direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #4, CNA #11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: c. Elements and goals of the facility's QAPI program -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for CNAs #4, #11, and #10 failed to include mandatory training on elements and goals of the facility's QAPI program. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of the training on elements and goals of the facility's QAPI program. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training for elements and goals of the facility's QAPI program should be completed upon hire and then annually. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on interviews and staff education records reviewed for four direct care staff employees (Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #7, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on written standards, policies and procedures for the facility's infection prevention and control program was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: d. Written standards, policies and procedures for the facility's infection prevention and control program -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for CNAs #7 and #10 failed to include mandatory training on written standards, policies and procedures for the facility's infection prevention and control program. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of the training on written standards, policies and procedures for the facility's infection prevention and control program. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training on written standards, policies and procedures for the facility's infection prevention and control program should be completed upon hire and then annually. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on interviews and staff education records reviewed for eight direct care staff employees (Nurse #8, Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #1, CNA #7, CNA #4, CNA # 11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on written standards, policies, and procedures for the facility's compliance and ethics program was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: e. Written standards, policies, and procedures for the facility's compliance and ethics program -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers During survey the facility was unable to provide an education folder/packet for Nurses #1 and #9. Review of the staff education records for Nurse #8, CNA #1, CNA #7, CNA #4, CNA # 11, and CNA #10 failed to include mandatory training on written standards, policies, and procedures for the facility's compliance and ethics program. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of the training on written standards, policies, and procedures for the facility's compliance and ethics program. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training on written standards, policies, and procedures for the facility's compliance and ethics program should be completed upon hire and then annually. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on interviews and staff education records reviewed for eight direct care staff employees (Nurse #8, Nurse #1, Nurse #9, Certified Nursing Assistant (CNA) #1, CNA #7, CNA #4, CNA # 11, and CNA #10) of eight employees reviewed, the facility failed to ensure that training on behavioral health was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Training Requirements, dated as revised 3/4/24, indicated but was not limited to: -Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. -Training content includes, at a minimum: f. Behavioral health -The Staff Development Coordinator (SDC) maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. The facility was unable to provide the surveyor with an education folder/packet for Nurses #1 and #9. Review of the staff education records for Nurse #8, CNA #1, CNA #7, CNA #4, CNA # 11, and CNA #10 failed to include mandatory training on behavioral health. During an interview on 7/1/24 at 10:00 A.M., the SDC said all education files and records had been provided to the survey team. The SDC said all education was completed on paper and the facility did not utilize any electronic training programs. During an interview on 7/1/24 at 10:57 A.M., the SDC said she had only been in the role for three months and has been trying to catch up on the mandatory trainings. The surveyor and the SDC reviewed the employee records and the SDC said there was no evidence of the training on behavioral health. The SDC said she would check in her office and review the records again and provide the findings to the survey team, if able. During an interview on 7/1/24 at 12:12 P.M., the Chief Nursing Officer (CNO) said the mandatory training on written standards, policies, and procedures for behavioral health should be completed upon hire and then annually. As of the end of survey, on 7/1/24, the survey team did not receive any additional education/training.

Based on interviews and review of the Activity Director's (AD) personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include: During an interview on 6/25/24 at 11:13 A.M., the Activity Director (AD) said she used to be the First [NAME] at the facility and picked up hours every other week as an Activity Assistant for a while. She said she was hired as the AD for the facility in July 2023 when the former AD left. She said a few weeks after she started her position as AD, she had to take a leave of absence, and June 2024 is her first full month back to work. Review of the AD's personnel file on 6/25/24 failed to indicate she was qualified therapeutic recreation specialist or an activities professional who had two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program, or was a qualified occupational therapist or occupational therapy assistant. During an interview with the AD and Regional Activity Director on 6/27/24 at 9:35 A.M., the Regional AD said she was aware the AD is not qualified to direct the activity program at the facility. During an interview on 6/27/24 at 2:15 P.M., the Human Resource Director said the former AD was terminated on 7/19/23, and they have been without a qualified AD since that time.

Based on observation, policy review, and interview, the facility failed to follow their policy and 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 properly label and date food products and maintain safe and clean equipment in two of two nourishment kitchenettes. Findings include: Review of the facility's policy titled Food: Safe Handling for Foods from Visitors, revised 2/2023, indicated but was not limited to: - Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. - Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and cleaned weekly. Review of the facility's policy, untitled and undated, indicated but was not limited to: - The foodservice department will check for expired products within the inventory. Discard all expired products. If products such as milk will expire before the next visit, discard to prevent negative outcomes. - Place a chart on the refrigerator outlining the expiration period for each item on your floor stock list. Use zip lock bags for condiments and use one label that identifies the date placed in inventory. This will help identify multiple items that expire 3 months or greater. - All open items that are patient items must have a proper label with open and expiration date. Outside items are not exempt from this requirement. In addition to a proper label and date, the patient's name, date of birth , and room number must be placed on the item. Discard items without these requirements. Review of the facility's policy titled Food Storage and Retention Guide, undated, indicated but was not limited to: - Specialty Items- shakes, supplements, thickened beverages: Dry storage and refrigeration at less than or equal to 41 degrees Fahrenheit per manufacturer guidelines. Review of the facility's policy titled Nourishment Room Cleaning, undated, indicated but was not limited to: - Housekeeping is to clean all horizontal and vertical surfaces. - Housekeeping is to dust mop and damp mop all floors. - Dining cleans the inside of the refrigerator. - Dining cleans the inside of drawers where snacks are stored. Review of the facility's cleaning schedule for the East and [NAME] units, undated, indicated but was not limited to: 6:00-6:45 Morning Rounds 6:45-7:30 Clean on unit common areas (see check sheet) 7:30-8:00 Clean off unit common areas (see check sheet) 2:05-2:30 Final Rounds Review of the facility's cleaning schedule check sheet for the East and [NAME] units indicated diet kitchen was on the cleaning schedule check sheet. Review of the facility's nourishment kitchenette par level and monitoring checklist, undated, indicated but was not limited to: - Refrigerator cleaned inside and free from any spills. - Everything is labeled and dated clearly. - Microwave is clean inside and out and free from spills and food residue. - Cabinets and drawers are clean and neat and food is rotated. Immediately throw away any food items not labeled including staff meals. On 6/24/24 at 8:30 A.M., the surveyor observed the following on the [NAME] Unit kitchenette: -Sink faucet and handheld spray nozzle with brown buildup that was easily scraped with fingernail; -Cabinets disorganized with items scattered within; -Drawers disorganized with condiment packages scattered throughout, not bagged and labeled; -Cabinets and hardware with chipping and peeling paint; -Freezer with ice buildup; -One facility container labeled Thick-It with a use by date of 6/22/24; -Nine packets of thickened coffee and tea (beverages used as a safety precaution for residents with swallowing difficulties) with use by dates ranging from 1/6/23 to 3/29/24; -One bottle of nutritional supplement in the refrigerator, opened with no label, undated. On 6/25/24 at 9:00 A.M. and on 6/26/24 at 8:46 A.M., the surveyor observed the following on the East Unit kitchenette: - microwave interior surface soiled on all sides; - Sink faucet and handheld spray nozzle with brown buildup that was easily scraped with fingernail; - Cabinets disorganized with items scattered and spilled sugar on shelving; - Drawers disorganized with condiment packages scattered throughout, not bagged and labeled; peeling contact paper, and small and large areas of a sticky, dark brown substance; - Cabinets and hardware with chipping and peeling paint; - Refrigerator wire shelving with drips of red liquid hanging from the wires; red drips on the lid of a Resident's yogurt; - One container of a resident's prune juice, opened, undated. Manufacturer's label read consume within 7-10 days; - Ice cream with no label, undated; - Two packages of cake mix in the freezer with no label, undated. During an interview with observation on 6/26/24 at 12:30 P.M., the Food Service Director (FSD) said the kitchen staff stocks the Unit kitchenettes, monitors item dating and labeling, monitors for expiration dates, and cleans the refrigerator and freezer. The FSD also said kitchen staff are responsible for cleaning drawers. The FSD and the surveyor observed the East Unit kitchenette together. The FSD said the refrigerator, freezer, drawers, and cabinets needed cleaning. The FSD said the sink faucets and the hand nozzles should be cleaned of buildup. The FSD said resident food items stored in the Unit kitchenettes should be labeled and dated and any food or drink that is expired or past the written use by date is discarded. The FSD said she was unaware of the prune juice's consumption range of seven to ten days after opening, and she was unaware of the expired thickened beverage packets in the [NAME] Unit kitchenette. The FSD said these items should have been discarded.

Based on interview, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Infection Preventionist failed to attend the last two quarterly QAPI meetings. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI), dated as revised 3/4/24, indicated but was not limited to: - The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. - The QAA Committee shall be interdisciplinary and shall consist at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role; and the Infection Preventionist. Review of the QAPI Attendance Sheets, dated 1/19/24, 2/26/24, 3/15/24, and 4/26/24, failed to indicate the Infection Preventionist was in attendance and the designated signature space was blank. Further review of the QAPI Attendance Sheets indicated the Quarterly Meetings were held on 1/19/24 and 4/26/24. During an Interview on 7/1/24 at 12:10 P.M., the Chief Nursing Officer (CNO) reviewed the QAPI Attendance Sheets, dated 1/19/24, 2/26/24, 3/15/24, and 4/26/24 and said the facility IP had not signed in. The CNO said the expectation was for the facility IP to be present at the QAPI Meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #2 was admitted to the facility in May 2023 with diagnoses of atrial fibrillation and hypertension. Review of the medical record for Resident #2 indicated he/she was unable to make his/her own health care decisions, a Health Care Proxy was activated and on admission to the facility the Resident Representative gave the facility permission to administer the pneumococcal vaccine, unless medically contraindicated. The consent form and immunization documentation in the electronic medical record failed to indicate the Resident and/or Resident Representative was educated on the risks, benefits, and potential side effects of the vaccine in order to make an informed decision. Further review of the medical record indicated Resident #2 received Prevnar13 (PCV13) on 4/30/15 (Historical). There was no further information provided in the medical record to indicate Resident #2 had received additional pneumococcal vaccinations or that administration of the vaccine was contraindicated. Review of the Medication Administration Record failed to indicate that Resident #2 received the pneumococcal vaccination as requested and in accordance with the CDC recommendations since consent was given, 43 days prior. Review of the CDC website Pneumococcal Vaccine Timing for Adults, dated 3/15/23 indicated the following: For adults 65 years or older who have only received PCV13, CDC recommends: -Give 1 dose of PCV20 at least 1 year after PCV13, or -Give 1 dose of PPSV23 at least 1 year after PCV13. During an interview on 6/22/23 at 10:30 A.M., the Infection Preventionist (IP) said that she could not find any documentation in the medical record or other files to show that education was completed with Resident #2 and/or their Resident Representative about the risks, benefits, and potential side effects of the vaccine. The IP further said that she could not find documentation in the medical record that a pneumococcal vaccination was administered to Resident #2 after admission to the facility and therefore, it was not administered. 4. Resident #1 was admitted to the facility in May 2023 with diagnoses of Type 2 Diabetes Mellitus and hydrocephalus (a condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage). Review of the medical record for Resident #1 indicated he/she was unable to make his/her own health care decisions, a Health Care Proxy was activated and on admission to the facility the Resident Representative declined the facility permission to administer the pneumonia vaccine. The electronic and paper medical record failed to indicate the Resident and/or Resident Representative was educated on the risks, benefits, and potential side effects of the vaccine in order to make an informed decision. During an interview on 6/22/23 at 10:30 A.M., the IP said that she could not find any documentation in the medical record or other files to show the education was done and therefore, the education about the risks, benefits, and potential side effects of the vaccine was not done with Resident #1 and/or the Resident Representative. During an interview on 6/22/23 at 2:30 P.M., the surveyor reviewed the findings for Residents #1, #2, #3, and #4 with the IP. The IP said the process for vaccine administration was not up to date and needed to be corrected. Based on observation, interviews, and records reviewed, the facility failed to ensure medical records were maintained that included documentation indicating that residents or resident's representatives, had been provided education regarding the benefits and potential side effects of the pneumococcal vaccine in order to make an informed decision regarding administration for four Residents (#4, #3, #2, and #1), and failed to provide the pneumococcal vaccine in accordance with the Centers for Disease Control and Prevention after permission was given for administration for three Residents (#4, #3, and #2), out of a total of five sampled residents. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised 11/21/22, indicated the following: - It is the policy of the facility to offer and administer pneumococcal vaccination to eligible individuals who consent for vaccination -The policy indicates pneumococcal vaccinations will be offered according to the guidance recommended by The Centers for Disease Control and Prevention. 1. Resident #4 was admitted to the facility in June 2023 with diagnoses of heart failure, chronic obstructive pulmonary disease, and status post pneumonia. Review of the medical record for Resident #4 indicated he/she was able to make his/her own health care decisions and on admission to the facility gave the facility permission to administer the pneumonia vaccine, unless medically contraindicated. The consent form and immunization documentation in the electronic medical record failed to indicate the Resident was educated on the risks, benefits, and potential side effects of the vaccine in order to make an informed decision. Further review of the medical record indicated Resident #4 had a Certificate of Immunizations from the Massachusetts Immunization Information System which indicated he/she received the Pneumococcal Polysaccharide (PPSV23) on 8/16/2011. There was no further information provided in the medical record to indicate Resident #4 had received additional pneumococcal vaccinations or that administration of the vaccine was contraindicated. Review of the Medication Administration Record failed to indicate that Resident #4 received the pneumococcal vaccination as requested and in accordance with the CDC recommendations since consent was given, 22 days prior. Review of the CDC website Pneumococcal Vaccine Timing for Adults, dated 3/15/23 (https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf) indicated the following: For adults 65 years or older who have only received PPSV23, the CDC recommends: -Give one dose of PCV15 or PCV20. -The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. -Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. 2. Resident #3 was admitted to the facility in May 2023 with diagnoses of dementia and hypertension. Review of the medical record for Resident #3 indicated he/she was unable to make his/her own health care decisions, a Health Care Proxy was activated and on admission to the facility the Resident Representative gave the facility permission to administer the pneumonia vaccine, unless medically contraindicated. The consent form and immunization documentation in the electronic medical record failed to indicate the Resident and/or Resident Representative was educated on the risks, benefits, and potential side effects of the vaccine in order to make an informed decision. Further review of the medical record indicated Resident #3 received the Pneumovax 23 (PCV23) on 11/17/2004 and received the Pneumovax 23 and Prevnar13 on 11/21/2018. There was no further information provided in the medical record to indicate Resident #3 had received additional pneumococcal vaccinations or that administration of the vaccine was contraindicated. Review of the Medication Administration Record failed to indicate that Resident #3 received the pneumococcal vaccination as requested and in accordance with the CDC recommendations since consent was given, 31 days prior. Review of the CDC website Pneumococcal Vaccine Timing for Adults, dated 3/15/23, indicated the following: For adults 65 years or older who have received PCV13 at any age and PPSV23 at or after age [AGE] years, CDC recommends: -If the vaccine provider and patient decide PCV20 is appropriate, the dose of PCV20 should be administered at least five years after the last pneumococcal vaccine.

Based on record reviews, interviews, and policy review, the facility failed to accurately transcribe an eye drop medication for both eyes and clarify the order to obtain the dose to be administered for one Resident (#3), out of a total sample of 19 residents. Findings include: Review the facility's policy titled Consultants, undated, indicated but was not limited to the following: -Consultants provide the Director of Nurses or Designee with written, dated, and signed reports of each consultation visit. Such reports contain the consultant's: a. Recommendations; b. Plans for implementation of his or her recommendations; c. Findings; and d. Plans for continued assessments. -The facility retains the professional and administrative responsibility for all services provided by the consultants. Resident #3 was admitted to the facility in July 2019 with diagnoses which included primary open angle glaucoma, bilateral, severe stage, presence of intraocular lens, secondary cataract, left eye, cortical age related cataract right eye, age related nuclear cataract, right eye. Review of the Report of Consultation, dated 1/11/23, recommended Resident #3 switch to preservative free Dorzolamide-Timolol (Preservative free Cosopt) two times a day both eyes. No dosage listed on the recommendations. Review of the Nursing Note, dated 1/11/23, indicated but was not limited to the following: -Resident back from his/her appointment with new recommendations: -Switch to Preservative-free Dorzolamide-Timolol two times a day both eyes. Review of Resident #3's current Physician's Orders indicated the following: -Dorzolamide Hydrochloride (HCI) Solution 2.0 %, instill one drop in both eyes two times a day for eye maintenance. -Timoptic Solution 0.5% (Timolol Maleate), instill one drop in both eyes two times a day for eye maintenance. Resident #3 was currently not receiving Preservative-free Dorzolamide-Timolol. Review of the January through March 2023 Medication Administration Records (MAR) indicated Resident #3 has received Dorzolamide Hydrochloride (HCI) Solution 2.0 %, and Timoptic Solution 0.5% eye drops daily since 1/11/23. During an interview on 03/27/23 at 1:45 P.M., Nurse #9 said if a resident comes back from a physician consult visit with new recommendations, you write the orders, notify the physician, and write a nursing note. She said she also sometimes puts the consult in the physician's book for them to see and sign off on the new recommendations. Nurse #9 said the physician's here say if the recommendations are from a consultant they sent them to, then we should take their recommendations as orders and can write them. During an interview on 3/27/23 at 1:45 P.M., Nurse #3 said, if a resident goes out to a consultant physician visit, the physician's will say they will agree with whatever the consultant says, so we can just write the orders when they return from their visit. During an interview on 3/27/23 at 3:34 P.M., the surveyor and Nurse #9 reviewed Resident #3's eye drops in the medication cart. Nurse #9 said the only medication she has for Resident #3 is separate multi-use bottles of Dorzolamide and Timolol and she does not know if they are preservative free. The surveyor reviewed the Report of Consultation, dated 1/11/23 with Nurse #9. Nurse #9 said it is not clear if the consultant wanted one medication: the preservative free Dorzolamide-Timolol (Cosopt) or continue with two separate medications the Dorzolamide and Timolol. During an interview on 3/27/23 at 2:05 P.M., the Director of Nurses (DON) said if a resident comes back from a consultant visit with recommendations, the nurse should notify the physician and document the physician was notified and approve the recommendations and then write the orders. She said, sometimes the house physicians tell the nurses they will agree with the consulting physician and they can go ahead and write the consultant's recommendations as orders. The DON reviewed the Report of Consultation, dated 1/11/23, and said she would read the Dorzolamide-Timolol as one medication because of the hyphen between the medications, but she would have to check to see what the Resident was currently receiving. The DON said she was not aware Resident #3 was switched to preservative free eye drops. Corporate Nurse #1 said the recommendations should also have been clarified with the physician for the dosage per eye. Review of Physician's Note, dated 3/27/23, indicated new orders for Cosopt (Dorzolamide-Timolol) preservative free ophthalmic solution 2-0.5% (Dorzolamide HCl-Timolol Maleate). Instill one drop in both eyes two times a day related to primary open angle glaucoma, bilateral, severe stage.

Based on record review and interviews, the facility failed to ensure a resident's drug regimen was free from unnecessary medications by continuing to administer an antibiotic, after it was determined the bacteria was resistant to the prescribed antibiotic for one Resident (#54), out of a total sample of 19 residents. Findings include: Resident #54 was admitted to the facility in July 2022 with a diagnosis which included dementia. Review of a Nursing Note, dated 3/17/23 at 7:57 P.M., indicated but was not limited to the following: -At approximately 5:45 P.M., Resident #54 was noted to have a flush-warm face. Temperature checked and noted to be at 100.3 degrees Fahrenheit. As needed APAP (Tylenol) 650 mg given at this time. -Resident was unable to say what is wrong. -Physician paged to notify of temperature. Review of a Nursing Note, dated 3/17/23 at 8:10 P.M., indicated but was not limited to the following: -Physician returned page and gave new order to check CBC (Complete blood count)/BMP (basic metabolic panel) blood test on the next lab day and obtain Urinalysis with culture and sensitivity to rule out urinary tract infection. Review of the current Physician's Orders indicated but was not limited to the following: -Obtain urinalysis with culture and sensitivity for fever with unknown origin for four days, initiated 3/17/23. - Marcrobid (antibiotic)100 milligrams (MG), give 100 mg by mouth two times a day for urinary tract infection for ten administrations. Report to physician if resistant. Initiated on 3/22/23 and completed on 3/27/23. Review of a Nursing Note, dated 3/21/23, indicated but was not limited to the following: -Resident has a slight fever on and off, no urine was obtained questioning a urinary tract infection, placed call to physician, new orders: 1. Straight cath and obtain urinalysis. Resident was straight cathed at 2:00 P.M., and stat labs were sent out. Review of the Urine Culture Final Updated Microbiology Results, dated and faxed to the facility on 3/25/23, indicated but was not limited to: -Positive Morganella morgannii (bacteria) greater than 100,000 cfu/ml. -Susceptibility: Nitrofurantoin (urine Only) (Macrobid): Resistant Review of the Medication Administration Record (MAR) indicated Resident #54 continued to be administrated Macrobid 100 mg until 3/27/23, two additional days after the facility was notified the Macrobid was not sensitive to the bacteria Morganella morgannii. Review of a Nursing Note, dated 3/25/23 (late entry), indicated the following: -Continues on Macrobid twice a day for urinary tract infection, urine culture and sensitivity back, sent to Physician #1, no call back yet. Upcoming nurse made aware to follow up. Further review of the medical record indicated there was no additional documentation of follow up with Physician #1 as of 3/28/23. During an interview on 3/28/23 at 11:00 A.M., the Director of Nurses (DON) said she was made aware today that Resident #54's urinalysis sensitivity report indicated Macrobid was not sensitive to the Resident's infection. She said, if the physician doesn't call back, the nurses need to follow up with the physician to see if she wants the Resident to continue on the same antibiotic or change the antibiotic to a more effective antibiotic. On 3/28/23 at 12:53 P.M., a review of the Physician's Orders indicated Resident #54 had new orders for the antibiotic ceftriaxone sodium, Inject 1 gram intramuscularly one time a day for urinary tract infection until 4/7/23.

3. Resident #63 was admitted to the facility in December 2022 with diagnoses which included mild-protein calorie malnutrition, dysphagia (difficulty swallowing), and dementia. Review of Resident #63's current Physician's Orders indicated: -Ensure (nutritional supplement) three times per day for supplement for weight loss, dated 3/3/23 Review of Resident #63's March Medication Administration Record (MAR) indicated Resident #63 was not administered Ensure as ordered from 3/3/23 through 3/19/23. During an interview on 3/27/23 at 8:30 A.M., Unit Manager #1 said the order for Ensure had been entered into the electronic medical record on 3/3/23 but was not signed off and administered until after the order had been revised on 3/19/23. Unit Manager #1 could not identify what had occurred with transcription causing the delay in administration of the Ensure supplements. During an interview on 3/28/23 at 8:30 A.M., the Director of Nurses (DON) said when the Ensure order was transcribed it was put into the electronic medical record as an ancillary order and therefore did not populate on the MAR for nurses to sign off and administer. The DON said she would expect orders that required administration to be transcribed into the MAR and should not be transcribed as an ancillary order. Based on interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for three Residents (#29, #53, and #63), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #29, to initiate a bowel protocol per physician's orders; 2. For Resident #53, to administer medications in accordance with standards of practice, instead leaving them with the Resident for self-administration; and 3. For Resident #63, to ensure orders were accurately transcribed and administered. Findings include: 1. Review of the facility's policy titled Bowel Protocol, revised 7/26/21, indicated but was not limited to the following: Purpose: -To assure residents have periodic bowel movements (BM) to prevent constipation Protocol: -The 7-3 charge nurse will initiate the laxative list on a daily basis (based on no BM x 3 days or however specified by MD) -The 7-3 charge nurse will either use a laxative form or document on the 24-hour report those residents who need to start a bowel protocol -The 3-11 charge nurse will administer Milk of Magnesia (MOM) and document on the 24-hour report and Medication Administration Record (MAR) -The 3-11 charge nurse will indicate the results from the MOM at the end of their shift and document it on the 24-hour report and inform the 11-7 charge nurse of the results -If no BM from the MOM, the 11-7 charge nurse will administer a suppository and document when given and must document on the 24-hour report and the MAR -The 11-7 charge nurse will indicate the results from the suppository at the end of their shift and document it on the 24-hour report and the MAR. The 11-7 nurse will inform the 7-3 charge nurse of the results -If the resident does not have a bowel movement from the suppository, the 7-3 charge nurse will administer a Fleet enema and document on the 24-hour report and the MAR -If the resident does not have a bowel movement from the Fleet's enema you must notify the supervisor immediately and call the MD/APRN for further interventions Resident #29 was admitted to the facility in November 2020 with diagnoses including chronic pain, need for assistance with personal care, cerebral infarction, and hemiplegia (paralysis of one side of the body). Review of the Minimum Data Set (MDS) assessment, dated 12/6/22, indicated Resident #29 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 and was an extensive assist with toileting and personal hygiene. Review of current Physician's Orders indicated the following: -Record bowel movement every night shift for surveillance, if no BM x 3 days, initiate bowel protocol per policy, 1/17/23 -Oxycodone HCL Tablet 5mg, give 1 tablet by mouth two times a day for pain, 6/29/21 -Oxycodone HCL Tablet 5mg, give 5mg by mouth every 6 hours as needed for moderate pain, 6/29/21 -Docusate Sodium Capsule 100mg, give 100mg by mouth every 12 hours as needed for bowels, 6/17/21 -Polyethylene Glycol 3350 Powder (MiraLAX), give 17 grams by mouth every 24 hours as needed for bowel regimen, dissolve in 6-8 ounces of fluid of choice, 1/31/23 -Milk of Magnesia (MOM) Suspension 400mg/5 milliliter (ml), give 30ml by mouth as needed for constipation, give 30ml orally in the morning 3rd day with no bowel movement (BM), 9/9/20 -Biscolax Suppository 10mg (Bisacodyl), insert 1 suppository rectally as needed for constipation, insert 1 suppository rectally at bedtime if MOM is ineffective, 9/9/20 -Enema, Disposable Enema, insert 1 application rectally as needed for constipation Fleet Enema, administer daily if no results from Dulcolax Suppository, 9/9/20 Review of the Chronic Pain Care Plan, revised 7/4/21, indicated the following intervention: -Follow bowel protocol to prevent/minimize constipation During an interview on 3/27/23 at 11:35 A.M., Resident #29 said sometimes it's hard to have a bowel movement and I have to push it out. Resident #29 said he/she can go up to 5 days at a time without a bowel movement, it's not comfortable, and causes pain in his/her right abdomen. Resident #29 said he/she was not sure if staff give him/her bowel medications. The Resident said he/she was supposed to be getting MiraLAX with his/her morning meds but has not gotten it. Review of the January, February, and March Medication Administration Records (MARs) indicated Resident #29 received the Oxycodone per physician's orders. Review of the Xanodyne Pharmaceuticals, Inc. website, revised August 2008, indicated but was not limited to the following: -Oxycodone Hydrochloride (Roxicodone) is an opioid analgesic -The less severe adverse events seen on initiation of therapy with ROXICODONE® are also typical opioid side effects. These events are dose dependent, and their frequency depends on the clinical setting, the patient's level of opioid tolerance, and host factors specific to the individual. They should be expected and managed as a part of opioid analgesia. The most frequent of these include constipation. Review of the East Unit BM Log for Resident #29 indicated the following: -No BM x 3 days (1/26/23 - 1/28/23) -No BM x 3 days (2/1/23 - 2/3/23) -No BM x 3 days (3/1/23 - 3/3/23) Further review of the East Unit BM Log failed to indicate staff consistently documented the Resident's bowel movements. Review of Resident #29's Treatment Administration Records (TARs) indicated the following: -January 2023, no BM's -February 2023 (2/1/23 - 2/3/23), no or N/A BMs -March 2023, no BMs documented 3/1/23 through 3/20/23 Further review of the January, February, and March 2023 MARs failed to indicate a bowel protocol was initiated per physician's orders. No bowel medications were administered to Resident #29. During an interview on 3/27/23 at 1:01 P.M., Certified Nursing Assistant (CNA) #4 and CNA #5 said the aides document daily in the BM book for the day, evening, and night shifts and should be consistently documenting even if residents do not have a BM. During an interview on 3/28/23 at 1:04 P.M., the surveyor reviewed Resident #29's medical record with Nurse #7 who said the Resident takes Oxycodone for pain. She said there is a physician's order to initiate a bowel protocol if no BM x 3 days per policy. She said the Resident has an order for PRN bowel medications but had not gotten any at all for the months of January, February, and March 2023, nothing. Nurse #7 said Resident #29 is not getting any bowel medications daily, they are just ordered PRN. During an interview with the Director of Nursing (DON) and Unit Manager #1 on 3/28/23 at 1:52 P.M., the surveyor reviewed Resident #29's medical record with the DON who said the Resident is on pain medicine including Oxycodone twice a day and as needed. She said the Resident has current orders for Colace, MiraLAX, an enema, MOM, and a suppository as needed but has not been administered any this month. The DON said there were no BMs x 3 days documented for the reviewed dates by the surveyor in January, February, and March and no nursing progress notes addressing it. She said the bowel protocol was not initiated per physician's orders. Unit Manager #1 said CNAs are supposed to fill out the bowel book daily. The DON said nurses are supposed to document bowel movements on the TAR but there were none documented for the date ranges reviewed with the surveyor. The DON said the expectation is to initiate the bowel protocol per physician's orders and said there was also no evidence of a laxative list initiated for the Resident by nursing per facility policy. 2. Resident #53 was admitted to the facility in January 2021 with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus, hypothyroidism, immune system disorder, cirrhosis of the liver, gastro-esophageal reflux disease (GERD), rheumatoid arthritis, and major depressive disorder. Review of the Minimum Date Set (MDS) assessment, dated 1/2/23, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an observation with interview on 3/26/23 at 9:39 A.M., the surveyor observed Resident #53 sitting in his/her wheelchair in their room with an overbed tray table directly in front of him/her. A plastic medication cup was observed on top of the tray table approximately half full of whole medication tablets/capsules inside. The Resident swallowed the pills. No staff were present. Resident #53 said he/she usually takes medications his/herself and staff do not come back to check on him/her to ensure the medications are taken. Resident #53 said he/she was not sure if staff evaluated his/her ability to self-administer and did not remember signing anything. Review of the March 2023 Medication Administration Record indicated the following: 8:00 A.M. medications were documented as being administered by Nurse #10: -Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth one time a day for chronic pain -Farxiga Tablet 10 mg, give 10 mg by mouth one time a day for diabetes mellitus (DM) -Loratadine Tablet, give 1 tablet by mouth one time a day related to disorder involving the immune mechanism -Multivitamin Tablet, give 1 tablet by mouth one time a day for maintenance -Omeprazole Tablet, delayed release, give 40 mg by mouth one time a day for GERD -Plaquenil Tablet 200 mg, give 200 mg by mouth one time a day for rheumatoid arthritis (RA) -Sulfasalazine Tablet 500 mg, give 500 mg by mouth one time a day for RA -Magnesium Oxide Tablet 400 mg, give 800 mg by mouth two times a day for supplement -Metformin HCL Tablet, 1000 mg, give 1000 mg by mouth two times a day for DM -Rifaximin (Antibiotic which helps prevent recurrence of certain liver problems) Tablet 550 mg, give 1 tablet by mouth two times a day -Artificial Tear Solution, instill 1 drop to each eye three times a day for dry eyes During an observation with interview on 3/27/23 at 9:26 A.M., the surveyor observed a box of Artificial Tears eye (eye lubricant) in a zip lock bag on the Resident's bed with an open date labeled as 3/2/23. Resident #53 said staff usually put the drops in for him/her and said staff gave his/her medications this morning in a medication cup and did not stay while he/she took his/her pills. The Resident said staff did not come back yet. Review of the medical record failed to indicate a physician's order was obtained for Resident #53 to self-administer medications. During an interview on 3/27/23 at 12:38 P.M., Nurse #5 said she was working with Nurse #6 that day who was new and assigned to Resident #53. Nurse #5 said the Resident did not self-administer that she knew of. Nurse #5 and Nurse #6 were unable to locate a self-administration assessment in the medical record. During an interview with the Assistant Director of Nursing (ADON) and Nurse #6 on 3/27/23 at 12:46 P.M., the surveyor reviewed Resident #53's medical record with the Assistant Director of Nursing (ADON) who said there was not an assessment for self-administration of meds. She said an assessment would have to be completed prior to the Resident self-administering for safety and a care plan created for it. The ADON said there were no current physician's orders to self-administer. Nurse #6 said she gave the Resident his/her A.M. meds and assisted him/her and, because the Resident was eating; she did not give him/her his/her eye drops and left them in the room with the Resident. During an interview on 3/28/23 at 8:12 A.M., Resident #53 said no one asked if he/she wanted to self-administer medications and did not want to; he/she wanted staff to administer them.

3. Review of Lippincott Nursing Procedures, eighth edition, indicated: -Oxygen administration helps relieve hypoxemia (abnormally low concentration of oxygen in the blood) and maintain adequate oxygenation of tissues and vital organs. Check the patient's room to make sure it is safe for oxygen administration. Whenever possible, replace electrical devices with non-electrical ones to reduce the risk of fire. If a patient care area is not already clearly labeled and your facility requires it, place an oxygen precaution sign on the door to the patient's room. A. Resident #11 was admitted to the facility in July 2021 with diagnoses which included hypertension, hyperlipidemia, and dementia. Review of Resident #11's current Physician's Orders indicated but were not limited to: -Oxygen at 1-4 liters via nasal cannula (device placed in resident's nostrils to deliver oxygen) as needed to maintain saturation >90% and as needed for shortness of breath or low oxygen saturation, dated 2/12/22 On 3/26/23 at 10:15 A.M., the surveyor observed Resident #11 in his/her room wearing Oxygen via nasal cannula at 2 liters. The Resident was using Oxygen from a portable tank and had an oxygen concentrator in her room. The nasal cannula oxygen tubing connected to the oxygen concentrator was dated 2/28. Family Member #1 said Resident #11 used the oxygen concentrator at night and the portable Oxygen during the day. Further review of Resident #11's room/doorway failed to indicate an oxygen in use sign was posted. B. Resident #44 was admitted to the facility in December 2022 with diagnoses which included respiratory failure and chronic obstructive pulmonary disease (COPD). Review of Resident #44's current Physician's Orders indicated but were not limited to: -Change oxygen tubing weekly on Sunday, 11-7 shift and PRN, dated 12/29/22 -Oxygen at 1-2 liters via nasal cannula continuously every shift for COPD, dated 12/29/22 Review of Resident #44's March 2023 Treatment Administration Record (TAR) indicated his/her oxygen tubing had been changed on 3/5/23, 3/19/23, and 3/26/23. On 3/26/23 at 9:05 A.M., the surveyor observed Resident #44 with an oxygen concentrator in his/her room. Oxygen was being delivered from the oxygen concentrator at 2 Liters via nasal cannula. The nasal cannula tubing was dated 2/28. Further review of Resident #44's room/doorway failed to indicate a cautionary oxygen in use sign was posted. During an interview on 3/28/23 at 8:15 A.M., the Director of Nurses said her expectation was for oxygen tubing to be changed and dated weekly. She said oxygen in use signs should be posted outside of the rooms when a resident is on Oxygen. Based on observation, interview, and policy review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for five Residents (#65, #69, #29, #11 and #44), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Residents #65 and #69, to maintain a clean oxygen concentrator filter free from dust and debris as ordered; 2. For Resident #29, to ensure proper care and storage of respiratory equipment; and 3. For Residents #11 and #44, to ensure oxygen tubing was changed weekly and oxygen in use signs were posted. Findings include: Review of the facility's policy titled Concentrator Maintenance, undated, indicated respiratory and oxygen equipment must be cleaned in order to prevent nosocomial infections and to ensure proper function. Further review indicated but was not limited to the following: - all oxygen concentrators should be wiped down to ensure cleanliness and filters should be cleaned at least weekly to prevent overheating Review of the facility's policy titled Equipment Changing, undated, indicated respiratory therapy equipment must be changed in order to prevent nosocomial infections. Further review indicated but was not limited to the following: - all equipment should be changed weekly and as needed if it becomes soiled or falls on the ground and marked with the date it was changed - list of equipment included but was not limited to: nasal cannulas, humidifiers, oxygen and suctioning tubing, simple masks, and nebulizer treatment equipment. 1 A. Resident #65 was admitted to the facility in August 2022 with diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), diabetes mellitus, and hypertension. On 3/26/23 at 8:26 A.M. and at 2:55 P.M., the surveyor observed the oxygen concentrator in use by Resident #65 and observed the filter (which is usually black) to be laden with dust and debris and appeared to be gray in color. Review of the current Physician's Orders for Resident #65 indicated an order to clean the oxygen filter weekly, night shift, Sundays. Review of the March 2023 Treatment Administration Record (TAR) for Resident #65 indicated the oxygen filter was due to be cleaned on Sunday night during the 11:00 P.M. to 7:00 A.M. shift, (3/27/23). During an interview on 3/27/23 at 6:45 A.M., Nurse #4 indicated all assigned tasks were completed throughout the 11:00 P.M. to 7:00 A.M. shift. Further review of the March 2023 TAR for Resident #65 indicated Nurse #4 documented the oxygen filter was cleaned as ordered. On 3/27/23, the surveyor observed Resident #65's oxygen concentrator filter as follows: - 6:57 A.M., filter appeared gray in color and laden with dust and debris; the Resident was receiving Oxygen that was connected via tubing to the concentrator while lying in his/her bed - 10:47 A.M., filter laden with dust; the Resident was receiving Oxygen that was connected via tubing to the concentrator while lying in his/her bed During an interview on 3/27/23 at 11:30 A.M., Nurse #3 observed Resident #65's oxygen concentrator filter and said the filter appeared to not have been cleaned, as ordered on the previous night and it was full of dust. She said the filter did not look like one that had been cleaned recently and that it must have gotten missed. B. Resident #69 was admitted to the facility in November 2022 with diagnoses including pneumonia, diastolic congestive heart failure, adult failure to thrive, and hypertension. Review of the current Physician's Orders for Resident #69 indicated an order to clean the oxygen filter weekly, night shift, Sundays. Review of the March 2023 TAR for Resident #69 indicated Nurse #4 documented the oxygen filter was cleaned as ordered. On 3/27/23 at 10:47 A.M., the surveyor observed Resident #69's oxygen concentrator filter to be laden with dust. The concentrator was running and the Resident was receiving Oxygen via tubing that was connected to the concentrator while sitting in the common area. During an interview on 3/27/23 at 11:26 A.M., Nurse #9 observed Resident #69's oxygen concentrator filter and said the filter was dirty and obviously had not been cleaned as ordered. During an interview on 3/27/23 at 3:22 P.M., the Director of Nurses was made aware of the surveyor's observations, reviewed photographs of the concentrator filters, and reviewed the TARs for Residents #65 and #69 and said the filters did not appear to have been cleaned and required cleaning. She could not explain why Nurse #4 would document that the filters had been cleaned when they had not. She said the expectation and policy for maintaining the cleanliness of the oxygen concentrator filters was not met. 2. Resident #29 was admitted to the facility in November 2020 with diagnoses including chronic obstructive pulmonary disease (COPD) and pneumonia. Review of current Physician's Orders indicated the following: -Change oxygen tubing weekly on Sunday, 11-7 shift and as needed (PRN) every night shift every Sunday related to COPD, 8/15/21 -Clean filter on oxygen concentrator weekly Sunday 11-7 every night shift every Sunday for maintenance, 9/5/21 During an observation with interview on 3/26/23 at 8:37 A.M., the surveyor observed Resident #29 lying in bed with a nasal cannula (lightweight tube in which one end splits into two prongs which are placed in the nostrils from which a mixture of oxygen (O2) and air flows) in place attached to an oxygen concentrator device. A nebulizer machine was observed on top of the Resident's bedside table. The facemask was resting on top of the nebulizer machine, not contained, and exposed to potential environmental contaminants. Resident #29 said he/she was on continuous O2 for his/her breathing. During an observation with interview on 3/27/23 at 10:00 A.M., the surveyor observed the Resident's nebulizer facemask resting on top of the nebulizer machine, not contained, and exposed to potential environmental contaminants. Resident #29 said he/she used the nebulizer machine to open up his/her lungs. During an observation with interview on 3/27/23 at 1:10 P.M., the surveyor and Nurse #6 observed the Resident's nebulizer facemask resting on top of the side table disconnected from the nebulizer tubing. The facemask was not contained and exposed to potential environmental contaminants. Nurse #6 picked up the facemask and placed it inside the Resident's top drawer of the side table where the nebulizer tubing was observed. The tubing was coiled, unprotected, and exposed to potential environmental contaminants in the drawer. Nurse #6 said both should have been stored in protective bags. On 3/28/23 at 8:16 A.M., the surveyor observed the front of the oxygen concentrator and filter located on the back of the concentrator to be laden with dust. Review of the March 2023 Treatment Administration Record indicated the filter on the oxygen concentrator and oxygen tubing had been changed/cleaned on 3/26/23. During an observation with interview on 3/28/23 at 9:30 A.M., the surveyor reviewed the Resident's respiratory equipment with the Director of Nursing (DON) who said the filter and oxygen concentrator were not cleaned and staff should not have documented on the TAR that they cleaned the filter and wiped down the respiratory equipment if they did not. She said it did not look like it was done per their policy and said the same for the nebulizer machine. The DON said the oxygen concentrator filter is supposed to be changed/cleaned weekly by the 11:00 P.M.-7:00 A.M. nurse and all respiratory equipment wiped down. She said the nebulizer facemask and tubing should be stored in clear plastic bags when not in use and replaced weekly.

Based on observation, record review, and policy review, the facility failed to ensure that a licensed nurse had the completed competencies to administer medications independently for Resident #49, resulting in medication errors. Findings include: Review of the facility's policy titled Medication Administration- General Guidelines, dated October 2019, indicated but was not limited to the following: -Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). -Five rights- right resident, right drug, right dose, right route and right time, are applied for each medication being administered. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. On 3/27/23 at 9:45 A.M., the surveyor observed Nurse #6 preparing and administering medications to Resident #49 as ordered for 9:00 A.M. (The surveyor was unaware, and Nurse #6 had not disclosed, that she was on orientation. The surveyor did not observe Nurse #6 being supervised by a preceptor). Review of Resident #49's current Physician's Orders indicated he/she was due to receive: -Aspirin Enteric Coated Delayed Release 81 milligrams (mg) -Isosorbide Mononitrate extended release (antianginal/vasodilator) 30 mg -Lasix (diuretic) 60 mg -Lisinopril (antihypertensive) 5mg -Magnesium Oxide (antacid), one tablet -Vitamin B Complex, one tablet -Vitamin D3 5,000 units -Wellbutrin Extended Release (antidepressant) 300 mg -Metformin (oral hypoglycemic) 500 mg -Primidone (anticonvulsant) 50 mg On 3/27/23 at 9:45 A.M., the surveyor observed Nurse #6 prepare and administer the following medications to Resident #49: -Aspirin Enteric Coated Delayed Release 81 mg -Isosorbide Mononitrate Extended Release 30 mg -Lasix 60 mg -Lisinopril 5 mg -Magnesium Oxide 400 mg -Vitamin B Complex with Vitamin B12, one tablet -Vitamin D3 5,000 units -Wellbutrin Extended Release 300 mg -Metformin 500 mg -Primidone 50 mg Nurse #6 administered Magnesium Oxide without a physician ordered dose. Nurse #6 also administered an incorrect form of Vitamin B Complex. Review of the March 2023 Medication Administration Record (MAR) indicated the Magnesium Oxide was administered through March 28th without a physician ordered dose by Nurse #6 a total of six times. Further review of the March 2023 MAR indicated the Magnesium Oxide was administered through March 28th without a physician ordered dose by two additional nurses as follows: Nurse #5- total of 7 times Nurse #7- total of 12 times During an interview on 3/28/23 at 7:49 A.M., the Assistant Director of Nurses (ADON) and the Administrator in Training/Payroll and Human Resources Consultant said Nurse #6 was hired in early March 2023 and was still orienting. Nurse #6 was orienting with a preceptor who is overseeing and available to her. They said that at times Nurse #6 is on one medication cart and her preceptor is on another. The Assistant Director of Nurses said there is a Competency Assessment form completed by the preceptor to indicate the orientees skill level. The ADON said she had not reviewed the Competency Assessment for Nurse #6. Review of Nurse #6's Competency Assessment was incomplete. Further review of Nurse #6's Competency Assessment indicated the competency for the administration of medication had not been fully verified. On 3/28/23 at 8:32 A.M., the surveyor and the ADON reviewed the Competency Assessment for Nurse #6. The Competency Assessment had not been completed and verified. The Competency Assessment identified many areas which indicated further education was required. The ADON said, after reviewing the Competency assessment, Nurse #6 should not have been left without direct supervision. During an interview on 3/28/23 at 12:25 P.M., Nurse #5 (who was the assigned preceptor for Nurse #6) said a preceptor should stay with someone who is orienting. Nurse #5 said that on 3/27/23 she was on her own team and Nurse #6 was on her own team. Nurse #5 said Nurse #6 was not ready to be alone and indicated that Nurse #6 needed more time orienting. During an interview on 3/28/23 at 8:30 A.M., the ADON said when administering medications, the nurse should confirm that all orders have a dose, and the right medication is being administered prior to giving them to the resident. Refer to F759

Based on observation, record review, and policy review, the facility failed to ensure that the medication error rate was not 5% or greater. A medication error rate of 7.41% was calculated following two observed errors of a total of 27 opportunities for error. Findings include: Review of the facility's policy titled Medication Administration- General Guidelines, dated October 2019, indicated but was not limited to the following: -Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). -Five rights- right resident, right drug, right dose, right route and right time, are applied for each medication being administered. The surveyor conducted medication administration observations of four nurses on two of two units between 3/27/23 and 3/28/23 with the following medication error observation. On 3/27/23 at 9:45 A.M., the surveyor observed Nurse #6 preparing and administering medications to Resident #49 as ordered for 9:00 A.M. (The surveyor was unaware, and Nurse #6 had not disclosed, that she was on orientation. The surveyor did not observe Nurse #6 being supervised by a preceptor). Review of Resident #49's current Physician's Orders indicated he/she was due to receive: -Aspirin Enteric Coated Delayed Release 81 milligrams (mg) -Isosorbide Mononitrate extended release (antianginal/vasodilator) 30 mg -Lasix (diuretic) 60 mg -Lisinopril (antihypertensive) 5mg -Magnesium Oxide (antacid), one tablet -Vitamin B Complex, one tablet -Vitamin D3 5,000 units -Wellbutrin Extended Release (antidepressant) 300 mg -Metformin (oral hypoglycemic) 500 mg -Primidone (anticonvulsant) 50 mg On 3/27/23 at 9:45 A.M., the surveyor observed Nurse #6 prepare and administer the following medications to Resident #49: -Aspirin Enteric Coated Delayed Release 81 mg -Isosorbide Mononitrate Extended Release 30 mg -Lasix 60 mg -Lisinopril 5 mg -Magnesium Oxide 400 mg -Vitamin B Complex with Vitamin B12, one tablet -Vitamin D3 5,000 units -Wellbutrin Extended Release 300 mg -Metformin 500 mg -Primidone 50 mg Nurse #6 administered Magnesium Oxide without a physician ordered dose. Nurse #6 also administered an incorrect form of Vitamin B Complex. Review of the March 2023 Medication Administration Record (MAR) indicated the Magnesium Oxide was administered through March 28th without a physician ordered dose by three different nurses as follows: Nurse #5- total of 7 times Nurse #7- total of 12 times Nurse #6- total of 6 times During an interview on 3/28/23 at 8:30 A.M., the ADON said when administering medications, the nurse should confirm that all orders have a dose, and the right medication is being administered prior to giving them to the resident.

Based on observations, interview, and policy review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to: 1. Follow infection control standards during a medication pass which included hand hygiene and proper handling of medication, and 2. Minimize the potential for cross-contamination (transfer of pathogens (biological contaminant) from one surface to another) of iHealth COVID-19 Antigen Rapid testing cards during the processing time. Findings include: 1. Review of the facility's policy titled Medication Administration- General Guidelines, dated October 2019, indicated but was not limited to the following: -Handwashing and hand sanitization: the person administering a medication adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass and prior to handling any medication. On 3/27/23 at 9:45 A.M., the surveyor observed Nurse #6 during medication administration. Nurse #6 was in orientation and unsupervised by a preceptor during the medication pass. The surveyor observed Nurse #6 perform the following: -Sanitize her hands using alcohol-based hand sanitizer -Set a medication cup onto the top of her medication cart -Open the top drawer of the medication cart, remove an over-the-counter bottle of aspirin, remove the cap of the medication bottle, pour one tablet into the cap, drop the tablet into the medication cup, close the bottle and return it to the top drawer of the medication cart -Remove an over-the-counter bottle of magnesium oxide from the top drawer of the medication cart, remove the cap of the medication bottle, pour one tablet into the cap, drop the tablet into the medication cup, close the bottle and return it to the top drawer of the medication cart -Remove a bottle Vitamin B Complex with Vitamin B12 from the top drawer of the medication cart, remove the cap of the medication bottle, utilize an ungloved finger to slide one tablet from the medication container to the cap, drop the tablet into the medication cup, close the bottle and return it to the top drawer of the medication cart During the observation of medication administration on 3/27/23 at 9:45 A.M., as specified above, Nurse #6 had not performed hand hygiene after touching the medication cart, drawer, and medication containers prior to touching a medication tablet with an ungloved finger that was administered to a resident. During an interview on 3/28/23 at 8:30 A.M., the Assistant Director of Nurses/ Infection Control Nurse said the expectation was that a nurse would pour the medication into the cap of the medication bottle and then pour it into the medication cup. She said if it was necessary to touch a medication the expectation was the nurse would don (put on) gloves. The Assistant Director of Nurses/ Infection Control Nurse said Nurse #6 should not have touched the medication with an ungloved finger. 2. On 3/27/23 at 6:53 A.M. and 6:56 A.M., while observing staff perform rapid antigen COVID-19 testing, the surveyor observed Staff #2 place Certified Nursing Assistant (CNA) #6's and CNA #7's testing cards on top of the table in the testing area while awaiting the results. Staff #2 did not place a protective barrier underneath each of the testing cards or disinfect the surface area after each use to help minimize the potential for cross-contamination. During an interview on 3/27/23 at 9:41 A.M., the Infection Preventionist (IP) said there should have been a protective barrier underneath the testing cards and the surface disinfected in between each test.

Based on observation, interview, and document review, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests and per manufacturer's instructions. Specifically, the facility failed to properly perform iHealth COVID-19 antigen rapid self-testing for four out of four staff members observed. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Specimen Collection, updated May 2022, indicated but was not limited to the following: -Proper specimen collection is the most important step in the laboratory diagnosis of infectious diseases. A specimen that is not collected correctly may lead to false or inconclusive test results. -Follow the manufacturer's instructions for specimen collection. Review of the iHealth COVID-19 antigen rapid test instructions for use (IFU), revised December 2021, indicated the following: -Immediately after adding sample to the sample port, the result will be ready in 15 minutes Note: Do NOT interpret your test result until after your 15-minute timer has completed, as the T-line (test line) may take as long as 15 minutes to appear. a. On 3/27/23 at 6:40 A.M., the surveyor observed Nurse #3 perform iHealth COVID-19 antigen rapid self-testing in the main lobby testing area. Nurse #3 added her sample to the sample port at 6:45 A.M., then placed the testing card on top of the testing table. The surveyor did not observe Nurse #3 write down the time. At 6:47 A.M., two minutes later, Nurse #3 said her test was negative then disposed of it. Nurse #3 did not wait the full 15 minutes for her test to complete prior to reporting to her assigned work area. During an interview on 3/27/23 at 9:00 A.M., Nurse #3 said the processing time is 15 minutes but had only waited four or five minutes because she got a control line. She said she could not remember if she had to wait the full 15 minutes or up to 15 minutes and could not ensure her test results were accurate if read before 15 minutes. b. On 3/27/23 at 6:48 A.M., the surveyor observed Certified Nursing Assistant (CNA) #6 perform iHealth COVID-19 antigen rapid self-testing in the main lobby testing area. Staff #2 assisted with the testing procedure and added CNA #6's sample to the sample port at 6:50 A.M., then placed the testing card on top of the testing table. The surveyor did not observe CNA #6 or Staff #2 write down the time. At 6:53 A.M., three minutes later, Staff #2 told CNA #6 her test was negative then disposed of it. Staff #2 did not wait the full 15 minutes for the test to complete prior to telling CNA #6 it was negative. CNA #6 did not question the time and reported to her assigned work area. During an interview on 3/27/23 at 9:09 A.M., CNA #6 said it was a 15-minute processing time. She said she did not write down the time and was told by Staff #2 that she was all set, so she thought she was all set. CNA #6 said inaccurate results could occur if the test was read prior to the 15 minutes. c. On 3/27/23 at 6:50 A.M., the surveyor observed CNA #7 perform iHealth COVID-19 antigen rapid self-testing in the main lobby testing area. Staff #2 assisted with the testing procedure and added CNA #7's sample to the sample port at 6:52 A.M. then placed the testing card on top of the testing area table. The surveyor did not observe CNA #7 or Staff #2 write down the time. At 6:56 A.M., four minutes later, Staff #2 told CNA #7 her test was negative. CNA #7 did not question the time and reported to her assigned work area. d. On 3/27/23 at 6:53 A.M., the surveyor observed Nurse #9 perform iHealth COVID-19 antigen rapid self-testing in the main lobby testing area. Staff #2 assisted with the testing procedure and added Nurse #9's sample to the sample port at 6:55 A.M., then placed the testing card on top of the testing area table. The surveyor did not observe Nurse #9 or Staff #2 write down the time. At 6:58 A.M., three minutes later, Staff #2 told Nurse #9 she was all set. Nurse #9 did not question the time and reported to her assigned work area. During an interview on 3/27/23 at 8:57 A.M., Nurse #9 said she is supposed to wait three minutes and usually does it herself. She said it's a three-minute processing time because that's what Staff #2 said when her test was done, but then said it's 10 minutes you have to wait. During an interview on 3/27/23 at 9:41 A.M., the surveyor reviewed observations of staff testing with the Infection Preventionist (IP) who said the facility started using the iHealth testing kits last October and provided real time education to staff at that time. She said she oversees staff testing and communicates with Staff #2, so she knows who needs to be tested. The IP said Staff #2 keeps track of the testing log and marks it for her. The IP said staff will either self-test or Staff #2 will assist them. She said there are no instructions posted at the testing station, but staff are expected to wait 15 minutes for the tests which could be invalid if read before. As far as staff writing down the start time for their tests, the IP said, It's been a challenge and said staff should not report to their work areas until they wait the 15 minutes. During an interview on 3/27/23 at 9:10 A.M., Staff #2 said staff are supposed to wait 15-20 minutes but said if there's a control line then you don't have to wait, it's negative. She then said she was not sure if the processing time was 15 minutes and said, I'm learning. Staff #2 said there is no timer and she did not write down the times, she just looks at the clock.