**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two Residents (#1 and #75), out of a total sample of 22 residents, were able to exercise their right to make decisions regarding their medical care when their Health Care Proxy (HCP: a document that gives someone the power to make healthcare decisions for a person who was unable to) was not invoked, and the facility had the HCP's sign advanced directives forms and consent forms. Specifically: 1. For Resident #1, the facility failed to ensure a Medical Order for Life-Sustaining Treatment (MOLST: a medical form that outlines the wishes of a person with a usually serious, progressive health condition regarding life-sustaining measures and end-of-life care (such as life support, palliative care, or Cardiopulmonary Resuscitation [CPR]), and that must be signed by an authorized health care professional (Physician, Nurse Practitioner, or Physician Assistant) form was not signed by the HCP, when the HCP was not invoked for the Resident. 2. For Resident #75, the facility failed to ensure that a MOLST form, consent for psychotropic medications and vaccination for the Respiratory Syncytial Virus (RSV: respiratory virus that infects the nose, throat, and lungs), was not signed by the HCP, when the Resident's HCP was not yet invoked. Findings include: 1. Resident #1 was admitted to the facility in February 2025 with diagnoses including Cerebrovascular accident (stroke) with aphasia (conditions that cause problems with communication) and Diabetes. Review of the Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1: -preferred language was English and Resident did not need interpreter services -was able to understand and understood others -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 Review of the Resident's clinical record indicated the following: -Nurse's Note, dated [DATE]: Resident's HCP will be in on [DATE] to sign paperwork as the Resident was Russian/Ukrainian speaking deeming it difficult to communicate. -Nurse's Notes, dated [DATE]: Resident was able to communicate his/her needs/wants, did understand and speak some English. -MOLST form, signed by the Resident's HCP on [DATE] -Social Service Note, dated [DATE]: the Resident was his/her own decision maker. Further review of the clinical record failed to indicate that Resident #1's HCP was invoked by the Physician. On [DATE] at 11:37 A.M., the surveyor observed Resident #1 dressed and seated in a wheelchair. During an interview at the time, the Resident said his/her primary language was Russian, but he/she was able to communicate in English and had no difficulty communicating with facility staff. During a follow-up interview on [DATE] at 1:31 P.M., Resident #1 said his/her HCP visited him/her and theResident was not sure if the HCP signed paperwork on his/her behalf. The Resident further said that he/she could not recall filling out paperwork about his/her wishes for life-sustaining treatment. During an interview on [DATE] at 11:40 A.M., the Assistant Director of Nurses (ADON) said nursing reviews the MOLST forms with residents. The surveyor reviewed Resident #1's MOLST form which was signed by the HCP on [DATE], and the ADON said if the Resident deferred to a HCP to sign the MOLST form, there should be a note in the chart to indicate this. During a follow-up interview on [DATE] at 3:23 P.M., the ADON said the HCP signed the Resident's MOLST form due to a language barrier as indicated in the Nursing Note dated [DATE]. The surveyor and the ADON reviewed the Resident's clinical record which indicated the Resident's HCP was not invoked and the Resident was able to make his/her own decisions. When the surveyor asked if information was provided to the Resident in his/her primary language if communication was determined to be difficult, the ADON said good point. 2. Resident #75 was admitted to the facility in February 2025 with diagnoses including Cognitive Communication Deficit and Dementia. Review of the MDS Assessment, dated [DATE] indicated Resident #75: -preferred language was English and he/she did not need interpreter services -was rarely understood or understands -was severely cognitively impaired as evidenced by a BIMS score of 0 out of 15 Review of the Resident's clinical record indicated the following: -Nursing admission Note, dated [DATE]: Resident was alert but did not speak English, Portuguese speaking only -MOLST form, signed by the Resident's HCP on [DATE] -Vaccination consent for RSV, signed by the HCP on [DATE] -Psychotropic medication consent for Zyprexa (antipsychotic medication) signed by the HCP on [DATE], and another on [DATE] -Psychotropic medication consent for Trazodone (antidepressant medication), signed by the HCP on [DATE] -Psychotropic medication consent for Cymbalta (antidepressant medication), signed by the HCP on [DATE] -HCP invocation form, signed by the Provider on [DATE] -Physician's order to invoke Resident #75's HCP on [DATE] Review of the Resident's Communication Care Plan, initiated on [DATE], indicated Resident #75 had a communication problem related to severe cognitive impairment due to Dementia and Cognitive Communication Deficit. Further review of the Communication Care Plan interventions failed to indicate documented evidence that the HCP was invoked due to language barriers and difficulty communicating with the Resident. On [DATE] at 11:26 A.M., the surveyor observed the following: -Certified Nurses Aide (CNA) #3 was assisting Resident #75, who was seated in a wheelchair, into another room across the hallway where he/she was previously located. Resident #75 was heard continuously state No .No . when the CNA attempted to have him/her enter the room. -CNA #3 was observed to communicate with Resident #75 in English and then CNA #3 said out loud I don't understand you . On [DATE] at 9:56 A.M., the surveyor and Nurse #2 reviewed Resident #75's clinical record. Nurse #2 said the Nurses on the floor obtain the consents for the psychotropic medications and also review the MOLST form. Nurse #2 said Resident #75 was Portuguese speaking and had cognition issues. Nurse #2 said there should be a Physician's order to invoke a Resident's HCP if this was indicated and that the Resident's HCP was invoked on [DATE]. The surveyor and Nurse #2 reviewed the Resident's paperwork including the MOLST form and consents for vaccines and psychotropic medications which were signed prior to the HCP invocation, and Nurse #2 said the Nurses would notify the Provider about invoking the HCP. Nurse #2 further said sometimes Residents defer to their family to sign paperwork, and if this was the case, there should be a documentation indicating this. During an interview on [DATE] at 11:49 A.M., the ADON said she would look into why the Resident's paperwork was signed by the HCP prior to invocation and said sometimes a Resident may defer to their HCP for signing paperwork, but if this was the case, there should be notation in the clinical record. During a follow-up interview on [DATE] at 3:23 P.M., the ADON said she reviewed Resident #75's clinical record and there was notation in a Nurse's admission Note that the staff deferred to the Resident's HCP due to a language barrier. The ADON said she was not sure if the clinical information relative to completing the MOLST form or consent forms were provided to the Resident in his/her native language prior to the HCP being invoked on [DATE]. During an interview on [DATE] at 11:50 A.M., the Director of Nursing (DON) said he was made aware of the concerns relative to Resident #1 and Resident #75's paperwork which were signed by their HCP prior to or without HCP invocation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. During the initial pool process on the [NAME] Terrace Unit on 3/5/25 and 3/6/25, the following concerns were expressed by residents: -One Resident, who requested to remain anonymous, said he/she was not given timely care or response to needs when he/she had them, that he/she did not ring the call light often, but did utilize it recently and it took an hour for a facility staff person to respond when he/she had to use the bathroom. The Resident said he/she also rang the call light for his/her roommate on the 3:00 P.M. to 11:00 P.M. shift on 3/4/25, and it took a staff person an hour and half to respond. -Resident #101 said he/she had episodes of incontinence which were new since admission to the facility because he/she had to wait for staff to assist him/her with toileting. Resident #101 said he/she had never been incontinent at home, and that it sometimes took a while for his/her call light to be answered. Resident #101 said that he/she had been given an incontinence brief, and that facility staff said if he/she needed to go an incontinence brief was in place, but the Resident said he/she prided him/herself on never being incontinent at home. -Resident #72 said he/she had to wait 30 minutes to an hour for assistance from staff on the 7:00 A.M. to 3:00 P.M. shift. The Resident said the staff are wonderful but that he/she needed assistance from staff when using the bathroom and because he/she had to wait, it has affected his/her ability to remain continent. 3. Resident #169 was admitted to the facility in March 2025 with diagnoses including history of falls, pubic fracture (one of the two bones forming the pelvis), muscle weakness and difficulty ambulating. Review of Resident 169's active Care Plans included the following: -Risk for falls, initiated 3/4/25 and included the following intervention (also initiated 3/4/25): assist with activities of daily living (ADLs) as needed -ADL assistance and Therapy Services were needed to maintain or attain the highest level of function ., initiated 3/4/25 and included the following interventions (also initiated 3/4/25 and revised 3/7/25): Assist of two staff with mobility/transfers with rolling walker and ADLs/toileting assist of two staff. On 3/6/25 at 2:13 P.M., the surveyor observed the following: -Resident #169's call light was lit and audible from the nursing station -Two Nurses were observed seated at the nursing station -2:20 P.M., Resident #169's call light remained lit. The surveyor observed Resident #169 in his/her room seated in a wheelchair positioned next to the bed. During an interview at the time, Resident #169 said he/she rang the call light to ask for assistance from staff to go back to bed. -2:27 P.M., the Resident's call light remained lit and was audible from the nursing station. During an interview at this time, Resident #169 said no staff had checked in with him/her yet since he/she originally initiated the call light. -2:30 P.M., the Resident's call light remained on, and staff were observed in the hallway. -2:32 P.M. (19 minutes later), a nurse was observed entering the Resident's room. 4. Resident #72 was admitted to the facility in December 2024 with diagnoses including muscle weakness and need for assistance with personal care. Review of the Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #72: -had clear speech, was understood and understands others -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -had bilateral range of motion impairments Review of the Resident's active Care Plans, included the following: -Risk for falls related to history of falls, muscle weakness, impaired balance ., initiated 12/15/24, included the following intervention: assist with ADLs as needed, (also initiated 12/15/24) -ADL Assistance and Therapy Services needed to maintain or attain the highest level of function, initiated on 12/15/24, included the following interventions: assist with mobility and ADLs as needed (initiated 12/15/24), ambulate to/from bathroom with four wheeled walker and one assist during the day shift and assist with wheelchair and one assist for toileting during the night shift (initiated 3/6/25) On 3/7/25 at 9:31 A.M., the surveyor observed the following: -Resident #72's call light was lit and was audible at the nursing station -One facility staff member and two Certified Nurse Aides (CNAs), including CNA #1, were observed at the nursing station conversing and and a Nurse was observed at a medication cart at the end of the hallway where the Resident's room was located. -9:33 A.M., a staff person was observed walking down the hallway and stopped at the Resident's room. Resident #72 told the staff person that he/she needed staff immediately because he/she needed to use the bathroom. The staff person was observed to inform CNA #1 who was standing near the nursing station that Resident #72 needed assistance. CNA #1 was observed to remain standing near the nursing station with the second CNA after this interaction. -9:35 A.M., the Administrator was observed to walk down the hallway and stopped at Resident #72's room and entered. -9:36 A.M., the Administrator approached CNA #1 (who remained standing with the other CNA near the nursing station), and CNA #1 said I know, they told me . and then went to Resident #72's room. CNA #1 was observed to assist Resident #72 to the bathroom, went to the Resident's closet, retrieved a pair of dark colored pants and returned to the bathroom. CNA #1 said to Resident #72 to ring when he/she was done and exited the room. -9:47 A.M., Resident #72's call light was lit, blinking red and was audible from the nursing station. A Nurse was observed at the medication cart in the hallway and other facility staff including Housekeeping and Rehabilitation staff were observed walking up/down hallway. -9:49 A.M. both call lights (white and red blinking) were observed on in Resident #72's room. -9:50 A.M. facility staff were observed seated at the nursing station where the call light was audible. -From 9:52 A.M. to 9:56 A.M., Resident #72 was heard yelling out for help numerous times, stating he/she was in the bathroom and needed help. The Resident's roommate (who had also engaged the call light) was heard telling him/her Nobody is coming . -9:56 A.M., (nine minutes after being assisted to the bathroom), Resident #72 continued to yell he/she needed help, and a CNA was observed to enter the room at this time stating she was coming. During an interview on 3/12/25 at 10:32 A.M., the Infection Preventionist (IP), who was assisting with staffing on the [NAME] Terrace Unit, said every staff person should be responding to resident call lights, including CNAs, Nursing, and Therapy. The IP said the resident call bells should be answered within four minutes, and that even if the staff who respond to the call light cannot assist, they were expected to answer the call light, speak with the resident and alert the staff who could assist with the resident's needs. The IP further said the resident call lights were audible at the nursing station, and that all staff who hear/see the call lights should respond. Based on observation, record review, and interview, the facility failed to ensure reasonable accommodations of resident's needs and preference were provided for five Residents (#98, #75, #101, #169 and #72) out of a total sample of 22 residents and on one Unit ([NAME] Terrace Unit) of three units observed. Specifically, the facility failed to: 1. answer call lights timely for Resident #98 and Resident #75 during the early morning times during shift change. 2. respond to resident call lights timely: a. on the [NAME] Terrace Unit. b. for Resident #101, resulting in the Resident being incontinent due to long wait times. 3. answer the Resident's call light timely for Resident #169, when he/she required staff assistance with mobility/transfers. 4. have staff respond timely to the call light for Resident #72, who required assistance to the bathroom and return to further assist the Resident after bathroom use as indicated. Findings include: Review of the facility policy titled Resident Call System, revised 9/12/22, indicated the nurses' station in the facility will be equipped to receive resident calls with a communication system through audible or visual signals from resident rooms, toilets, and bathing facilities. The policy also included the following: -Facility associates should always be aware of the call lights -Associates should answer call lights whether they are assigned to provide care to that resident Review of the Resident Council Meeting Meetings, dated 1/30/25, indicated the following: -Nursing: ----Old Minutes: Call bells are not being answered in a timely manner. ----New Business: Residents were reminded that the call bells are to be answered within five minutes. Staff reminded that any staff member can answer a call bell. 1. During a Resident Council meeting held on 3/6/25 from 11:00 A.M. to 11:30 A.M., the following was said relative to call bell wait times: -Resident #98 said that he/she has had to wait 15 to 30 minutes for someone to answer his/her call light. Resident #98 said he/she had to wait so long that he/she had an accident before he/she was able to get to the bathroom. Resident #98 said that long wait times occur most often on the early morning shift. Resident #98 further said his/her anxiety increased when he/she had to wait so long to use the bathroom. -Resident #75 said he/she recently had to wait 30 minutes to go to the bathroom. Resident #75 said this happened most often during the early morning, often when the staff changed shifts from the overnight shift (11:00 P.M. to 7:00 A.M.) to the daytime shift (7:00 A.M. to 3:00 P.M.). 2a. On 3/11/25 from 8:13 A.M. until 8:21 A.M., the surveyor observed the following on the [NAME] Terrace Unit: -8:13 A.M.: room [ROOM NUMBER] call light was turned on. -Certified Nurses Aide (CNA) #2 was passing breakfast trays -Nurse #2 was passing medications -CNA #2 and Nurse #2 remained in the hallway for the duration of this observation, walking by room [ROOM NUMBER] multiple times without responding to the lit-up call bell light. -8:21 A.M. (eight minutes later), Nurse #2 the entered room [ROOM NUMBER] and the call bell was turned off.

Based on interview, and record review, the facility failed to ensure one Resident (#62) of four applicable residents reviewed, out of a total sample of 22 residents, had the opportunity to formulate advanced directives and/or ensure that their wishes relative to advances directives were implemented. Specifically, for Resident #62, the facility failed to ensure that the Nurse Practitioner (NP) signed all required areas of the Medical Order for Life Sustaining Treatment (MOLST) form. Findings include: Review of the facility policy titled Advanced Directives and Advance Care Planning, reviewed 9/26/24, indicated the following: -Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advanced directive. Resident #62 was admitted to the facility in February 2025 with diagnoses including Acute Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disorder (COPD). Review of Resident #62's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act Form indicated the Resident's Health Care Proxy was invoked on 2/19/25. Review of Resident #62's MOLST form indicated the following: -The front page of the form was signed and completed by the Resident's Health Care Proxy and Nurse Practitioner (NP). -The back page of the form was completed, indicating no artificial nutrition and signed by the Resident's Health Care Proxy on 2/23/25. -The Nurse Practitioner (NP) failed to sign the back side of the MOLST form. During an interview on 3/12/25 at 8:10 A.M., the surveyor and the Assistant Director of Nursing (ADON) reviewed the current MOLST form. The ADON said the back side of the form was invalid because it was not signed by the Provider (Nurse Practitioner).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice relative to a Peripherally Inserted Central Catheter (PICC: central venous access catheter inserted through a vein and can provide intravenous [IV] access for the administration of medications, parenteral nutrition or other solutions) for one Resident (#110), of one applicable resident who was receiving IV antibiotics, out of a total sample of 22 residents. Specifically, for Resident #110, the facility failed to ensure: -accurate measurement and documentation of the external catheter length (measured from the catheter exit site to the 0 mark or, if no 0 mark is present, to the suture flange. Each line is measured as 1 centimeter/cm) and arm circumference. -identify a change in the external catheter length placing the Resident at risk for potential catheter related complications. Findings include: Review of the facility policy/procedure titled PICC Dressing Change, revised 8/19/24, indicated the following: -A transparent semipermeable dressing over a PICC requires changing at least every seven [7] days . -PICC line dressing changes require sterile technique to reduce the risk of vascular catheter-associated infection . -Use a sterile disposable tape measure or the incremental markings on the catheter to measure the external length of the catheter from the hub (end of the catheter tubing) to skin entry. -Compare the measurement to the external length documented at the time of PICC insertion to make sure the catheter hasn't migrated (moved out of place) . -Measure upper-arm circumference when clinically indicated to assess the presence of edema and deep vein thrombosis. Take the measurement ten [10] cm above the antecubital fossa (inner elbow) and compare the measurement to the baseline -If you withdraw the catheter a significant amount inadvertently during a dressing change, measure the catheter from the exit site to the hub and reapply a sterile dressing. Never advance the catheter back inside the insertion site because the contact with the skin may introduce microorganisms to the catheter. Notify the practitioner, and prepare for a chest X-ray or other diagnostic test to determine the position of the PICC tip (inside the body) Resident #110 was admitted to the facility in February 2025 with diagnoses including Metabolic Enchalopathy, Sepsis, Methicillin Susceptible Staphylococcus Aureus (MSSA) infection and Aspiration Pneumonia. Review of the Hospital Vascular Access Insertion Procedure Note, dated 2/13/25, indicated the following: -PICC line was placed into the Resident's upper right extremity for medication that required vascular access -the total catheter length was 41 cm -the tip location of the PICC line was placed in the superior vena cava -the external catheter length was two [2] cm out. -the arm circumference was 36 cm Review of the Hospital Discharge summary, dated [DATE], indicated the following relative to Resident #110: -admitted to the hospital for severe acidosis (high levels of acid in the blood) and Diabetic Ketoacidosis (DKA: serious and can be life-threatening, develops when the body does not produce enough insulin), complicated by respiratory failure, Influenza Type A, Respiratory Syncytial Virus (RSV), severe sepsis, and MSSA secondary to aspiration pneumonia. -Discharge medications included: Cefazolin (antibiotic) two [2] gram (gm) IV push every eight [8] hours. Review of the IV Infusion Note, dated 2/25/25, indicated: -IV Infusion Provider was contacted by the facility due to the staff being unable to flush the Resident's PICC line. -The needle-less catheter was exchanged -the PICC was able to be flushed -the PICC was secured at the 2 cm (external catheter length) mark and was ready for use. Review of the February 2025 and March 2025 Physician's orders included the following: -Cefazolin Sodium Solution Reconstituted 1 gm, use 1 gram intravenously every 8 hours for infection, bacteremia, initiated 2/25/25 and discontinued 2/26/25 -Cefazolin Sodium Injection Solution Reconstituted 2 gm, use 2 grams intravenously every 8 hours for infection, bacteremia, initiated 2/26/25 and discontinued on 3/10/25 -Change PICC line transparent dressing, as needed for concern of line movement or infection. -Measure upper arm circumference (10 cm above antecubital. -Measure external catheter length. If length has changed since last measurement; if concern of line movement, infection, hold antibiotic and notify Medical Doctor (MD), initiated 2/25/25 -PICC Gauge: 4 French (Fr: unit of measure): Total Length: 41 cm # Lumens 1 Type of infusion: intermittent, for Bacteremia, initiated 2/25/25 -Observe PICC line insertion site, every shift for s/s (signs/symptoms) of infection. Notify MD, accordingly, initiated 2/2/25 -Change PICC line dressing on admission on e time only for one day. Measure upper arm circumference (10 cm above antecubital). Measure external catheter length, initiated 2/25/25 Review of the Infection Care Plan, initiated 2/25/25, indicated the Resident was on IV antibiotics via PICC line in his/her right upper arm for MSSA Bacteremia. The care plan included the following interventions: -Medications as ordered, initiated 2/25/25 -Care of PICC line as ordered. Report any abnormalities to Nurse Practitioner (NP)/MD (initiated 3/7/25) Review of the February 2025 and March 2025 Medication Administration Records (MARs) indicated Resident #110 received the IV antibiotic medication as ordered by the Physician. Review of the Minimum Data Set (MDS) Assessment, dated 3/1/25, indicated Resident #110: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 of 15 -received antibiotics during the reference period. Review of the February 2025 Treatment Administration Record (TAR) indicated the following was documented on 2/25/25 for Resident #110: -arm circumference was measured at 36 cm -external catheter length was measured at 41 cm Review of the March 2025 TAR indicated the following documented on 3/4/25 for Resident #110: -arm circumference was measured at 12 -external catheter length was measured at 4 On 3/6/25 at 7:31 A.M., the surveyor observed Resident #110 lying upright in bed and dressed in a hospital gown. An IV pole was observed on the side of the Resident's bed and had an empty bag labeled Cefazolin 2 gm per 100 milliliters (ml) dated 3/6/25 at 6:00 A.M., and was being infused. During an interview at the time, the Resident said he/she was septic, recently had the flu and pneumonia, and had a PICC placed. The Resident showed the surveyor his/her upper inner elbow where a transparent dressing was observed dated 3/4/25. On 3/7/25 at 9:24 A.M., the surveyor observed Resident #110 awake and lying upright in bed. An IV pole was observed on the side of the bed, and an empty bag labeled Cefazolin 2 gm per 100 milliliters (ml) dated 3/7/25 at 6:00 A.M. was hung on the IV pole and was not infusing. During an interview at the time, the Resident said he/she received the IV antibiotic that morning and had no issues or side effects from the infusion. The surveyor observed the Resident's transparent dressing on his/her right upper inner arm was dated 3/4/25. On 3/7/25 at 3:51 P.M., the surveyor observed Resident #110 dressed and ambulating with Rehabilitation Staff in the hallway heading towards his/her room. The Resident was dressed in a short-sleeved shirt, and the PICC tubing was observed hanging from his/her right arm. During an interview on 3/7/25 at 4:21 P.M., Nurse #1, who had cared for Resident #110, said the arm circumference and external catheter length were measured weekly during the Resident's scheduled dressing change. Nurse #1 said the staff would measure 10 cm from the antecubital site (inner elbow) in order to obtain a measurement for the Resident's arm circumference. Nurse #1 further said that the external catheter would be measured from the insertion site to the end of the exposed tubing. Nurse #1 said it was important to obtain accurate measurements to ensure the PICC had not migrated because it would be a major issue since it should be positioned in the superior vena cava. Nurse #1 said the measurements obtained should be compared to what the measurements were when the PICC was initially placed to ensure the PICC was in the correct location. On 3/7/25 at 4:32 P.M., the surveyor and the Assistant Director of Nurses (ADON), who was overseeing the Unit reviewed the documented measurements for the Resident's arm circumference and external catheter length obtained on 2/25/25 and on 3/4/25. The ADON said there was a discrepancy with the measurements and that she would have to re-measure the Resident's arm circumference and external catheter length immediately. The surveyor accompanied the ADON into Resident #110's room and the ADON obtained the following measurements with the surveyor present: -arm circumference: 35.5 cm -external catheter length: 12 cm (difference of 10 cm since insertion) During an interview following the observation, the ADON said she could not speak to the measurements that were obtained on 2/25/25 and 3/4/25 and documented in the Resident's record. During an interview on 3/7/25 at 4:48 P.M., the surveyor and the Infection Preventionist (IP) reviewed the Resident's hospital paperwork and IV Infusion paperwork, both dated 2/25/25. The IP said the Resident's PICC total catheter length was 41 cm, the external catheter length was 2 cm, and the arm circumference was 36 cm prior to admission. The IP said she also went to observe Resident #110's PICC after the ADON and the surveyor, did not obtain measurements, but said the external catheter length was definitely not 2 cm. The IP said if the external catheter length changed by 1 cm, the Nurse should not have used the PICC and should have contacted the Provider for additional orders on how to proceed.

2. Resident #62 was admitted to the facility in February 2025 with diagnoses including Congestive Heart Failure (CHF), cellulitis and open wound of left lower leg, muscle weakness, and protein-calorie malnutrition. Review of the MDS Assessment, dated 2/17/25, indicated Resident #62: -had moderate cognitive impairment as evidenced by a BIMS score of 8 out of 15 -was at risk for pressure ulcers, and had no pressure ulcers at the time of admission -had two or more venous or arterial ulcers Review of the Potential/Actual Impairment to Skin Integrity Care Plan, initiated 2/12/25, indicated the Resident had impaired strength/range of motion, impaired functional mobility, impaired balance, fragile skin, cellulitis, edema, and vascular wound on his/her left lower extremity and included the following intervention: -weekly skin checks, initiated 2/12/25 Review of the Resident's clinical record included a Weekly Skin Assessment completed on 3/10/25. Further review of the clinical record failed to indicate documented evidence that the Weekly Skin Assessments were completed as required during the weeks of 2/16/25 and 2/23/25. On 3/12/25 at 10:30 A.M., the surveyor requested evidence of the Resident's weekly skin assessment since admission from the Assistant Director of Nurses (ADON), who was overseeing the Unit. During an interview on 3/12/25 at 11:30 A.M., the Director of Nursing (DON) said there were no weekly skin assessments completed as scheduled on 2/18/25 and 2/25/25 for Resident #62. The DON said the weekly skin assessments should have been completed, they were scheduled in the electronic medical record to be completed weekly. The DON further said the facility utilized a paper tool in addition to ensure the completion of weekly skin assessments. Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards of practice related to skin care for two Residents (#22 and #62), out of a total sample of 22 residents. Specifically, the facility failed to ensure: -a new skin alteration was identified by facility staff and an investigation completed to determine the cause of the skin alteration for one Resident (#22). -weekly skin checks were completed for one Resident (#62) as indicated per their comprehensive care plan. Findings include: Review of the facility policy titled Area of Focus: Basic Skin Management, revised 11/21/24, indicated the following: -All residents have a head-to-toe skin inspection upon admission/readmission, then completed weekly, and as needed by nursing . -It is the responsibility of the Certified Nurses Aides (CNAs) and therapy department to notify nursing if a change of the resident's skin is identified . -If any new skin alteration/wound is identified, it is the responsibility of the nurse to perform and document an assessment/observation, obtain treatment orders, and notify medical doctor (MD) and responsible party. {sic} 1. Resident #22 was admitted to the facility in February 2022 with diagnoses including Vascular Dementia with behavioral disturbance. Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/25/24 indicated Resident #22 had a Brief Interview of Mental Status (BIMS)) score of seven out of 15 indicating he/she was severely cognitively impaired. On 3/5/25 at 11:05 A.M., the surveyor observed Resident #22 seated in his/her room in his/her wheelchair. Resident #22 was observed to have bilateral scabbed areas on either side of his/her philtrum (middle space underneath the nose on the upper lip. When the surveyor asked about the scabbed areas on his/her upper lip the Resident said he/she was unsure where they came from. Review of Resident #22's Weekly Skin Assessments from 1/4/25 through 3/6/25 failed to indicate documentation pertaining to how Resident #22 acquired the injuries on his/her bilateral upper lip or when the injuries occurred. On 3/10/25 at 8:29 A.M., the surveyor observed Resident #22 seated in the hallway in his/her wheelchair. The Resident was observed to still have the bilateral scabbed areas on the upper lip. During an interview on 3/10/25 at 9:26 A.M., Certified Nurses Aide (CNA) #5 said she regularly took care of Resident #22. CNA #5 said she was unsure what the bilateral scabbed areas on Resident #22's upper lip was from or when they first appeared. During a follow-up interview on 3/10/25 at 9:32 A.M., CNA #5 said she spoke with Resident #22 and Resident #22 told her he/she thought the scabbed areas were from being shaved. During an interview on 3/10/25 at 12:55 P.M., Nurse #5 said she thought the bilateral scabbed areas on Resident #22's upper lip were from being shaved. Nurse #5 said there should be documentation in the Resident's medical record indicating what the scabs were from, how the injuries occurred, and when the injuries occurred. Nurse #5 further said this information should be documented on the weekly skin report until the areas were resolved. Review of the Nursing Progress Notes from 1/30/25 through 3/11/25 failed to indicate documentation as to how Resident #22 acquired the injuries on his/her bilateral upper lip or when the injuries occurred. During an interview on 3/11/25 at 10:05 A.M., Unit Manager (UM) #1 said she was unaware of the bilateral scabbed areas on Resident #22's upper lip until it was brought to the Nurse's attention by the surveyor on 3/10/25. UM #1 said she had reviewed the Resident's medical record and could find no documentation to indicate how the injuries occurred or when the injuries occurred to the Resident's bilateral upper lip. UM #1 further said as soon as any staff members had noticed the injuries it should have been reported immediately so staff could check the Resident's skin for additional injuries and to investigate how the injuries occurred, and this was never done. UM #1 said Resident #22 was not usually one of the Resident's who had his/her face shaved so she would need to look further into the situation to see if she could figure out how the injuries occurred as there was no documentation to support how or when the incident occurred. UM #1 said skin injuries for Resident #22 were especially a concern because he/she was on an anticoagulant (medication that thins the blood) and having injuries to his/her skin put the Resident at risk for increased bleeding.

Based on observation, interview, and record review, the facility failed to ensure that necessary respiratory care and services in accordance with professional standards of practice were in place for one Resident (#4) out of a total sample of 22 residents. Specifically, for Resident #4, the facility failed to ensure Physician's orders were in place for the daily use of Continuous Positive Airway Pressure (CPAP) machine and oxygen therapy. Findings include: Review of the facility policy titled BiPAP/CPAP Administration Policy, revised 9/3/24, indicated the following: -When CPAP or BiPAP is ordered, the following must be included in the written order: a. Mode (i.e. CPAP, BiPAP, CPAP Auto set etc.). b. Pressure setting c. Size and type of mask (i.e. small, nasal, or full-face mask.) d. Liters of Oxygen (if ordered.) e. Frequency of use (example-at night when sleeping and with naps as tolerated.) Resident #4 was admitted to the facility in October 2020 with diagnoses including Complex Sleep Apnea. Review of the most recent comprehensive Minimum Data Set (MDS) Assessment, dated 8/21/24, indicated Resident #4 scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS) indicating that he/she was cognitively intact. On 3/5/25 at 10:23 A.M., the surveyor observed Resident #4 sitting in his/her room. The surveyor also observed a CPAP machine and oxygen concentrator in the Resident's room. During an interview at the time, Resident #4 said he/she utilized the CPAP every night with oxygen added to the machine. Resident #4 said the nursing staff at the facility set the CPAP up for him/her and he/she was unsure of the exact settings that were being used. Review of Resident #4's March 2025 Physician's orders failed to indicate orders for the required CPAP pressure settings and the oxygen flow rate (LPM-liters per minute) to be added when the CPAP machine was in use. Further review of March 2025 Physician's orders indicated: -CPAP .on while sleeping/napping and off while awake, start date 4/26/24. Review of the March 2025 Treatment Administration Record (TAR) indicated the Resident utilized his/her CPAP daily from 3/1/25 through 3/9/25. Review of Resident #4's Altered Respiratory Status Care Plan dated 10/27/20, indicated the following: -Oxygen with CPAP .Pressure setting 4/0 with 1.5% humidity, Medium size with nasal pillows, liter of oxygen 2 lp/m .{sic} During an interview on 3/11/25 at 6:55 A.M., Nurse #3 said Resident #4 utilized his/her CPAP with oxygen every night. Nurse #3 said when a Resident has CPAP with oxygen there should be Physician's orders in place that included the settings for the CPAP and the oxygen liter flow rate. Nurse #3 reviewed Resident #4's Physician's orders and said Resident #4 had no orders in place for the use of the CPAP machine with oxygen. During an interview on 3/11/25 at 7:39 A.M., Unit Manager (UM) #1 said Resident #4 had no orders in place for CPAP settings or an oxygen flow rate. UM #1 said there was documentation in the care plan that included the correct CPAP setting and oxygen flow rate but there also needed to be a Physician's order in place for the administration of any treatment such as CPAP and oxygen use.

Based on record review, and interview, the facility failed to ensure that professional standards of care and treatment for hemodialysis (treatment that cleans the blood by removing waste and excess fluids when a person's kidneys no longer functioned properly) were implemented for one Resident (#15), of one applicable resident, out of a total sample of 22 residents. Specifically, for Resident #15, the facility failed to ensure a Physician's order was in place for fluid restriction and documentation was maintained for the amount of fluid intake the Resident consumed during a 24-hour period when the Resident was receiving hemodialysis services. Findings include: Review of the facility policy titled Hemodialysis Offsite Policy, reviewed 9/6/24, indicated the following: -The facility and dialysis facility dieticians should coordinate the nutritional care including monitoring, documenting and deciding how and when to address weight changes in nutrition issues. a. This included identifying weight fluctuations due to fluid depletion between dialysis sessions, possible fluid volume deletion in the immediate post-dialysis period or associated with anorexia which may be due to renal failure. b. Observe fluid restriction as ordered by the physician. Review of the facility policy Monitoring Intake and Output, reviewed 9/10/24, indicated the following: -The facility will ensure the nursing staff monitors and documents intake and output consistent with Practitioner orders and professional standards. Resident #15 was admitted to the facility in May 2020 with diagnoses including End Stage Renal Disease (ESRD) and received dialysis services three days weekly. Review of Resident #15's March 2025 Physician's orders failed to indicate documentation that the resident was on fluid restriction. Review of Resident #15's Alteration in Nutrition and Hydration due to ESRD on Hemodialysis Care Plan, revised 6/2/21, indicated the following: -Encourage good fluid intake up to 1200 cubic centimeter (cc- unit of measure) per day. Further review of the Resident's medical record failed to indicate evidence that the nursing staff maintained documentation of how much fluid intake Resident #15 had daily. During an interview on 3/10/25 at 1:47 P.M., Nurse #6 said when a resident is on a fluid restriction there should be a Physician's order in place for the amount of fluid the resident is not to exceed each day. Nurse #6 said documentation is done in the intake and output (I&O) book. The surveyor and Nurse #6 reviewed the I&O book and failed to find documentation to show Resident #15's fluid intake was being monitored and recorded daily. Nurse #6 said she could not be sure exactly how much fluid intake Resident #15 was getting each day as there was no documentation. During an interview on 3/10/25 at 2:12 P.M., Unit Manager (UM) #1 said Resident #15 should have had a Physician's order in place for his/her fluid restriction and nursing staff should be documenting daily, exactly how much fluid intake Resident #15 was getting, and this was not being done. UM #1 said she could not be sure exactly how much fluid Resident #15 took in each day as there was no documentation. During an interview post survey on 3/17/25 at 9:26 A.M., the Dialysis UM, from the dialysis facility that provided treatment to Resident #15 said the nursing facility should be able to provide the Dialysis Dietician or Dialysis Nursing Staff information regarding daily fluid intake if it was requested. The Dialysis UM said fluid intake information could be utilized if the Resident was experiencing unexpected changes in his/her weight that needed to be addressed.

Based on interview, and record review, the facility failed to implement recommendations made by the Behavioral Health Care Team for one Resident (#51), out of a total sample of 22 residents. Specifically, for Resident #51, the facility failed to ensure a recommended lipid panel (blood test that measures the levels of various fats in the blood stream) and Hemoglobin A1C (HbgA1c-test used to identify Diabetes [disease that affects how the body uses blood sugar]) labs were drawn as recommended by the Behavioral Health Physician Assistant (PA) for monitoring after the Resident was started on antipsychotic medication. Findings include: Review of the National Alliance on Mental Illness (NAMI) website article (https://www.nami.org/general/why-screening-for-diabetes-is-important-especially-if-you-take-psychiatric-medications/), titled Why Screening for Diabetes is Important (Especially if You Take Psychiatric Medications), dated 3/25/14, indicated: -the American Diabetes Association suggests screening regularly for Diabetes for those who use medications to treat mental health conditions as medications used to treat mental health conditions pose an additional risk for the increase in Diabetes. Resident #51 was admitted to the facility in December 2023 with diagnoses including generalized anxiety disorder, psychotic disorder, Depression, adjustment disorder with depressed mood, Major Depressive Disorder recurrent severe with psychotic symptoms, and Dementia with psychosis. Review of the Physician Assistant's Behavioral Health Group Note, dated 6/25/24, indicated that Resident #51 was started on an antipsychotic medication due to psychosis, and a lipid panel and HbgA1c lab work should be drawn after three months of antipsychotic medication use. Review of the June 2024 Physician's orders indicated the following orders: -Zyprexa (antipsychotic medication) 2.5 milligrams (mg) .one time a day, start date 6/19/24 and end date 6/24/24. -Risperidone (antipsychotic medication) 0.5 mg .at bedtime, start date 6/26/24 and end date 7/3/24. Review of the July 2024 Physician's orders indicated the following orders: -Risperidone 0.25 mg .in the morning, start date 7/3/24 and end date 7/8/24. -Risperidone 0.5 mg .in the afternoon, start date 7/3/24 and end date 7/8/24. -Risperdal (Brand name for Risperidone) 0.5 mg .two times a day, start date 7/8/24 and end date 7/10/24. -Risperdal 0.5 mg .in the morning, start date 7/10/24 and end date 9/2/24. -Risperdal 1 mg .at bedtime, start date 7/10/24 and end date 9/2/24. Review of the September 2024 Physician's orders indicated the following orders: -Risperdal 0.5 mg .in the morning, start date 9/3/24 and end date 3/4/25. Review of Resident #51's June 2024, July 2024, August 2024, and September 2024, Medication Administration Records (MARs) indicated the Resident was administered antipsychotic medications as ordered. Review of Resident #51's medical record failed to indicate any evidence that the recommended lipid panel or HbgA1c lab had been drawn since the Behavioral Health PA's recommendation was made on 6/25/24. During an interview on 3/11/25 at 2:15 P.M., Nurse #7 said the Behavioral Health Team notes and recommendations were faxed directly to the Resident's Primary Care Provider (PCP). Nurse #7 said the PCP reads the recommendations and then returns a copy of the notes to the facility that is signed, showing that it has been reviewed. During an interview on 3/11/25 at 2:38 P.M., Unit Manager (UM) #2 said the Behavioral Health Team notes and recommendations were faxed directly to the Resident's Primary Care Provider (PCP). UM #2 said the PCP reads the recommendations and then returns a copy of the notes to the facility that is signed, showing it was reviewed and if the PCP want any recommendations implemented, the PCP would write a telephone order or verbally tell the nursing staff at the facility. UM #2 said she was unable to find any documentation that orders were put into place for the Behavioral Health Teams' recommendation for a lipid panel and a HbgA1c test. UM #2 said she was unsure why it was not ordered by the PCP after reviewing the Behavioral Health Teams' notes. UM #2 further said no one at the facility typically reads the Behavioral Health Teams' notes to ensure that recommendations were not missed.

Based on interview, and record review, the facility failed to limit the timeframe for a PRN (as needed) psychotropic medication to 14 days for one Resident (#40), out of a total sample of 22 total residents. Specifically, for Resident #40, the facility failed to ensure the PRN use of Trazodone (antidepressant medication) was limited to 14 days. Findings include: Review of the facility policy titled Psychotropic drug use, long term care {sic}, reviewed 5/20/24, indicated the following: -As-needed orders for psychotropic drugs should be limited to 14 days, at which time the prescribing practitioner should then review the order . Resident #40 was admitted to the facility in February 2025 with diagnoses including Depression and Adjustment Disorder with Anxiety. Review of Resident #40's March 2025 Physician's orders indicated the following order: -Trazodone .Give 25 milligrams (mg) every 24 hours as needed .start date 2/23/25 and no end date. Review of Resident #40's March 2025 Medication Administration Record (MAR) indicated that the Resident was administered the PRN Trazodone on 3/2/25 and 3/10/25. During an interview on 3/11/25 at 9:02 A.M., Nurse #9 said PRN psychotropic medications need to be reviewed and a new order put into place by the Physician after 14 days of use. Nurse #9 said PRN psychotropic medications should have a stop day of Day 14, it would fall off the orders and could not be given after Day 14 without Physician review. During an interview on 3/11/25 at 9:50 A.M., Unit Manager (UM) #1 said Resident #40's PRN order for Trazodone exceeded the 14-day limit, should have had a stop date of 3/9/25, and been reviewed by the Physician at that time for continued use and it was not.

Based on observation, and interview, the facility failed to ensure that medications were stored in a secure manner for one medication cart (Hampden Garden Long Hall Cart) out of three medication carts observed, out of a total of six medication carts. Specifically, the facility failed to ensure that an injectible Insulin Lispro Pen was securely stored when the medication cart was left unattended in the hallway, and accessible to Unit residents. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, revised 8/1/24, indicated the following: -Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 3/7/25 at 4:00 P.M., the surveyor observed the Hampden Garden Long Hall Cart was unattended with an Insulin Lispro Pen on top of the medication cart. The surveyor observed a resident wheeling past the cart with the unattended medication and into his/her room. The surveyor observed that the medication cart with the Insulin Lispro Pen remained unattended until 4:19 P.M., when Nurse # 4 returned to the medication cart. During an interview on 3/7/25 at 4:19 P.M., Nurse #4 said the Nurse who was assigned to the Hampden Garden Long Hall medication cart, where the Insulin Lispro Pen remained on top of the cart had left the floor and was on a on break. Nurse #4 further said that the Insulin Lispro Pen should not be left unattended due to the risk that a resident could take it. Nurse #4 removed the pen to store in her medication cart until the assigned Nurse returned to the Unit. During an interview on 3/12/25 at 9:35 A.M., the surveyor reviewed the observations of the unattended Insulin Lispro Pen on top of the medication cart with the Assistant Director of Nursing (ADON). The ADON said that no medications should be left on top of the medication cart unsupervised.

Based on interview, and record review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at one out of four quarterly meetings reviewed. Specifically, the facility failed to ensure the Director of Nursing (DON) and Infection Preventionist (IP) or a person designated to represent them were in attendance at the June 2024 quarterly QAPI meeting. Findings include: Review of the facility policy titled Quality Assessment and Assurance Committee, revised 8/30/22 indicated the following: >The QAA Committee must be composed of, at a minimum: -The Director of Nursing (DON) -The Medical Director or his/her designee -The Infection Preventionist (IP), and -At least three other staff members, one of whom must be the facility's Administrator . Review of the Meeting Attendance Sign-in Sheet for the QAPI Meeting held on 6/17/24 failed to indicate evidence that the DON or the IP were in attendance at the meeting. During an interview on 3/12/25 at 10:48 A.M., with the Administrator and the DON, the Administrator said he had no documented evidence that the DON or the IP was at the June 2024 QAPI Meeting. The Administrator further said it was required to have the DON or IP present at QAPI meetings or a Representative who would provide an updated report for the DON or IP to the QAPI committee. The Administrator said he did not have documented evidence the DON or the IP were in attendance or that their reports were presented at the QAPI meeting by a designee as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure three Unit ([NAME] Terrace, Hampshire Woods, and Hampden Gardens) kitchenettes were maintained in a safe and sanitary condition, out of three unit kitchenettes observed. Findings include: Review of the facility's policy titled Cleaning Schedule, reviewed 4/30/24, indicated the following: -Equipment and Utensil Cleaning and Sanitization- A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc. -The Director of Food and Nutrition Services develops a cleaning schedule to include all equipment and areas to be cleaned. Review of the facility's Stocking List for Unit's Nourishment Room, updated 9/6/24, indicated the following: -Make sure to clean fridge, microwave, cupboards, and counters. On 3/5/25 at 5:02 P.M., the surveyor observed the following in the Hampden Garden Unit kitchenette: -Toaster was laden with crumbs -Inside the cabinet that stored snacks had dried dark brown splatter noted on the shelves and door. On 3/5/25 at 5:06 P.M., the surveyor observed the following in the [NAME] Terrace Unit kitchenette: -Toaster was laden with crumbs, and dried pieces of bread were stuck in the toaster; crumbs were black in color. During an interview on 3/5/25 at 5:13 P.M., the Food Service Director (FSD) said the [NAME] Terrace Unit toaster was laden with crumbs and this could pose a fire risk due to the large amount of crumbs left in the toaster. The FSD said he was unsure who was responsible for cleaning the toasters on a regular basis. On 3/6/25 at 7:35 A.M., the surveyor observed the following in the Hampden Garden Unit kitchenette: -Bottom of the refrigerator had a large dried brown spot and multiple dried dirty paper towels under the lower refrigerator drawer. -Inside the cabinet that stored snacks there was dried, dark brown splatter noted on the shelves and door. On 3/6/25 at 7:38 A.M., the surveyor observed the following in the [NAME] Terrace Unit kitchenette: -Refrigerator had dried yellow material on the floor. During observations of the Unit Kitchenettes on 3/11/25 from 10:23 A.M. to 10:32 A.M., with Dietary Aide #1, the surveyor observed the following: Hampshire Woods Unit kitchenette: -Thick dried brown material on the refrigerator floor. Hampden Garden Unit kitchenette: -Large dried brown spot and dirty paper towels remained on the bottom of the unit refrigerator. -Dried brown splatter was still noted inside the snack cabinets on the shelving and door. [NAME] Terrace Unit kitchenette: -Refrigerator had dried yellow material on the floor. Following the observations Dietary Aide #1 said the kitchenettes should be cleaned daily and it was the job of the afternoon dietary aides who stocked the snacks to make sure the kitchenettes were cleaned. Dietary Aide #1 said the refrigerators on all the units should have been wiped clean and the cabinets on the Hampden Gardens Unit should have been wiped down. During observations of the Unit Kitchenettes on 3/11/25 at 10:47 A.M., with the FSD, the surveyor observed the following: Hampshire Woods Unit kitchenette: -Thick dried brown material on the refrigerator floor. Hampden Garden Unit kitchenette: -Large dried brown spot and dirty paper towels remained on the bottom of the unit refrigerator. -Dried brown splatter was still noted inside the snack cabinets on the shelving and door. [NAME] Terrace Unit kitchenette: -Refrigerator had dried yellow material on the floor. Following the observation the FSD said all the Unit refrigerators should be cleaned daily by staff and this did not appear to have been happening on a daily basis. The FSD said all dried food or liquid materials should have been cleaned out of the refrigerator on all the Units and the cabinets on the Hampden Garden Unit as this could lead to foodborne illness concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility policy titled Transmission-Based Precautions (TBP) and Isolation Procedure, revised 9/24/24, indicated the facility will implement and utilize TBP to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. The policy also included the following: -TBP must be used when a resident develops signs and symptoms of a transmissible infection . -The facility should refer to CDC- Appendix A to determine the type and duration of precautions recommended for select infections and conditions, unless the facility has been provided more stringent guidance from local and state health authorities. -The facility should also initiate TBP for a constellation of new symptoms consistent with a communicable disease. Empirically initiated TBP may be adjusted or discontinued when additional clinical information becomes available (e.g. confirmatory laboratory testing). -Contact Precautions are intended to prevent transmission of pathogens that are spread by direct (e.g. person to person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves before entering or upon entering (i.e. before making contact with the resident or the resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. Review of the Centers for Disease Control and Prevention (CDC) document titled About C. Diff, dated 12/18/24, indicated the following: -C.Diff is a germ that causes diarrhea and colitis and can be life-threatening. -C.Diff can affect anyone. -Most cases of C.Diff infection occur when you've been taking antibiotics or not long after you've finished the antibiotic course. -Symptoms of C.Diff include diarrhea, fever, stomach tenderness or pain, loss of appetite, and nausea. -People are up to 10 times more likely to get C.Diff infection while taking an antibiotic or during the three months after, with longer courses potentially doubling their risk. -Other risk factors include recent stay at a hospital or nursing home and previous infection with C.Diff . -C.Diff germs spread from person to person in poop [sic], but the bacteria are often found in the environment. -When C.Diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces . Review of the CDC document titled Appendix A: -Type and Duration of Precautions Recommended for Selected Infections and Conditions, dated 2/7/25, indicated: >Contact Precautions and handwashing with soap and water are recommended for individuals with C.Diff. Resident #75 was admitted to the facility in February 2025 with diagnoses including Dementia and Aspiration Pneumonia. Review of the Minimum Data Set (MDS) Assessment, dated 2/12/25, indicated Resident #75: -was rarely or never understood/understands -had severe cognitive impairment as evidenced by a BIMS score of 0 out of 15 -was dependent on staff with toileting -required assistance of staff with dressing and personal hygiene On 3/7/25 at 7:58 A.M., the surveyor observed Resident #75 calling out loudly from his/her room. Thesurveyor observed Resident #75 was dressed, seated in a wheelchair, and was shifting back and forth while seated saying, I can't wait please . The Resident was observed to pull at the top back of his/her pants while continuing to call out. The surveyor relayed the observation to Nurse #1 who said she would follow-up with the Resident and also let the Certified Nurses Aide (CNA) know. Review of the Provider Note, dated 3/10/25, indicated Resident #75 was examined and the following was noted: -elevated white blood cell (WBC: could indicate inflammation or symptom of infection) and abdominal pain over past two days -the Resident's abdomen had tenderness -increased restlessness and indication of abdominal pain -Start Augmentin (antibiotic) 500/125 twice daily for three days, for possibility of intra-abdominal infection Review of the March 2025 Physician's orders indicated: -Stool for C.Diff, ordered 3/10/25 at 2:30 P.M., and discontinued 3/11/25 On 3/11/25 at 8:59 A.M., the surveyor observed Resident #75 awake and lying in bed. The surveyor did not observe any signage outside of the Resident's room indicating TBP were in place. The surveyor observed an Activities Assistant going from resident room to resident room and passing water pitchers at this time. Review of Resident #75's laboratory test results, dated 3/11/25 at 10:18 A.M., indicated: -C. Diff positive, critical result -critical results were acknowledged by Nurse #2 During an interview on 3/11/25 at 10:55 A.M., CNA #2 said she was just notified that the Resident was positive for C.Diff infection, and they were in the process of moving the Resident to another room. The surveyor observed the Resident's room had no signage indicating TBP for Resident #75 was in place. During an interview on 3/11/25 at 10:56 A.M., Nurse #2 said she entered the Physician's order to test Resident #75 for C.Diff the previous day (3/10/25). Nurse #2 said they were able to obtain a stool specimen on 3/10/25. Nurse #2 said they would typically put a resident on TBP if they were symptomatic or if they had a laboratory culture pending. Nurse #2 said when the Physician's order was obtained, it was change of shift, and she reported to the 3:00 P.M. to 11:00 P.M. shift the Resident's current status. Nurse #2 said she alerted the nursing staff that the Resident was positive for C.Diff, and they were currently in the process of moving the Resident to another room. When the surveyor asked Nurse #2 how staff knew what PPE was required when providing care for the Resident, Nurse #2 said she told the nursing staff. During an interview on 3/11/25 at 11:20 A.M., the Infection Preventionist (IP) said she was unaware that Resident #75 had a C.Diff specimen ordered on 3/10/25. The IP said when the Physician gave an order to obtain a C.Diff specimen, Resident #75 should have been placed on Contact Precautions. 4. Review of the facility policy titled Transmission-based Precautions and Isolation Procedures, revised 9/24/24, included the following: -the use of Droplet Precautions applies when respiratory droplets contain pathogens which may spread to another susceptible individual. Respiratory pathogens can enter the body via the nasal mucosa, conjunctivae and less frequently the mouth. -examples of droplet-borne organisms that may cause infections include but are not limited to influenza . Review of the facility matrix, provided to the survey team shortly after entrance on 3/5/25, indicated Resident #95 and Resident #62 were on TBP, and resided in the same room. a. Resident #95 was admitted to the facility in February 2025. Review of a Nurse's Note dated 2/28/25, indicated the Resident was complaining of slight cough and not feeling well. Resident #95 was swabbed for Influenza (Flu) and was positive. Review of a Provider Note, dated 3/8/25, indicated the following: -Resident #95 was positive for flu, changed to full-strength Tamiflu (anti-viral medication) 75 milligrams (mg), twice daily for 5 days through 3/11/25 - Resident has a productive cough and fatigue, receiving updraft [sic] treatments. Review of the March 2025 Physician's orders indicated Isolation: -Contact and Droplet Precautions for Flu, every shift, initiated on 2/28/25 and discontinued on 3/10/25. b. Resident #62 was admitted to the facility in February 2025. Review of a Nurse's Note, dated 2/28/25, indicated the Resident called an ambulance at approximately 1:00 A.M. due to complaints of not being able to breathe. Review of the Resident #62's clinical record indicated: -he/she was readmitted to the facility on [DATE] -Provider note, dated 3/4/25: positive for Influenza upon re-admission from the hospital -Nursing Note, dated 3/4/25: remains on precautions and Tamiflu for Influenza . On 3/5/25 at 10:56 A.M., the surveyor observed Resident #95 and Resident #62 lying in their individual beds in the same room. Two signs were posted outside of the room which indicated the following: -Stop. Enhanced Barrier Precautions (and indicated for B on a round sticker) >everyone must: cleanse their hands before entering and leaving the room >staff and providers must also: wear gloves and a gown for high-contact resident care activities. -Stop. Special Droplet/Contact Precautions (did not indicate a letter on a round sticker) >Only essential personnel should enter this room. >everyone must: cleanse hands when entering and leaving the room >wear a mask >wear eye protection (face shield or goggles) >gown and glove at the door On 3/7/25 at 8:29 A.M. through 8:39 A.M., the surveyor observed the following: -Two signs indicating Enhanced Barrier Precautions and Special Droplet/Contact Precautions were observed outside of the room entrance. -A bin containing PPE including gowns, eye protection and masks. Gloves were observed upon entry into the Residents' room. -Activity Assistant (AA) #1 entered Resident #95 and Resident 62's room with a surgical mask and gown on. AA #1 did not have eye protection or gloves on. AA #1 was observed to remove her gown and exited the room shortly after. During an interview after AA #1 exited the room, AA #1 said she was passing beverages to the Residents in the room, and because she was not touching anything, she only had to put on a mask and a gown. The surveyor and AA #1 reviewed the signage posted outside of the room. AA #1 said the signs are new to her within the last few weeks, and that she had never had to put on eye protection before. AA #1 said she had not received any training on the signage. When the surveyor asked if she knew what the signage posted was for, AA #1 said both Residents had the Flu. The surveyor encouraged AA #1 to speak with nursing about the signage and the requirements for PPE at this time. On 3/7/25 at 1:50 P.M., the surveyor observed CNA #6 don an N95 mask (without performing hand hygiene), don a gown and gloves and entered the room to reposition Resident #62. CNA #6 did not don eye protection. CNA #6 assisted Resident #62 with repositioning, removed the N95 mask, gown and gloves and donned a surgical mask upon exiting the room. During an interview following the observation at 1:55 P.M., CNA #6 said she regularly worked on the other floors, but was assisting on this unit today. CNA #6 said the Enhanced Barrier signage was for residents who had catheters and skin issues, and the Special Droplet/Contact signage was for residents who were sick. CNA #6 said it was her understanding that the position of the sign indicated who the precautions were for. CNA #6 said the Special Droplet/Contact Precautions were placed above Resident #95's name so they were indicated for him/her, and the Enhanced Barrier Precautions would be indicated for Resident #62. CNA #6 said relative to Resident #62, she would only need to gown and glove when providing care. The surveyor and CNA #6 eviewed the Special Droplet/Contact Precaution signage posted outside of the room, and after reviewing the sign, CNA #6 said she would need to put on a gown, gloves mask and eye protection prior to entering the Residents' room. CNA #6 said she did not put on eye protection when she repositioned Resident #62 and she should have. CNA #6 looked in the PPE bin located outside of the Residents' room and said there was no eye protection in the bin and said that she would need to get some more. 5. Review of the facility policy titled Enhanced Barrier Precautions, revised 6/30/24, indicated the facility should use EBP as an additional Multi-drug Resistant Organism (MDRO) mitigation strategy for residents that meet the following criteria, during high contact care activities. The policy also included the following: -EBP are indicated for residents with any of the following: >infection or colonization with a CDC-targeted MDRO . Review of the facility procedure titled Hand Hygiene, reviewed 8/18/24, indicated the following: -hand hygiene is a general term to refer to handwashing, antiseptic handwashing, antiseptic hand rubbing, and surgical hand asepsis -the hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient -hand hygiene is the single most important procedure to prevent infection -to protect patients from health care-associated infection, hand hygiene must be performed routinely and thoroughly -an alcohol-based hand rub is appropriate for decontaminating the hands: >before direct patient contact, putting on gloves . >after removing gloves >after contact with a patient or with bodily fluids, excretions, mucous membranes, non-intact skin, or wound dressings (if hands are not visibly soiled) >after contact with inanimate objects in the patient's environment a. Resident #72 was admitted to the facility in December 2024 with diagnoses including neuromuscular dysfunction of the bladder and Extended Spectrum Beta Lactamase (ESBL). Review of the CDC document, dated 4/11/2024, indicated the following: -Enterobacterales are a group of bacteria that cause infections in healthcare settings and communities. -Some species are also a normal part of the human gut. -Some Enterobacterales produce enzymes called extended-spectrum beta-lactamases (ESBLs). -Extended-spectrum beta-lactamases (ESBLs) break down certain antibiotics, making some infections caused by ESBL-producing Enterobacterales difficult to treat. -ESBL-producing Enterobacterales can spread from person to person through dirty hands and surfaces. Review of Resident #72's March 2025 Physician's orders indicated the following: -Enhanced Barrier Precautions (EBP) every shift related to history of ESBL in urine, initiated 3/5/25 b. Resident #170 was admitted to the facility in February 2025 with diagnoses including left hip fracture and need for assistance with personal care. On 3/7/25 from 9:31 A.M. through 9:45 A.M., the surveyor observed the following: -EBP signage was posted outside of the Resident's room, and a PPE bin containing gowns outside of the door entry -9:31 A.M., Resident #72 initiated the call light -9:36 A.M., CNA #1 entered the Resident's room with a surgical mask and gloves in place, but did not don a gown. -CNA #1 assisted Resident #72 to the bathroom located inside of the room, then went to the Resident's closet, retrieved some pants, returned to the bathroom and then instructed the Resident to ring when he/she was done. -CNA #1 exited Resident #72's room with a glove on her left hand (did not remove the glove or conduct hand hygiene after exiting the room) and entered Resident #170's room with the same gloved hand. -CNA #1 exited Resident #170's room shortly after with the gloved left hand (did not remove the glove nor perform hand hygiene) and entered the clean linen room. -CNA #1 exited the clean linen room shortly after holding a towel in the gloved left hand and re-entered Resident #170's room. -CNA #1 exited Resident #170's room a second time with the gloved left hand (did not remove the glove nor perform hand hygiene), re-entered the clean linen room and exited short after holding a hospital gown and a brief in the left gloved hand and returned to Resident #170's room. -9:45 A.M., CNA #1 drew the privacy curtain around Resident #170 and at this time, the surveyor intervened prior to care being provided to Resident #170 as CNA #1 continued to have the gloved left hand that was contaminated. During an interview at the time, CNA #1 said she had a bad habit of forgetting to remove her gloves. CNA #1 said she should have removed gloves and performed hand hygiene after caring for Resident #72, but she did not. CNA #1 said there would be a risk for cross contamination by not removing her glove and performing hand hygiene. On 3/7/25 at 10:25 A.M., the surveyor and CNA #1 reviewed the EBP signage outside of Resident #72's room. CNA #1 said the EBP signage indicated the precautions were for Resident #72, but she was not sure why. During an interview on 3/11/25 at 11:20 A.M., the surveyor relayed observations of the precaution signage and infection control concerns relative to Resident's #95, #62, #72 and #170 with the IP. The IP said Resident's #95 and #62 had Influenza, and the expectation was for all staff to defer to the Special Droplet/Contact sign which indicated to put on a gown, gloves, mask and eye protection prior to entering the room. The IP said she understood that there may be confusion from staff on what to do when multiple signs were posted outside of the Residents' room. Relative to the observation with CNA #1, the IP said the facility would need to do more education on the precaution signage and infection control practices. 5. Resident #50 was admitted to the facility in February 2025. Review of Resident #50's March 2025 Order Summary Report indicated the following: -Vancomycin HCI (antibiotic). Give 125 milligrams (mg) by mouth four times a day for C-DIFF until 3/17/25, beginning on 3/8/25. On 3/11/25 at 8:48 A.M., the surveyor observed the following: -CNA #2 entered Resident #50's room, carrying a breakfast tray and wore a surgical mask. -A Contact Plus sign was located on the outside of the door and indicated that staff and providers must: ---Clean hands before entering the resident's room ---Wear gown and gloves, change between residents ---Wash hands with soap and water before exiting. ---Hand sanitizer alone is not sufficient when exiting a resident's room. -CNA #2 performed hand hygiene using the hand sanitizer located on the wall, prior to exiting the Resident's room. -CNA #2 exited the Resident's room and immediately entered the next room over, which had an EBP sign located on the outside of the door. During an interview immediately following the observations, CNA #2 said she entered Resident #50's room to bring in a breakfast tray and did not have any contact with the Resident in the room therefore did not need to wear all the PPE indicated on the sign posted at the door. CNA #2 said that when she exited the room, she used the hand sanitizer, and did not wash her hands with soap and water before leaving Resident #50's room or before entering the room next door, which had EBP's in place. CNA #2 said that per the sign she should have washed her hands with soap and water before exiting Resident #50's room. During an interview on 3/11/25 at 9:04 A.M., the IP said it was her expectation that when a Contact Plus sign was located outside of a resident's room, that staff were donning all the required PPE noted on the sign prior to entering the room, doffing the PPE and washing their hands with soap and water before exiting the room. The IP said the Contact Plus sign indicated someone in the room was on precautions due to either C.Diff, a gastrointestinal (GI) symptoms or norovirus. Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections on one unit ([NAME] Terrace), out of a total of three units, affecting eight Residents (#167, #99, #75, #95, #62, #72 #170, and #50), out of a total sample of 22 residents. Specifically, 1. for Resident #167, the facility failed to ensure Personal Protective Equipment (PPE: items such as gowns, gloves, etc. to prevent the spread of infection from one person to another) was donned correctly, the surface used to set up treatment supplies was cleaned and disinfected before use, and that the scissors used to cut of an old dressing were cleaned and disinfected before using them to cut new dressing materials, placing the Resident at increased risk of contamination and infection. 2. for Resident #99, the facility failed to ensure that dressing materials brought into the Resident's room were not returned to the treatment cart for storage placing the [NAME] Terrace unit at risk for cross contamination. 3. For Resident #75, the facility failed to implement Contact Precautions when the Resident had a suspected infection, and results were pending for Clostridium Difficile (C.Diff: multi-drug resistant organism [MDRO] that is infectious and causes diarrhea and colitis [inflammation of the colon]). 4. For Residents #62 and #95, the facility failed to implement Special Contact/Droplet Precautions for both Residents who were diagnosed with Influenza. 5. For Residents #72 and #170, the facility failed to implement Enhanced Barrier Precautions (EBP) as indicated for both Residents who were at high risk for contracting infections. 6. For Resident #50, the facility failed to implement Contact Plus Precautions for a Resident diagnosed with C-Diff. Findings include: Enhanced Barrier Precautions (EBP) - refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities. 1. Resident #167 was admitted to the facility in February of 2025 with diagnoses including Arthritis due to other bacteria of the left wrist and Heart Failure. On 3/7/25 at 11:28 A.M., the surveyor observed the following during wound care to Resident #167 provided by Nurse #1: -Nurse #1 performed hand hygiene at the Resident's room door and began to don a gown. While donning the gown Nurse #1 bent forward causing the lower half of the gown to touch the floor. -Nurse #1 finished donning the gown and prepared to enter the room when the surveyor intervened and made her aware of the observed gown touching the floor. -Nurse #1 removed the gown, performed hand hygiene, donned a new gown and gathered supplies to enter the Resident's room. -Nurse #1 dropped the bleach wipe on the floor and stated she would not be able to wipe the over-bed table to clean and disinfect the table. Nurse #1 then draped the table with a towel without cleaning or disinfecting the table and set up treatment supplies on the towel. -Nurse #1 used new scissors from a suture removal kit to remove the old dressing from the Resident, disposed of the old dressing and set the scissors on the draped table without cleaning or disinfecting the scissors. -Nurse #1 doffed gloves, performed hand hygiene, and donned new gloves. -Nurse #1 cleansed the wound with wound cleanser and gauze and patted the area dry. -Nurse #1 doffed the soiled gloves, performed hand hygiene, and donned new gloves. -Nurse #1 cut a piece of plain packing strip with the previously used scissors that were not cleaned or disinfected and applied the packing strip to the wound. -Nurse #1 covered the wound with gauze, wrapped it with gauze wrap, and secured it with tape. -Nurse #1 disposed of trash, doffed PPE, and performed hand hygiene before exiting the room. During an interview on 3/7/25 at 12:20 P.M., the surveyor reviewed the wound care observations with Nurse #1. Nurse #1 said she should have cleaned and disinfected the scissors between using them to cut off the old dressing and to cut the new dressing supplies because the old dressing was considered dirty, but she did not. Nurse #1 declined to answer any further questions from the surveyor. During an interview on 3/11/25 at 3:42 P.M., the surveyor reviewed the wound care observations with the Infection Preventionist (IP). The IP said there was concern with Nurse #1 entering room to perform wound care with a gown that had touched the floor as the floor was dirty and this could cause contamination of the wound. The IP further said the table and scissors should have been cleaned and disinfected as the table and the old dressing were considered contaminated, and this could contaminate the new dressing and/or wound. 2. Resident #99 was admitted to the facility in September 2024 with diagnoses including Malignant Neoplasm of the Glottis, Gastrostomy Status and Extended-Spectrum Beta Lactamase (ESBL). On 3/12/25 at 9:18 A.M., the surveyor observed the following during a Gastrostomy Tube (G-tube) site care for Resident #99 provided by Nurse #8: -Nurse #8 performed hand hygiene, donned a gown and gloves. -Nurse #8 gathered supplies off the treatment cart and entered the Resident's room. -Nurse #8 placed supplies on the counter in room, cleaned and disinfected the over-bed table and draped it with a disposable pad. -Nurse #8 gathered the supplies from the counter and set them up on the draped table. -Nurse #8 removed old dressing from G-tube site, disposed of it, doffed gloves, performed hand hygiene and donned new gloves. -Nurse #8 cleansed the G-tube site area with normal saline soaked gauze and patted the area dry. -Nurse #8 doffed gloves, performed hand hygiene and donned new gloves. -Nurse #8 applied a clean drain sponge gauze to the site, and secured it with tape. -Nurse #8 disposed of the used supplies, cleaned and disinfected the table, doffed gown and gloves, performed hand hygiene and exited the room with the opened package of gauze. -Nurse #8 brought the package of opened gauze to the treatment cart and placed it in a drawer. During an interview on 3/12/25 at 9:30 A.M., Nurse #8 said she should not have placed the opened gauze package that was used in Resident #99's room back into the treatment cart. During an interview on 3/12/25 at 9:40 A.M., the IP said that because the gauze had been set on a surface in Resident #99's room and then brought out and placed into the treatment cart, there was a risk for cross-contamination.

Based on observation, interview and policy review, the facility failed to ensure that residents were treated with dignity during communal dining in one dining room (Hampshire Woods) out of two communal dining rooms, and for one Resident (#87) out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. serve residents who were seated at the same table, their meals at the same time. 2. be in a seated position while assisting Resident #87 during mealtime. Findings include: Review of the facility procedure guide for Food Service and Dining, undated, indicated the following: -Serve residents who are at the same table at the same time. -If assisting a resident with eating, sit where he or she can see you. 1. On 12/13/23 at 8:32 A.M., the surveyor observed four residents seated at a table in the dining room located on Hampshire Woods Unit. Two of the four residents at the table had their breakfast meals and were eating, while the other two residents did not have their breakfast meals and one of the two residents without a meal was observed to reach out and try to take food off another resident's meal tray. During an interview immediately following the observation, Certified Nurses Aide (CNA) #2 said that there was a second food truck with additional meal trays on it, however it had not yet been delivered to the unit. The surveyor observed that one of the two residents who did not have a breakfast meal tray received his/her meal at 8:47 A.M., 15 minutes after the other two residents at the table were observed to be eating their breakfast. The surveyor observed the second of the two residents who did not have a breakfast meal and was attempting to take food from another resident's tray received his/her meal at 8:52 A.M., 20 minutes after the other two residents at the table were observed to be eating their breakfast. 2. On 12/13/23 at 9:07 A.M., the surveyor observed CNA #1 standing next to Resident #87 while assisting him/her with eating. On 12/13/23 at 9:13 A.M., the surveyor observed CNA #1 remained standing next to Resident #87 while assisting him/her with eating. During an interview on 12/13/23 at 9:22 A.M., CNA #1 said that she should have been seated the entire time she was assisting Resident #87 with eating but she did not sit as required.

Based on observation, interview, record and policy review, the facility failed to implement a care plan for one Resident (#69) out of a total sample of 23 residents. Specifically, the facility failed to consistently implement weekly skin checks for a Resident who was at risk for skin breakdown. Findings include: Review of the facility policy titled, Skin Integrity and Pressure Ulcer/Injury Prevention and Management, reviewed on 3/31/23, indicated the following: -A skin assessment/inspection should be performed weekly by a Licensed Nurse. Resident #69 was admitted to the facility in February 2023 with diagnoses that included the following: Type II Diabetes (a condition where the body is unable to use insulin properly resulting in high blood sugar levels) with foot ulcer, and Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body) following a Cerebral Infarction (stroke) affecting the left side of the body. Review of the Resident's At Risk For Break In Skin Integrity care plan, initiated on 2/21/23, and revised on 6/7/23, indicated the Resident was to have weekly skin checks by a Licensed Nurse. Review of the Weekly Skin Integrity Data Collection Assessments indicated that that no weekly skin assessments had been completed per the Resident's care plan from 6/8/23 until 9/21/23 (total of 13 missed assessment opportunities). Review of the Admission/readmission Collection tool dated 7/26/23, indicated a skin assessment had been completed upon the Resident's return from the hospital, and that a red, shearing injury (an injury which occurs to the skin due to internal body structures and skin tissue moving in opposite directions) was noted on the coccyx (triangular bone at the base of the spine). Further review of the medical record indicated no documented evidence that weekly skin assessments had been completed from 7/26/23 (when the coccyx injury was documented) until 9/21/23. The skin assessment completed on 9/21/23 indicated a right heel Deep Tissue Injury (DTI- an injury to a patient's underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) appears to be a blister which had opened and drained. The surrounding area was macerated (softening and breakdown of skin due to excess moisture) with an open center which was dark blue and black. During an interview on 12/14/23 at 9:13 A.M., Unit Manager (UM) #2 said the facility policy is that weekly skin checks were to be completed for all residents and documented in the assessment section of the electronic medical record (EMR). The surveyor and UM #2 reviewed the skin assessments and noted that the Resident had a skin assessment completed on 7/25/23 upon return from the hospital. UM #2 said that the next documented skin assessment was completed on 9/21/23 at which time it was discovered that the Resident had an area of concern on his/her heel. UM #2 said that no skin assessments had been completed between 7/26/23 and 9/21/23 and the skin assessments should have been completed weekly per the care plan and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 63 was admitted to the facility in August 2023 with diagnoses including corticobasal degeneration (CBD-a form of gradually worsening brain damage that causes problems with movement, speech, memory, and swallowing), and a G-tube. Review of the facility policy titled, Medication Administration through an Enteral Tube (G-tube), dated January 2022, indicated the following: -Facility should administer each medication separately and flush the tubing between each medication - administer with 15 milliliters (mls) water after each medication is given. -Allow medication to flow down the medication syringe via gravity. Do not push medication through a tube. Flush after each dose with at least 15 mls of water. According to Lippincott Nursing Procedure Manual, 9th edition, December 11, 2023- Enteral Tube Drug Instillation, Long Term Care, indicated the following: Equipment Needed: purified water (sterile, distilled, ultrafiltered, ultraviolet-light treated). -Flush the enteral tube with at least 15 mls of purified water. Review of the Physician's orders dated December 2023, indicated the following: -Administer 15 mls of water via enteral access device (G-tube) after administration of each medication. On 12/13/23 at 8:05 A.M., during a medication administration observation, the surveyor observed Nurse #3 mix five separate medications with 10 mls of normal saline (salt water, not water). Nurse #3 drew the medication into a medication syringe, depressed the plunger and instilled (pushed) the medication into the Resident's stomach (the medication was not allowed to flow down the syringe via gravity). Nurse #3 then drew up 15 mls of normal saline, depressed the plunger and instilled (pushed) the saline flush into the Resident's stomach. Nurse #3 repeated this process for each of the five medications that were administered. On 12/13/23 at 8:55 A.M., the surveyor and Nurse #3 inspected the bottle of normal saline used to mix the medications and flush the G-tube. After reviewing the Physician's orders, Nurse #3 said she should have used sterile water and not normal saline solution to mix the medications and flush the G-tube. During an interview on 12/13/23 at 9:54 A.M., the Assistant Director of Nurses (ADON) said Nurse #3 should have administered the medications and flush by gravity and not instilled (pushed) them into the Resident's stomach. The ADON further said Nurse #3 should have used water, not normal saline to dilute the medications and flush the G-tube. Based on observations, interviews and record review, the facility failed to provide care and services that met professional standards of care for two Residents (#26 and #63), out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. Monitor serum (blood) levels of anti-seizure medications for Resident #26 resulting in breakthrough seizures (seizures that occur after they have been controlled with medications) and hospitalization. 2. Administer medications through a gastrostomy tube (G-tube: a tube surgically inserted through the skin and the stomach wall directly into the stomach and used to provide nutrients and medication) per professional standards for Resident #63. Findings include: 1. Resident #26 was admitted to the facility in September 2022 with a diagnosis of Seizure Disorder/Epilepsy. Review of the Nursing 2022 Drug Handbook, Wolters Kluwer, 42nd Edition, page 1495 titled Valproate Sodium (Valproic Acid, an anti-seizure medication) indicated but was not limited to: -Monitor drug level. Therapeutic level is commonly considered to be 50-100 micrograms per milliliter (mcg/ml) for seizure control. Review of the Resident's medical record indicated Resident #26 was hospitalized from [DATE] through 9/14/23. Review of the hospital Discharge/Transfer Note dated 9/14/23, indicated the following: - Resident presented from nursing home due to increased lethargy and hypotension (low blood pressure), found to have septic shock (life-threatening condition that occurs when the blood pressure drops to a dangerously low level after an infection) of an unknown origin. He/she was started on broad-spectrum antibiotics. The Resident's medical course was complicated by a breakthrough seizure, likely due to sub-therapeutic (a concentration of a drug lower than what is usually prescribed to treat a disease effectively) Valproic Acid levels (the amount of Valproic Acid in the blood) due to interaction with Meropenem (an antibiotic). His/her Keppra (an anti-seizure medication) was increased and his/her Valproic Acid was discontinued while Meropenem was being prescribed for use. Review of the Facility Nurse Practitioner (NP) Progress Note dated 9/14/23, indicated the following: -Initial re-admission visit following hospitalization for septic shock. -Plan is for Resident to be switched back to his/her home anti-epileptic regimen seven days after the last dose of Meropenem (9/14/23). -Resident will be given a one-time dose of Valproic Acid of 1000 milligrams (mg) then 750 mg daily as maintenance. -Keppra will be decreased back to 1 gram (1000 mg) twice daily. -We will follow-up with repeat levels (lab work to determine if therapeutic (effective) levels of anti-seizure medication in the Resident's blood to avoid further seizure activity) one week after that (which would be 9/21/23). Review of the Resident's medical record indicated no evidence that laboratory (lab) work to monitor levels of anti-seizure medication was ordered or obtained as outlined in the NP note dated 9/14/23. Further review of the Resident's medical record indicated the Resident was again hospitalized from [DATE] through 9/28/23 due to having multiple seizures while in the facility. Review of the hospital Discharge/Transfer Note dated 9/28/23, indicated the following: -Patient was admitted for multiple seizures and found to have low blood pressure. -His/her seizures were likely caused by sub-therapeutic Valproic Acid levels, and his/her Valproic Acid was increased from 750 mg daily to 500 mg twice per day. -Valproic Acid levels were found to be sub-therapeutic. Review of the Facility NP Progress Note dated 10/2/23, indicated the following: -Resident's Valproic Acid levels were found to be sub-therapeutic and his/her dose was increased from 750 mg daily to 500 mg twice per day. -Plan: Epilepsy/Resident re-hospitalized with a [sic] second breakthrough seizure due to sub-therapeutic Valproic Acid level. -Plan to follow Valproic Acid and Keppra levels (with lab work drawn) weekly for three weeks. Review of the Physician's Progress Note dated 10/18/23, indicated the following: -Follow Keppra and Valproic Acid levels weekly for three weeks. Further review of the Resident's medical record indicated no evidence the Valproic Acid and Keppra lab work to monitor levels was ordered or obtained as recommended by the NP and Physician on 10/2/23 and 10/18/23. During an interview on 12/13/23 at 1:14 P.M., the surveyor and the NP reviewed the NP progress notes. The NP said she should have written an order to monitor the Resident's Valproic Acid and Keppra levels and failed to do so. The NP said, I own that, I should have either written an order or given the Nurse a verbal order. The NP further said she reviewed all the Resident's lab work and was unable to find any recent Valproic Acid and Keppra levels that had been obtained. The NP reviewed the hospital discharge summary and said the Resident's Valproic Acid level (drawn at the hospital) was 31.6 mcg/ml, that normal levels should be between 50-100 mcg/ml, and low levels would put the Resident at risk for breakthrough seizures. The NP said Valproic Acid levels should be regularly monitored at intervals of every four to six months, and more frequently if actively titrating (adjusting) the medication doses. The NP further said she did not realize she did not order the lab work until the surveyor brought it to her attention. During an interview on 12/14/23 at 11:10 A.M., the surveyor asked Unit Manager (UM) #1 to describe the facility process for ensuring recommendations written in Provider (Physician/ NP) notes were implemented. UM #1 said the NP and Physician were responsible for providing a written or verbal order which nursing would implement. UM #1 further said she would glance at progress notes to familiarize herself with what was going on with the residents to keep informed, as well as to inform family members if they have questions and for the purposes of care plan meetings. UM #1 said she was not aware the NP wanted Valproic Acid and Keppra lab work to be obtained following the Resident's multiple hospitalizations. During an interview on 12/15/23 at 9:39 A.M., the NP said she was able to find a Valproic Acid and Keppra level that was drawn on 2/20/23. The surveyor and NP reviewed NP and Physician progress notes from October 2022 to 12/15/23, with multiple references pertaining to monitoring Valproic Acid and Keppra levels. The NP said there was no evidence of Valproic Acid levels being obtained regularly and it should have been done for monitoring. During an interview on 12/15/23 at 10:37 A.M., the Consultant Pharmacist said Valproic Acid levels should be monitored at least every six months and more frequently as needed for medication dosage changes.

2. Resident #55 was admitted to the facility in February 2023 with diagnoses including fracture of the femur (thigh bone) and Diabetes Mellitus (a chronic condition that results in too much glucose (sugar) in the blood). Review of the Physician Order Summary Report printed on 12/14/23, indicated the following orders: -Insulin Lispro (a short acting version of insulin that helps the body turn food into energy and controls blood sugar levels) inject as per sliding scale (total dose medication dependent on blood sugar level) subcutaneously (under the skin) before meals three times a day (TID). Date initiated - 7/7/23. Review of the Medication Administration Record (MAR) for October 2023, November 2023, and December 1-14, 2023, indicated the Resident's blood glucose monitoring with sliding scale coverage as needed was performed three times a day. Review of the Consultant Pharmacist Report dated 10/16/23, indicated a Consultant Pharmacist recommendation to discontinue the sliding scale insulin and reduce the frequency of blood glucose monitoring. Further review of the Consultant Pharmacist Report indicated the Consultant Pharmacist recommendation had been accepted, with a modification from the Medical Provider, dated 10/20/23 to decrease the blood glucose monitoring to two times a day, twice a week. During an interview on 12/15/23 at 8:38 A.M., the surveyor and UM #2 reviewed the Consultant Pharmacist report with the accepted Medical Provider recommendation. UM #2 said that the Medical Provider recommendation to decrease the blood glucose monitoring to two times a day (BID), twice a week had not been implemented. During an interview on 12/15/23 at 9:34 A.M., the surveyor and the NP reviewed the Consultant Pharmacist Report dated 10/16/23, that she signed on 10/20/23. The NP said she had approved the Pharmacist recommendation with the modification to decrease the blood glucose monitoring to twice a day (BID), two times a week rather than to discontinue the sliding scale. The NP said that she was more comfortable with twice a day (BID), twice a week blood glucose testing and Insulin given as needed as the Resident had a history of high blood sugar levels when ill. The NP said she was not aware that the recommendation to decrease the blood glucose monitoring to two times a day (BID), twice a week had not been implemented. During an interview on 12/15/23 at 11:18 A.M., the DON said the MRR forms were faxed to the facility by the Consultant Pharmacist. He said the Unit Managers (UMs) were responsible to check the Pharmacy fax and give the Pharmacist recommendations to the Medical Provider for review. The Medical Provider then reviews and signs the recommendations and returns them to the UM. The UM or a staff Nurse transcribes any new orders from the Medical Provider. The DON said the Pharmacy recommendations that were signed by the NP should have been implemented, but they were not as required. Based on record review and interviews, the facility failed to act upon recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) for two Residents (#36 and #55), out of a total sample of 23 residents. Specifically, the facility staff failed to ensure: 1. For Resident #36, that the Consultant Pharmacist recommendations were communicated to the Medical Provider (Physician/ Nurse Practitioner[NP]) pertaining to duplicate therapy related to anticoagulants (also known as blood thinners - medications that keep blood clots from forming). 2. For Resident #55, that the Consultant Pharmacist recommendations, accepted and modified by the Medical Provider were implemented as required. Findings include: Review of the facility's policy titled, Medication Regimen Review, revised 8/17/23 included but was not limited to: -Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing (DON) to act upon the recommendations contained in the MRR. -For those issues that require Physician/Prescriber intervention, the facility should encourage the Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. -The attending Physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. -The attending Physician should address the Consultant Pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. -The facility should maintain readily available copies of the Consultant Pharmacist reports on file in the facility as part of the resident's permanent health record. 1. Resident #36 was admitted to the facility in July 2022 with diagnoses including Congestive Heart Failure (CHF: condition where the heart cannot pump blood well enough to meet the body's needs) and Atrial Fibrillation (Afib: an irregular and often very rapid heart rhythm). Review of the Resident's record included progress notes by the Consultant Pharmacist that indicated MRRs conducted with recommendations on the following dates: -8/18/23 -10/15/23 Further review of the Resident's record indicated no evidence of the MRR forms dated 8/18/23 and 10/15/23. During an interview on 12/15/23 at 8:54 A.M., the DON said the Consultant Pharmacist usually faxes recommendations directly to the nursing units and the Unit Managers (UMs) will take the fax and follow-up directly with the Provider (Physician/ Nurse Practitioner [NP]). The DON further said that once the Provider responds to the recommendations, a copy of the MRR form is made and forwarded to him (the DON). During an interview on 12/15/23 at 11:02 A.M., the Consultant Pharmacist said she routinely sends her monthly recommendations to the facility via fax to the nursing units as well as e-mails to the Unit Managers and the DON. During an interview on 12/15/23 at 11:40 A.M., the DON said he was unable to locate the MRRs from 8/18/23 and 10/15/23 and that he requested the Consultant Pharmacist fax copies to the facility so they could be addressed.

Based on observation, interview and policy review, the facility failed to ensure medications were stored safely and securely on one unit (Hampden Gardens), out of three units observed. Specifically, an unlocked medication cart was left unattended in the hallway on Hampden Gardens Unit, where it could be easily accessed by unauthorized staff, residents or visitors. Findings include: Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, revised 8/7/23 included but was not limited to: -Store all drugs and biologicals in locked compartments .permitting only authorized personnel to have access. -Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 12/13/23 at 10:15 A.M., during an observation on the Hampden Gardens Unit, the surveyor observed an unlocked, unattended medication cart in the unit hallway. The surveyor also observed that a member of the housekeeping staff was mopping the floor next to the unsecured medication cart and a resident was propelling him/herself down the hall in close proximity to the medication cart. The surveyor did not observe any other visible staff members at this time. Shortly after observing the unlocked cart, the surveyor observed Nurse #1 at the end of the hallway at a different medication cart. During an interview at the time, the surveyor asked Nurse #1 to identify which Nurse was assigned to the unattended, unsecured medication cart. Nurse #1 said that the Nurse assigned to the unattended, unsecured medication cart had left the nursing unit to take a coffee break. At this time, Unit Manager (UM) #1 was observed to approach the medication cart and locked the cart. During an interview with UM #1, UM #1 said the Nurse should not have left the medication cart unlocked and unattended.

Based on observations, interviews, and policy review, the facility failed to provide a sanitary environment to prevent contamination and transmission of infections for one Resident (#87) out of a total sample of 23 residents. Specifically, the facility staff failed to conduct appropriate hand hygiene while assisting Resident #87 with eating. Findings include: Review of the facility policy titled Resident Dining Services, revised on 4/26/23, indicated the following: -Associates involved in dining services will wash their hands prior to distributing trays to the residents, when serving food to residents, and after handling soiled dinnerware and food waste. On 12/13/23 at 8:53 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 assisting a resident with his/her breakfast by holding the eating utensil and bringing food to the resident's mouth. During an interview at the time, the surveyor asked CNA #1 how much assistance Resident #87 required during meals, she said that she usually helped the current resident with their cereal and then proceeded to Resident #87 to provide him/her with assistance. Without washing or sanitizing her hands after she finished assisting the current resident, CNA #1 picked up a part of the muffin on Resident #87's plate with bare hands and began to assist the Resident with eating the muffin. During an interview following the observation, CNA #1 said that she usually wore gloves when providing assistance with eating and she usually used the sanitizer wipes that were located in the dining room in between residents. CNA #1 said that she did not use the sanitizer wipes today, and used bare hands to hold the muffin while assisting Resident #87 with his/meal. CNA #1 said that she should have had on gloves at that time.

Based on policy review, record review, and interview, the facility failed to administer the Pneumococcal Vaccine as required for one Resident (#55), out of five applicable residents putting the Resident at risk for facility acquired infections. Specifically, the facility staff failed to administer the Pneumococcal Vaccine for Resident #55 when an informed consent was signed by the Resident. Findings include: Review of the facility policy titled, Influenza Vaccine & Pneumococcal Vaccine Policy for Residents, dated 1/25/23, indicated the following: -Each Resident is offered a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. -The Resident's medical record includes documentation that indicated, at a minimum the following: a. That the Resident or Resident's Representative was provided education regarding the benefits and potential side effects of pneumococcal immunization, and b. That the Resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications. -If contraindications are noted or if the Nurse has any question based on the assessment findings, the Physician is notified of the assessment for further directions. -If, based on the Nurse's assessment, contraindications are not noted, the pneumococcal vaccine is administered per Physician standing orders. Resident #55 was admitted to the facility in February 2023 with diagnoses including fracture of the femur (thigh bone) and Diabetes Mellitus (a chronic condition that results in too much sugar in the blood). Review of the Informed Consent for Pneumococcal Vaccine indicated the Resident had signed the informed consent on 2/21/23. Review of the Immunization record indicated no evidence the Resident had received the Pneumococcal Vaccine. During an interview on 12/14/23 at 3:14 P.M., Unit Manager (UM) #2 said the Nurses usually obtained the consents for immunization on admission but Resident #55 had been admitted to another floor, and she was not aware that the Resident had signed the consent form. During an interview on 12/14/23 at 4:52 P.M., the Infection Preventionist (IP) said she had reviewed Resident #55's medical record, had no evidence that the Pneumococcal Vaccine had been offered to the Resident at the facility or prior to admission, or that the immunization was contraindicated. The IP said that the admitting Nurse normally completed consent forms for immunizations and administered the vaccines. She said the last time the facility had audited the immunization records for vaccination completion was two years ago and that she was not aware the Resident had not been immunized, as required. During an interview on 12/15/23 at 7:38 A.M., the Director of Nurses (DON) reviewed the Informed Consent for Pneumococcal Vaccine and Immunization record and the immunization record for Resident #55 and said the Resident had not been offered the Pneumococcal Vaccine as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. Resident #26 was admitted to the facility in September 2022. Review of the Resident's medical record indicated that the resident was transferred to the hospital on 9/25/23. Further review of the medical record indicated no documentation that the Office of the State Long-Term Care Ombudsman and the Resident and/or his/her Respresentative were notified in writing of the transfer. During an interview on 12/13/23 at 1:58 P.M., the Director of Social Services said she updates the Ombudsman of transfers at the end of each month but had not updated the Office of the Long Term Care Ombudsman of residents who had been transferred out of the facility since September 13, 2023. The Director of Social Services said the Ombudsman had not been updated on Residents #10, #88, #69, and #26 transfers to the hospital, as required. The Director of Social Services further said for Residents #69, and #26 the Resident and/or their Resident Representative should have received a Notice of Transfer or Discharge at the time they were transferred from the facility or shortly thereafter and she was unable to find documentation that this had been done as required. Based on interview, record review, and policy review, the facility failed to provide required written notices of transfer or discharge for four Residents (#10, #88, #69, and #26) out of a total sample of 23 residents. Specifically the facility failed to: -Provide written notice of transfer or discharge to the Office of the Long-Term Care Ombudsman for Residents #10, #88, #69, and #26. -Provide written notice of transfer or discharge to the Resident and/or Resident Representative for Residents #69 and #26. Findings include: Review of the facility policy titled Transfers and Discharges, reviewed 8/9/23, indicated the following: -The facility will follow the limited conditions under which the Centers for Medicare and Medicaid has outlined how the facility may initiate transfer or discharge of a resident . 1a. Resident #10 was admitted to the facility in September 2023. Review of the medical record and Notice of Resident Transfer or Discharge, dated 10/16/23, indicated the Resident was transferred to the hospital from the facility on 10/16/23. Further review of the medical record indicated no documentation that the Office of the State Long-Term Care Ombudsman was notified in writing of the Resident's transfer. 1b. Resident #88 was admitted to the facility in October 2023. Review of the Notice of Resident Transfer or Discharge, dated 10/16/23, indicated the Resident was transferred to the hospital from the facility on 10/16/23. Further review of the medical record indicated no documentation that the Office of the State Long-Term Care Ombudsman was notified in writing of the Resident #88's transfer. 2a. Resident #69 was admitted to the facility in February 2023. Review of the Resident's medical record indicated that the Resident was transferred to the hospital on [DATE]. Further review of the medical record indicated no documentation that the Office of the State Long-Term Care Ombudsman and the Resident and/or his/her Representative were notified in writing of the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure their staff promoted and facilitated Resident self-determination relative to manner of bathing for one Resident (#2) out of a total of 19 sampled residents. Findings include: Resident #2 was admitted to the facility in May 2021 with a diagnosis of end stage Multiple Sclerosis (a disabling disease of the brain and spinal cord which can cause vision loss, pain, fatigue, and impaired coordination). Review of the Resident's Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score 15. Further review of the MDS indicated the following: Section F, Daily Preferences, indicated it was very important for the Resident to choose between tub bath, shower, bed bath, or sponge bath. Section GG, Functional Abilities, indicated the Resident was totally dependent on staff for showering and bathing. Review of the Certified Nurse Aide (CNA) Documentation Survey Report, from 2/28/22 - 5/7/22, indicated the following: The week of 2/28-3/5/22, the Resident received two showers. The week of 3/6-3/12/22, the Resident did not receive any showers. The week of 3/13-3/19/22, the Resident received only one shower. The week of 3/20-3/26/22, the Resident received only one shower. The week of 3/27-4/2/22, the Resident received only one shower. The week of 4/3/22-4/9/22, the Resident received only one shower. The week of 4/10-4/16/22, the Resident received only one shower The week of 4/17-4/23/22, the Resident received only one shower. The week of 4/24-4/30/22, the Resident did not receive any showers. The week of 5/1-5/7/22, the Resident received two showers. During an interview on 5/10/22 at 9:38 A.M., the Resident said he/she is supposed to have a shower two times per week and has not had a shower in over a week. There was no evidence in the clinical record that Resident #2 refused showers at any time. During an interview on 5/11/22 at 2:11 P.M., Nurse #2 said Resident #2's shower days are Tuesday and Friday on the evening shift, but there are times when showers cannot be accommodated due to staffing issues, but are then offered the next day. She further said, if a Resident is scheduled to have showers two times per week, they should have showers two times per week, unless the resident refuses. Nurse #2 then said if a resident refuses a shower, or has a sponge bath in lieu of a shower, the CNA should document as such in their notes. During an interview on 5/13/22 at 9:50 A.M., CNA #5 said that residents do not always receive showers due to difficulties in staffing and CNAs being too busy answering call bells.

Based on interview and record review, the facility failed to ensure staff provided a Notice of Transfer and Discharge to the Resident and/or the Resident's representative in writing upon transfer to the hospital for one Resident (#39) out of 19 residents sampled. Findings Include: Resident #39 was admitted to the facility March of 2022. Review of the Nursing Home to Hospital Transfer Form dated 3/29/22 indicated Resident #39 was sent to the hospital. Review of the Nursing Home to Hospital Transfer Form dated 4/18/22 indicated Resident #39 was sent to the hospital. Further review of the Resident's medical record indicated no documentation that Resident #39 and/or his/her Resident representative was provided in writing a Notice of Transfer and Discharge at the time of hospitalization. During an interview on 5/11/22 at 1:04 P.M., with the Director of Nursing (DON) and Admissions Director, the admission Director said nursing sends out the notice of transfer or discharge at the time a resident goes out to the hospital. The DON said she was unable to provide any documentation that the notice of transfer and discharge was provided to the Resident and/or the Resident representative when Resident #39 was transferred to the hospital on 3/29/22 and 4/18/22, as required.

Based on interview and record review the facility failed to ensure staff provided a Notice of Bed Hold Policy and Return to the Resident and/or the Resident's representative in writing upon transfer to the hospital for one Resident (#39) out of 19 residents sampled. Findings Include: Review of the facility policy titled Bed hold/Reservation of Room, reviewed 8/7/21 indicated the following: The facility will provide written information to the resident or resident representative, the nursing facility policy on bed-hold period and the residents return to the facility to ensure that residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility . Resident #39 was admitted to the facility March of 2022. Review of the Nursing Home to Hospital Transfer Form dated 3/29/22 indicated Resident #39 was sent to the hospital on 3/29/22. Review of the Nursing Home to Hospital Transfer Form dated 4/18/22 indicated Resident #39 was sent to the hospital on 4/18/22. Further review of the Resident's medical record indicated no documentation that Resident #39 and or his/her resident representative was provided with a Notice of Bed hold policy and return. During an interview on 5/11/22, at 1:04 P.M., with the admission Director and the Director of Nursing (DON), the admission Director said the Admissions Department calls families to discuss holding a bed at the facility when a resident is transferred to the hospital but there was no formal bed hold policy paperwork provided to the Resident and/or Resident representative upon transfer to the hospital. The DON said she was unable to provide documentation that a Bed hold policy was provided to the Resident and/or Resident representative for Resident #39, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff developed/and or implemented care plans for three Residents (#2, #40, #92) out of a total of 19 sampled residents. Specifically failed to implement range of motion and stretching exercises for Resident #2, failed to develop and implement a behavioral care plan for Resident #40, and failed to turn and reposition Resident #92 at prescribed intervals. Findings include: 1. For Resident #2 the facility failed to implement range of motion (ROM) and stretching exercises as recommended by Physical Therapy (PT). Resident #2 was admitted to the facility in May 2021 with a diagnosis of Multiple Sclerosis (a disabling disease of the brain and spinal cord which can cause vision loss, pain, fatigue, and impaired coordination). Review of the Resident's Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score 15. Further review of the MDS, Section G, Functional Status, indicated the Resident had impairment to his/her ROM in both his/her upper and lower extremities. Review of the clinical record included a staff education attendance sheet, dated 9/15/21, that included passive range of motion exercises (PROM, somebody physically moving part of the body) to be completed by facility staff for the Resident's right arm, signed by various clinical staff who were in attendance. Review of the PT Discharge summary, dated [DATE], indicated the following: - Staff lacks knowledge of appropriate ROM with proper support and amount of stretch for flexor (a muscle whose contraction bends a limb or other part of the body) tightness in right upper extremity (RUE). - PT has begun assessing ROM and tolerance to PROM, discussed options and will now move to educate Certified Nursing Assistant (CNA) staff. - CNA staff have been given formal instruction, both visual and verbal. - CNAs will provide gentle PROM for the RUE without concerns with appropriate education and visual aides in place. During an observation and interview on 5/10/22 at 4:25 P.M., the surveyor observed Resident #2 with contractures (a condition of shortening and hardening of the muscles, tendons, or other tissues often leading to deformity and rigidity of joints) to both his/her upper extremities. He/she said his/her left hand was contracted prior to admission to the facility and he/she had tightness in his/her pectoral (chest) muscles and demonstrated some movement in his/her right hand. He/she also said he/she felt like his/her contractures have worsened due to facility staff not stretching his/her arms and feels as though his/her tendons are shortening. He/she further said prior to his/her admission to the facility, home caregivers assisted in stretching his/her arms. During an interview on 5/11/22 at 2:15 P.M., CNA #2 said that to her knowledge, there were no stretching exercises prescribed for Resident #2. During an interview on 5/11/22 at 2:24 P.M., CNA #4 said she used to take care of Resident #2 on a different unit, there was a stretching program in place and PT educated staff on how to perform the stretches. During an interview on 5/11/22 at 2:45 P.M., the Physical Therapy Assistant (PTA) said he worked with Resident #2 in September, 2021 and the stretching interventions he initiated and educated staff on should still be in place for Resident #2. During an interview on 5/11/22 at 4:00 P.M., Resident #2 said nobody assists him/her with ROM exercises or stretches recommended by the PT, she feels her ROM has declined, and he/she would never refuse the exercises if offered. During an interview on 5/12/22 at 1:40 P.M., Nurse #2 said staff have not been doing ROM exercises for Resident #2 since the Resident moved to this unit and she was not familiar with the PT education sheet that was in the Resident's clinical record. 2. For Resident #92, the facility failed to implement his/her turning and repositioning schedule every two hours. Resident #92 was admitted to the facility in April 2021 with a diagnosis of Alzheimer's Disease, early onset. Review of the MDS Assessment, dated 4/19/22, indicated the Resident required extensive assistance of two or more persons for bed mobility (how a person moves to and from lying position, turns side to side, and positions body while in bed). Review of the Resident's Care Plan included: 4/20/21 - The Resident is at risk for impaired skin integrity and is unable to position him/herself 4/30/21 - The Resident required the assistance of two persons for repositioning every two hours and as needed. Review of the Documentation Survey Report, Turn and Repositioning Task (CNA Documentation) for 5/11/22 indicated the Resident was positioned on his/her left side at 8:00 A.M. and 10:00 A.M., and 4:00 P.M., 6:00 P.M., and 8:00 P.M. on his/her left side. Review of the Documentation Survey Report, Turn and Repositioning Task for 5/12/22 indicated the Resident was positioned on his/her right side at 6:00 A.M. On 5/12/22, the surveyor observed the Resident lying on his/her back in bed with a pillow under his/her left upper body, tilting the Resident towards his/her right side during the following times: 7:30 A.M. 8:34 A.M. 9:05 A.M. 10:27 A.M. During an observation and interview on 5/12/22 at 11:02 A.M., the surveyor observed the Resident on his/her back with a pillow under his/her left upper body with CNA #3 present in the room. CNA #3 said when a pillow is tucked under a Resident's left side, that is considered to be positioned to the right for documentation purposes. The surveyor reviewed her observations of the Resident's positioning as well as the CNA documentation indicating the Resident had been positioned on his/her right side since 6:00 A.M., CNA #3 said the Resident should be repositioned right away. During an interview on 5/12/22 at 1:17 P.M., CNA #1 said the Resident was supposed to be repositioned every two hours. After reviewing the CNA documentation for turning and repositioning for 5/11/22, indicating the Resident was on his/her left side at 8:00 A.M., 10:00 A.M., 4:00 P.M., 6:00 P.M., and 8:00 P.M., CNA #1 said the Resident was likely not repositioned every two hours, as required. 3. For Resident #40 the facility failed to ensure its staff developed a comprehensive, person-centered care plan that included interventions, measurable objectives, and timeframes relative to mood and behavior. Resident #40 was admitted to the facility in January 2022 with diagnoses including disorientation, adjustment disorder, restlessness, and agitation. Review of the 3/1/22 Behavioral Health Group encounter note indicated the following: -Resident was being seen for adjustment disorder with depressed mood -Nursing reported that the Resident had been with depressed mood, agitation/irritable mood, and forgetfulness -BIMS 14/15 (indicating the Resident was cognitively intact) -Resident currently not prescribed psychotropic medications (a drug that affects behavior, mood, thoughts, or perception) Review of the 3/8/22 Behavioral Health Group encounter note indicated the following: -Resident was very agitated and irritable during the encounter -Resident told provider I hope you die in the facility, that would make me happy -Nursing reported increased confusion and irritably over the last week -Resident refused medications -Cognition appeared to be decreased since last encounter -Current medications now include Trazodone (an antidepressant) -Redirect Resident as needed Review of the 3/15/22 Behavioral Health Group encounter note indicated the following: -Recent addition of Buspsar (an antianxiety medication) due to continued behaviors of agitation and anxiety -Stable today but has had symptoms of hallucinations since she was last seen Review of Resident #40's care plans indicated no person-centered care plan relative to mood and behaviors had been developed. During an interview on 5/11/22 at 9:13 A.M., the Director of Social Services said that it did not appear that a mood and behavior care plan with personalized interventions or goals had been developed for the Resident. She said one should have been initiated when the Resident was referred to psych services and was not, as required.

Based on observations and interviews, the facility staff failed to ensure two medication carts were properly secured on one unit on two separate days. Findings include: During an observation and interview on 5/11/22 at 4:20 P.M., on the Hampden Gardens Unit, the surveyor observed an unlocked, unattended medication cart in the corridor, drawers facing outward with no nurse in sight and residents in the immediate area. The surveyor observed Nurse #3 in a resident's room out of sight of the cart. Nurse #3 said she should have locked the cart before walking away. During an observation and interview on 5/13/22 at 7:30 A.M., on the Hampden Gardens Unit, the surveyor observed an unlocked, unattended medication cart in the hallway with residents in the immediate area and Nurse # 1 in a resident's room down the hall. Nurse #1 said the cart should have been locked and was not, as required.

2. For Resident #84 the facility failed to ensure the attending physician reviewed and responded to a MRR recommendation made by the pharmacist. Resident #84 was admitted to the facility February 2022. Review of Resident #84's record indicated that the pharmacist completed a MRR and made recommendations on 2/22/22. Further review of the MRR indicated no documented evidence the MRR recommendation was reviewed, responded to, or signed off by the attending physician. During an interview on 5/11/22 at 3:22 P.M., the Director of Nursing said the MRR from 2/22/22 had not been reviewed and responded to by the attending physician, as required. Based on record review and interview, the facility staff failed to ensure pharmacy recommendations/irregularities were responded to timely and were documented within the clinical record for two sampled Residents (#40 and #84), out of a total of 19 sampled residents. Findings include: 1. For Resident #40 the facility failed to ensure the attending physician reviewed and responded to a Medication Regimen Review (MRR) recommendation made by the pharmacist. Resident #40 was admitted to the facility in January 2022. A record review indicated that a MRR had been conducted on 2/27/22 and indicated that the facility staff see the report for any noted irregularities and/or recommendations. Further record review indicated no evidence of the MRR report. During an interview on 5/11/22 at 3:04 P.M., the Director of Nursing provided a copy of the recommendation made on 2/27/22. The recommendation included a section for the physician to provide their response to the recommendation as well as their signature, both were blank. During a follow up interview on 5/11/22 at 3:22 P.M., the DON said that she could not find evidence in the Resident's clinical record that the recommendation made on 2/27/22 had been addressed by the physician, as required.

Based on record review and interview, the facility staff failed to ensure one Resident (#21) was evaluated for a gradual dose reduction (GDR) of a psychotropic medication (a medication that affects behavior and mood) out of a total of 19 sampled residents. Findings include: Resident #21 was admitted to the facility in March 2019. A record review indicated a Medication Regimen Review (MRR) had been conducted on 3/22/22 and included the following: -Resident #21 had received Celexa (an antidepressant) 30 milligrams (mg) daily for management of depressive symptoms since June 2020. -Please attempt a GDR to Celexa 20 mg daily Further review of the MRR indicated that on 3/31/22, the physician declined the recommendation and requested that the facility's psychiatric services evaluate the Resident for a GDR. Review of the Resident's clinical record indicated no evidence that Resident #21 had been evaluated by the facility's psychiatric services to determine if a GDR was appropriate at this time. During an interview on 5/11/22 at 10:269 A.M., Social Worker #2 said that she was not aware of any recommendation for the Resident to be seen by the facility's psychiatric services and is currently not followed by them.

Based on record review and interview, the facility staff failed to ensure the accuracy of a medical record related to Medical Orders for Life Sustaining Treatment (MOLST) for one Resident (#59) out of a total of 19 sampled residents. Resident #59 was admitted to the facility in October 2021. Review of the clinical record included a MOLST signed by the Resident's representative and the attending physician on 3/1/22 which indicated the following: no artificial nutrition and no artificial hydration. Review of the May 2022 Physician's Orders indicated: use artificial nutrition and use artificial hydration. During an interview on 5/12/22 at 11:30 A.M., the Director of Nursing (DON) said the Physician's Orders did not match the MOLST, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff provided the proper care and services for an external urinary catheter (a device used outside of one's body to collect and drain urine) for one Resident (#2) out of a total of 19 sampled residents potentially increasing his/her risk of urinary infection. Findings include: Review of the PureWick female external catheter manufacturer guidelines included the following information: - Assess device placement and patient's skin at least every two hours. - Replace the PureWick female external catheter every 8-12 hours or when soiled with feces or blood. - Change suction tubing per hospital protocol or at least every 30 days. - The collection canister, canister lid, collector tubing, pump tubing and PureWick urine collection system should be cleaned and disinfected at the time of each use, or at a minimum, daily. The power cord should be cleaned and disinfected at the time of each use, or at a minimum, daily. - The PureWick urine collection system canister should be emptied before volume reaches 1800 milliliters (ml.) or as needed. - The canister and tubing should be replaced every 60 days, or sooner if you see signs of degradation. Resident #2 was admitted to the facility in May 2021 with a diagnosis of end stage Multiple Sclerosis (a disabling disease of the brain and spinal cord which can cause vision loss, pain, fatigue, and impaired coordination). Review of the Resident's Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score 15. Review of the May 2022 Physician's Orders included the following: - Apply PureWick device every shift, change every 12 hours and as needed, initiated 1/21/22. Further review of the Physician's Orders did not include any further orders relative to the care and services of the external catheter or device. During an observation and interview on 5/10/22 at 9:38 A.M., the surveyor observed tubing coming from the Resident feeding into a container which contained a liquid substance. The Resident explained the device was called a PureWick and it is used to manage his/her incontinence. The Resident explained the device included a cotton pad worn in the perineum (the space between the anus and vulva or scrotum) with a tube that pulls urine into a container placed onto an electric suction device. During an interview on 5/10/22 at 4:30 P.M., the Resident said PureWick was changed every morning and used throughout the whole day unless it became soiled after having had a bowel movement. During an interview on 5/11/22 at 4:00 P.M., the Resident said he/she is lucky if the urine collection container gets emptied once per day let alone every shift and he/she thinks the tubing has only been changed once since he/she has been here. He/she further said that to his/her knowledge, staff only empty the canister, they don't clean the tubing or the machine. The Resident said when he/she lived at home, he/she used to run sterile water through the equipment to clean it as well as utilized a long brush to get rid of urine build up and particles in the tubing. During an interview on 5/12/22 at 11:04 A.M., Certified Nursing Assistant (CNA) #3 said the Resident's wick is changed once per day unless it becomes soiled due to having a bowel movement, the canister is usually emptied when it is really full and she has never cleaned the tubing. During an interview on 5/12/22 at 11:45 A.M., Nurse #2 said facility staff changed the wick every shift and she thought the device was cleaned nightly, indicating the night shift nurses were responsible for managing various types of tubing, however she did not know for sure the tubing had ever been changed and did not know what the cleaning protocol for the PureWick was. She further said there was nothing in writing indicating that the machine, including the tubing had ever been cleaned or maintained. During an interview on 5/12/22 at 1:02 P.M., the Director of Nursing (DON) said there were no protocols in place for the care and services of the PureWick device, as required.

Based on observation and interview, the facility staff failed to ensure food items stored in the unit kitchenettes were dated and labeled in two out of three kitchenettes (Hampshire Woods Unit and Hampden Gardens Unit). Findings Include: On 5/11/22 at 2:00 P.M., the surveyor observed the following unlabeled and undated items in the Hampshire Woods Unit kitchenette: -2 plastic containers containing food in the kitchenette refrigerator -An open bag of cashews with an expiration date of 2020 in the cabinet At the time of the observation the Staff Development Coordinator said all items brought in for residents should be dated and labeled with the resident's name. She further said the two plastic containers in the refrigerator and bag of cashews were not labeled or dated, as required. On 5/11/22 at 2:37 P.M., the surveyor observed the following unlabeled and undated items in the Hampden Gardens Unit kitchenette. -A half consumed milkshake in the freezer -A half consumed ice cream cup in the freezer -A half consumed electrolyte drink in the freezer At the time of the observation Nurse #2 said all items stored in the unit freezers should be labeled with a resident room number and a date, and the items in question were not labeled or dated, as required. During an interview on 5/12/22 at 11:40 A.M., the Food Service Director (FSD) said resident food that is stored in the kitchenettes needs to be labeled and dated and that any items not labeled or dated should be discarded.