Based on record and policy review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASRR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for one Resident (#73) out of a total sample of 18 residents. Specifically, for Resident #73, the facility staff failed to request a Level II PASRR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings Include: Resident #73 was admitted to the facility in August 2023, with diagnoses including Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #73's Level I PASRR screen from a previous nursing facility admission dated 4/7/22, indicated that he/she had a history of a mood disorder, severe anxiety, and did not meet criteria for SMI, therefore a Level II PASRR evaluation was not needed. Review of the facility policy for Pre-admission Screening and for Mental Disorder (MD) and/or Intellectual Disability (ID) Patients, last reviewed 2/16/24, indicated the following: -Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if .there is a significant change in status that results in new evidence of possible mental disorder, intellectual disability or a related condition. -Social Services will be responsible for coordinating updates as needed per state requirements. -Social Services will be responsible for notifying the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a patient who has a MD or ID for patient review. Review of the Behavioral Health Note dated 10/5/23, indicated the Resident was experiencing increased behaviors (yelling), delusions (false beliefs) and hallucinations (false perceptions of objects or events involving the senses: sight, sound, smell, touch and taste). Further review of the Behavioral Health Note indicated that Resident #73 had been given an increase in the antipsychotic (drugs used to treat psychosis- a collection of symptoms that affect your ability to tell what is real and what is not) medication Zyprexa for management of these symptoms. Review of Resident #73's Social Services Progress Notes indicated that the Resident had experienced repeated episodes of calling out and yelling behaviors during the following dates: -10/6/23 - 10/8/23 -10/15/23 -11/2/23 -11/9/23 -11/12/23 -11/14/23 -11/16/23 -11/26/23 -11/27/23 Review of Resident #73's medical record indicated that the Resident had been diagnosed with Visual Hallucinations on 10/26/23 and Delusional Disorder on 10/30/23. Further review of the Resident's medical record failed to indicate that the Level I PASRR was updated and re-submitted for an additional Resident Review (a review that assesses the need for a more in-depth assessment: Level II evaluation) when new mental health diagnoses were identified on 10/26/23 and 10/30/23. Review of Resident #73's Psychosocial/Behavior care plan, last revised 8/29/24 indicated: -The Resident has a history of audio and visual hallucinations that can be very upsetting to him/her. -The Resident has a disruptive behavior of constant/repetitive calling out for others. -The Resident can become weepy at times. During an interview on 9/23/24 at 9:35 A.M., Social Worker (SW) #1 said that she was responsible for reviewing the PASRR evaluations. SW #1 also said that she had not been aware until May 2024 that the facility was required to re-submit a Level I when a Resident had a change in condition such as a new mental health diagnosis. SW #1 further said that Resident #73's Level I PASRR had not been re-submitted to the Department of Mental Health PASRR office but that it should have been.

Based on observation, interview, and record review, the facility failed to develop a care plan for the use of a positioning aid for one Resident (#6) out of a total sample of 18 residents. Specifically, for Resident #6, the facility failed to ensure a care plan was developed for the use of bilateral (both sides) wedge cushions (a triangular shaped cushion used to aid in positioning for health issues or comfort) while the Resident was in bed. Findings include: Review of the facility policy titled Body Positioning, released 1/17/17, indicated the following: -Positioning techniques should be used with residents with stroke and other neurological impairments for the following reasons: >Orthopedic enhancement of postural alignment >Increase stability -Documentation >In the care plan, document positioning needs and interventions and approaches to meet resident's needs. Resident #6 was admitted to the facility in March 2020, with diagnoses including a history of Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) with spastic hemiplegia [paralysis of one side of the body] affecting the right side (a possible side effect from a stroke that causes muscles to be in a constant state of contraction). Review of the most recent Minimum Date Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 7/31/24, indicated Resident #6: -was dependent for bed mobility, -never spoke, -was rarely and/or never understood, -and rarely and/or never able to understand. During an observation on 9/18/24 at 9:54 A.M., the surveyor observed Resident #6 lying in bed and he/she had large wedge cushions bilaterally placed on either side of his/her upper body. During an observation on 9/19/24 at 8:53 A.M., the surveyor observed Resident #6 to be lying in bed. The surveyor further observed that large wedge cushions were bilaterally placed on either side of his/her upper body. Review of Resident #6's September 2024 Physician's orders did not indicate any order in place for the use of the bilateral wedge cushions. Review of Resident #6's Care Plan did not indicate that a care plan had been developed for the use of the bilateral wedge cushions while Resident #6 was in bed. Further review of the Resident's medical record indicated no additional documentation on when the bilateral wedge cushions were recommended for use for the Resident or who recommended that the Resident needed the bilateral wedge cushions. During an interview on 9/19/24 at 9:06 A.M., Nurse #1 said there should be a care plan developed when a Resident utilized wedge cushions in bed, so staff knew to place them on either side of the Resident when he/she was in bed. During an interview on 9/19/24 at 9:27 A.M., Certified Nurses Aide (CNA) #1 said Resident #6 utilized the bilateral wedge cushions when he/she was in bed because he/she had a stroke and needed the wedge cushions for positioning. During an interview on 9/19/24 at 9:43 A.M., Unit Manager (UM) #1 said Resident #6 used the bilateral wedge cushions when he/she was in bed. UM #1 said the use of wedge cushions while in bed to help with positioning had been recommended by the Therapy Department and there should have been a care plan in place for the use of the wedge cushions. UM #1 further said a care plan for the use of wedge cushions for Resident #6 had not been developed. During an interview on 9/19/24 at 11:12 A.M., the Director of Rehabilitation (DOR) was unable to find any documentation that Resident #6 had been evaluated by the Therapy Department for the use of bilateral wedge cushions while in bed. The DOR said when a Resident needed a positioning aid the Therapy Department would evaluate the use of a positioning aid, document in therapy notes that the positioning aid was needed and why, acquire a Physician's Order for the use of the positioning aid, update or create a Care Plan for the positioning aid, and provide education to staff, and this was not done for Resident #6. The DOR further said she could find no documentation on when the bilateral wedge cushions were recommended or who recommended the bilateral wedge cushions for Resident #6's use while he/she was in bed.

Based on observations, interviews and record review, the facility staff failed to ensure access to a call light (a device used to alert staff of a request/need) for one Resident (#4), out of a total sample of 19 residents. Specifically, Resident #4's call light was not accessible during meals when he/she was eating in his/her room without staff presence/supervision. Findings include: Resident #4 was admitted to the facility in April 2017 with diagnoses of Acute Respiratory Failure with Hypercapnia (where the lungs are unable to adequately oxygenate the blood and eliminate carbon dioxide, resulting in abnormally elevated carbon dioxide levels) and Dysphagia (difficulty with swallowing). Review of the Minimum Data Set (MDS) Assessment, dated 4/17/23, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of the Activities of Daily Living (ADL) Care plan, revised 5/5/23, included the following intervention: -call light to be within reach On 6/6/23 at 9:00 A.M., the surveyor observed Resident #4 seated in a wheelchair in his/her room eating breakfast. The call light was observed clipped to its cord against the wall behind the Resident and was not accessible. During an interview, the Resident was observed to cough and bring up chewed breakfast food. The surveyor asked Resident #4 if he/she was okay, the Resident responded yes, but I need a bucket. The surveyor alerted Certified Nurse Aide (CNA) #3 who was down the hallway outside of the Resident's room, who said he would assist. On 6/6/23 at 10:52 A.M., the surveyor observed Resident #4 seated in his/her room in the same position as earlier observed. An emesis bucket was observed on the Resident's overbed table. The call light remained clipped to its cord against the wall and was not accessible. On 6/7/23 at 8:27 A.M., the surveyor observed the Resident seated in his/her room in a wheelchair. The call light was not accessible and was located behind the bedside table which was located behind the Resident. Another call light was observed between the side rail and the mattress of the bed and was not visible nor accessible to the Resident. During the observation, the Resident asked the surveyor for something to drink. The surveyor relayed the request to Unit Manager (UM) #2 who assisted the Resident. On 6/7/23 at 9:28 A.M., the surveyor observed Resident #4 seated in a wheelchair in his/her room with a breakfast plate on an overbed table in front of him/her. The Resident requested more hot cereal from the surveyor who relayed the request to CNA #5 who was in the unit dining room area. CNA #5 obtained the hot cereal and accompanied the surveyor to Resident #4's room. During an interview, CNA #5 said Resident #4 required assistance with care/transfers and was able to alert staff to his/her needs by utilizing the call light. The surveyor asked CNA #5 if the Resident's call light was accessible to him/her. CNA #5 was observed to look around, pull the cords from the wall where the call lights were attached, pull the call light out from behind the bedside table which was behind the Resident, and place the call light on the Resident's lap. CNA #5 said that it was not accessible and should have been since he/she used it frequently to request assistance. During an interview on 6/8/23 at 9:29 A.M., UM #2 said Resident #4 had swallowing difficulty and was at risk for aspiration (when food/fluid/other material enter a person's airway and into the lungs). She further said the Resident should have his/her call bell accessible at all times to alert staff of needs/requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement the plan of care for four Residents (#4, #10, #18 and #75), out of a total sample of 19 residents. Specifically the facility failed to: 1) For Resident #4, implement the plan of care relative to Activities of Daily Living (ADLs) and swallowing. 2) For Resident's #10 and #18, ensure the Physician's Orders relative to medication parameters were implemented. 3) For Resident #75, ensure the plan of care relative to fall prevention was implemented. Findings include: 1. For Resident #4 the facility failed to ensure the plan of care and/or Physician's Orders were implemented relative the level of supervision and adaptive equipment as recommended by the Speech Language Pathologist (SLP- clinician who assess, prevent, diagnose and treat swallowing disorders) to reduce the risk of aspiration (inhalation of food/fluid/substances into the airway and lungs). Resident #4 was admitted to the facility in April 2017 with diagnoses including Dysphagia (difficulty swallowing), Peripheral Vascular Disease (PVD- circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and muscle weakness. Review of a Minimum Data Set (MDS) Assessment, dated 4/17/23, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and required supervision when eating. Review of the SLP Discharge summary, dated [DATE], indicated the following: -education was provided to Resident and staff on levels of swallowing difficulty, diet level, safe swallow strategies, -supervision during meals to increase carryover of safe swallow strategies, and -upgrade to thin liquids with the use of the Provale cup (limited flow cup for the delivery of thin liquids) and ensuring that all beverages are provided with the Provale cup . Review of the ADL Care Plan, revised 5/5/23, indicated Resident #4 required assist with ADLs and included the following interventions: -continual supervision during eating, one staff to eight resident (1:8 group) -cue Resident on proper eating techniques -Resident utilizes Provale cup Review of the June 2023 Physician's Orders included the following: -Use Provale cup with thin liquids On 6/6/23 at 9:00 A.M., the surveyor observed Resident #4 seated in a wheelchair in his/her room eating breakfast which was on an overbed table positioned in front of him/her. No staff were present in the room. During a brief interview, Resident #4 was observed to cough and bring up chewed breakfast food. The surveyor asked if he/she was okay, and the Resident responded yes, but I need a bucket. The surveyor relayed the Resident's request to Certified Nurse Aide (CNA) #3, who provided assistance. During an interview with CNA #3, the surveyor relayed the previous observations and CNA #3 said the Resident was okay to eat by him/herself and was cleared by the SLP to do so. On 6/6/23 at 10:52 A.M., the surveyor observed the Resident seated in a wheelchair in his/her room with an overbed table placed in front of him/her. A bin was observed on the overbed table positioned in front of the Resident and contained some chewed up food mixed with fluids. On 6/7/23 at 9:28 A.M., the surveyor observed the Resident seated in a wheelchair in his/her room with an overbed table positioned in front of him/her, finishing a bowl of hot cereal. The Resident asked the surveyor for more hot cereal and the surveyor exited the room and went to the unit dining area where breakfast was being served. CNA #5 was observed to get a bowl of hot cereal and accompanied the surveyor to Resident #4's room. She was observed to provide the Resident with the bowl of hot cereal, instruct him/her to eat slowly and then leave the room while the Resident was eating. On 6/7/23 at 12:32 P.M., the surveyor observed the Resident seated in a wheelchair in his/her room eating lunch. There was no staff in the room providing supervision during the meal, as care planned. The Resident had a regular hot beverage cup (not a Provale cup) containing coffee, and was observed to drink from it during the observation. During an interview on 6/8/23 at 8:55 A.M., the SLP said that she had worked with Resident #4 for swallowing. She said he/she was impulsive and needed to be cued by staff to slow down while eating. She further said that supervision should be provided during the meal and that all liquids should be provided in the Provale cup to prevent risk of aspiration. The SLP said the facility had numerous Provale cups, that there are usually some available on the unit, but if there were not, the unit staff could contact the Dietary Department to request more. During an interview on 6/8/23 at 9:29 A.M., Unit Manager (UM) #2 said Resident #4 typically eats in the unit dining room and that supervision should be provided by staff while he/she was eating. She further said that Resident #4 had an increased risk of aspiration and if not eating in the dining room, staff would have to supervise him/her while eating in his/her room. UM #2 said all of the Resident's liquids should be provided in the Provale cup, as care planned, that the Resident had not been refusing the specialized cup, and that if there were none available on the unit, staff could call the Dietary Department to get more. During a follow-up interview on 6/8/23 at 10:41 A.M., the SLP said she re-evaluated Resident #4 and that he/she was back to old habits of shoveling food and not taking time to chew/swallow his/her food. The SLP said once the Resident was given verbal cues, he/she did not have any issues and that facility staff needed to provide supervision and cues to slow him/her down while eating. 2. For Resident's #10 and #18, the facility staff failed to ensure the Physician's Orders were implemented on when to hold a blood pressure medication for administration relative to specific parameters. a) Resident #10 was admitted to the facility in December 2021 with diagnoses including Cerebral Infarction (Stroke) and Hypertension (HTN - high blood pressure). Review of the Physician's Orders, dated April 2023 through June 2023 included the following: -Metoprolol Tartrate (medication to treat high blood pressure) 25 milligrams (mg), give two tablets twice daily for Hypertension. -Hold if Systolic (phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) Blood Pressure (BP) is less then 100 or heart rate (HR) is less then 60. -Lisinopril (medication to treat high blood pressure) 20 mg, give one tablet in the evening for Hypertension. -Hold for Systolic BP less then 100 or HR less then 60. Review of the April 2023 MAR indicated the following: -on 4/7/23 Metoprolol which was scheduled at 6:00 A.M. was documented as administered when the Resident's Systolic BP was 95 (parameter indicated to hold was if less than 100) Review of the May 2023 MAR indicated the following: -on 5/31/23 Metoprolol scheduled at 5:00 P.M. was documented as administered when the Resident's Systolic BP was 92. Review of the June 2023 MAR indicated the following: - on 6/2/23 Metoprolol and Lisinopril scheduled at 5:00 P.M. and 6:00 P.M., respectively, was documented as administered when the Resident's Systolic BP was 90. On 6/8/23 at 9:59 A.M., UM #2 reviewed the Resident's clinical record with the surveyor. UM #2 said that the Resident's blood pressure medication Metoprolol was administered and should have been held on 4/7/23, 5/31/23 and 6/2/23. She further said that Lisinopril was administered and should also have been held on 6/2/23. b) Resident #18 was admitted the the facility in April 2022 with diagnoses including Hypertension and Chronic Kidney Disease. Review of the Physician's Orders from April 2023 through June 2023 included the following: -Metoprolol 25 mg, give 0.5 tablet twice daily for Hypertension. -Hold if Systolic BP is less then or equal to 100, hold if Diastolic (phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood) BP is less then or equal to 60 and hold if HR is less then or equal to 60. Review of the April 2023 MAR indicated the following dates and times when Metoprolol was administered: -4/2/23 at 9:00 P.M., the Resident's HR was 60, -4/3/23 at 9:00 A.M., the Resident's HR was 60, -4/11/23 at 9:00 A.M., the Resident's Diastolic BP was 60 -4/12/23 at 9:00 A.M., the Resident's Diastolic BP was 55 -4/22/23 at 9:00 A.M., the Resident's Diastolic BP was 60 -4/23/23 at 9:00 P.M., the Resident's Diastolic BP was 55 -4/27/23 at 9:00 P.M., the Resident's Diastolic BP was 58 Review of the May 2023 MAR indicated the following dates and times Metoprolol was administered: -5/11/23 at 9:00 A.M., the Resident's Systolic BP was 92 -5/17/23 at 9:00 A.M., the Resident's Diastolic BP was 55 -5/4/23 at 9:00 P.M., the Resident's Systolic BP was 93 -5/7/23 at 9:00 P.M., the Resident's Diastolic BP was 58 -5/10/23 at 9:00 P.M., the Resident's Diastolic BP was 57 -5/11/23 at 9:00 P.M., the Resident's Diastolic BP was 51 -5/16/23 at 9:00 P.M., the Resident's Diastolic BP was 53 -5/17/23 at 9:00 A.M., the Resident's Diastolic BP was 55 -5/18/23 at 9:00 P.M., the Resident's Diastolic BP was 59 -5/20/23 at 9:00 P.M., the Resident's Diastolic BP was 58 Review of the June 2023 MAR indicated the following dates and times Metoprolol was administered: -6/2/23 at 9:00 A.M., the Resident's Systolic BP was 98 and his/her Diastolic BP was 55 -6/4/23 at 9:00 A.M., the Resident's Systolic BP was 98 and his/her Diastolic BP was 59 -6/6/23 at 9:00 A.M., the Resident's Diastolic BP was 60 On 6/8/23 at 10:07 A.M., UM #2 reviewed the Resident's MARs for April 2023 through June 2023 with the surveyor. She said the Metoprolol was administered on the reviewed dates/times and should have been held according to the parameters within the Physician's orders. She further said if the Resident had a low blood pressure or heart rate and the medication was administered, the blood pressure and/or heart rate could drop even lower which could be concerning. 3. For Resident #75 the facility failed to ensure that foot rests on the wheelchair were used during transport only. Resident #75 was admitted to the facility in September 2022 with a diagnosis including Alzheimer's Disease. Review of an incident report dated 6/2/23, indicated the Resident sustained an unwitnessed fall in his/her room. The Resident was found on the floor with his/her right leg caught up in the leg rests. Further review indicated, under the section for supervisor evaluation and follow-up- the Resident had a fall related to the foot rests on the wheelchair. The Resident was attempting to get up and tripped on the foot rest. Plan was to use the foot rests when transporting the Resident in the wheelchair. Review of the Resident's care plan for falls, with goal date of 6/20/23, indicated the following intervention: -No foot rests on the wheelchair unless transporting the Resident. On 6/6/23 at 3:42 P.M., the surveyor observed the Resident in his/her room, seated in a wheelchair with bilateral foot rests. On 6/7/23 at 9:05 A.M., the surveyor observed the Resident in the dining room, seated in a wheelchair with bilateral foot rests. On 6/7/23 at 2:42 P.M., the surveyor observed the Resident in the dining room, seated in a wheelchair with bilateral foot rests. During an interview on 6/7/23 at 3:43 P.M., Unit Manager (UM) #1 said the Resident was supposed to have wheelchair foot rests on only during transport. UM #1 looked at Resident #75, who was still in the dining room, seated in a wheelchair with bilateral foot rests. UM #1 said Resident #75 should not have the foot rests on and that she did not know the Resident had them on the last two days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #4, the facility failed to ensure its staff obtained laboratory services as ordered by the Physician. Resident #4 was admitted to the facility in [DATE] with diagnoses including Type II Diabetes (DM II) and Fatty Liver. Review of the [DATE] Physician's Orders indicated the following: -obtain Liver Function Tests (LFTs) every six months (every April and October) -obtain HgbA1c (blood test to assess average blood sugar levels over the past three months) every three months (every January, April, July, October) Review of the Resident's clinical record indicated the the Resident's HgbA1c was last obtained in [DATE]. There was no further documented evidence that the HgbA1c level was drawn after that date (scheduled in January and [DATE]). Further review of the clinical record indicated there was no documented evidence that LFT's were obtained as ordered by the Physician. On [DATE] at 9:29 A.M., the surveyor reviewed Resident #4's clinical record with Unit Manager (UM) #2. UM #2 said that the ordered lab work for obtaining the HgbA1c was last completed in [DATE] and should have been obtained in January and [DATE] but was missed. She further said the LFTS were last completed in [DATE] and should have been completed in [DATE] and [DATE]. UM #2 said when there was a Physician's Order for scheduled lab work, the process included submitting these orders to the laboratory for scheduled lab work to be completed as ordered and this did not appear to have been done. Based on record review and interview, the facility failed to report out of range laboratory values to the Physician for Resident (#75), and to obtain Physician ordered laboratory services for one Resident (#4), out of a total sample of 19 residents. Specifically 1. For Resident #75, the facility failed to ensure its staff reported an out of range Valproic Acid level of 40 micrograms per milliliter (ug/ml), [normal range is 50-100 ug/ml], and 2. For Resident #4 the facility failed to provide Physician ordered laboratory services for liver function tests (LFTs- a test to help diagnose and monitor liver disease or damage) and Hemoglobin A1c (a test that measures the average blood sugar levels over the past three months) tests. Findings include: 1. Resident #75 was admitted to the facility in [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder and anxiety disorder. Review of the Valproic Acid (level of Valproic acid in the blood when taking Depakote- a medication used as a mood stabilizer; a low level indicates the medication is ineffective and a high level indicates toxicity) laboratory test, dated [DATE], indicated a result of 30 ug/ml (out of reference range). Review of a Physician's order, dated [DATE], indicated to increase the Depakote to 500 milligrams (mg) twice a day for seven days and check the Valproic Acid level on [DATE]. Review of the Valproic Acid laboratory test, dated [DATE], indicated a result of 42 ug/ml (out of reference range). Review of the clinical record indicated no evidence that the Physician was notified of the laboratory result on [DATE]. Review of the Physician's orders indicated no new order for Depakote was obtained on [DATE]. Review of the [DATE] Medication Administration Record (MAR) indicated the Resident was administered Depakote 500 mg by mouth twice a day from [DATE] through [DATE]. During an interview on [DATE] at 4:20 P.M., Unit Manager (UM) #1 reviewed the clinical record with the surveyor and said the Physician should have been notified of the laboratory result on [DATE] and a new order for Depakote should have been obtained since the original order was only good for seven days (expired on [DATE]).

Based on observations, interviews and record review, the facility failed to maintain complete and accurate medical records for one Resident (#10), out of a total sample of 19 Residents. Specifically, the facility staff failed to ensure: a) Residuals (amount of liquid drained from the stomach following administration of enteral feeding [a form of nutrition that is delivered into the digestive system as a liquid via a feeding tube]) were documented in the clinical record. b) The order to obtain residuals was discontinued when the Resident transitioned to taking all meals by mouth. Findings include: Resident #10 was admitted to the facility in December 2021 with diagnoses including Cerebral Infarction (stroke), Dysphagia and Gastrostomy (G-tube: a feeding tube surgically inserted through the abdomen and into the stomach to deliver liquid food/fluids/medications). Review of the MDS Assessment, dated 2/6/23, indicated Resident #10 was severely cognitively impaired as obtained from staff interview, was dependent on staff with eating, and had a feeding tube which provided greater then 51% caloric needs and greater then 501 cubic centimeters (cc's) of fluids daily. Review of the Physician's Orders, dated January 2023 through June 2023, included the following: -check G-tube residual volumes, hold for residual of 30 cc's or greater for one hour. If the residual remains greater then 30 ccs, call the Provider for further directions (initiated 8/19/22). Further review of the Physician's Orders indicated G-tube feedings were discontinued on 4/13/23 and the Resident was on a modified consistency diet, all meals with the assistance from staff. Review of the Resident's Medication Administration Record (MAR) and Treatment Administration Records (TAR) from January 2023 through June 2023 indicated no documented evidence that residuals were obtained. On 6/7/23 at 8:42 A.M., the surveyor observed CNA #7 assisting Resident #10 with the breakfast meal. During an interview at that time, CNA #7 said the Resident was doing well with eating by mouth and was currently off the G-tube feedings. On 6/7/23 at 12:22 P.M., the surveyor observed Nurse #2 assisting Resident #10 with the lunch meal. Nurse #2 said Resident #10 was doing well with eating by mouth. When the surveyor inquired about the residual checks for Resident #10, Nurse #2 said that he was still checking them. On 6/7/23 at 3:08 P.M., Nurse #2 reviewed Resident #10's clinical record with the surveyor. He said that he checked G-tube residuals whenever he was administering medications or fluids to the Resident. When asked, Nurse #2 said that he was not sure if there were parameters when checking the Resident's G-tube residuals but upon reviewing the Physician's order said there were parameters indicated. Nurse #2 further said that there was no place to document the amount obtained when checking the Resident's residuals because the order was entered incorrectly so there was no designation on where this information should be documented (MAR or TAR). He further said that he checks the residuals but does not document the amounts obtained. On 6/8/23 at 9:49 A.M., UM #2 reviewed the clinical record with the surveyor. UM #2 said she spoke with the Provider who discontinued the residual checks because Resident #10 was no longer receiving feedings through the G-tube. She further said that when the Resident was receiving G-tube feedings, the residuals should have been checked and the amount obtained documented within the MAR or TAR. UM #2 said that the order was entered incorrectly so the amounts obtained from the residual checks were not documented and should have been.

Based on observations and interview, the facility failed to ensure provided meals were palatable and of appropriate temperatures on two (Village Unit and Courtyard Unit), out of the two units observed. Findings include: During the initial pool process on 6/6/23 the survey team identified the following meal concerns: -Cold food -Bland food -Overcooked food 1. On 6/7/23 at 11:53 A.M., the surveyor observed the steam table arrive on Village Unit for lunch service. On 6/7/23 at 12:01 P.M., the surveyor observed the start of lunch trays being served to the residents in the Village dining room. On 6/7/23 at 12:32 P.M., the final meal had been delivered and the surveyor obtained the following temperatures and palatability with Activities Assistant #1: -pureed mac and cheese: 99 degrees Fahrenheit (F) tasted lukewarm, not hot, bland, with a runny consistency -pureed mixed vegetables:100 degrees (F), tasted lukewarm, not hot, bland, with a runny consistency -pureed stuffed peppers: 100 degrees (F), tasted lukewarm, not hot, with a runny consistency -regular consistency mixed vegetables: 98 degrees (F), tasted lukewarm and bland 2. On 6/7/23 at 11:59 A.M., the surveyor observed the steam table arrive on Courtyard Unit for lunch service. On 6/7/23 at 12:04 P.M., the surveyor observed the start of lunch trays being served to the residents in the Courtyard Dining Room. On 6/7/23 at 12:44 P.M., a test tray was conducted and the following temperatures obtained with Dietary Aide #2: -regular texture stuffed pepper: 121 degrees F, tasted lukewarm -ground mixed vegetables: 120 degrees F, tasted lukewarm -puree carrots: 115 degrees F, tasted cold -pureed mac and cheese: 100 degrees F, tasted lukewarm and had a runny consistency -strawberry mousse: 50 degrees F, tasted greasy, oily, and strong artificial strawberry flavor During an interview on 6/7/23 at 1:00 P.M., Dietary Staff #2 said that there were times that the resident meal trays were sitting on the service counter waiting to be distributed by staff. Dietary Aide #2 further said the plates were not warmed and the covers for the plate allowed for venting which did not help with keeping the food warm. On 6/8/23 at 11:57 A.M., the surveyor reviewed the dining observations from lunch on 6/7/23 from the Village and Courtyard Units, and the obtained temperatures during the test trays with the Food Service Director (FSD). The FSD said that the temperatures of the food were usually taken prior to leaving the kitchen when the food was put into the steamtable. She further said the ideal temperatures for the hot items would be around 145 degrees F. The FSD said that hot food temperatures of 98 to 120's were not acceptable and that those temperatures were concerning. She further said that the pureed food consistency should hold its shape, like uncooked muffin mix, and should not be runny/liquidy and spreading across the plate when served.

Based on observations, policy reviews and interviews, the facility failed to ensure its staff adhered to Infection Control policies/practices by encouraging social distancing and mask wearing for residents who were negative for COVID-19 infection and who were in close contact with symptomatic COVID-19 positive Residents (#18 and #23). The facility also failed to ensure appropriate donning (putting on) and doffing (removing), use of personal protective equipment (PPE), conduct testing by staff in a manner to minimize the spread of COVID-19 infection during an active outbreak on two of three units observed. Findings include: Review of the facility policy titled Protective Attire Technique, revised 2022, indicated that employees wear appropriate protective attire when providing care to residents in isolation. The policy also included the following: -Order of protective attire application and removal: Application: 1. gown 2. mask/eyewear/face shield 3. gloves Removal: 1. gloves 2. gown 3. mask/eyewear/face shield Review of the facility policy titled Corona Virus (COVID-19) Transmission Precautions, revised 4/2023, indicated in order to prevent transmission of COVID-19 to others . a plan will be implemented to ensure minimal risk of exposure and further positive cases. -Masks will be worn as indicated by facility protocol or guidance at the time of entry if indicated as determined by COVID-19 cases in the facility. -Eye protection is worn as indicated by facility protocol and or guidance at the time of entry if indicated as determined by COVID-19 cases in the facility. The policy also included the following: -COVID-19 is primarily transmitted from person to person via respiratory droplets, produced when an infected person coughs or sneezes. The virus spreads between people who are in close contact with one another, i.e. within 6 feet of each other for more then 15 minutes. It is possible that a person with COVID-19 can transmit this through surfaces or objects, by touching these objects and then touching their own mouth, nose or possibly their eyes, and could potentially transmit the virus. Review of the Massachusetts Department of Public Health (MA DPH) Memorandum titled Comprehensive PPE Guidance, dated 5/5/23, included the following PPE requirements for staff when caring for patients with suspected or confirmed COVID-19: -DPH recommends that a fit-tested N95 filtering face-piece respirator or alternative and eye protection be used when caring for patients with suspected or confirmed COVID-19. If there is any contact with potentially infectious material, an isolation gown and gloves should also be used. -Respirators: Proper use of respiratory protection by health care personnel (HCP) requires a comprehensive program (including medical clearance, training, and fit testing) that complies with the Occupational Safety and Health Administration (OSHA) ' s Respiratory Protection Standard. -N95 respirators should always be discarded after doffing, such as when leaving a patient room . -Eye Protection: Disposable eye protection should be discarded when it is removed for any reason; it should not be reused. Reusable eye protection should be cleaned and disinfected when visibly soiled and after removal/doffing. -Isolation Gowns: Gowns should be disposed of or laundered after each patient encounter -Gloves: Gloves should be worn when there is any contact with potentially infectious material. HCP should perform hand hygiene prior to donning and after doffing gloves. Upon entrance to the facility on 6/6/23, the survey team was informed by the receptionist that there was a COVID-19 outbreak on the Courtyard Unit and N95 masks were to be worn at all times while on the Unit. During the initial pool process on the Courtyard Unit, on 6/6/23 at approximately 8:40 A.M., Nurse #4, who worked on Courtyard Unit, informed the surveyor that N95 masks and eye protection (face shield or goggles) were to be worn while on the Courtyard Unit. 1. Resident #18 was admitted to the facility in November 2021. Review of the Minimum Data Set (MDS) Assessment, dated 2/27/23, indicated Resident #18 was severely cognitively intact as evidenced by a Brief Interview of Mental Status Score of 3 out of 15. Review of the clinical record indicated Resident #18 tested positive for COVID-19 infection on 6/4/23 and was placed on Isolation Precautions. On 6/6/23 at 10:29 A.M., the surveyor observed Isolation signage outside of the Resident's room. The Resident was observed inside of the room, was not wearing a mask and was actively coughing. On 6/6/23 at 11:20 A.M. through 11:48 A.M., the surveyor observed Resident #18 self-propelling in a wheelchair through the common areas of the Courtyard Unit and into the common area where other residents were seated. Resident # 18 refused to wear a face mask despite attempts from staff to apply, and refused to leave the common area where an activity was occurring and other residents were positioned. The surveyor observed seven residents seated in the common area with the Activities Aide. Some residents did not have face masks in place and some had face masks that was not worn appropriately (did not cover the mouth and/or nose). The Activities Aide, was wearing an N95 mask, and did not have protective eyewear in place. The surveyor observed Resident #18 approach the Activities Aide and several other residents during the observation and attempted to converse with the other residents who did not have face masks on or face masks that covered their mouth/nose. During the observation, the surveyor did not observe facility staff assist the other residents with distancing away from Resident #18, attempt to engage Resident #18 in any individual activity, or assist with appropriate mask wearing of the residents who were in the common area near Resident #18. During an interview on 6/6/23 at 11:48 A.M., Certified Nurse Aide (CNA) #8 said Resident #18 refuses to wear a face mask and refuses to stay in his/her room. When asked by the surveyor how the facility staff are keeping the other residents on the Unit safe from COVID-19 exposure, CNA #8 said that they encourage and assist residents with wearing face masks. When the surveyor asked about the residents in the common area with Resident #18 who were not wearing a face mask or wearing the face masks appropriately, CNA #8 said that she would assist the residents with appropriate mask wearing. On 6/6/23 at 3:56 P.M. through 4:00 P.M., the surveyor observed Resident #18 in the common area with four residents watching a television program. Resident #18 did not have face mask in place and the four residents seated near him/her had surgical masks that were not worn appropriately (not covering the mouth and/or nose). Resident #18 was actively coughing and within close proximity of the four other residents. A CNA was observed monitoring the activity and did not provide education to Resident #18 to cover his/her nose/mouth when coughing, did not offer him/her a face mask or attempt to reposition other residents away from him/her, or assist the other residents with appropriate face mask wearing. 2. Resident #23 was admitted to the facility in July 2018. Review of the clinical record indicated the Resident tested positive for COVID-19 infection on 5/31/23 and was placed on Isolation precautions. On 6/6/23 at 9:37 A.M., the surveyor observed Isolation signage and a PPE bin outside of Resident #23's room. CNA #9 entered the room wearing an N95 mask, eye protection, gown and gloves in place. CNA #9 assisted setting up the Resident's breakfast tray and assisted with making his/her bed. Shortly after, the surveyor observed CNA #9 remove her gown and gloves and exit the room. The surveyor did not observe CNA conduct hand hygiene upon exiting the room, nor did CNA #9 remove her N95 mask or discard or disinfect her eye protection. During an interview immediately following the observation, CNA #9 said that Resident #23 was on Isolation precautions because he/she was positive for COVID-19 infection. She said that prior to entering the room, staff were to wear an N95 mask, gown, gloves and eye protection. She further said when exiting the room, staff were to remove their gown and gloves but did not need to remove their N95 mask or eye protection. 3. On 6/6/23 at 8:33 A.M., the surveyor observed breakfast service on the Courtyard Unit where numerous residents were seated. The Dietary Aide, who was serving the breakfast meal, had a surgical face mask in place and did not have an N95 mask and eye protection on. The surveyor observed CNA #4, who was serving breakfast meals to the residents, wear only an N95 mask and did not have eye protection in place. On 6/6/23 at 4:20 P.M., the surveyor observed a Dietary Aide in the common area near the Unit refrigerator. He had a surgical mask on, not an N95 mask, and did not have eye protection on. Resident #18, who was COVID-19 positive, was in the common area near the Unit refrigerator. 4. On 6/6/23 from 1:14 P.M. through 1:45 P.M., the surveyor observed Housekeeping Staff #1 enter resident rooms who were identified as COVID-19 positive. The residents' rooms were observed to have Isolation Precaution signage posted outside of the room indicating that staff had to complete the following: - conduct hand hygiene prior to entering and upon exiting room - don a N95 mask, eye protection, gown and gloves prior to entering the room The surveyor observed Housekeeping Staff #1 donn an N95 mask, gown, gloves and eye protection in place prior to entering the first COVID-19 positive room and exit shortly after, without doffing the N95 mask and eye protection. The surveyor observed Housekeeping Staff #1 continue to enter the remaining COVID-19 positive rooms and prior to exiting, was observed to remove only her gown and gloves, and did not remove her N95 mask nor remove or disinfect her eye protection. After exiting the last room, the surveyor observed Housekeeping Staff #1 doff her gown and gloves, conduct hand hygiene and walk down the hallway where other residents/staff were located with her cart. During an interview on 6/6/23 at 1:50 P.M., Housekeeping Staff #1 said that she cleans the rooms of residents who are on Isolation Precautions at the end of her shift. She said that she does not change her N95 mask nor clean/disinfect her eye protection after exiting these rooms, but will change her N95 mask and discard her eye protection at the end of her shift after these rooms are completed. On 6/6/23 at 4:32 P.M., the surveyor relayed the observations from the Courtyard Unit with the Director of Nurses (DON), the Infection Preventionist (IP) and the [NAME] President (VP) of Clinical Operations. The VP of Clinical Operations said the COVID-19 outbreak started on 5/30/23 and outbreak testing identified additional staff and residents who were positive. She said when caring for a resident who was on Isolation Precautions, an N95 mask, eye protection, gown and gloves are to be worn. She said when exiting the Isolation room, all PPE was to be disposed of, hand hygiene conducted and a new N95 mask and eye protection donned. The VP of Clinical Operations said there was no shortage of PPE, but if facility staff are using reusable eye protection, like goggles, they were to disinfect them immediately upon exiting the Isolation room. She further said that communication was sent to facility staff on the PPE expectations on the Unit, and that all department managers like Maintenance, Rehabilitation, Dietary and Activities were also notified of what the PPE expectations were on the Unit due to the COVID-19 outbreak. The VP of Clinical Operations said that when staff were on the Courtyard Unit and not caring for the residents who are on Isolation precautions, they were to wear N95 mask and eye protection and were to encourage all residents to wear face masks and encourage social distancing (remaining six feet apart). 5. On 6/7/23 at 3:22 P.M., the surveyor observed multiple Nurses and CNAs enter the Courtyard Unit for the 3:00 P.M. to 11:00 P.M. shift and congregate near the nurse's station. The Nurses and the CNAs were observed to conduct COVID-19 testing via rapid testing method at the nurse's station where other staff and residents were observed. The surveyor observed the staff being tested lower their N95 masks to obtain a nasal swab sample, insert the sample into the test kit and reposition their masks over their noses. The test kits with pending COVID-19 tests were observed to be placed on the desk of the nursing station while the staff waited for results. An unmasked resident was observed self-propelling around and behind the nurse's station during this observation. On 6/8/23 at 12:46 P.M., the surveyor reviewed the facility education and outbreak plan with the VP of Clinical Operations, the IP, the DON, and the Administrator. The VP of Clinical Operations said after the outbreak occurred, facility staff were educated on 5/31/23 on Isolation precautions, appropriate donning and doffing, outbreak testing schedule, importance handwashing and encouraging residents on the Courtyard Unit to remain six feet apart and wear surgical masks, and for staff to wear N95 masks while on the Unit. Review of the education provided indicated the Courtyard Unit also received education by Unit Manager (UM) #2 on what to do when a resident who was on Isolation precautions refused to remain in their rooms and included keeping other residents at least six feet apart, encouraging all residents to wear face masks, engaging the resident on isolation in an activity that they could do on their own, and clean/disinfect the area after they leave. The VP of Clinical Operations said that on 6/4/23, the staff identified that Resident #18, who was symptomatic, did not comply with the Isolation precautions, and at that time, the Courtyard Unit instituted N95 masks and protective eyewear for all staff, which included Rehabilitation, Dietary, Activities and Maintenance staff, when on the unit. She further said that the facility staff were educated on the process for conducting rapid testing for COVID-19 and that when facility staff were conducting the test, they should be in an office space away from other staff/residents. She further said that the COVID-19 testing should not be conducted on the Unit at the Nurse's station. 6. On 6/6/23 the surveyor observed CNA #1, on the Hillside Unit, with no face mask on (required, as the facility was in an active COVID-19 outbreak) from 4:20 P.M. through 5:00 P.M. The surveyor observed CNA #1 interacting with several residents during this time. During an interview on 6/6/23 at 5:04 P.M., CNA #1 said she would like to be able to wear a mask but she could not because she had a hard time breathing and the masks made her tired.