Based on record and policy review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review Level I (PASRR-screening that assesses for Serious Mental Illness or Developmental Disabilities [Level I screen (initial pre-screening completed prior to admission to a Nursing Facility]) was completed prior to admission for one Resident (#107) out of a total sample of 26 residents. Specifically, for Resident #107, the facility failed to ensure that a Level I screen was completed prior to the Resident's admission to the facility to assist in determining the level of services needed. Findings include: Review of the facility policy titled PASRR Screening for Admission/Readmission, last revised 7/29/24, indicated: -that prior to admission, the facility will complete a Level I PASRR to evaluate for the presence of a mental disorder or intellectual disability. Resident #107 was admitted to the facility in July 2024, with diagnoses including Post Traumatic Stress Disorder (PTSD- a mental health condition that is caused by an extremely stressful or terrifying event - either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). Review of Resident #107's medical record failed to indicate a Level I PASRR had been completed prior to admission to the facility. Further review of the medical record indicated that the Level I had been completed on 8/15/24, after the Resident's admission to the facility. During an interview on 10/8/24 at 3:46 P.M., the Director of Nursing (DON) said that Resident #107's Level I PASRR had been completed late and should have been completed prior to the Resident's admission to the facility.

Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections within the facility on one Unit (Fourth Floor) out of three total Units. Specifically, the facility failed to: 1) clean and disinfect a glucometer (device used to test sugar level in the blood) after resident use to prevent potential contamination and potential transmission of blood-borne disease. 2) ensure wound care supplies brought into a resident room were designated for use on that resident and stored in that resident's room to prevent potential cross-contamination. Findings include: 1) Review of the facility policy titled Glucometer Cleaning, revised 5/2/24, indicated the following: -Blood glucose meters (glucometer) . must be cleaned and disinfected after each patient/resident use. -Per OSHA [Occupational Safety and Health Administration] and manufacturer's guidelines, and EPA [Environmental Protection Agency] approved disinfectant, effective against HBV (Hepatitis B Virus-a virus that can cause infection of and damage to the liver), HCV (Hepatitis C Virus- a virus that can cause infection of and damage to the liver, and HIV (Human Immunodeficiency Virus-a virus that can cause weakening of the bodies ability to fight infection and illness) is used on glucometers. PDI wipes (a specific brand of disinfectant wipes) meet this requirement. On 10/8/24 at 3:45 P.M., during a medication pass process on the Fourth Floor Unit, the surveyor observed Nurse #1 take a cloth glucometer storage bag containing a glucometer, lancets (device used to pierce skin to obtain blood sample for glucometer), alcohol prep pads (used to clean/disinfect the finger used for before lancet), and test strips (inserted to glucometer to obtain blood) and bring the items into a resident room. Nurse #1 was observed to set the storage bag on the resident's bed next to the resident. The surveyor then observed Nurse #1 take supplies out of the bag, perform the blood test, and then return the glucometer to the storage bag, zip the bag and return it to the medication cart. The surveyor did not observe Nurse #1 disinfect the glucometer before placing it into the storage bag. During an interview immediately following the observation, Nurse #1 said the glucometer was used for all residents on her assignment. Nurse #1 further said she should not have placed the cloth storage bag on the bed or placed the glucometer back into the bag without cleaning and disinfecting the glucometer with PDI wipes due to the risk for cross-contamination. During an interview on 10/9/24 at 12:41 P.M., the surveyor reviewed Nurse #1's observation with the Infection Control Preventionist (ICP). The ICP said the expectation would be that Nurse #1 should not have brought the cloth storage bag into the resident room or set it on the resident's bed to prevent cross-contamination. The ICP also said that Nurse #1 should have cleaned and disinfected the glucometer per facility policy before placing the glucometer back into the storage bag to prevent cross-contamination. 2) Review of the facility policy titled Wound Care: Assessment and Documentation of Wounds, revised 7/1/24, indicated the following: -any leftover supplies that have been brought into the room, should be labeled with open date and left in [the] room, -do not place [supplies] back into treatment cart. On 10/9/24 at 10:08 A.M., during a wound care observation on the Fourth Floor Unit, the surveyor observed the Staff Development Coordinator (SDC)/Wound Nurse use a bottle of wound cleanser (a solution used to clean wounds) and then place the bottle of wound cleanser on the resident's bed. After completion of the wound care, the surveyor observed the SDC/Wound Nurse take the bottle of wound cleanser and place it into the treatment cart. During an interview immediately following the observation, the SDC/Wound Nurse said she should not have placed the bottle of wound cleanser on the resident's bed and then return it to the treatment cart due to concern for cross-contamination. During an interview on 10/9/24 at 12:38 P.M., the ICP said the expectation was that the SDC/Wound Nurse would not place a shared wound care supply onto the resident's bed. The ICP further said, if the wound care supply was placed in the resident's room and/or bed, that it should have been labeled and left in the resident's room per facility policy to prevent cross-contamination.

Based on observations, policy review, and interviews, the facility failed to provide a dignified dining experience for one Resident (#14) out of a total sample of 26 residents. Specifically, staff stood over the Resident while feeding meals, rather than sitting at eye level. Findings include: Review of the facility policy for Feeding Assistance, last revised 12/14/22, indicated that staff assisting residents will sit in close proximity to those they are helping and engage the resident in the mealtime task. Resident #14 was admitted to the facility in August 2012 with diagnoses including Dementia (a group of symptoms that effects memory, thinking and interferes with daily life) and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 4/19/23, indicated that Resident #14 was assessed by staff to have a severe cognitive impairment and was rarely/never understood. Further review of the MDS indicated that the Resident was totally dependent for feeding tasks. On 7/18/23 at 9:48 A.M., the surveyor observed Nurse #1 feeding Resident #14 breakfast. The Nurse was standing over Resident #14 while feeding him/her breakfast and was not at eye level with the Resident. On 7/19/23 at 9:31 A.M., the surveyor observed Nurse #1 feeding Resident #14 breakfast. The Nurse was standing over Resident #14 while feeding him/her breakfast and was not at eye level with the Resident. During an interview on 7/19/23 at 9:33 A.M., Nurse #1 said that she had been standing over Resident #14 while feeding him/her. During an interview on 7/19/23 at 9:52 A.M., the Director of Nurses (DON) said that the staff member should have been sitting down while feeding the Resident and not standing.

Based on interview and record review, the facility failed to refer two Residents (#81 and #110) out of three applicable residents, in a total sample of 26 residents for a Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen for Mental Illness (MI), intellectual disability, or related condition in order to determine if they require specialized services) Preadmission Screening and Resident Review (PASRR). Specifically, the facility staff failed to refer both Residents for a Level II evaluation for: 1. Resident #81 who was identified post admission to have a diagnosis of MI and had limitations in major life activities due to MI within the last six months of his/her admission to the facility. 2. Resident #110 who required an inpatient Psychiatric hospitalization. Findings include: 1. Resident #81 was admitted to the facility in June 2020. Review of Resident #81's Level 1 Preadmission Screening and Resident Review (PASRR- an evaluation to determine if a Resident has MI or Intellectual or Developmental Disability (ID/DD) and needs an additional Level II evaluation), dated 6/5/20, indicated that Resident #81 did not have a diagnosis of MI. Review of the Physician's Progress Note, dated 2/8/23, indicated that Resident #81 had a diagnosis of Paranoid Schizophrenia present on admission to the facility. Further review of the Physician's Progress Note, dated 4/3/23, revealed that the Resident had been hospitalized prior to his/her admission to the facility due to a diagnosis of failure to thrive (FTT- a decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability) after the death of his/her mother. Further review of the clinical record did not indicate that the Level I evaluation had been updated and resubmitted as required, after it had been identified that the Resident had a diagnosis of MI and had limitations in major life activities present on admission. During an interview on 7/20/23 at 1:01 P.M., Social Worker #2 said that the facility Social Workers should have updated and submitted the Level I evaluation to the Department of Mental Health (DMH) PASRR office once it had been determined that the Resident had a pre-existing mental health diagnosis as required, and it had not been. 2. Resident #110 was admitted to the facility in April 2023. Review of the clinical record indicated that Resident #110 had been transferred to a Psychiatric hospital on 6/16/23 for behaviors. Further review of the clinical record did not indicate that the Level I evaluation had been updated and resubmitted as required, after it had been identified that the Resident had been admitted for an inpatient Psychiatric hospitalization. During an interview on 7/20/23 at 1:01 P.M., Social Worker #2 said that a Level II PASRR evaluation should have been obtained by the facility Social Workers from the DMH PASSR office after the resident's change in condition prompting Psychiatric hospitalization as required, and it had not been.

Based on record review and interview, the facility failed to develop a baseline care plan for one Resident (#423) out of a total sample of 26 residents. Specifically, facility staff failed to develop a baseline care plan for Resident #423 as required, and did not develop a comprehensive care plan in its place within 48 hours of the Resident's admission to the facility. Findings include: Review of the facility policy for Baseline Care Plans, revised October 2022, indicated the facility developed baseline plan care plans within 48 hours of resident admissions to promote continuity of care and communication across disciplines. Resident #423 was admitted to the facility in May 2023 with diagnoses including Diabetes Type II and Myocardial Infarction (heart attack). Review of Resident #423's clinical record did not include any evidence that a baseline care plan had been developed for the Resident within 48 hours of his/her admission to the facility, or that a comprehensive care plan had been developed in place of the baseline care plan as required. During an interview on 7/20/23 at 4:00 P.M., Nurse #2 said baseline care plans were to be completed by the admitting Nurse. Nurse #2 reviewed Resident #423's clinical record with the surveyor and said no baseline care plan had been completed as required, but it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide an indwelling Foley/urinary catheter (a tube placed through the urethra into the bladder to drain urine) care, per professional standards of practice for one Resident (#380) out of a total sample of 26 residents. Specifically, the facility staff failed to obtain Physician's orders and develop a plan of care for the care and management of Resident #380's Foley catheter. Findings include: Resident #380 was admitted to the facility in June 2023 with a diagnosis of Extended Spectrum Beta-Lactamase (ESBL-enzyme found in some strains of bacteria that is resistant to antibiotics) in the urine. Review of the Centers for Disease Control's (CDC) Guidelines For Prevention of Catheter Associated Urinary Tract Infections 2009, reviewed 6/6/2019, indicated to consider implementing a system for documenting the following in the patient record: -indications for catheter insertion -date and time of catheter insertion -individual who inserted catheter -date and time of catheter removal Review of the facility policy titled Foley Catheter Care, revised 12/21/22, indicated: -It is the policy of the Jewish Healthcare Center that indwelling catheters will be clean and cared for according to current infection control standards. -Review Medical Doctor order to include appropriate diagnosis for foley catheter as well as size and balloon size. -Keep catheter drainage system and tubing free from kinks and covered with privacy bag. -Flush Foley catheter per MD orders for occlusion, signs of infection, encrustation. Review of the hospital Patient Care Referral to the facility, dated 6/29/23, indicated Resident #380 had urinary retention (inability to empty all the urine from the bladder) while in the hospital and a Foley catheter was placed on 6/28/23. Review of Resident #380's comprehensive care plan, initiated 6/29/23, did not include any information relative to the care and management of a Foley catheter. Review of the Minimum Data Set (MDS) assessment dated [DATE], Section H, indicated that the Resident had an indwelling urinary catheter. Review of Resident #380's July 2023 Physician's orders did not include any orders for the care and maintenance of the Foley catheter. On 7/18/23 at 4:04 P.M., the surveyor observed the Resident sitting in a chair next to his/her bed. The Resident had an indwelling urinary catheter tube that extended from the bottom of the Resident's pant leg that was connected to a urinary drainage bag. The drainage bag was observed attached to the bed frame. On 7/19/23 at 9:27 A.M., during an observation and interview, the surveyor observed the Resident dressed and lying in bed. There was a urinary catheter tube extending from the bottom of the Resident's pant leg and attached to the bed frame. Resident #380 said the Foley catheter was placed in the hospital before he/she was admitted to the facility. The Resident further said that the Foley catheter had not been changed since his/her admission to the facility. During a record review and interview on 7/19/23 at 10:52 A.M., Nurse #3 said the Resident had no orders for Foley catheter care and management. Nurse #3 further said the Resident should have had Physician's orders for Foley catheter care, including the catheter size and balloon size. During an interview on 7/19/23 at 11:19 A.M., the Director of Nursing (DON) said Resident #380 should have had Physician's orders for the care and management of the Foley catheter, but did not.

Based on observation, record review, and interview, the facility failed to provide care according to professional standards of practice for one Resident (#59) with a Gastrostomy tube (G-tube - also known as a feeding tube: medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) out of three applicable sampled residents, in a total sample of 26 residents. Specifically, facility staff failed to administer enteral (delivery of nutrients through a feeding tube directly into the stomach) feedings according to the Physician orders, monitor and accurately record the amount of enteral feed administered to Resident #59, when the Resident was not allowed to take any nutrition by mouth (NPO), which increased the Resident's risk for reduced nutritional intake. Findings include: Resident #59 was admitted to the facility in December 2018 with diagnoses including anoxic (lack of oxygen) brain damage, Dysphagia (swallowing difficulty), and Gastrostomy status. Review of the facility's policy, titled Enteral Nutritional Therapy: Tube Feeding, revised 10/16/22, included: - It is the facility's policy to provide adequate nutrition via feeding tube when a resident is unable to take oral nutrition. - The amount of enteral feed administered was to be documented. Review of Resident #59's Nutrition Care Plan, initiated 7/1/21 and revised 2/9/23, included: - The Resident required 100% nutrition support related to Dysphagia, swallowing problem due to anoxic brain injury. - The Resident was at risk for malnutrition. - The Resident was dependent with tube feeding. Further review of the Nutrition Care Plan indicated the current tube feeding prescribed included: Give one liter of Jevity 1.2 Cal (calorically dense tube feeding formula) at 115 cubic centimeters (cc: unit of measurement) per hour (hr) until bottle is empty (up 8:00 P.M.) via G-tube . Review of the July 2023 Physician's orders included an active enteral feed order, initiated 7/21/22, as follows: In the evening give one liter of Jevity 1.2 Cal overnight at 115 cc/hr. Run until bottle is empty. Hang at 8:00 P.M. On 7/18/23 at 11:31 A.M., the surveyor observed a one liter bottle of Jevity 1.2 Cal which hung from the tube feed pole in Resident #59's room. The enteral feed formula bottle tube was not connected to the Resident's G-tube and the bottle had remaining enteral feed formula in it. The front of the bottle indicated it had been hung at 9:00 P.M. on 7/17/23. On 7/19/23 at 10:35 A.M., the surveyor observed a one liter bottle of Jevity 1.2 Cal which hung from the tube feed pole in Resident #59's room. The enteral feed formula bottle tube was not connected to the Resident's G-tube and the Resident was not in the room. The bottle had remaining enteral feed formula in it which the surveyor observed to be between 200 and 250 milliliters (ml [one ml is equivalent to one cc]), per the markings on the side of the bottle. The front of the bottle indicated it had been hung at 9:00 P.M. on 7/18/23. Review of Resident #59's July 2023 Medication Administration Record (MAR) indicated one liter of Jevity 1.2 Cal was administered overnight, starting at 8:00 P.M. on 7/17/23 and 7/18/23, and that the enteral feed formula ran until the bottle was empty. Review of Resident #59's clinical record included no evidence that facility staff monitored and accurately documented the amount of enteral feed formula administered to the Resident on 7/17/23 and 7/18/23, beginning on the evening (3:00 P.M. through 11:00 P.M.) shift and through the overnight shift (11:00 P.M. through 7:00 A.M.). During an interview on 7/19/23 at 10:35 A.M., Nurse #6 said the one liter bottle of Jevity 1.2 Cal was hung on the 7/18/23 evening shift and disconnected on the overnight shift. Nurse #6 then said she did not know why there was remaining enteral feed formula left in the bottle. During an interview on 7/19/23 at 11:34 A.M., Nurse #9 said Resident #59 did not always receive all of his/her enteral feed formula as ordered. Nurse #9 said this happened when the enteral feed formula bottle was hung later than 8:00 P.M. Nurse #9 said no matter what time the enteral feed formula bottle was hung, it had to be removed at 5:30 A.M. because the Resident's responsible party wanted it to be disconnected at that time. During an interview on 7/19/23 at 12:12 P.M., The Unit Manager (UM) said enteral feed pumps stored information relative to how much enteral feed formula was administered to residents. The UM said staff could monitor how much enteral feed formula was administered to residents by reviewing the stored information in the pump. He said in order for the pumps to be accurate, staff would have to clear the previous information stored in the pump before running more feeding. The surveyor and the UM observed Resident #59's enteral feed formula bottle at that time, which was in the Resident's room, dated 7/18/23 and had remaining feed in the bottle. The UM said the remaining enteral feed formula was approximately 250 ml. The UM also said 250 ml was a lot of enteral feed formula for Resident #59 not to receive. The UM then accessed the stored information on the enteral feed pump and said the stored information indicated the Resident had received 1800 ml of enteral feed formula within the last 11 hours, but that this was not accurate and was due to staff not clearing the previously stored information. The UM then said no residents on the Unit were on strict intake and output monitoring, and when asked how staff monitored for accuracy of enteral feed formula administration for Resident #59, he said, that's a good question. The UM further said he was unaware Resident #59 had not received his/her enteral feed as ordered on 7/18/23 and 7/19/23, from the evening shift through the overnight shift until the surveyor's inquiry. During an interview on 7/19/23 at 3:05 P.M., Nurse #8 said she recalled working the overnight shift within the previous two weeks, and that she worked with Resident #59 during that overnight shift but could not recall the exact date. Nurse #8 said she disconnected Resident #59's enteral feeding around 5:50 A.M. so that the Resident could receive incontinent care and medications via his/her G-tube. Nurse #8 said there was remaining enteral feed formula in the bottle, but she did not measure or record the amount left over, as required. Nurse #8 said she did not re-connect the enteral feed to the Resident or run the enteral feed until the bottle was empty. During an interview on 7/19/23 at 4:28 P.M., Nurse #7 said she worked the 11:00 P.M. through 7:00 A.M. (overnight) shift regularly and that Resident #59 was routinely on her assignment. Nurse #7 said she disconnected Resident #59's enteral feed every morning, around 5:30 A.M., when she worked so the Resident could have incontinent care and medications. Nurse #7 said she never reconnected the enteral feed for the Resident after disconnecting it for incontinent care and medications even if there was enteral feed formula left in the bottle. Nurse #7 said she did not record how much enteral feed formula was administered or how much was left over when she disconnected the enteral feed and there was remaining enteral feed formula left in the bottle because she thought the Resident's responsible party reconnected it after medications were administered to the Resident. During an interview on 7/21/23 at 12:45 P.M., the UM said he spoke with Resident #59's Nurse Practitioner (NP) on 7/19/23 once he became aware that the Resident did not always receive his/her ordered amount of enteral feed formula on the overnight shift. The UM said the NP provided no change in enteral feed orders and that the instruction provided by the NP was to ensure enteral feed formula was administered to the Resident as ordered.

Based on observation, record review, and interview, the facility failed to store all drugs in locked compartments, as required, for one Resident (#59) out of a total sample of 26 residents. Specifically, for Resident #59, the facility staff failed to store all drugs in a locked compartment when medications were observed stored in the Resident's room, not locked, and accessible to unauthorized persons. Findings include: Review of the facility's policy, titled Medication Storage in the Facility, dated December 2019, included: - Medications and biologicals are stored safely, securely, and properly . - The medication supply is accessible only to Licensed Nursing personnel, Pharmacy personnel, or staff members lawfully authorized to administer medications. Resident #59 was admitted to the facility in December 2018 with diagnoses including Gastrostomy (G-tube/ feeding tube- medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) status, Dysphagia (swallowing difficulty), Spastic Quadriplegia, and cognitive communication deficit. Review of Resident #59's Activities of Daily Living (ADL) Care Plan, initiated 7/15/21 and revised 11/16/22, indicated the Resident was NPO (nil per os: nothing by mouth). Review of the Minimum Data Set (MDS) assessment, dated 4/26/23, indicated: - Resident #59 was rarely/never understood. - Completion of a staff assessment was required to determine Resident #59's mental status which indicated the Resident was severely cognitively impaired. - Resident #59 was dependent on staff for self care. On 7/19/23 at 10:30 A.M., the surveyor observed the following medications stored, unlocked and accessible to unauthorized personnel, in Resident #59's room: -one bottle of Chlorhexidine Gluconate (prescription) Oral Rinse USP (United States Pharmacopeial - organization that develops and disseminates public compendial quality standards for medicine) 0.12%. -one bottle of Nystatin (prescription to treat fungal infections) Oral Suspension USP 100,000 units per milliliter (ml). -one bottle of Biotene Dry Mouth Oral Rinse lined up on top of the nightstand which was positioned to the left side of the head of the bed. -one 0.5 fluid (fl) ounce (oz) bottle of artificial tears. -one 1.5 fl-oz bottle of Deep Sea Premium Saline Nasal Moisturizing Spray. -one eight fl-oz spray bottle of Hydrogen Peroxide First Aid Antiseptic. -one 15 gram (gm) bottle of Nyamic Nystatin (prescription antifungal medication) Topical Powder 100,000 USP units/gm. -one three oz bottle of Antifungal Powder stored on a rolling bedside table, which was positioned to the right side of the bed, next to the wall. During an interview on 7/19/23 at 10:35 A.M., Nurse #6 said Resident #59 was dependent on staff for self-care and administration of medications. Nurse #6 also said the Resident's responsible party was allowed to administer medications to Resident #59 per order of the Provider and that the medications the surveyor observed had been stored, unsecured, in the Resident's room for as long as she could remember. Nurse #6 said Resident #59 required total assistance from staff at the facility and that the Resident also had private duty personnel, not employed by the facility, who provided one to one services throughout the day and night. Nurse #6 said the medications stored on Resident #59's nightstand and bedside table were accessible to anyone who entered the room and should have been stored in a locked compartment as required, but they were not.

Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety for two of nine applicable unit refrigerators. Specifically, the unit refrigerators on the 3 North Unit and the 3 East Unit contained expired and unlabeled food items. Findings include: Review of the facility policy titled Use & Storage of Foods Brought in by Family & Visitors, revised 5/2021, indicated: -Food that needs refrigeration is stored in a container labeled with the patient's name, date and room number. -Any food unlabeled or beyond day three will be discarded On 7/19/23 at 7:55 A.M., the surveyor observed an open bag of organic pitted prunes with no name, dated 7/9/23, in the 3 East Unit refrigerator. During an interview on 7/19/23 at 8:00 A.M., Dietary Staff #1 told the surveyor that the prunes should have been discarded but they were not. On 7/19/23 at 9:08 A.M., the surveyor observed the following food items in the 3 North Unit refrigerator: -in the freezer, a clear plastic bag containing pieces of waffles and bread dated 7/8/23. -in the freezer, a container of sorbet not dated with white frost covering the container. -in the refrigerator, a white plastic container of cottage cheese with a printed expiration date of 7/11/23 on the bottom. -in the refrigerator, an open cardboard cake box with no date containing a small piece of dried out cut up cake. During an interview on 7/19/23 at 9:12 A.M., Dietary Staff #1 said that the plastic bag with the waffles, sorbet, cottage cheese, and cake should have been removed from the refrigerator and discarded but they were not. She further said that she was aware of the policy to label food properly with a residents name and the date when the item was put into the refrigerator, and then to discard food after it had been in the refrigerator for three days.

Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal immunization per the Centers for Disease Control and Prevention (CDC) recommendations for four Residents (#1, #3, #4, and #5) out of a total sample of five residents. Findings include: Review of the facility policy titled Immunization: Influenza and Pneumonia, last revised 5/11/23, indicated the following: -It is the policy of the Jewish Healthcare Center to offer vaccines to all patients/residents admitted to the facility, and to educate the elderly population regarding the flu and Pneumonia vaccine, stressing the need to build their immune system thru immunization. -Pneumonia to be given when needed. -Pneumonia will be asked annually . Review of the CDC website Pneumococcal Vaccine Timing for Adults (https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf), dated 3/15/23 indicated the following: -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last pneumococcal vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20) . 1. Resident #1 was admitted to the facility in May 2023 and was over the age of 65. Review of the Resident's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated the Resident had received the PCV13 on 2/26/16 and the PPSV23 on 12/4/03. Review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated or offered any additional CDC recommended Pneumococcal Vaccination. 2. Resident #3 was admitted to the facility in March 2020 and was over the age of 65. Review of the Resident's MIIS Vaccine Administration Record indicated the Resident had received the PCV13 on 3/4/16 and the PPSV23 on 11/15/06. Review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated or offered any additional CDC recommended Pneumococcal Vaccination. 3. Resident #4 was admitted to the facility in May 2008 and was over the age of 65. Review of the Resident's immunization section in the electronic medical record (EMR) indicated the Resident had received the PCV13 on 11/21/17 and the PPSV23 on 12/7/07. Review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated or offered any additional CDC recommended Pneumococcal Vaccination. 4. Resident #5 was admitted to the facility in August 2022 and was over the age of 65. Review of the Resident's MIIS Vaccine Administration Record indicated the Resident had received the PCV13 on 3/16/15. Review of the Resident's immunization section in the EMR indicated the Resident had received the PPSV23 on 1/28/97. Further review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated and/or offered any additional CDC recommended Pneumococcal Vaccination. During an interview on 6/13/23 at 11:27 A.M., the Assistant Director of Nursing (ADON) said the facility currently did not have a process in place to educate and offer the Residents and/or Resident Representative's the recommended PCV20. During an interview on 6/13/23 at 12:50 P.M., the Medical Director said the facility had begun talking about rolling out (giving) the PCV20 but had not yet implemented a plan to do so. She further said the facility wanted its residents to be as protected as possible and for immunocompromised residents and those who had not had a Pneumococcal Vaccination in five or more years, she felt those residents could benefit from updated vaccination. She also said when a new recommendation for vaccination comes out, it should be followed up on as soon as possible. During an interview on 6/13/23 at 1:16 P.M., the ADON said at this time Residents #1, #3, #4, and #5 had not been offered education or the opportunity to receive the PCV20 vaccination as recommended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, the facility failed to ensure completed Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion, for two Residents (#2 and #3), out of a total sample of 25 residents. Findings include: Review of the CMS Long-Term Care Facility Assessment Instrument 3.0 User's [NAME], Version 1.17.1, dated October 2019, indicated the following relative to MDS transmittals: -Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Document review indicated the date of completed MDS assessments for the following residents: -Resident #2 had a quarterly MDS assessment completed on 6/30/21 -Resident #3 had a quarterly MDS assessment completed on 6/30/21 During an interview on 09/2/21 at 12:14 P.M., the MDS Nurse said the MDS assessments for the residents listed above were not transmitted timely, and were not submitted to CMS within 14 days after completion, as required.

Based on policy review, record review, observation and interview, the facility failed ensure the plan of care relative to a fall interventions was implemented and followed for one Resident (#25), out of a total sample of 25 residents. Findings include: Review of the facility's Accident Management policy, dated 7/31/93 (and last revised 8/1/21), indicated the following: -A fall risk assessment tool will be completed on all residents upon admission, quarterly, annually and whenever there is a significant change in resident status. -An assessment score of 13 represents high risk for a fall. Interventions to eliminate falls would be considered, put in place and care planned. Resident, staff and family members will be educated regarding patient/resident at risk for falling and the interventions put into place. -Alarms are checked for functioning at the beginning of every shift and signed for by the Certified Nursing Assistant. Resident #25 was admitted to the facility in October 2019 with the following diagnoses: Parkinson's disease, muscle weakness, restless leg syndrome and dementia. Review of a Fall Risk Evaluation, dated 10/10/19, indicated the Resident was a high fall risk as evidenced by a score of 13. Review of the fall care plan, date initiated 10/30/19, indicated the following intervention: -Chair and bed alarms, re-evaluate the need for continued use on an as needed basis. Review of the clinical record indicated the Resident sustained 9 falls without major injury between 10/19/19 and 4/18/21. Review of a Physician's Order, date 6/14/21, indicated: Check function/placement of alarms every shift. Review of a fall report, dated 7/26/21, indicated the Resident sustained an unwitnessed fall in the bedroom at 9:25 A.M. and the alarm was not on the recliner, nor sounding at the time of the fall. Review of the Interdisciplinary Investigation/Post Fall, dated 7/27/21, indicated the Resident fell from his/her recliner. The intervention was to educate staff to ensure the chair alarm is placed in the recliner when out of the wheel chair. On 8/31/21 at 9:58 A.M., the surveyor observed the Resident sitting in a wheel chair in his/her room. The surveyor observed the alarm box attached to the back of the chair and it was turned to the off position. On 9/1/21 at 10:52 A.M., the surveyor observed the Resident sitting in a wheelchair in his/her room. The surveyor observed an alarm box attached to back of the wheel chair and it remained in the off position. On 9/1/21 at 3:59 P.M., the surveyor and Nurse #3 observed the Resident sitting in the wheel chair in his/her room. Nurse #3 said the alarm box attached to the back of the chair was in the off position and should not have been. During an interview on 9/3/21 at 3:30 P.M., the Director of Nurses said the Resident was a high fall risk and had fallen several times. She said the Resident was care planned for bed and chair alarm. She said for the fall that occurred on 7/26/21, the fall plan was not followed, but should have been. She also said the alarm box should have been turned to the on position while in use.

Based on record review, interview and observation, the facility failed to provide podiatry care for one Resident (#67) out of a total sample of 25 residents. Findings include: Resident #67 was admitted to the facility in February 2020 with the following diagnosis: Diabetes Mellitus (DM). During an interview on 9/1/21 at 12:49 P.M., the Resident said he/she had not received podiatry care for as long as he/she could remember. The Resident said especially with my diabetes I should have seen someone. Review of the request for ancillary services form, including podiatry care, indicated the Resident had signed the request on 2/26/20, but did not indicate if he/she wanted to receive podiatry care. Continued record review indicated the Resident had not seen a podiatrist. During an interview on 9/1/21 at 1:55 P.M., Nurse #7 said she found it hard to believe the Resident had not seen a podiatrist, especially because he/she was a diabetic. Nurse #7 looked at the request for ancillary services form and said she could not say if podiatry services had been offered to the Resident because the form was incomplete. On 9/2/21 at 11:15 A.M., the surveyor and Nurse #5 observed the Resident in bed. Nurse #5 removed the sock from the Resident's right foot. The Resident's large toe and second toe had been amputated. The remainder of the toes had extremely long toenails that curled around and touched the bottom side of the toes. Nurse #5 said his/her toenails really needed to be cut.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, policy review, record review and interview, the facility failed to follow Professional Standards of Practice for an indwelling Venous Access Port ([NAME]) (an implanted device placed under the skin on the right chest wall with a tube that leads into the superior vena cava, a large vessel in the heart, and used to access the circulatory system to draw blood for laboratory analysis, and administer fluids and medications for long term therapies), specifically related to site assessment for one Resident (#282), out of a total sample of 25 residents. Findings included: Review of the website: https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf, Guidelines for the Prevention of Intravascular Catheter-Related Infections indicates the following: -The catheter site should be monitored visually on a regular basis for tenderness at the insertion site, fever without obvious source, changes in the catheter site, new discomfort, or other manifestations suggesting local or bloodstream infection. Review of the facility policy titled Venous Access Port ([NAME]) Dressing Change, undated, (Copyright 2012 Resource Nurse Continuing Education, Inc.), indicated: -A [NAME] needle insertion site is a potential entry site for bacteria and should be assessed every two hours during continuous therapy, and the assessment should include absence or presence of erythema (redness of the skin), drainage, swelling, induration (hardening of the soft tissue), skin temperature at site, and any complaint of tenderness. Resident #282 was admitted to the facility in August 2021 with diagnoses including Myelodysplastic Syndrome (a rare group of disorders that cause disruption of blood cell production, also known as pre-Leukemia; a blood cell cancer), and weakness. Review of the Resident record indicated the following Physician's Orders: -Double lumen implanted port ([NAME] with two access ports) on right chest wall, dated 8/19/21 -IV Potassium Chloride 20 mEq (milliequivalents: a measurement) in Normal Saline 0.9% ( a solution of salt and water) at 125 milliliters (ml)/hour via port continuous (total of 60 mEq over 6 hours: three 250 ml bags) every shift for a Potassium of 2.9 (Potassium is a mineral present in the body that helps nerve function and muscle contraction. A normal Potassium level is 3.6-5.2. Low Potassium levels can cause muscle cramping and lead to abnormal heart rhythms), dated 8/25/21. There were no orders related to the assessment, monitoring or flushing of the [NAME]. Review of the Medication Administration Record (MAR), dated August 2021, indicated Resident #282 received the Potassium Chloride infusion as ordered. There were no assessments of the [NAME] site documented on the MAR. Review of the Treatment Administration Record (TAR), dated August 2021, indicated no assessments had been completed for the [NAME] on the 2 days the Resident received the potassium chloride infusions. Review of the Nursing Care Plan, initiated 8/23/21, indicated Resident #282 was at risk for medical complications related to multiple diagnoses and 1 intervention was right implanted port care per policy. Review of the progress notes indicated no assessments were completed related to the implanted port during the Potassium Chloride infusions. During an interview on 9/2/21 at 11:12 A.M., Nurse #9 said that if the [NAME] is accessed it should have a linked assessment on the treatment sheet (TAR) to monitor every shift and it was not there, as required. During a subsequent interview on 9/7/21 at 11:57 A.M., Nurse #9 said, based on the absence of documentation, the site assessment was not done, as required.

Based on observation and interview, the facility failed to ensure emergency drug kits were re-ordered when medications were dispensed from the emergency kits in one out of two medication rooms. Findings include: On 8/31/21 at 4:40 P.M., the surveyor observed the fourth floor medication room with Nurse #1 and the following was observed: - The intravenous (IV) emergency kit was opened; Nurse #1 said when she accessed the kit yesterday (8/30/21), it was already opened. Nurse #1 said she should have faxed the pharmacy to replace it. - The antibiotic kit was opened; Nurse #1 said that she had opened the kit last week and forgot to fax the pharmacy for a replacement. - The emergency glucagon (a solution used for diabetics if their blood sugar becomes low) kit was opened on 8/16/21 and not replaced. Nurse #1 said the kit should have been replaced when opened.

Based on record review and interview, the facility's staff failed to ensure that anti-psychotic medications (a class of medications used to treat mental disorders) used on an as needed (PRN) basis were limited to 14 days, for one Resident (#71), out of a total sample of 25 Residents. Findings included: Resident #71 was admitted to the facility in April 2021 with a diagnosis of Dementia with Behavioral Disturbance, and entered into Hospice care in July 2021. Review of the Physician's Orders for August 2021 indicated the following PRN orders: -Haldol gel (an anti-psychotic medication used to treat certain mental disorders) 1 milligram per milliliter (mg/ml), apply 4 mg topically every four hours as needed for agitation/restlessness. Order date 7/30/21 with no stop date or review date indicated. -Olanzapine (Zyprexa: an anti-psychotic medication used to treat certain mental disorders) 5 milligrams by mouth (PO) give one tablet by mouth every 12 hours as needed for anxiety. Order date 7/21/21 with no stop date or review date indicated. Review of the August 2021 Medication Administration Record indicated Resident #71 received the Haldol gel PRN eight times in August, for agitation/restlessness, and received the Olanzapine 5 mg tablet PRN two times in August, for anxiety. Review of the Physician progress notes indicated no documentation that the PRN medications had been reviewed and reordered on the 14th day, as required. During an interview on 9/7/21 at 9:57 A.M., Nurse #9 said orders for PRN anti-psychotics should be reevaluated in 14 days and she did not see a re-evaluation in 14 days for the PRN Haldol topical gel, or the PRN Zyprexa, as required. During a subsequent interview on 9/7/21 at 12:14 P.M., Nurse #9, said there was no documentation in the record that a review of the PRN anti-psychotic medications was completed, as required.

Based on observation and interview, the facility failed to ensure insulin pens were labeled, as required, in one out of four medication carts. Findings include: On 8/31/21 at 4:30 P.M., the surveyor observed the fourth floor medication cart with Nurse #2. There were three Lantus (insulin) pens without a name or date. The surveyor asked Nurse #2 which residents the pens belonged to. Nurse #2 said there was only one resident who received Lantus insulin, but she really could not say which Lantus pen belonged to the resident and why there were three Lantus pens in the cart. Nurse #2 said the Lantus pens should have the resident's name and the date when first used. On 8/31/21 at 4:40 P.M. the surveyor observed the fourth floor medication room with Nurse #1, the following was observed: - Two multidose vial of Purified Protein Derivative (PPD - a solution that checks for tuberculosis exposure), both were opened with no date. Nurse #1 said all multidose vials needed to be dated when opened and she could not see a date on either of them.

Based on observation, document review and interview, the facility failed to ensure adequate and safe food storage, in two of three unit nourishment kitchens, to help minimize the risk of food borne illnesses. Findings include: Review of the facility's Use and Storage of Food Brought in by Family and Visitors policy, dated November 2016, indicated the following: -Food that needs refrigeration is stored in a container labeled with the patient's name, date and room number. Review of the facility's Nourishment Supply Requisition policy, date revised April 2005, indicated the following: -Traypassers will inventory nourishment kitchens in the A.M., using the requisition form. -Traypassers will deliver all needed supplies to nourishment kitchens. All items will be dated and rotated. On 9/7/21 between 8:20 A.M. and 9:30 A.M., the surveyor observed the following in two of the three nourishment kitchens: Fourth floor north kitchen: -Three pre-portioned cups of peanut butter, with a sticker on top containing a date of 9/1/21 and to discard after three days. Third floor refrigerator/freezer unit across from the nurse's station: -The following items were observed stored in the freezer without a name and/or date on them: an opened box of toffee ice cream bars and a Lean Cuisine frozen meal. Third floor north kitchen: -12 pre-portioned cups of peanut butter, with a sticker on top containing a date of 9/3/21 and to discard after three days. Third floor east kitchen: -The following dated pre-portioned cups of peanut butter with stickers to discard after three days: one cup dated 8/5/21, two cups dated 8/22/21, two cups dated 8/23/21, four cups dated 8/30/21 and one cup dated 9/3/21. Third floor south kitchen: -The refrigerator had two disposable containers of cooked food and one covered bowl of spaghetti and meatballs, all were unlabeled and undated. -In a cabinet, there were also the following dated pre-portioned cups of peanut butter with stickers to discard after three days: one cup dated 8/30/21, three cups dated 8/31/21 and six cups dated 9/3/21. During an interview on 9/7/21 at 9:00 A.M., Nurse #7 (third floor nurse) said all food/beverage items brought in from outside the facility for a resident should have the resident's name on it and the date when brought in. She said dietary staff labels everything they send from the main kitchen. Nurse #7 and the surveyor observed the unlabeled and undated items in the freezer and refrigerator on the third floor. She said the observed food items had no name labels and/or dates as required, and would need to be discarded. During an interview on 9/7/21 at 10:58 A.M., the Food Service Director (FSD) said food and drink items brought in for a resident for storage on a unit would need to be labeled with the resident's name and date it was brought in. He said the pre-portioned peanut butter cups should have been thrown out on the third day of the date on the sticker, but they had not been, as required.

3. For Resident # 58, the facility failed to ensure complete documentation related to positioning. Resident #58 was admitted to the facility in May 2005 with diagnoses including anoxic brain injury (injury caused by a complete lack of oxygen to the brain) and involuntary movements. Review of the Activities of Daily Living care plan, date initiated 7/15/21, indicated the following interventions: -Check enablers every 30 minutes and release every two hours and as needed (PRN) for positioning. -Resident is totally dependent on (one-two) staff for repositioning and turning in bed every two hours and as necessary. -Side rails: observed for injury or entrapment related to side rail use. Reposition every two hours and as necessary to avoid injury. Review of the Skin Risk/ Bladder Incontinence care plan, date initiated 7/16/21, indicated the following interventions: -Reposition at least every two to three hours and PRN with one to two assist, Review of the August 2021 Positioning Sheet indicated the following days/times that had no documentation for positioning: -8/1/21 through 8/6/21, 8/9/21, 8/14/21 through 8/16/21, 8/18/21 through 8/22/21, 8/24/21, 8/25/21, 8/29/21 and 8/31/21: from 8:00 A.M. through 2:00 P.M. -8/7/21, 8/8/21, 8/22/21, 8/29/21 and 8/30/21: from 12:00 P.M. through 6:00 A.M. Review of the September 2021 Positioning sheet indicated the following days/times that had no documentation for positioning: -9/1/21: from 8:00 A.M. through 10:00 P.M. -9/2/21: from 8:00 A.M. through 2:00 P.M. During an interview on 9/3/21 at 10:54 A.M., after reviewing the August and September 2021 positioning sheet, Nurse #7 said the documentation was incomplete and Certified Nursing Assistants should have documented the Resident's position every two hours. 4. For Resident #64, the facility staff failed to complete a quarterly side rail assessment. Resident # 64 was admitted to the facility in June 2019 with diagnoses including a history of falling, rheumatoid arthritis and tremors. Review of the facility's Side Rail Use/Entrapment Assessment Policy, dated 12/1/19, indicated the following: -On all new admissions, the nurse will complete a side rail assessment to determine the individual needs of each resident. -Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bed rail effectiveness should be reviewed on a quarterly basis. Review of a Physician's Order, undated, indicated: two half rails up when in bed to aid with positioning and provide spatial boundaries Review of a Comprehensive Bed Rail Assessment, dated 6/23/19, indicated recommendation to use side half partial side rails at all times when in bed for a positioning aide. Further review of the Resident's clinical record indicated the side rail assessment was completed on: 12/15/19, 3/5/20, 5/27/20, 8/12/20, 11/2/20, 2/3/20 and 5/14/21. During an interview on 9/2/21 at 4:47 P.M., after reviewing the Resident's clinical record, the Assistant Director of Nurses said a quarterly side rail assessment was not completed in September 2019, but should have been, as required. Based on observation, record review and interview, the facility failed to maintain medical records that were complete and accurately documented for four Residents (#23, #39, #58 and #64) out of a total sample of 25 residents. Findings include: 1. For Resident #23, the facility failed to accurately document the Treatment Administration Record (TAR). Resident #23 was admitted to the facility in October 2019. On 8/31/21 at 10:04 A.M., the surveyor observed the Resident seating in a wheelchair in his/her room. The surveyor observed the Resident had edema to both lower legs. The Resident wore a pair of sneakers with ankle socks. Review of the Physician's Order, dated 6/14/21, indicated to apply Thrombo-Embolus Deterrent stockings (TED - stockings used to decrease edema) to bilateral lower extremities in the morning and remove at bedtime. Review of the TAR, dated September 2021, indicated a transcription to: -Apply TED stockings to bilateral lower extremities in the morning and remove at bedtime. The TAR was initialed on 9/2/21. The initials indicated the TED stockings were applied as ordered. On 9/2/21 at 2:02 P.M., the surveyor and Nurse #7 observed the Resident seating in a wheelchair in his/her room. Nurse #7 said the Resident did not have the TED stockings on as ordered. The surveyor showed the TAR dated September 2021 with a nurse's initials. Nurse #7 said the TAR should not have been initialed if the treatment was not done. During an interview on 9/2/21 at 2:05 P.M. Certified Nurse's Aide (CNA) #1 said she overheard the conversation that the surveyor had with Nurse #7. CNA #1 said the Resident always refused to wear the TED stockings. During an interview on 9/2/21 at 3:39 P.M. with Nurse #8 she said she had cared for Resident #23 and had initialed the TAR. Nurse #8 said she assumed the CNA had applied the TED stockings, but she should have not initialed the TAR unless she had checked herself. 2. For Resident #39, the facility failed to accurately transcribe a Physician's Order for weights. Resident #39 was admitted to the facility in March 2021 with diagnoses including chronic kidney failure. Review of a Physician's Order, dated 7/15/21, indicated to weigh the Resident two times a week on Monday and Thursday; report a two pound weight gain in one day or a five pound weight gain in three days. During an interview on 9/2/21 at 8:34 A.M., Nurse #7 said the order did not make sense and it should have been clarified. Nurse #7 said that she believed the order should have been to notify the Physician if the Resident had a five pound weight gain in one week, but was not sure.

Based on document review, observation and interview, the facility failed to don (put on) the required Personal Protective Equipment (PPE) after a staff member tested positive for COVID-19. Findings include: Review of the Center for Disease Control and Prevention recommendations to prevent, SARS-CoV-2 Spread in Nursing Homes, updated on 3/29/21, indicated the following: -Because of the high risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any Health Care Personal (HCP) or a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak. HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. During an interview on 8/31/21 at 7:15 A.M., the Director of Nurses (DON) said that a staff member had tested positive for COVID-19 on 8/23/21. On 8/31/21, during the initial screening process between 7:30 A.M. - 11:15 A.M. on the third floor, the surveyor observed staff members providing direct care to the residents. None of the staff members were observed wearing gowns during care. During an interview on 8/31/21 at 12:00 P.M., the DON said that when the staff member tested positive she reached out to the state's epidemiologist. The DON handed the surveyor an email that she had received from the epidemiologist that indicated: Add gowns and gloves for high contact care activities for COVID-naive and recovered residents until 14 days with no new positive cases on the affected units. The DON said the staff member who had tested positive had been on all of the units so staff should have been wearing gown and gloves with high contact care. The DON said she had missed the instructions for PPE use in the email and the facility had not implemented the increased use of PPE. During an interview on 9/02/21 at 2:41 P.M., the Infection Preventionist (IP) was asked why staff were not wearing gowns and gloves with direct care. The IP said that there had been so many changes and she had missed the instructions from the epidemiologist.