Every finding on record at Aberjona Rehabilitation and Nursing Center

Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure food was labeled and dated. 2. Ensure beard nets were worn in the food preparation area. 3. Ensure employee meals were not stored with resident food and ingredients. Findings include: Review of policy titled Food Safety Requirements, revised 2/2023, indicated, but was not limited to the following: -Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. -Dry food storage - keep foods/beverages in a clean, dry area off the floor. -Refrigerated storage - labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded and keeping food covered in tight containers. Review of policy titled Food Safety Requirements, revised 2/2023, indicated, but was not limited to the following: -Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Review of the 2022 U.S. Food and Drug Administration (FDA) food code indicated the following: -FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD -FOOD shall be protected from contamination by storing the FOOD: in a clean, dry location; where it is not exposed to splash, dust, or other contamination; and at least 15 cm (6 inches) above the floor. 1. During the initial kitchen walk through on 5/14/24 at 7:15 A.M., the surveyor made the following observations in the walk in refrigerator: -One carton of fish base, open and undated. -One carton of lobster base, open and undated. -One package of single sliced cheese, open and updated. -One half gallon of milk, open and undated. -One half gallon of orange juice, open and undated. -One half gallon of half and half dairy creamer, open and undated. -One bottle of lemon juice, open and undated. -One large open container of fresh spinach, open and undated. -One tray applesauce poured into individual single serving bowls, undated. -One tray of fruit cocktail poured into individual single serving bowls, undated. During the initial kitchen walk through on 5/14/24 at 7:15 A.M., the surveyor made the following observations in the dry storage area: -One large container of chocolate pudding, open and undated. -One empty, open cookie wrapper in a box of dry pudding mix. -One open, uncovered, undated bag of uncooked lasagna. During the initial kitchen walk through on 5/14/24 at 7:15 A.M., the surveyor made the following observations in the walk-in freezer: -One box of frozen chicken placed directly on the floor. During a tour of the unit kitchenettes on 5/15/24 at 9:00 A.M., the surveyor made the following observation: -Two half gallons of milk, opened and undated. -One half gallon of orange juice dated 5/5, which was ten days prior to the observation. -One unopened yogurt container, expiration date 5/4/24, which was eleven days prior to the observation. During an interview on 5/15/25 at 9:55 A.M., the Food Service Director (FSD) said containers should be dated when opened if they have a shortened expiration date once opened. The FSD said he did not have a system in place for ensure milk and juices were not served after seven days of being opened. During an interview on 5/15/25 at 11:32 A.M., the Administrator said the facility should be following their policy for labeling and dating foods and beverages. 2. During initial kitchen walk through on 5/14/24 at 7:15 A.M., the surveyor observed three male dietary staff members with beards who were not wearing beard nets, two of which were actively preparing food. The beards were long enough that skin was not visible through beard. During an interview on 5/14/24 at 7:24 A.M., the FSD said he has not required beard nets to be worn during cooking, preparing, or assembling food in the kitchen. During an interview on 5/15/25 at 11:32 A.M., the Administrator said she was unaware beard nets were required and would need to refer to the facility policy on beard nets. 3. On 5/15/24 at 9:53 A.M., the surveyor made the following observation in the kitchen's walk-in refrigerator: -An undated, glass reusable container, filled with meat and vegetables. During an interview on 5/15/24 at 9:53 A.M., The FSD said it was a staff members lunch, and that it should not be in there.

Based on record review, policy review and interviews, the facility failed to provide services that met professional standards of quality for one Resident (#261) out of a total sample of 22 residents. Specifically, the facility failed to follow a physician order for documenting total volume intake for Resident #261. Findings include: Review of facility policy titled Care and Treatment of Feeding Tubes, dated 2/2023, indicated the following: -Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. Resident #261 was admitted to the facility in May 2024 with diagnoses including dysphagia (difficulty chewing and swallowing) and malignant neoplasm of esophagus. Review of the Brief interview for Mental Status exam dated 5/10/24, indicated the Resident scored a 15 out of a possible 15, indicating Resident #261 has intact cognition. Review of the physicians' orders dated 5/10/24 indicated the following: -Jevity 1.5 calorie/fiber oral liquid (Nutritional supplement) Give 240 milliliter (ml) via Gastrostomy tube (g-tube) (G-tube: tube inserted through the abdomen into the stomach to provide nutrition) three times a day related to dysphagia. -Flush g-tube with a bolus free water flush 175 ml four times a day. -G-tube flush orders with 60 ml's before and after administration of medication, administer five ml of water in between medication administered. -Document total intake via g-tube every night shift. Review of Medication Administration Record (MAR) for May 2024 failed to indicate a complete daily total intake was documented, as ordered by the Physician. Rather, the night shift nurses were documenting the intake for the night shift only. During an interview on 5/15/24 at 9:56 P.M., Nurse #1 said the total daily intake should have been documented, but was not. During an interview on 5/15/24 at 10:02 P.M., Unit Manager #1 said the order was entered incorrectly, the total daily intake should be documented and not only for night shift. During an interview on 5/15/24 at 10:36 A.M., the Director of Nursing said the total intake should show the volume of the entire day.

Based on observation, record review and interview the facility failed to ensure an intervention for a pressure ulcer was implemented for one Resident (#37) out of 3 residents identified with pressure ulcers, out of a total sample of 22 residents. Specifically, the air mattress power unit was not on and functioning in accordance with the medical plan of care. Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Management, dated as implemented 6/1/22 indicated the following: Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing existing pressure injuries. 4. Interventions for Prevention and to Promote Healing, c. Evidence-based interventions for preventions will be implemented for all residents who are assessed at risk or who have a pressure injury present. Review of the Invacare MicroAir User Manual, not dated, indicated the following: Installing the power unit. Power button: Once the power button is pressed and released, a green led illuminates indicating that the control unit is on. Resident #37 was admitted to the facility in 1/2023 and has diagnoses that include anemia, unspecified severe protein-calorie malnutrition, unspecified dementia, and pressure ulcer of other site, stage 4. Review of the comprehensive Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 1/22/23 indicated Resident #37 scored a 10 out of 15 on the Brief Interview for Mental Status Exam, indicating moderately impaired cognition, required extensive assistance from staff for daily care, was at high risk for developing pressure ulcers and had a stage 4 pressure ulcer, on admission. Review of the MDS Care Area Assessment worksheet indicated Resident #37 entered the facility with a stage 4 pressure ulcer on his/her coccyx. On 3/28/23 at 7:38 A.M., Resident #37 was observed resting in bed. He/she said he/she was not comfortable, he/she was positioned with pillows and an air mattress, and the power unit was affixed to the foot board of the bed. The air mattress power unit did not have illumination and there was no vibration to touch. The air mattress to touch had a lot of give, air was present and was not totally deflated. Review of the physician's orders indicated the following: *Low Air loss mattress on setting 2-monitor for proper setting and function every shift, dated 1/13/23. On 3/28/23 the following observations were made by the surveyor: *At 10:52 A.M., Resident #37 was resting in bed, the low air loss mattress power unit was not illuminated, and the power was not running to touch. *At 1:07 P.M., Resident #37 was observed laying on his/her back. The low air loss mattress was not illuminated, the power was not running to touch. *At 1:37 P.M., Nurse #4 entered Resident #37's room, she was asked by Unit Manager #2 to check the Resident's foot. *At approximately 1:40 P.M., after Nurse #4 exited Resident #37's room, the air mattress was observed to not be illuminated, nor was the power running. *At 3:40 P.M., Resident #37 was resting in bed, the low loss air mattress was not illuminated, and the power not on per observation and to touch. The mattress was soft with give, some air present. Clean linens were placed at the end of the bed, which indicated staff had entered the room. On 3/29/23 at 6:51 A.M., Resident #37 was resting in bed. The low air loss mattress was not illuminated, and the power was not running per observation and touch. During an interview on 3/29/23 at 6:57 A.M., Nurse #2 said Resident #37 had a pressure ulcer, and she was not sure if the Resident had an air mattress. Nurse #2 accompanied the surveyor to Resident #37's room and acknowledged the power unit for the air mattress was not on and running. During an interview on 3/29/23 at approximately 7:00 A.M., Unit Manger #2 said Resident #37 was admitted with a sacral wound and had a healing scab on his/her foot. Unit Manger #3 said the air mattress was an intervention in place and should be functioning and the setting should be at 2.

Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurate for one Resident (#37) out of a total sample of 22 residents. Specifically, the MDS indicated Resident #37 was on a hospice care program while a resident in the facility. Resident #37 was admitted to the facility in 1/2023 and has diagnoses that include anemia, unspecified severe protein-calorie malnutrition, unspecified dementia, and pressure ulcer of other site, stage 4. Review of the comprehensive Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 1/22/23 indicated Resident #37 scored 10 out of 15 on the Brief Interview for Mental Status Exam, indicating moderately impaired cognition, required extensive assistance from staff for daily care. Further review of the MDS, Section O, Special Treatments and Programs, indicated Resident #37 received Hospice Care while a resident in the facility. Review of Resident #37's medical record failed to indicate a physician's order, care plan or progress notes indicating Resident #37 was receiving hospice care services. During an interview on 3/29/23 at 7:14 A.M., Unit Manager #2 said the Resident is not on hospice care and had been prior to admission to the facility. Unit Manager #2 said she was not sure why the MDS was coded as receiving hospice care for the Resident. During an interview on 3/29/23 at 8:22 A.M., MDS nurse #1 said the Resident was not admitted on hospice care services, was not receiving hospice care services, and the MDS was coded in error.

Based on observation and interview the facility failed to store medications securely for 1 Resident (#305) out of 22 sampled Residents. Findings Include: Review of the facility's policy titled Medication Storage, dated 6/22/22, indicated All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. Resident #305 was admitted to the facility in March 2023 with diagnoses including spinal stenosis, hypertensive chronic kidney disease, and anxiety disorder. Review of Resident #305's most recent Minimum Data Set, dated dated dated [DATE], indicated that Resident #305 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating that Resident #305 is cognitively intact. During an observation on 3/28/23 at 7:30 A.M., the surveyor observed a bottle of Latanoprost Ophthalmic Solution 0.005 % prescription eye drops on Resident #305's tray table. Resident #305 said that nursing staff always leaves the eye drops and said staff will come back eventually for them. Resident #305 said that the eye drops were left on his/her tray table since last night and said he/she does not have a locked drawer or locked box. Review of Resident #305's March 2023 Physician Orders, indicated an order for Latanoprost Ophthalmic Solution 0.005 % - Instill 1 drop in both eyes one time a day. The order further indicated that the eye drops are to be administered at 8:00 P.M. During an interview on 3/28/23 at 10:15 A.M., Nurse #1 said the eye drops should be locked up in the medication cart after the nurse administers them. The Nurse acknowledged Resident #305's eye drops were in fact not secured in the medication cart. During an interview on 3/28/23 at 10:16 A.M., Unit Manager #1 said Resident #305 is not allowed to self-administer the eye drops alone. The Unit Manager said the nurse should be administering the eye drops to Resident #305 and then taking the eye drops back to the medication cart.

Based on observation, interview, and record review, the facility failed to implement transmission-based precautions timely to help prevent the spread of potential infection for one Resident (#456) out of a total sample of 22 residents. Findings include: Review of the facility policy titled Isolation Precautions revision date 5/24/2022 indicated: -It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. This policy specifies the different types of precautions, including when and how isolation should be used for a resident. -Facility staff will apply Transmission-Based Precautions, in addition to standard precautions to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. -The rationale for the selected transmission-based precautions will be documented in the medical record. -Information regarding the precaution to be utilized will be communicated through verbal reports, written in-house communication forms, and signage. Resident #456 was admitted to the facility in March 2023 with diagnoses including contusion of the scalp, chronic kidney disease, and congestive heart failure. The Resident's Minimum Data Set Assessment had not yet been completed. During an observation/interview on 3/28/23 at 8:04 A.M., Resident #456 was observed in his/her room with no contact precaution cart observed outside of his/her room. Resident #456 said he/she just arrived at the facility a day prior. During an observation on 3/29/23 at 8:30 A.M., Resident #456 had a contact precaution sign with Personal Protective Equipment (PPE) on the door. Review of Resident #456's medical record indicated the following: -A skilled progress note dated 3/28/23, indicated Resident #456 was on precautions for VRE (Vancomycin-Resistant Enterococci) in the urine. -Hospital Discharge Paperwork printed on 3/27/23, discussed Patient infection status as positive for VRE through a rectal screen with an onset date of 3/17/23 added to medical record on 3/21/23. During an interview on 3/29/23 at 10:23 A.M., Unit Manager #1 said upon receiving a new admission, nursing receives a report from the facility. Unit Manager #1 said receiving report is just a guide and nursing should be looking at the chart sent with the resident, as well as asking the resident questions if they are alert and oriented. Unit Manager #1 said Resident #456's status of requiring contact precautions was not received in report and it was realized later by another staff member. During an interview on 3/29/23 at 10:27 A.M., Nurse #3 said he admitted Resident #456 but never received report that he/she was on precautions for VRE. Nurse #3 explained that contact precautions entail staff to put on a gown and gloves prior to entering the resident's room and there could be a risk to other residents and staff by not having Resident #456 on precautions when he/she arrived to the facility. Nurse #3 thought VRE was in the urine of Resident #456 but discharge paperwork indicated it was in the rectum. During an interview on 3/29/23 at 10:49 A.M., the Director of Nursing said she put a cart in front of the residents room on 3/28/23 but acknowledged that it wasn't there when the surveyor screened Resident #456 at 8:04 A.M. The Director of Nursing said Resident #456 was no longer on antibiotics but said the expectation for someone admitted with VRE was to place on precautions and to swab the resident. The Director of Nursing said Resident #456 was not swabbed for VRE while at the facility.

Based on observation, record review and interview, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy titled 'PICC Catheter Dressing Change', policy number V-C, revised April 2017 indicated the following: -Assessment of the PICC site to include external catheter length -Documentation of the catheter assessment, including external catheter length. Resident #56 was readmitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, required assistance with care activities and received IV medications. On 4/20/22 at 9:43 A.M., Resident #56 said he/she is receiving IV antibiotics through a PICC line (a thin, soft catheter that is inserted into a vein in the arm, leg or neck with the tip of the catheter positioned in a large vein that carries blood into the heart). Resident #56 was observed to have a dressing dated 4/15/22 in place covering a PICC line in his/her right upper arm. Review of Resident #56's medical record indicated the following: -Hospital PICC line discharge instructions and a card indicating the PICC line was placed on 3/3/22 with 0 centimeters (cm) external length. -A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Measure circumference of upper arm of affected arm with each dressing change. Measure length of line that is exposed. -March 2022 Treatment Administration Record (TAR) failed to indicate the PICC line dressing was documented as being changed on 3/15/22 and 3/22/22. The TAR further failed to indicate any measurements of Resident #56's upper arm circumference or the length of line that was exposed were obtained. -April 2022 TAR failed to indicate any measurements of Resident #56's upper arm circumference or the length of line that was exposed. -Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Infuse 2 gm every twelve hours. -March 2022 and April 2022 Medication Administration Records (MAR) which indicated the Resident had received IV [MEDICATION(S)] as ordered 3/4/22-4/21/22. Further review of Resident #56's medical record failed to indicate any measurements of the PICC line external length or the Resident's upper arm circumference had been obtained or documented while the Resident was in the facility and receiving IV medication through the PICC line. During an interview on 4/21/22 at 9:53 A.M., Unit Manager #1 said no measurements related to PICC line care are required. Unit Manager #1 said the only time measurements would be obtained would be to monitor an infection or something concerning. During an interview on 4/21/22 at 12:24 P.M., Nurse #1 said that PICC dressings are changed weekly or as needed if soiled. She said that measurements should be taken each time a dressing change is done and should measure the circumference of the arm and any external length of the catheter. Nurse #1 said the measurements should be documented in the progress note portion of the TAR and that it should be done each time the dressing is changed. During an interview on 4/21/22 at 12:37 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said during weekly dressing changes measurements of arm circumference and external length of catheter should be obtained. The DON and ADON acknowledged there was no documentation of measurements being obtained in the Resident's medical record. During an interview on 4/21/22 at 3:00 P.M., the DON acknowledged that measurements during PICC dressing changes were not implemented as per order and there were missing entries on the March TAR. The DON further said that she had spoken with the physician after speaking with the surveyor earlier in the day and he had ordered a dressing change. The DON said that the dressing change had just occurred and the Resident's external catheter measured 15 cm. The DON was unable to say if she had any concerns about the change between the documented external length of Resident #56's PICC line as 0 cm on 3/3/22 and the facility measurement of 15 cm on 4/21/22 and acknowledged that the Resident had been receiving IV medication without nursing staff documenting any measurements or getting confirmation that the PICC line was not displaced. The DON said she did not believe that the 0 cm external length documented by the hospital at the time of PICC placement was accurate. During an interview on 4/21/22 at 3:28 P.M., the DON said that she spoke with the physician about the increased external catheter length and said that since there is no clear documentation of any measurements related to the Resident's PICC line, an x-ray will be ordered to confirm placement. Review of Resident #56's medical record on 4/22/22 at 7:15 A.M., indicated the following: -A chest X-Ray originally dated 4/14/22 with an addendum documented 4/21/22 at 3:33 P.M. which indicated the tip of the right sided peripherally inserted central catheter is in the projection of the proximal right [MEDICATION(S)] vein. -A telephone order dated 4/21/22 at 3:58 P.M. to reposition the PICC line via the RN IV service. This telephone order further had a handwritten unsigned note to D/C the PICC and place a new PICC. -A procedure note for Vascular Access Device Insertion dated 4/21/22 at 9:10 P.M. that Resident #56's right PICC was dislodged at 11 cm. -An additional procedure note for Vascular Access Device Insertion indicated a PICC line was placed into the Resident's left arm on 4/21/22. During an interview on 4/22/22 7:26 A.M., the DON said that the IV RN service came in late yesterday to try to reguide the PICC line into the Resident's arm and was unable to do so. The DON said a new PICC line was placed in the Resident's left arm. On 4/22/22 at 7:56 A.M., Resident #56 was observed in his/her room sitting in a chair. The Resident said he/she thinks the PICC line was changed from his/her right to left arm because it wasn't working properly but he/she wasn't positive. The Resident was observed to have a PICC line with a dressing covering it in his/her left arm. During an interview on 4/22/22 at 8:25 A.M., Unit Manager #1 said she thought the PICC line was changed because of concerns about placement and the line not being in the proper place. During an interview on 4/22/22 at 11:00 A.M., the DON and Administrator acknowledged that there were no measurements obtained after the 4/14/22 chest x-ray and antibiotics were administered twice daily. The DON and Administrator acknowledged the Resident's PICC line was replaced because it was unable to be repositioned and placement couldn't be confirmed.

Based on observation, interview, policy review, and record review, the facility 1) Failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain usual body weight and prevent significant weight loss for 1 Resident (#59); and 2) Failed to ensure hydration was monitored for 1 Resident (#101) resulting in the need for intravenous hydration, out of a total sample of 23 residents. Findings include: 1. For Resident #59, the facility failed to address a significant weight loss. Review of the facility's policy titled Monitoring Resident's weights, undated, indicated the following: *Nurse team leader initiates daily weight. *If weight differs (plus or minus) 5 pounds, recheck weight. *If recheck of weight still indicates a difference of 5 pounds or more: Notify the nurse manager, MD, Dietitian, MDS and DNS. Review of the Centers for Medicare and Medicaid Services (CMS) parameters for evaluating the significance of unplanned and undesired weight loss are: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5 % 6 months 10% Greater than 10% Resident #59 was admitted to the facility in December 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's most recent Minimum Data Set (MDS) assessment, dated 3/7/22, indicated Resident #59 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated he/she is cognitively intact. During an observation on 4/20/22 at 9:09 A.M., Resident #59 was observed eating breakfast in bed, he/she appeared to be thin and picking around on his/her breakfast plate. Review of Resident #59's weights indicated the following: *On 12/17/21-98.0 pounds (lbs.) *On 12/30/21-89.5 lbs. (8.67% weight loss in approximately two weeks) *On 1/14/22-84.2 lbs. (additional 5.92% weight loss in approximately two weeks; 14.1% loss in one month) *On 1/21/22-82.2 lbs. *On 2/4/22-81.8 lbs. *On 2/11/22-82.0 lbs. Review of Resident #59's medical record failed to indicate any follow up with an assessment, documentation, or interventions of the above weight loss. During an interview on 4/22/22 at 7:14 A.M., Unit Manager (UM#2) said, in general, after a weight loss is identified, the staff reweighs the Resident and checks the scales, if the staff do all the above and the weight loss remains, the dietitian is notified, the medical doctor is notified, and supplements and/or medications are introduced in the Resident's diet and the resident is also monitored closely. UM #1 said that both of Resident #59's weight losses were severe and they should have been identified with interventions put in place. During an interview on 4/21/22 at 9:27 A.M., Dietitian #1 reviewed Resident #59's clinical record and told the surveyor that no interventions were initiated for Resident #59 after he/she lost weight between the following dates: 12/17/2021, 12/30/21, and 1/14/2022. Dietitian #1 said that weight loss is communicated to her through the computer system creating a trigger for her to follow up on. Dietitian #1 then asks for reweighs and adds and documents interventions if the weight loss is confirmed. Dietitian #1 said Resident #59's weight loss was significant and should have been addressed. 2. For Resident #101, the facility failed to monitor hydration status, resulting in the need for intravenous (IV) fluids. Review of the facility's policy titled 'Nutrition and Hydration Management Process and Protocols', undated, indicated the following: -The nutrition and hydration needs are monitored and maintained as a regular part of our care planning efforts. -Clinical measures such as body weight, food and fluid intake, special diet requirements and eating skills are used to assess and identify resident needs. -Upon admission, a comprehensive assessment is completed which includes nutrition and hydration needs. -Residents with poor intake, inadequate weight, weight change and dehydration have interventions initiated to promote gain and increase intake of food and/or fluids. -If supplements are ordered as part of the care plan approach to maintaining proper nutrition, it is documented in ML (milliliters) consumed per facility guidelines. Resident #101 was admitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #101's Minimum Data Set assessment (MDS), dated [DATE], indicated the Resident had moderate cognitive impairment and scored an 11 out of 15 on the Brief Interview for Mental Status exam (BIMS). The MDS further indicated the Resident had no behaviors and requires extensive assistance with a physical assist of one person with eating and that the Resident had coughing or choking during meals and difficulty or pain when swallowing and received a mechanically altered diet and that the Resident required an indwelling urinary catheter. On 4/20/22 at 9:00 A.M., Resident #101 was observed in bed. He/she appeared thin and frail and was observed to have some loss of thick saliva mixed with food residue out of his/her mouth. On 4/21/22 at 8:48 A.M., Resident #101 was observed in bed unsupervised with his/her breakfast tray in front of him/her on an overbed table. The food was untouched and a cup of juice was observed to have spilled on the tray. Resident #101 said he/she hadn't eaten or had anything to drink yet and that staff sometimes helps him/her. The Resident appeared thin and frail. At 9:02 A.M., a Certified Nursing Assistant (CNA) removed the untouched tray from the Resident's room. Review of Resident #101's orders indicated the following: -an order dated 3/31/22 for a regular diet with a pureed texture and nectar consistency. -an order dated 3/31/22 to monitor Foley catheter output every shift Review of Resident #101's medical record indicated the following: -A care card/Kardex which indicated the Resident was a total assist with one person physical assist for eating -An initial nutrition assessment, dated 3/31/22, which indicated the Resident's estimated fluid needs were 1140-1425 mL daily. The assessment further indicated the Resident was a nutritional risk for potential weight loss related to selective appetite and dysphagia as evidenced by less than 50% of meals consumed. -A speech therapy evaluation, dated 3/31/22, which indicated the Resident required assistance bringing the cup to his/her mouth and experienced anterior loss of fluids (loss of fluids out of the side of the mouth) one time during the assessment with a delayed cough and that the Resident had difficulty clearing at times due to weak cough. -A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . -A care plan meeting summary, dated 4/5/22, which indicated speech recommends a puree liquid diet and that the Resident is not drinking much. -A Nurse Practitioner (NP) progress note to review labs, dated 4/6/22, which indicated an assessment of dehydration and to monitor the Resident's hydration. -A nurse progress note, dated 4/13/22, which indicated the Resident had trouble on and off with swallowing water per his/her family. -A skin and weight note, dated 4/13/22 which indicated the Resident had a 5% weight loss possibly related to inadequate oral food intake and dysphagia. Less than 50% of diet consumed. House supplement offered. -A nurse progress note, dated 4/17/22, which indicated the Resident was non-compliant with medications and decline in appetite was noted. The note further indicated the Resident refused to open his/ her mouth and take a bite of food. Intake of fluids as needed, Resident asks for it constantly and as offered would only take a sip at times and repeatedly asks for it again. Family aware of situation. -A nurse progress note, dated 4/19/22, which indicated the Resident was lethargic throughout the evening. Foley catheter re-inserted due to Resident not voiding after it was removed yesterday morning. Pus/yellow/green discharge noted coming from genitals. Urine cloudy. Resident having increasing difficulty swallowing. Medications crushed in applesauce. -A nurse progress note, dated 4/20/22, which indicated Resident shows high decline in his/her progress, non compliant with medications took only partial medications with trouble swallowing at times and wouldn't swallow medication completely. Resident highly weak and lethargic. Review of Resident #101's April 2022 Treatment Administration Record (TAR) indicated the following Foley catheter output, in milliliters (mLs), documented each shift with the following daily totals: 4/5/22: 1210 4/6/22: 650 4/7/22: 700 4/8/22: 900 4/9/22: 700 4/10/22: 700 4/11/22: 660 4/12/22: 600 4/13/22: 500 4/14/22: 350 4/15/22: 700 4/16/22: 740 4/17/22: 470 4/19/22: 400 4/20/22: 475 Further review of Resident #101's medical record failed to indicate any monitoring of the resident's hydration status had been documented after the Resident's 4/6/22 NP visit for dehydration. The record failed to indicate any additional interventions had been initiated to increase intake of fluids and failed to indicate any documentation that the Resident's decrease in urine output had been addressed. During an interview on 4/21/22 at 1:45 P.M., Unit Manager (UM) #1 said she and the NP met with the Resident's family yesterday and discussed IV hydration and the family declined. Unit Manager #1 reviewed the Resident's chart with the surveyor and acknowledged that Resident #101 was still his/her own person and had not had his/her Health Care Proxy (HCP) activated. UM #1 was unable to say if she asked the Resident if he/she wanted IV hydration. UM#1 acknowledged there was no documentation of this discussion with the Resident's family and there should be. UM#1 said she talked to the Resident's family again today and they are now considering IV hydration. UM#1 said she would check with the physician about the Resident's status. Review of Resident #101's medical record on 4/22/22 at 7:30 A.M. indicated the following: -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A physician's note dated 4/21/22 at 3:52 P.M. which indicated the Resident was seen for lethargy and a urinary tract infection ([CONDITION(S)]), cannot give much history, he/she does open his/her eyes and says a few words. The Resident says he/she is not well but does not give any more history. The note further indicated lethargy likely due to dehydration as he/she clinically appears to be dry. Not eating or drinking much. Losing ability to sustain himself/herself nutritionally. We will give him/her IV fluids if possible, if not then subcutaneous. The facility failed to add any interventions to monitor hydration or address Resident #101's decrease in oral intake and decrease in urinary output until 4/21/22 (16 days after the care plan meeting which indicated the Resident was not drinking much and 15 days after the NP progress note indicated the Resident was dehydrated). During an interview on 4/22/22 at 8:11 A.M., UM #1 said Resident #101 had an IV put in the previous day and had received IV fluids and IV antibiotics through it. UM #1 said that the Resident's HCP was activated and IV hydration was ordered the previous afternoon. UM #1 said nursing staff was monitoring urinary output and documenting this in the TAR but there was no formal monitoring of hydration or fluid intake. UM #1 said the Resident was only drinking sips of water at a time and asked for water frequently in the morning almost every day last week. UM #1 said Resident #101 is now only able to take water off a spoon. UM#1 was unable to say how hydration was monitored and said that the Resident needs total assistance for Activities of Daily Living (ADLs). UM#1 acknowledged that Resident #101 did not have his/her HCP activated until 4/21/22 and said resident didn't answer her when asked if he/she wanted IV hydration. UM#1 said it would make sense to monitor intake and output, especially if a resident is not taking much fluid or food by mouth. During an interview on 4/22/22 at 10:19 A.M., the Speech Therapist said she has worked with the Resident since admission and that during sessions the Resident was frequently requesting water. The Speech Therapist said there is a concern for dehydration when someone is on a thickened liquid diet. The Speech Therapist said she would expect monitoring to be documented including what was consumed and how much. During an interview on 4/22/22 at 9:51 A.M., NP #1 said the Resident was admitted with dysphagia and was on nectar thick liquids. NP #1 acknowledged that she wrote to monitor hydration in her 4/6/22 visit note and acknowledged that there was no documentation that staff was monitoring hydration. NP#1 acknowledged there was no documentation regarding IV hydration being offered to the Resident or his/her HCP prior to surveyor discussing with UM#1. NP#1 said the Resident requires total assistance with meals and said her expectation would be that staff is recording fluid intake, how often it is offered and what is offered. NP#1 said she wasn't notified of the Resident's decline in hydration until 4/20/22. During an interview on 4/22/22 at 10:53 A.M., the Director of Nursing (DON) and Administrator said that monitoring of hydration should include what was offered to a resident, how much was consumed and when it was consumed. The DON acknowledged there was no documentation of Resident #101's hydration being monitored.

Based on record review, policy review, and interview, the facility failed to maintain complete and accurate wound care orders for 1 Resident (#80), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled 'Clean Dressing Change' effective 1/12/22 indicated: *Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #80 was admitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #80's Minimum Data Set assessment (MDS), dated [DATE], indicated the Resident was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, requires assistance with care activities, and was admitted with pressure ulcers. During an interview on 4/20/22 at 9:22 A.M., Resident #80 said he/she has wounds on his/her back. Review of Resident #80's medical record indicated the following: -A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #80's April 2022 Treatment Administration Record (TAR) indicated the following: -Santyl Ointment 250 unit/gram- apply to coccyx/ Right buttocks topically for every day shift for unstageable wound was signed off 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20. Further review of Resident #80's medical record failed to indicate any orders for a cleansing solution and topical dressing for the coccyx/ right buttocks wound. During an interview on 4/21/22 at 8:39 A.M., Unit Manager #1 said nurses perform wound care daily. Unit Manager #1 said treatments will be ordered by the physician and/or Nurse Practitioner (NP) and will be put directly into the electronic health record (EHR). Unit Manager #1 reviewed the treatment order for Resident #80 and said it was incomplete and missing a cleansing solution and the topical dressing to cover the Santyl. Unit Manager #1 said Santyl would not be left uncovered but she was unable to say what dressing had been put in place for Resident #80. During an interview on 4/21/22 at 9:57 A.M., the Assistant Director of Nursing (ADON) said she examines all wounds upon admission and once a week will go around with the treatment nurse and observe the wounds. The ADON said Resident #80's wound should have had orders for cleansing and covering.

Based on record review, interview, and policy review, the facility failed to ensure physician's orders were implemented for 1 Resident (#56), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled 'PICC Catheter Dressing Change', policy number V-C, revised April 2017, indicated the following: -Assessment of the PICC site to include external catheter length -Documentation of the catheter assessment, including external catheter length. Resident #56 was readmitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's Minimum Data Set (MDS) assessment, dated 3/10/22, indicated the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS further indicated the Resident had no behaviors, did not reject care, required assistance with care activities, and received intravenous (IV) medications. On 4/20/22 at 9:43 A.M., Resident #56 said he/she is receiving IV antibiotics through a PICC line (a thin, soft catheter that is inserted into a vein in the arm, leg, or neck with the tip of the catheter positioned in a large vein that carries blood into the heart). Resident #56 was observed to have a dressing dated 4/15/22 in place covering a PICC line in his/her right upper arm. Review of Resident #56's medical record indicated the following: -Hospital PICC line discharge instructions and a card indicating the PICC line was placed on 3/3/22 with 0 centimeters (cm) external length. -A current physician's order to change PICC/midline catheter dressing once weekly. Measure circumference of upper arm of affected arm with each dressing change. Measure length of line that is exposed. -March 2022 Treatment Administration Record (TAR) failed to indicate the PICC line dressing was documented as being changed and measurements obtained on 3/15/22 and 3/22/22. The TAR further failed to indicate any measurements of Resident #56's upper arm circumference or the length of line that was exposed. -April 2022 TAR failed to indicate any measurements of Resident #56's upper arm circumference or the length of line that was exposed. Further review of Resident #56's medical record failed to indicate any measurements of the PICC line external length or the Resident's upper arm circumference had been obtained or documented since the Resident was readmitted to the facility with the PICC line. During an interview on 4/21/22 at 9:53 A.M., Unit Manager #1 said no measurements related to PICC line care are required. Unit Manager #1 said the only time measurements would be obtained would be to monitor an infection or something concerning. During an interview on 4/21/22 at 12:24 P.M., Nurse #1 said PICC dressings are changed weekly or as needed if soiled. She said measurements should be taken each time a dressing change is done and should measure circumference of arm and any length of catheter. Nurse #1 said the measurements should be documented in the progress note portion of the TAR and it should be done each time the dressing is changed. During an interview on 4/21/22 at 12:37 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said during weekly dressing changes measurements of arm circumference and external length of catheter should be obtained. The DON and ADON acknowledged there was no documentation in the Resident's medical record of measurements being obtained. Refer to F684

Based on observation and interview, the facility failed to ensure that infection control protocols for cleaning and disinfecting equipment during the medication pass were followed to prevent the spread of infection. Findings include: During the medication pass on 4/21/22 at 9:15 A.M., Nurse #1 was observed giving medications to Resident #155. Nurse #1 entered Resident #155's room with a cart that had a blood pressure cuff and on it and a pulse oximeter. Before administering the medications, Nurse #6 took Resident #155's blood pressure and oxygen saturation using the pulse oximeter. After administering the medications, Nurse #1 exited Resident #155's room with the cart and left it in the hallway and placed the pulse oximeter on top of the medication cart. Nurse #1 failed to disinfect the blood pressure cuff and pulse oximeter after using it on Resident #155. During an interview with the Administrator on 4/21/22 at 1:00 P.M., she acknowledged all equipment is to be disinfected after resident use.

Based on observation, interview, record review, and policy review, the facility failed to ensure the physician's orders for oxygen administration were in place for 1 Resident (#205), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled 'Oxygen Administration Policy and Procedure' effective 7/16/19 indicated: -Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Resident #205 was admitted to the facility in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #205's Minimum Data Set assessment (MDS) in process dated 4/20/22 indicated the Resident was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status exam (BIMS). On 4/20/22 at 8:48 A.M., Resident #205 was observed in his/her room wearing oxygen (O2) via nasal cannula at 1 liter (L). Resident #205 said he/she has been wearing the O2 continuously since being admitted to the facility. On 4/21/22 at 8:49 A.M., Resident #205 was observed in a chair in his/her room wearing O2 at 1L via nasal cannula. Review of Resident #205's medical record indicated an order dated 4/18/22 to maintain saturation above 90% every shift on O2 via nasal cannula. The physician's order failed to indicate what setting the Resident's oxygen should be at. During an interview on 4/22/22 at 8:04 A.M., Unit Manager #1 said that if a resident is wearing oxygen they need an order, unless it is an emergency.

Based on record review, observation, staff interview, and policy review, the facility failed to notify the physician of changes in condition of 1 Resident (#59), out of a sample of 23 residents. Findings include: Review of the facility's policy titled Changes in Resident's condition or Status with no revision date indicated the following: *It is the policy of this facility, except in medical emergencies to notify the Resident, his or her attending physician, and Representative, (sponsor) of changes in the Resident's condition and/or status. *All changes in the Resident's medical condition will be recorded in the Resident's medical record. Resident #59 was admitted to the facility in December 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's most recent Minimum Data Set (MDS) assessment, dated 3/7/22, indicated Resident #59 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated he/she is cognitively intact. Review of Resident #59's weights indicated the following: *On 12/17/21: 98.0 pounds (lbs.) *On 12/30/21: 89.5 lbs. (8.67% weight loss in approximately two weeks) *On 1/14/22: 84.2 lbs. (5.92 %weight loss in approximately two weeks) Review of Resident #59's medical record failed to indicate the physician was notified of the significant weight loss. During an interview on 4/22/22 at 7:14 A.M., Unit Manager (UM) #2 said, in general, after a weight loss is identified, the staff reweighs the Resident, checks the scales, and if the staff do all the above and the weight loss remains, the physician is notified. UM #2 confirmed that notification of Resident #59's weight loss to the physician was not done.

Based on records reviewed and interviews for one of the three sampled residents (Resident #1), the facility failed to he/she was free of a significant medication error, when due to a transcription error, Resident #1 was administered [MEDICATION NAME] (a diuretic medication) 20 milligrams (mg) three times a day on Monday, Wednesday and Saturday, however, his/her physician's orders [REDACTED].#1 was transferred to the Hospital Emergency Department for evaluation. Finding include: Review of the Facility's Medication Error Recognition and Prevention Policy, dated as revised on 8/26/20, indicated errors can occur during prescription and transcription when not adhering to the five categories of medication errors, which are the following; wrong medication, wrong resident, wrong route, wrong dose and wrong time. Review of Resident #1's medical record indicated, Resident #1 had a [DIAGNOSES REDACTED]. Review of Resident #1's acute Hospital Medication Discharge Summary indicated, Resident #1's medications included [MEDICATION NAME] 20 milligrams (one tablet) by mouth, once per day, every Monday, Wednesday and Friday. Review of Resident #1's Medication Administration Record [REDACTED]. The Facility's Medication Incident Report indicated, on 8/25/20, Resident #1's medication order for [MEDICATION NAME] was incorrectly transcribed and Resident #1 received additional five doses. During an interview on 9/23/20 at 4:26 P.M., Nurse #1 said on 8/12/20, Resident #1's [MEDICATION NAME] medication was transcribed incorrectly upon admission as 20 mg by mouth, three times a day, every Monday, Wednesday and Saturday. Nurse #1 said Resident #1's acute Hospital Medication Discharge Summary indicated Resident #1 [MEDICATION NAME] medication order was for 20 mg by mouth, once per day, every Monday, Wednesday and Friday. During an interview on 10/23/20 at 10:47 A.M., Nurse #2 said he did not recall reviewing and transcribing Resident #1's [MEDICATION NAME] with Nurse #1. Nurse #2 said during a residents admission process, he will review his/her medications with another nurse when transcribing and had not realize Resident #1's [MEDICATION NAME] was transcribe incorrectly. During an interview on 9/23/20 at 1:01 P.M., The Director of Nurses said Resident #1's [MEDICATION NAME] was transcribe incorrectly on admission and that he/she received a total of five extra doses. The Director of Nurses said when the facility has a new admission, it is the responsibility of two nurses to closely review the resident's medication orders to ensure transcription is completed correctly. On 9/23/20, the facility provided Surveyor #1 with a plan of correction which addressed the concern as evidenced by: A) All new admissions to the facility and residents who were prescribed [MEDICATION NAME], records were audited from 8/25/20 to 9/02/20 to ensure medication transcription were completed correctly. B) The facility will continue to conduct random audits of new admissions for three months C) Nursing Supervisor will oversee and review all new admission medication orders in the facility. D) On 8/26/20 Nurse #1 attended an in-service on medication transcription, completed a medication pass competency and written exam on 9/2/20 and completed a weekly review audit for a month including Nurse #1's follow up progress checkpoints. E) On 8/26/20 Nurse #2 attended an in service on medication transcription, completed a medication written exam on 9/2/20, medication pass competency on 9/18/20 and completed a weekly review audit for a month including Nurse #2's follow up progress checkpoints. F) 9/18/20 Audits were completed by the Director of Nurses related to Nurse #1 and Nurse #2 follow-up progress checkpoints. G) QAPI, medication audits will be discussed at the monthly meeting with QAPI team and discussions of medications will continue on a monthly basis. H) A nursing wide facility mandatory medication in service on transcription errors and how it can be prevented was completed on 9/2/20 and 9/8/20. I) Facility wide mandatory nursing medication pass reviews were completed on 9/22/20. H) The Facility's Medication Error Recognition and Prevention Policy, was reviewed and revised 8/26/20, to include that all new admissions will be reviewed by senior management. J) The Director of Nurses and/or his/her designee will be responsible for overall compliance.

Based on observation, record review, and interview, the facility failed to ensure staff properly implemented the use of Personal Protective Equipment (PPE) while providing care for residents negative for COVID-19 ([MEDICAL CONDITION] causing respiratory illness), increasing the risk for transmission of COVID-19/disease. Findings include: On 8/24/2020 at 11:10 A.M., the surveyor observed Activity Staff #1 enter room [ROOM NUMBER] on the third-floor unit. A resident under quarantine for COVID-19 resided in room [ROOM NUMBER]. Activity Staff #1 was wearing a mask, but did not have any eye protection on. Activity Staff #1 asked the resident in room [ROOM NUMBER] if he/she needed anything and left the room. On 8/24/2020 at 11:15 A.M., the surveyor observed Activity Staff #1 enter room [ROOM NUMBER] on the third-floor unit. A resident who was negative for COVID-19 resided in room [ROOM NUMBER]. Activity Staff #1 was wearing a mask, but did not have any eye protection on. During an interview on 8/24/2020 at 11:16 A.M., Activity Staff #1 said she was not sure if her glasses provided adequate eye protection, and would get goggles for future resident room visits. On 8/24/2020 at 11:28 A.M., the surveyor observed Activity Staff #2 assisting a resident in room [ROOM NUMBER] with a video call. The resident was negative for COVID-19. Activity staff #2 did not have eye protection on over his eyes while assisting the resident. During an interview on 8/24/2020, Activity Staff #2 said he should have had his eye protection on when he was assisting the resident in room [ROOM NUMBER] with the video call. On 8/24/2020 at 12:13 P.M., the surveyor observed Unit Manager #1 enter room [ROOM NUMBER] on the second-floor unit. Unit Manager #1 was not wearing eye protection when she entered the room. The surveyor observed Unit Manager #1 assisting the resident in the b-bed with setting up his/her lunch tray. The resident in 224 was negative for COVID-19. During an interview on 8/24/2020 at 12:20 A.M., Unit Manager #1 said she did not wear her eye protection in room [ROOM NUMBER] because she was not performing high-contact care with the resident in 224. Review of the CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated July 15, 2020, indicated healthcare personnel should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of the facility policy Facility Procedure following MA DPH Guidelines July 30, 2020 for PPE, undated, indicated COVID-19 negative residents always require a face mask and goggles or face shields (eye protection). During an interview on 8/24/2020 at 9:15 A.M., the Assistant Director of Nursing said staff entering rooms of residents negative for COVID-19 should wear a facemask and eye protection to protect against transmission of COVID-19.

Based on observation, the facility failed to follow infection control practices in response to COVID-19 on 2 of 2 units. On 7/6/20, the following was observed on the second floor unit: * At 8:05 A.M., a staff member walked into the hallway out of a resident's room with used gloves still on. On 7/6/20, the following was observed on the third floor unit: * At 7:10 A.M., a staff member walked into the hallway out of a resident's room with used gloves still on. * At 7:30 A.M., a staff member placed a used isolation gown on the hallway railing and walked away. * At 8:30 A.M., a staff member touched a resident's muffin and peeled banana with ungloved hands during breakfast.

Based on observation and interview, the facility staff failed to ensure that residents had a safe, comfortable and home-like environment on 2 of 3 nursing units. Findings include: [NAME] During rounds on 7/9/19 at 10:36 [NAME]M., the surveyor observed the following on the 2nd floor: 1. room [ROOM NUMBER]; the bed was missing a headboard and the wall behind the head of the bed had holes and gauges where the bed frame had come in contact with the wall. The surveyor also observed a white blanket rolled up and placed between the head of the bed and the wall and a piece of toast and a dirty towel on the floor between the head of the bed and the wall. The surveyor then observed the bathroom door to be gauged and the radiator in the bathroom to be dented, scraped and falling apart. 2. room [ROOM NUMBER] B there were several water stains on the ceiling and the radiator cover was falling off. 3. The shower room floor had broken and missing tiles. 4. The ceiling vent in front of the nurses station was rusted over the entire surface. B. During rounds on 7/ 10/19, at 9:10 [NAME]M., the surveyor observed the following on the 3rd floor: 1. The day room had 1 missing ceiling tile and 1 ceiling tile was falling down. 2. room [ROOM NUMBER] closet ceiling had an approximately 6 inch metal pipe exiting from a hole and entering a hole in the back of the closet wall. The pipe was half wrapped with pink insulation and white metal foil, both of which were torn and falling off. The pipe also had 3 white cables exiting the closet walls and wrapped around the pipe. The ceiling from which the pipe exited had brown staining circling the pipe. 3. room [ROOM NUMBER] the wall had peeling paint. 4. room [ROOM NUMBER] the outlet for the television cable was coming out of the wall exposing the wiring. 5. room [ROOM NUMBER] the wallpaper surrounding the air conditioner was peeling. 6. room [ROOM NUMBER] beneath the window the paint was peeling, the laminate was falling off and there were brown stains. Under the radiator was rusted. 7. room [ROOM NUMBER] beneath the window the laminate was falling off. 8 The vent in front of the nurse's station was rusted. During an interview on 7/10/19, the Administrator said that there were currently no plans for renovations.

Based on observation, interview and record review, the facility staff failed to ensure that a plan of care for a chair alarm was implemented for 1 Resident (#54) and failed to ensure a weekly weight was obtained for 1 Resident (#58), out of a total sample of 24 Residents. Findings include: 1. Resident #54 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) indicated Resident #54 had a moderate cognitive impairment, scoring an 8 out of 15 on the Brief Interview for Mental Status (BIMS) and required extensive assistance with transfers and ambulation. Review of the plan of care and the physicians orders for (MONTH) 2019 indicated that Resident #54 was to have a chair alarm to alert staff of an attempt to self ambulate every shift. On 7/09/19, at 10:00 [NAME]M. the surveyor observed Resident #54 in the 3rd floor dining room attempting to stand up. The chair alarm did not sound and the cord to the chair alarm box was disconnected. On 7/10/19 at 11:49 [NAME]M. the surveyor observed Resident #54 sitting in his/her wheelchair. The cord to the chair alarm was disconnected. During an interview with Unit Manager #1, on 7/11/19 at 8:33 [NAME]M., she said that Resident #54 should have had a chair alarm connected to remind him to ask for assistance with ambulation. 2. For Resident #58, the facility staff failed to ensure a weekly weight was obtained. Resident #58 was admitted to the facility in 5/2019 with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE], revealed that Resident #58 had a Brief Interview for Mental Status score of 15 out of a possible 15 which indicated that he/she is cognitively intact. The Minimum Data Set also indicated that Resident #58 required extensive assistance for all activities of daily living. Review of Resident #58's nutritional care plan dated 5/28/19 indicated an intervention that the resident's weight should be taken weekly. Review of Resident #58's record indicted that since the nutritional care plan was put in place 6 weeks ago, his/her weight has only been taken once. During an interview on 7/11/19 at 9:01 [NAME]M., Nurse Manager #1 said that there should have been an order for [REDACTED].

Based on observation and interview the facility staff failed to ensure resident call lights were within reach. Findings include: 1. During rounds on 7/9/19, at 7:30 [NAME]M., the surveyor observed the following; a. room [ROOM NUMBER] B the call light was lying on the floor at the head of the bed and Resident #28 was sitting in a chair at the foot of the bed. b. room [ROOM NUMBER] B the call light was lying on the floor at the head of the bed. The resident was asleep in the bed. c. room [ROOM NUMBER] B the resident was sitting on edge of bed with the call light on the floor out of reach. The surveyor observed a Certified Nurse's Aide (CNA) enter the room with a breakfast tray, assist the resident to set up the meal and leave the room without ensuring the resident had access to the call light. 2. room [ROOM NUMBER] B on 7/9/19, at 10:12 [NAME]M., and again at 12:34 P.M., the surveyor observed the call light was lying on the floor at the head of the bed. Resident #28 was sitting in a chair at the foot of the bed. During an interview on 7/9/19, at 12:35 P.M., Resident #28 said that the CNA's were supposed to put the call light across the bed so she/he could reach it but that they often forget to do so. Resident #28 also said that she/he requires help to walk to the bathroom and will sometimes go without help because the call light is not in reach. Review of the facility policy titled Call Light, Use of and dated 3/2009, indicated to be sure the call light is always placed within the alert resident's reach.

Based on observation and interview, the facility staff failed to provide a dignified dining experience for residents on 1 out of 3 units. Findings include: The following observations were made in the third floor unit dining room on 7/9/19, at 8:25 [NAME]M., during the breakfast meal: -There were 3 residents seated at a table. Two residents were provided their meals and began to eat. The third resident waited 10 minutes for his/her meal to arrive. -A second table had 3 residents seated and waiting for breakfast. Two residents were provided their meals and began to eat. The third resident waited 20 minutes for his/her meal to arrive. The following observations were made in the third floor unit dining room on 7/9/19 at 12:23 P.M., during the lunch meal: -There were 3 residents seated at a table. Two residents were provided their meals and began to eat. The third resident waited 10 minutes for his/her meal to arrive. -A Certified Nursing Assistant was assisting a resident with self-feeding. The Certified Nursing Assistant was seated on the arm rest of the chair, rather than the seat, raised above the level of the resident. The following observations were made in the third floor unit dining room on 7/10/19 at 8:25 [NAME]M., during the breakfast meal: -There were 4 residents seated at a table. Three residents were provided their meals and began to eat. The third resident waited 10 minutes for his/her meal to arrive. The following observations were made in the third floor unit dining room on 7/10/19 at 12:00 P.M., during the lunch meal: -There were 2 residents seated at a table. One resident was provided his/her meal and began to eat. The second resident waited 10 minutes for his/her meal to arrive. -A Certified Nursing Assistant was observed asking a resident if he/she would like a bib. The following observations were made in the third floor unit dining room on 7/11/19 at 8:15 [NAME]M., during the breakfast meal: -A Nurse referred to a resident as a feed in front of residents. During an interview on 7/11/19 at 8:30 [NAME]M., Unit Manager #1 confirmed that meals should be delivered to all residents sitting at a table at the same time.