Every finding on record at Armenian Nursing & Rehabilitation Center

Based on observations and interviews, the facility failed to provide a homelike environment during dining on one of two nursing units. Specifically, on the second-floor unit, residents were observed eating meals on meal trays in the dining room.Findings include:On 12/9/25 at 8:42 A.M., the surveyor observed residents in the second-floor dining room eating breakfast. Meals were served to the residents on the trays. On 12/9/25 at 12:12 P.M., the surveyor observed 19 residents eating lunch in the second-floor dining room. All residents had their meals served on the trays. On 12/10/25 at 8:07 A.M., the surveyor observed nine residents, sitting at four different tables eating breakfast in the second-floor dining room. All residents had their meal served to them on the trays. On 12/10/25 at 12:14 P.M., the surveyor observed 19 residents eating lunch in the second-floor dining room. All residents had their meal served to them on the trays. On 12/11/25 at 8:33 A.M., the surveyor observed six residents in the dining room on the second-floor. Three residents had already finished eating their breakfast, and three residents were eating their breakfast meal which was served to them on the trays. During an interview on 12/11/25 at 8:34 A.M., Certified Nurse Aide (CNA) #2 said that they always serve the meals in the dining room on the trays. During an interview on 12/11/25 at 8:38 A.M., Nurse #2 said that it is the practice of the facility not to remove the meals from the trays in the dining room. During an interview on 12/11/25 at 8:43 A.M., the Director of Nurses said that it has always been the practice of the facility to serve the meals in the dining room on the trays. The Director of Nurses further said that it would create a more homelike environment to remove the meals from the trays when serving the residents.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#11 and #20) out of a total sample of 21 residents. Specifically, the facility failed to provide assistance and/or supervision with meals as per the plan of care for Resident #11 and for Resident #20. Findings include:Review of the facility policy titled Activities of Daily Living (ADL), not dated, indicated ADL assistance will be provided according to the needs of the residents. ADL include: bathing, grooming, mobility, incontinence care, positioning, transfer, eating and others. 1a. Resident #11 was admitted to the facility in April 2025 with diagnoses that included major depressive disorder, asthma, presbyopia, chronic kidney disease, and fibromyalgia. Review of most recent Minimum Data Set (MDS) assessment, dated 10/31/25, indicated he/she scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review of the MDS indicated the Resident required supervision/touching assistance from staff for eating. Review of Resident #11's activity of daily living care plan, dated 5/12/25, indicated Supervision during meals. Review of Resident #11's nutrition care plan, dated 5/6/25, indicated Encourage the Resident to attend the dining room for meals to enhance socialization and to provide supervision/encouragement while eating. Review of the care card binder on the unit, failed to indicate a care card/Kardex (a document that informs the staff of the required level of assistance required by a resident) for Resident #11 to indicate the level of assistance required to care for the Resident. On 12/9/25 at 8:11 A.M., the Resident was observed in bed with his/her breakfast tray set up to consume with their privacy curtain pulled unable to be seen from the hallway. No staff were present in the room. On 12/10/25 at 8:02 A.M., the Resident was observed eating breakfast alone in his/her room sitting on the side of the bed. The curtain was pulled around the Resident, and he/she was not visible from hallway. On 12/11/25 from 8:11 A.M. to 8:25 A.M., the Resident was observed in bed with his/her breakfast tray set up to consume with their privacy curtain pulled, door shut and light off unable to be seen from the hallway. No staff were present in the room. The surveyor requested a copy of Resident #11's care card/ Kardex but the facility did not provide one. During an interview on 12/11/25 at 8:18 A.M., CNA #1 said each Resident has a Kardex to follow and all staff are expected to follow their plan of care. During an interview on 12/11/25 at 8:20 A.M., Nurse #1 said staff are expected to stay with Resident #11 during the whole meal. Nurse #1 said staff need to stay to make sure the Resident eats. 1b. Resident #20 was admitted to the facility in December 2021 with diagnoses that included congestive heart failure, dysphagia, oral phase and weakness. Review of the Minimum Data Set, dated [DATE], indicated a Brief Interview for Mental Status score of 10 out of 15, indicating moderate cognitive impairment. The MDS further indicated that the Resident required supervision or touching assistance with meals/ eating. Review of Resident #20's active Activities of Daily Living (ADL) care plan indicated the following intervention: [Resident] is supervised with eating - Needs assistance setting up meal and cutting food into bite-sized pieces and reminders to insert dentures, intervention dated as revised 9/28/23. Review of Resident #20's active Nutrition care plan indicated the following: [Resident] is at risk for compromised nutritional status r/t hx (related to history of) adult FTT (failure to thrive), BMI (body mass index) 30 = obesity, dx: (diagnoses) diet-controlled DM (diabetes mellitus), dementia, hx: dysphagia (difficulty swallowing) and selective appetite. Review of the Resident ADL Guide (resident care card utilized to inform the staff of the level of assistance the resident requires) for Resident #20 indicated that the Resident requires supervision or touching assistance for assistance with eating. On 12/9/25 at 8:15 A.M. the surveyor observed Resident #20 sitting up on the side of his/her bed eating breakfast alone in the room. The door to the resident room was closed and the Resident was sitting behind a closed curtain. On 12/9/25 at 12:18 P.M., the surveyor observed Resident #20 sitting on the side of his/her bed with the privacy curtain pulled. The Resident was eating lunch alone in his/her room. During a continuous observation on 12/10/25 from 8:13 A.M. to 8:27 A.M., the surveyor observed the nurse bring the breakfast tray into Resident #20's room and then exit the room. The Resident was observed sitting on the side of his/her bed eating breakfast alone in the room. During a continual observation on 12/11/25 from 8:11 A.M. to 8:23 A.M., the surveyor observed staff bring the breakfast tray into Resident #20's room and exit the room. The Resident was observed sitting on the side of his/her bed eating breakfast alone in their room. The privacy curtain was pulled around the Resident's bed and the door to the Resident's room remained closed. During an interview on 12/11/25 at 8:19 A.M., the Director of Nurses said that staff use paper care cards to inform the staff of the level of assist a resident requires. During an interview on 12/11/25 8:20 A.M. Nurse #1 said that if a resident's care plan indicates the need for supervision or touching assistance is required for eating, staff should remain with them for the duration of the meal and the care plan should be followed. She further said that Resident #20 should be supervised for meals based on his/her care plan. She said that with the Resident's door closed and or the curtain pulled, staff are not able to supervise the Resident, but they should be. During an interview on 12/11/25at 8:45 A.M., the Director of Nurses said that if a resident's care plan indicates the need for supervision, then the staff should be providing supervision during the meal to the resident. She further said that nurses and CNA's who are not assisting in the dining room should be cycling through the unit to supervise the residents who require supervision during meals to ensure they are safely eating their meals.

Based on observation and interviews the facility failed to provide a dignified dining experience for several residents on one resident care unit (the first floor), out of two resident units. Findings include: Review of the facility policy titled Dignity, not dated, indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. On 1/14/25 from 8:49 A.M. to 8:59 A.M., the surveyor observed a nurse standing while feeding a resident in his/her room. On 1/15/25 from 8:11 A.M. to 8:20 A.M., the surveyor observed a staff member deliver a resident his/her breakfast tray to the resident room. The staff member did not set up the tray but left it within reach of the resident and then exited the room. The surveyor observed the resident unable to initiate self-feeding. During lunch service in the first floor dining room on 1/14/25 at 12:01 P.M., a Resident was sitting at a table with three other residents who were being assisted by staff with eating. The Resident was hunched over with his/her head down facing the table with no meal in front of him/her while his/her tablemates were being assisted with eating. At 12:21 P.M., 20 minutes later, a staff member sat down with the Resident to assist with eating, the other tablemates were finished eating at this time. During breakfast service on the first floor on 1/15/25 at 8:51 A.M., a staff member delivered a breakfast tray to a resident in his/her room. At 8:57 A.M., a Certified Nursing Assistant was observed standing while feeding the resident, not at eye level of the resident, who was lying in his/her bed. During an interview on 1/16/25 at 7:54 A.M., Nurse #1 said staff should not serve a dependent resident meal to the resident until a staff member is ready to assist them with that meal. Nurse #1 said staff should be seated while assisting residents with their meal. During a follow up interview on 1/16/25 at 8:37 A.M., Nurse #1 said staff should not be standing while assisting with feeding residents and all residents at a table in the dining room should be served meals at the same. During an interview on 1/16/25 at 8:10 A.M., Certified Nurse Aide (CNA) #1 said staff should not leave meal trays in front of dependent residents until a staff member is ready to assist them. CNA #1 said staff should not stand while feeding a resident and instead the staff need to sit. During an interview on 1/16/25 at 9:19 A.M., the Director of Nurses (DON) said she expects when the meal is delivered to the resident then the staff should be ready to assist that resident. The DON said she expects staff to sit while feeding a resident and that all residents should be served their meal trays at the same time if they are sitting at a table in the dining room. 45984

Based on observation, interview and record review, the facility failed to develop a care plan for one Resident (#53), out of a total sample of 19 residents. Specifically, the facility failed to develop a vision care plan. Findings Include: Review of the policy titled Care Plan-Comprehensive, undated, indicated: Policy: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's of medical, nursing, mental and psychological needs is developed for each resident. -Residents will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychological needs. -For newly admitted residents, the comprehensive care plan must be completed within seven days of the completion of the comprehensive assessment (MDS Admission Assessment) and no more than 21 days after admission. Resident #53 was admitted to the facility in August 2022 with diagnoses that included low vision right eye category 2, blindness left eye category 5, combined forms of age-related cataract, central retinal artery occlusion, left eye, chronic systolic (congestive) heart failure and weight loss. Review of Resident #53's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #53 has a Brief Interview for Mental Status (BIMS) exam score of 10 out of a possible 15 which indicated he/she has moderate cognitive deficits. The MDS assessment also indicated Resident #53 requires dependent assistance for self-care activities and has moderate vision impairments. On 1/14/25 at 8:10 A.M., the surveyor Resident #53 sitting in his/her chair eating breakfast. Resident #53 was asked what he/she was having for breakfast, he/she said I can't see everything on my plate. Resident #53 said he/she is unable to see out of his/her left eye and his/her vision in the right eye is blurry. Resident was asked if staff inform him/her what is on their plate, he/she said no but knows what food it is once he/she tastes it. On 1/15/25 at 12:15 P.M., the surveyor observed Resident #53 sitting in his/her chair getting ready to eat lunch. Resident #53 was asked if he/she was able to see what was on his/her plate for lunch. Resident #53 said he/she has something dark and something light on his/her plate and knows there is something to drink. Resident #53 was asked if he/she was able to identify his/her dessert, he/she said no. Resident #53 again stated that he/she will know what food it is once he/she tastes it. Record review on 1/15/25 at 3:43 P.M., failed to indicate a care plan was developed for low vision with interventions for Resident #53. During an interview on 1/16/25 at 8:25 A.M., Unit Manager #2 said the facility works with the family to identify the best strategies for the resident with visual deficits and educate the staff. Unit Manager #2 said she was not aware that Resident #53 was unable to identify the food on his/her plate. Unit Manager #2 said she would expect a visual care plan to be developed and implemented on admission. During an interview on 1/16/25 and 9:15 A.M., the Director of Nursing said she would expect a vision care plan to be developed on admission.

Based on observation, record review and interview, the facility failed for two Residents (#63 and #61), out of a total sample of 19 residents, to provide weekly skin assessments in accordance with the physician's order. Specifically, 1. For Resident #63, the facility failed to complete weekly skin assessments, as per the physician's order, resulting in four missed weekly skin assessments, 2. For Resident #61, the facility failed to complete weekly skin assessments, as per the physician's order. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility policy titled Pressure Ulcer Risk Assessment and Prevention, not dated, indicated Skin assessment will be done by a licensed nurse on admission and weekly thereafter. Skin will be assessed for the presence of developing pressure ulcers or other skin conditions. 1. Resident #63 was admitted to the facility in December 2024 and has diagnoses that include but are not limited to mild cognitive impairment, neoplasm of bladder, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 scored a 9 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having moderately impaired cognition. Further, the MDS indicated Resident #63 as dependent on staff for bathing, upper and lower dressing, has no unhealed pressure ulcers, and is at-risk for developing pressure ulcers. During an observation and interview on 1/14/24 at approximately 9:30 A.M., Resident #63 was observed sitting in a wheelchair in the dining/activity room. Resident #63 said his/her feet hurt. When asked if he/she had any open areas or injuries, he/she said it feels like they (feet) are cut. Review of Resident #63's medical record indicated the following: - A nursing Admission/ReAdmission (sic) assessment dated [DATE], indicated Resident #63 was assessed to have intact skin. - A physician's order indicated weekly skin assessment by a licensed nurse, document under assessments in PCC (the electronic medical record) every evening shift, every Friday. Start date 12/20/24. Review of Resident #63's clinical record failed to indicate any weekly skin assessments were completed. Review of the Treatment Administration Record (TAR) for December 2024 and January 2025, indicated the dates for the weekly skin assessments, signed off by licensed nursing, occurred on 12/20/24, 12/27/24, 1/3/25 and 1/10/25, resulting in four missed weekly skin assessments. During an interview on 1/15/25 at 3:49 P.M., Nurse #4 said assessing a resident's skin is done on admission and then weekly on-going. Nurse #4 said this is completed for all residents. Nurse #4 said the weekly skin assessment is documented on the weekly skin assessment in the electronic medical record. At this time, Unit Manager #2 came over and looked at Resident #63's assessments tab in the electronic medical record and said there were no weekly skin assessments there. Unit Manager #2 checked the progress notes and said there were no nursing notes regarding skin assessments. Unit Manager #2 said there was a note dated 1/10/25 regarding Resident #63's coccyx. Unit Manager #2 said the nursing staff are required to document on the weekly skin assessment the status of the resident's skin and not just sign the TAR. Review of the nursing note dated 1/10/24 at 12:44 P.M., indicated the primary nurse requested the physician and this nurse to assess Resident #63's coccyx due to redness at site. The note indicated the coccyx cleft is red and blanching, and the physician determined the area had some moisture-associated skin damage at coccyx cleft due to warm moist environment. In accordance with the physician's order, Resident #63 should have had weekly skin assessments completed for the weeks of 12/20/24, 12/27/24, 1/3/25, and 1/10/25. During an interview on 1/16/25 at 9:19 A.M., the Director of Nurses said she expects the weekly skin checks to be completed as ordered. 43846 2. Resident #61 was admitted to the facility in March 2024 with diagnoses that included Parkinson's disease, end stage renal disease, and type 2 diabetes. Review of Resident #61's most recent Minimum Data Set (MDS) assessment, dated 12/14/24, indicated he/she scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating moderate cognitive impairments. The MDS further indicated the Resident is at-risk for developing pressure ulcers. Review of Resident #61's physician order, dated 3/28/24, indicated Weekly skin assessment by a licensed nurse, document under assessments in the electronic medical record. Review of Resident #61's diabetes care plan, dated 3/28/24, indicated Weekly skin assessment by a licensed nurse. Review of Resident #61's assessment section in the electronic medical record indicated the last completed skin assessment occurred on 11/21/24. Review of Resident #61's nursing progress notes from 11/24/24 through 1/15/25 failed to indicate that the Resident refused any skin checks. During an interview and observation of Resident #61's medical record on 1/16/25 at 8:06 A.M., Nurse #2 said Resident #61 does have an order for weekly skin checks and they should be done under the assessment tab in the electronic medical record. Nurse #2 said the last skin check recorded in the medical record was on 11/21/24. Nurse #2 said if a resident refuses a skin check, then it should be written in a nurse's progress note. During an interview on 1/16/25 at 9:19 A.M., the Director of Nurses said she expects the weekly skin checks to be completed as ordered.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#45 and #64) out of a total sample of 19 residents. Specifically, the facility failed to provide assistance and/or supervision with meals as per the plan of care for Resident #45 and for Resident #64. Findings include: Review of the facility policy titled Activity of Daily Living, not dated, indicated ADL assistance will be provided according to the needs of the residents. ADL include bathing, grooming, dressing, mobility, incontinence care, positioning, transfer, eating and others. 1a. Resident #45 was admitted to the facility in September 2024 with diagnoses that included dementia, dysphagia, cognitive communication deficit and depression. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. The MDS further indicated he/she is dependent on staff for eating. On 1/14/25 from 8:48 A.M. to 8:59 A.M., the surveyor observed Resident #45 in bed with his/her breakfast tray setup with out any staff present. Resident #45 was observed not initiating self- feeding. On 1/14/25 from 12:09 P.M. to 12:23 P.M., the surveyor observed Resident #45 in the dining room with his/her lunch tray setup without any staff present assisting him/her. Resident #45 was observed not initiating self-feeding and falling asleep at times. On 1/15/24 from 8:38 A.M. to 9:00 A.M., the surveyor observed Resident #45 in bed with his/her breakfast tray setup without any staff present. Resident #45 was observed not initiating self- feeding. Review of Resident #45's Activity of Daily Living (ADLs) care plan, dated 9/9/24, indicated ADL DEPENDENT: The Resident is dependent on staff with all ADLs due to: Dementia. During an interview on 1/16/25 at 7:54 A.M., Nurse #1 said Resident #45 needs assist from a staff member to eat. During an interview on 1/16/25 at 7:55 A.M., the MDS Nurse said if the Resident MDS is coded as the Resident being dependent with eating then that resident needs a staff member to feed them. During an interview on 1/16/25 at 8:10 A.M., Certified Nurse Aide (CNA) #1 said she is Resident #45's regular CNA during the day and said the Resident is a dependent resident and needs assist to eat his/her meal. CNA #1 said if the meal was in front of the Resident a staff member should be with him/her to assist the Resident with their meal. During an interview on 1/16/25 at 9:19 A.M., the Director of Nurses (DON) said if a resident is coded as dependent for eating then a staff member should be assisting the resident with their meal. 45984 1b. Resident #64 was admitted to the facility in January 2022 with diagnoses including chronic diastolic heart failure, dysphagia (difficulty swallowing) and Parkinson's disease. Review of Resident #64's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that Resident #64 requires supervision or touching assistance from staff while eating meals. The surveyor made the following observations: - On 1/14/25 at 8:15 A.M., Resident #64 was sitting up in his/her bed eating his/her breakfast in his/her room at the end of the hallway. There were no staff members in his/her room offering assistance or providing supervision and the Resident could not be seen by staff from the hallway. - On 1/15/25 from 8:11 A.M. until 8:26 A.M., Resident #64 was sitting up in his/her bed eating his/her breakfast in his/her room at the end of the hallway. There were no staff members in his/her room offering assistance or providing supervision and the Resident could not be seen by staff from the hallway. - On 1/15/25 at 12:05 P.M., Resident #64 was eating lunch in his/her room at the end of the hallway. The resident was standing, hunched over his/her bedside table where the lunch tray was. Resident #64 was eating very rapidly and not alternating bites and sips of liquid. There were no staff members in his/her room offering assistance or providing supervision and the Resident could not be seen by staff from the hallway. - On 1/16/25 at 8:12 A.M., Resident #64 was eating breakfast in his/her room at the end of the hallway. The resident was standing, hunched over his/her bedside table where the lunch tray was. Resident #64 was eating very rapidly and not alternating bites and sips of liquid. The Resident's door was shut to his/her room. there were no staff members in his/her room offering assistance or providing supervision and the Resident could not be seen by staff from the hallway. At 8:33 A.M., 21 minutes since Resident #64 received his/her breakfast tray, a staff member checked in on the resident. Review of Resident #64's ADL Guide indicated that the resident requires supervision or touching assist while eating. Review of Resident #64's ADL Assistance care plan indicated the following interventions dated 2/8/24: Supervise and/or assist resident during meals to dysphagia and prefers to take his/her meals in his/her room. Review of Resident #64's nutrition care plan dated and revised 10/11/24 indicated that the resident is at risk of compromised nutritional status related to selective appetite with a history of dysphagia with silent aspiration of fluids. The care plan had the following intervention: Monitor for signs/symptoms of aspiration (wheezing, trouble breathing, a hoarse voice after eating, drinking and/or vomiting, or experiencing heartburn) at meal and snack time. Review of Resident #64's document titled Speech Therapy - Speech Language Pathologist Discharge Summary, dated from 2/8/24 - 5/7/24 for dysphagia therapy, indicated the following: - D/C (Discharge) instructions: Upright for intake, small bites/sips, slow rate, alternate solids/liquids, clear bolus before next bite. The document indicated that staff were educated on the discharge instructions for Resident #64. Review of Resident #64's Dietary Quarterly Assessment completed by the Registered Dietitian, dated 1/8/25, indicated the following: - Risk Factors: Silent aspiration of fluids During an interview on 1/16/25 at 8:37 A.M., Nurse #1 said staff will look at the care plans to know what type of ADL care residents need. Nurse #1 said Resident #64 is on aspiration precautions and he/she should be supervised as much as possible while eating. Nurse #1 said he/she can choke in an instant and staff need to do a better job with his/her supervision while he/she is eating. During an interview on 1/16/25 at 9:21 A.M., the Director of Nursing (DON) said the Certified Nursing Assistants use care cards to know what ADL care each residents need. The DON said the facility uses rotating supervision where staff go around and check in on each resident while they are eating in their rooms. The DON said a resident can choke in an instance and Resident #64 should be supervised more closely during meals.

Based on policy review and interview, the facility failed to educate and offer the COVID-19 vaccine to one of one (Nurse #3) sampled staff member. Findings include: Review of the facility policy COVID-19 Infection Control Protocol dated as revised 11/6/23, indicated: All employees are encouraged to be vaccinated with the current vaccine requirements to be considered vaccinated according to DPH guidelines. We will honor employees' wishes and can decline vaccine booster for religious, medical and personal reasons in accordance to the most current DPH guidelines. During an interview with the Director of Nursing (DON) on 1/16/25 at 9:32 A.M., the surveyor requested evidence that the facility had educated Nurse #3 on the benefits and risks and potential side effects associated with the COVID-19 vaccine. The surveyor also requested evidence the facility had offered Nurse #3 the COVID-19 vaccine or information on obtaining the vaccine. The DON said the facility had not educated Nurse #3 about the COVID-19 vaccine or offered the COVID-19 vaccine, or provided information either verbally or in writing on how to obtain the vaccine. The DON said Nurse #3 was not offered a consent or declination form for the vaccine. The DON said that when staff ask her about acquiring the vaccine, she directs them to their local pharmacy. The DON said Nurse #3 had not asked her about how to obtain the COVID-19 vaccine.

Based on observation and interviews, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on two out of two units. Findings include: During an initial tour of the 1st and 2nd floor Units on 1/24/24 the surveyors met with the residents and the following concerns were expressed: -At 8:23 A.M. Resident #12 said he/she disliked the food at the facility. -At 8:36 A.M. Resident #17 said the meals are horrible. -At 8:50 A.M. Resident #222 said he/she disliked the food at the facility. -At 9:10 A.M. Resident #49 said the tea and oatmeal is often cold. On 1/25/24 at 7:30 A.M., during the breakfast tray line observation, the surveyor observed that the plate warmer was not being utilized and that all resident drinks were pre-poured and already on the trays. On 1/25/24 at 8:07 A.M., the 2nd floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 8:13 A.M., and the following was recorded and observed: - Milk was 61.3 degrees Fahrenheit and tasted room temperature, not cold. - Juice was 63.1 degrees Fahrenheit and tasted room temperature not cold. - Scrambled eggs had a rubbery texture, and lacked in seasoning and flavor. The eggs were 98.6 degrees Fahrenheit and tasted room temperature, not hot. - Cinnamon Bread was 85.4 degrees Fahrenheit and tasted room temperature. - Oatmeal was 116 degrees Fahrenheit and tasted warm, not hot. On 1/25/24 at 8:12 A.M., the 1st floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 8:22 A.M., and the following was recorded and observed: - Milk was 60.6 degrees Fahrenheit. - Juice was 64.5 degrees Fahrenheit. - Scrambled eggs had a rubbery texture, and tasted were bland. The eggs were 109 degrees Fahrenheit and tasted cold, not hot. - Toast was 102 degrees Fahrenheit and tasted cool, not hot. - Oatmeal was 113.2 degrees Fahrenheit, and tasted warm not hot. On 1/25/24 at 11:26 A.M., the surveyor observed that the plate warmers were not being utilized, and that all resident drinks were pre-poured and already on the trays. On 1/25/24 at 11:56 A.M., the 2nd floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 12:08 A.M., and the following was recorded and observed: - Milk was 57.7 degrees Fahrenheit and tasted room temperature, not cold. - Juice was 59.5 degrees Fahrenheit and tasted room temperature not cold. - Beef was 101.8 degrees Fahrenheit and was greasy; the beef tasted warm, not hot. - Rice was 109.2 degrees Fahrenheit and was warm, not hot. - Vegetable medley was 105.4 degrees Fahrenheit and tasted warm, not hot. - Hummus was 74.6 degrees Fahrenheit and tasted room temperature. On 1/25/24 at 12:05 A.M., after all resident trays were served on the 1st floor the surveyor received the test tray, and the following was recorded and observed: - Milk was 59.3 degrees Fahrenheit and tasted warm, not cold. - Juice was 60 degrees Fahrenheit and tasted warm, not cold. - Beef was 102.9 degrees Fahrenheit, tasted oily, and was warm, not hot. - Rice was 106 degrees Fahrenheit and tasted warm, not hot. - Vegetable medley was 135.1 degrees Fahrenheit and tasted hot. - Hummus was 82.7 degrees Fahrenheit and tasted room temperature. During an interview on 1/26/24 at 7:57 A.M., the Food Service Director (FSD) said she conducts test trays intermittently but has not been recording the results. The FSD said the acceptable parameters for hot food would be 160-165 degrees Fahrenheit when the residents receive their meals. The FSD would expect cold drinks to be around 36-40 degrees Fahrenheit when the residents receive them. The FSD said drinks are pre-poured in advance, for breakfast the milk and juice is pre-poured around 7:00 A.M., half an hour before the tray line begins, and roughly an hour before all residents receive their trays. The FSD said the plate warmer is functional.

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 ensure produce with significant signs of decomposition was discarded, that staff did not store their drinks with resident food and ingredients, and that food was labeled and not kept beyond the use-by date in the main kitchen and unit kitchenettes. Findings include: Review of the undated facility's policy titled Food Handling indicated, but was not limited to, the following: - Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. - Prepared foods should be checked before serving to residents and non-labeled and foods older than 72 hours should be discarded. - Food should be stored appropriately in the refrigerator or at room temperature. - Foods should be labeled when opened and foods prepared in the facility should also be labeled. - Foods should be discarded on or before its expiration date. - Foods prepared in the facility should be discarded within 72 hours. Prepared foods should be inspected daily. On [DATE] at 07:14 A.M., the surveyor made the following observations during the initial walkthrough of the main kitchen: - A shaker bottle (a bottle with a wire ball in it for the purpose of mixing powders or additives, typically dietary supplements or flavoring, into liquid) filled with pink liquid stored next to resident food and ingredients in the walk-in refrigerator. - Two containers of strawberries with significant signs of decomposition, including discoloration, deterioration of texture, and the presence of a white, wispy growth. - A bag of cilantro with significant signs of decomposition, including discoloration and deterioration of texture. - Ground beef, the package was open but undated in the walk-in refrigerator. - A container of nectar thick consistency apple juice, opened but unlabeled in the walk-in refrigerator. - Deli meat, opened and wrapped in plastic wrap, with two dates: ,d+[DATE] and ,d+[DATE], in the walk-in refrigerator. - Cheese, opened and wrapped in plastic wrap, with two dates: ,d+[DATE] and ,d+[DATE]. - A container of apple cider, opened and almost empty but undated in the walk-in refrigerator. - A half gallon container of milk, open but undated in the walk-in refrigerator. During an interview on [DATE] at 7:26 A.M., the kitchen staff said the shaker bottle belongs to a cook. On [DATE] at 07:30 A.M., the surveyor made the following observations during the initial walkthrough of the 1st floor kitchenette: - An open container of milk, dated ,d+[DATE] On [DATE] at 07:35 A.M., the surveyor made the following observations during the initial walkthrough of the 2nd floor kitchenette: - A bottle of cranberry juice, opened but undated During an interview on [DATE] at 7:57 A.M., the Food Service Director (FSD) said all refrigerators are checked daily, and that during the daily checks produce is cycled and produce with signs of spoilage is discarded. The FSD said the strawberries and cilantro should have been discarded. The FSD said employee drinks should not be stored in the walk-in refrigerator with the resident food and ingredients, even if the drink is covered; the FSD said employees have designated refrigerators to store their drinks and food. The FSD says all food items, including milk, should be labeled and dated when they are opened or prepared, and should be discarded after three days. The FSD said that for the food items labeled with two dates that the earlier date is the prepared or opened date, and the later date is the use-by date. The FSD said the unit kitchenettes should be checked twice a day and any unlabeled or expired food should be discarded.

Based on record review and interview, the facility failed to respond to grievances communicated to staff by the resident council. Specifically, the facility failed to respond to grievances about a lack of showers and green vegetables. Findings include: Review of the facility's policy 'Grievance Policy', (undated), indicated, but was not limited to: - The facility supports each resident's right to voice grievances and assures that after receiving the complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress towards resolution. - Grievances can be voiced during the resident council meeting or at any time during the day, - Complaints/grievances can be raised by residents either verbally or in writing. - Residents have the right to prompt efforts by the facility to resolve grievances. - The Social Worker, who is the Grievance Official, retains records of grievances for at least three years and records will be available for review as needed. Grievance procedures included: - Staff member receiving complaint will notify the nursing supervisor, social worker, director of nurses or the administrator if the issue is not resolved to resident's satisfaction at the time of the complaint. - Unresolved complaints will be discussed in the interdisciplinary meeting within three business days of the complaint or knowledge of the complaint and considered a grievance] if not resolved in seven days. - The social worker, director of nurses, administrator, or designees will acknowledge the complaint/s by communicating with the resident and or the resident's responsible party. - The facility will conduct an investigation and take appropriate steps towards resolution of the complaint. - The facility will notify the resident and/ or responsible party about the results of the investigation within seven days after the interdisciplinary meeting. - The facility will communicate with the resident and/or family member about the resolution of the issues. - The facility will have documentation of the grievance and description of the resolution. - All grievances should be addressed with the resident and/or responsible party within 30 days of the initial interdisciplinary meeting, unless unable to meet with the ombudsman within a reasonable time for unresolved issues. If not resolved within 30 days, the facility will make a diligent effort to come up with a resolution as soon as possible. - Evidence demonstrating results of all grievances will be kept for a period of at least three years from the issuance of the resolution. Review of the resident council meeting minutes for 10/30/23, attended by residents and the Activity Director, indicated one resident complained of a missing blanket. Review of the grievance log entries for October and November 2023, failed to indicate a reference to a missing blanket, or a resolution. Review of the resident council meeting minutes for 11/27/23, attended by residents and the Activity Director, indicated the missing blanket from the previous month was not referenced and a resolution was not documented. The meeting minutes indicated one resident complained showers were only offered once per week, and another resident complained he/she had not showered recently. Review of the grievance log entries for November and December 2023, failed to indicate a reference to staff not offering or providing showers. Review of the resident council meeting minutes for 12/26/23, attended by residents and the Activity Director, indicated the complaint of a lack of showers was not referenced and a resolution was not documented. The meeting minutes indicated two residents asked for more green vegetables, including green beans, peas, asparagus, and spinach. Review of the grievance log entries for December 2023, failed to indicate a reference to the residents' requests for more green vegetables. During an interview with the resident group on 1/25/24 at 10:04 A.M., they said they did not recall expressing a concern in previous meetings about a missing blanket or of wanting more green vegetables. Residents said they did not know if council meetings were documented or if the facility responded to concerns raised by the council. During an interview with the Grievance Official (Social Worker) on 1/25/24 at 12:01 P.M., she said the facility discovered, during a mock survey held during the first week of January 2024, residents' grievances communicated in the resident council meetings were not relayed to the Grievance Official (Social Worker) Director of Nurses or the Administrator. The Grievance Official said that after learning of this communication breakdown she investigated and resolved the complaint of the missing blanket. The Grievance Official said she was unaware of residents' complaints from the November and December 2023 council meetings regarding a lack of showers and wanting more green vegetables with meals. The Grievance Official said these concerns were not investigated or resolved.

Based on observations, interviews, and record review, the facility failed to implement their Abuse policy when one Resident (#14) alleged he/she witnessed the abuse of his/her roommate, out of a total sample of 25 residents. Specifically, Resident #14 alleged that he/she witnessed Nurse #5 physically abuse his/her roommate in October 2023, and on 1/25/24 at 9:27 A.M., the surveyor made the Nursing Home Administrator (NHA) aware of Resident #14's allegation. Findings include: Review of the facility's policy titled, Abuse Prevention Program: Investigations and Protection of Patients, undated, indicated the following: -Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator or his/her designee will appoint a member of management to investigate the alleged incident. The Clinical Director is responsible for investigation if needed. -The Administrator, Clinical Director, or designee will report the suspected abuse to the Department of Public health, Elder Abuse Hotline, the Police, or other regulating bodies as indicated. -The individual conducting the investigation will as [sic] a minimum: -Witness reports will be obtained in writing. Either the staff member will write their statement & and date it, or the investigator may obtain the staff statement, read it back to the member and have him/her sign and date it. Resident #14 was admitted to the facility in June 2021 with diagnoses including major depressive disorder and diabetes. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 11/29/23, indicated that on the Brief Interview for Mental Status exam Resident #14 scored a 15 out of a possible 15, indicating intact cognition. During an interview on 1/25/24 at 8:57 A.M., Resident #14 told the surveyor that in October of 2023 he/she witnessed a nurse physically force his/her roommate to take medications and said the nurse grabbed the roommate by the back of the neck and head and forced him/her to take the medication. Resident #14 said that the roommate was telling the nurse no and tried pushing the nurse away but said that the nurse kept her hands around the roommate's neck and back of his/her head, putting the medication cup to the roommate's mouth until the roommate complied and took the medication. Resident #14 said he/she notified the Assistant Director of Nursing (ADON) the next morning of what he/she had witnessed and that it was abuse. On 1/25/24 at 9:27 A.M., the surveyor notified the NHA of Resident #14's allegations. The NHA said the facility is aware of the allegation of physical abuse by the nurse and after speaking with the alleged victim in October 2023, decided to review the concern as a grievance rather than an allegation of abuse. The NHA said a grievance was initiated on 10/19/23 after the facility Social Worker (SW) #1, Director of Nursing (DON) and Activities Director (the translator) spoke with Resident #14's roommate on 10/19/23 and asked him/her if they feel safe, and he/she said yes and that there was no issue. On 1/25/24 the surveyor notified both the DON and NHA that Resident #14 told the surveyor in detail, and continues to verbalize, that he/she had witnessed abuse in October 2023. The DON and NHA said that they would follow-up. Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the allegation to the state agency within the required 2 hour time frame in October 2023. Review of the active working schedule in the facility indicated that Nurse #5 continued to work in the facility, without a change in room or assignments, after the allegation of abuse was reported on 10/19/23. Review of the Medication Administration Record (MAR), indicated Nurse #5 worked directly with Resident #14 and the alleged victim, administering medications, providing treatments, and obtaining vital signs after the allegation of abuse on 10/19/23. The facility failed to conduct resident interviews and failed to ensure Nurse #5 was removed from the facility after Resident #14 reported physical abuse, potentially exposing Resident #14 and other residents in the facility to abuse. During an interview on 1/25/24 at 2:23 P.M., the Assistant Director of Nursing (ADON) said she was aware of the abuse allegation on 10/19/23 because Resident #14 told her that Nurse #5 forced Resident #18 to take his/her mediations the night before and said that Resident #14 told her that the nurse should be fired. The ADON said she notified the NHA and DON a few minutes later and was told that the NHA, DON and SW #1 were already aware of the issue. The ADON said the allegations reported by Resident #14 are reportable events and should have been reported because Resident #14 can recognize abuse. During a follow-up interview on 1/26/24 at 9:16 A.M., the ADON said that when abuse is alleged it was the expectation that the accused is suspended pending investigations and that the abuse policy and procedures be implemented. During an interview on 1/26/24 at 9:28 A.M., SW #1 said the facility didn't start an abuse investigation in October 2023 because they didn't think the allegation rose to the level of abuse. SW #1 said in hindsight interventions should have been implemented immediately to ensure residents feel safe, and the facility should have implemented the abuse policy, including but not limited to reporting the allegation to the Department of Public Health, interviewing residents and staff, removing the alleged nurse from having access to residents, and obtaining written statements. During a follow-up interview on 1/29/24 at 9:44 A.M., with the DON and SW #1, the DON said the facility should have thoroughly investigated the abuse allegation in October 2023 and reported it. As well, she said as of 1/29/24, the facility had not implemented the abuse policy, despite being notified of Resident #14's continued concern 5 days prior. SW #1 said no residents were interviewed in October 2023 and none had been since the report was relayed to the facility by the surveyor on 1/25/24.

Based on interviews and record review, the facility failed to report an allegation of abuse to the State Agency no later than two hours after the allegation was made. Specifically, on 10/19/23 Resident #14 reported to the facility that he/she witnessed Nurse #5 abuse his/her roommate and the allegation was not reported to the Department of Public Health (DPH) Health Care Facility Report Agency (HCFRS) until 1/25/24 when the surveyor discussed the allegation with the Nursing Home Administrator (NHA). Findings include: Review of the facility's policy titled, Abuse Prevention Program: Investigations and Protection of Patients, undated, indicated the following: -The Administrator, Clinical Director, or designee will report the suspected abuse to the Department of Public health, Elder Abuse Hotline, the Police, or other regulating bodies as indicated. Resident #14 was admitted to the facility in June 2021 with diagnoses including major depressive disorder and diabetes. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 11/29/23, indicated that on the Brief Interview for Mental Status exam Resident #14 scored a 15 out of a possible 15, indicating intact cognition. During an interview on 1/25/24 at 8:57 A.M., Resident #14 told the surveyor that in October of 2023 he/she witnessed a nurse physically force his/her roommate to take medications and said the nurse grabbed the roommate by the back of the neck and head and forced him/her to take the medication. According to Resident #14, the roommate was telling the nurse no and tried pushing the nurse away but said that the nurse kept her hands around the roommate's neck and back of his/her head, putting the medication cup to the roommate's mouth until the roommate complied and took the medication. Resident #14 said he/she notified the Assistant Director of Nursing (ADON) the next morning of what he/she had witnessed and that it was abuse. On 1/25/24 at 9:27 A.M., the surveyor notified the NHA of Resident #14's allegations. The NHA said the facility is aware of the allegation of physical abuse by the nurse and after speaking with the alleged victim in October 2023, decided to review the concern as a grievance rather than an allegation of abuse. Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the allegation to the state agency in October 2023. During an interview on 1/25/24 at 2:23 P.M., the Assistant Director of Nursing (ADON) said she was aware of the abuse allegation on 10/19/23 because Resident #14 told her that Nurse #5 forced Resident #18 to take his/her mediations the night before and said that Resident #14 told her that the nurse should be fired. The ADON said the allegations reported by Resident #14 are reportable events and should have been reported. During an interview on 1/26/24 at 9:28 A.M., Social Worker (SW) #1 said the facility should have implemented the abuse policy including but not limited to reporting the allegation to the Department of Public Health. During a follow-up interview on 1/29/24 at 9:44 A.M., with the DON and SW #1, the DON said the facility should have reported the allegation when it was made in October 2023.

Based on interviews and record review, the facility failed to thoroughly investigate an allegation of abuse by one Resident (#14) out of a total sample of 25 residents. Findings include: Review of the facility's policy titled, Abuse Prevention Program, undated, indicated but is not limited to the following: Our abuse prevention program provides policies and procedures that govern, as a minimum: -Identification of occurrences and patterns of potential mistreatment/abuse. -The protection of residents during abuse investigation -Timely and thorough investigations of all reports and allegations of abuse. -An ongoing review and analysis of abuse incidents; and the implementation of changes to prevent future occurrences of abuse. Review of the facility's policy titled, Abuse Prevention Program: Investigations and Protection of Patients, undated, indicated the following: -Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator or his/her designee will appoint a member of management to investigate the alleged incident. The Clinical Director is responsible for investigation if needed. -The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. -The individual conducting the investigation will as [sic] a minimum: A. Review the completed documentation forms. B. Review the patient's medical record to determine events leading up to the event interview the persons reporting the incident. C. Interview the patient is needed. D. Notify the Physician as needed to determine the resident's current level of cognitive function and medical condition. E. Interview staff members who have had contact with the resident during the period of the alleged incident. Resident #14 was admitted to the facility in June 2021 with diagnoses including major depressive disorder and diabetes. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 11/29/23, indicated that on the Brief Interview for Mental Status exam Resident #14 scored a 15 out of a possible 15, indicating intact cognition. During an interview on 1/25/24 at 8:57 A.M., Resident #14 told the surveyor that in October of 2023 he/she witnessed a nurse physically force his/her roommate to take medications and said the nurse grabbed the roommate by the back of the neck and head and forced him/her to take the medication. According to Resident #14, the roommate was telling the nurse no and tried pushing the nurse away but said that the nurse kept her hands around the roommate's neck and back of his/her head, putting the medication cup to the roommate's mouth until the roommate complied and took the medication. Resident #14 said he/she notified the Assistant Director of Nursing (ADON) the next morning of what he/she had witnessed and that he/she believed it was abuse. On 1/25/24 at 9:27 A.M., the surveyor notified the NHA of Resident #14's allegations. The NHA said the facility is aware of the allegation of physical abuse by the nurse and after speaking with the alleged victim in October 2023, decided to review the concern as a grievance rather than an allegation of abuse. Review of the active working schedule in the facility indicated that Nurse #5 continued to work in the facility, without changes in room or staffing assignments, after the allegation of abuse was reported on 10/19/23. Review of the medication administration record (MAR), indicated Nurse #5 worked directly with Resident #14 and the alleged victim, administering medications, providing treatments, and obtaining vital signs after the allegations of abuse on 10/19/23. The facility failed to conduct resident interviews and failed to ensure Nurse #5 was removed from the facility after Resident #14 reported physical abuse, potentially exposing Resident #14 and other residents in the facility to abuse. During an interview on 1/25/24 at 2:23 P.M., the Assistant Director of Nursing (ADON) said she was aware of the abuse allegation on 10/19/23 because Resident #14 told her that Nurse #5 forced Resident #18 to take his/her mediations the night before and said that Resident #14 told her that the nurse should be fired. The ADON said she notified the NHA and DON a few minutes later and was told that the NHA, DON and SW #1 were already aware of the issue. During a follow-up interview on 1/26/24 at 9:16 A.M., the ADON said that when abuse is alleged it was the expectation that the accused is suspended pending investigations and that the abuse policy and procedures be implemented, which includes a thorough investigation. During an interview on 1/26/24 at 9:28 A.M., Social Worker (SW) #1 said the facility didn't start the investigation in October 2023 because they didn't think the allegation rose to the level of abuse. SW #1 said in hindsight interventions should have been implemented immediately to ensure residents feel safe, and the facility should have implemented the abuse policy including but not limited to interviewing residents and staff, removing the alleged nurse from having access to residents, and obtaining written statements. During a follow-up interview on 1/29/24 at 9:44 A.M., with the DON and SW #1, the DON said the facility should have thoroughly investigated the abuse allegation in October 2023.

Based on observations, interviews and record review, for two Residents (#31 and #12) out of 25 sampled residents, the facility failed to provide supervision during meals. Specifically, 1. For Resident #31, the facility staff failed to provide supervision and verbal cues during meals. 2. For Resident #12, the facility failed to provide supervision or touching assistance during meals. Findings include: A review of the facility policy titled 'Activities of Daily Living' with no revision date indicated the following: -In order to protect the safety and well-being of staff and residents and to promote quality care, this facility provides assistance with activities of daily living (ADL) as needed. -ADL assistance will be provided according to the needs of the residents. -ADL includes eating. 1. Resident #31 was admitted to the facility in December 2020 with diagnoses including dysphagia and Dementia. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] did not indicate a Brief Interview for Mental Status score (BIMs) score because the Resident is rarely/never understood. Further review of the MDS assessment's functional abilities and goals for self-care indicated the following interim performance: -Eating-dependent, helper does all of the effort, resident does none of the effort to complete the activity. On 1/24/24 at 9:26 A.M., the surveyor observed Resident #31 in his/ her room sitting in a wheelchair eating breakfast on his/her own. There were no staff members in the area supervising the Resident while he/she was eating. On 1/25/24 at 8:38 A.M., the surveyor observed Resident #31 in his/her room sitting in a wheelchair eating breakfast on his/her own. There were no staff members in the area supervising the Resident while he/she was eating. On 1/25/24 at 8:43 A.M., the surveyor observed Resident #31 in his/her room sitting in a wheelchair eating breakfast on his/her own. There were no staff members in the area supervising the Resident while he/she was eating. A review of the Resident's January 2024 physician's orders indicated the following: -Supervised feed (verbal cues for attention) order date 10/3/23. A review of the Resident's ADL care plan dated 4/27/23 indicated the following: -Resident can at times feed himself/herself but eats very slowly. He/she requires supervision and cueing to stay on task and complete his/her meal and may need to be fed depending on the level of his/her fatigue. A review of the Kardex (resident's Activities of Daily Living guide) indicated the following: -Eating-Supervision A review of the speech therapy notes dated 3/29/23 indicated the following: -Evaluation: Supervision during meals for verbal cues to attend to task iso [sic] cognitive deficits. *Supervision-how often does the patient require supervision/assistance at mealtime due to swallow safety? 91-100 % of the time. -Swallow strategies-recommend supervision for verbal cues iso cognitive impairments iso dementia, requires occasional redirection 2/2 distracted by external stimuli. A review of the dietary quarterly assessment dated [DATE] indicated the following: -Resident experienced significant weight loss in May 2023, weight is now stable. CNAs and dietary staff encouraged to leave Resident's meal tray for a longer period of time since he/she is a very slow eater. He/she seems to be able to focus on one food at a time, so if the dietary staff/CNAs notice that the Resident has finished a food, they will adjust his/her plate so eating the next food is more convenient. -Risk factors-oropharyngeal dysphagia, dementia, slow eater and generally minimal po (by mouth) intake. During an interview on 1/26/24 at 8:21 A.M., Certified Nurse's Assistant (CNA)#1 said that the Resident requires supervision while eating, he/she eats very slowly, he/she requires a staff member present at all times during the meal to encourage and cue the Resident to eat. If the Resident is left without supervision and cueing, he/she will not eat enough food. During an interview on 1/26/24 at 8:31 A.M., Unit Manger #2 said that the Resident should be supervised at all times during meals, his/her physician's order indicates supervision and verbal cues at meals, the Resident does eat very slowly, if he/she wants to eat on his/her own, the staff should remain in the room to verbally cue him/her. During an interview on 1/26/24 at 9:52 A.M., the speech therapist said after reviewing the most recent speech notes dated 3/29/23, the Resident does require supervision with verbal cues during meals. 48671 2. Resident #12 was admitted to the facility in March 2022 with diagnoses including dysphagia (difficulty swallowing) and dementia. A review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/24, indicated a Brief Interview for Mental Status score (BIMs) score of 15 out of 15 indicating intact cognition. Further review of the MDS assessment for functional abilities and goals for self-care indicated the following: *Resident #12 is Dependent for all functional tasks related to Activities of Daily Living (ADL) and requires supervision or touching assistance with eating - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance. *Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. During an observation 1/24/24 at 8:23 A.M., the surveyor observed the Resident in his/her room sitting in a wheelchair eating breakfast alone and could not be seen from the hallway. Adaptive equipment was observed on the breakfast tray. Food was observed on the Residents' clothing. No staff members were in the room or in the hallway. There was no staff member in the area supervising the Resident while he/she was eating. During an observation on 1/25/24 at 8:15 A.M., the surveyor observed the Resident in his/her room sitting in a wheelchair eating breakfast alone and could not be seen from the hallway. Adaptive equipment was observed on the breakfast tray. Food was observed on the Resident's clothing. No staff members were in the room or in the hallway. There was no staff member in the area supervising the Resident while he/she was eating. Review of Resident #12's physician orders indicated the following: *Diet Order: Mechanically altered diet. NAS (No Added Salt) diet Ground texture, Nectar/Mildly Thick consistency. * House supplement as needed. May offer 120 ml house supplement if meal intake <50%. *Magic Cup two times a day. A review of the Resident's ADL care plan dated 4/18/23 indicated the following: *Nutrition; Resident is at risk for compromised nutritional status r/t oropharyngeal dysphagia, vascular dementia and hx significant weight loss. *Encourage food and fluid intake throughout the day and at meals. *Encourage the Resident to attend the dining room for meals to enhance socialization and to provide supervision encouragement while eating. *Resident is able to feed him/herself with supervision, no added salt (NAS) ground diet with nectar thick liquids provided daily. Diet upgraded from puree to ground on 8/2/23. *The Resident will be assisted with putting in dentures before breakfast and take them out after dinner to assist with masticating meals. *Monitor and document oral intake on our food preferences and offer alternative entrees, if needed. Offer health supplement PO intake is less than 50% at meals provide appropriate positioning utensils adaptive equipment and or assistance at meals and snacks. *Provide appropriate positioning, utensils/adaptive equipment and/or assistance at meals and snacks. *ADL Dependent: Resident is dependent on staff with all ADL's due to severe osteoarthritis, chronic pain, dementia. *Resident is able to feed him/herself with supervision. A review of the dietary quarterly assessment dated [DATE] indicated the following: *Diet- Super cereal at breakfast. *Dietary Supplement- Magic Cup bid between meals. *Liquid Consistency- Nectar *Feeding Ability- Supervision or touching assistance. *Adaptive Equipment- Built up red spoons. *Physical Limitations- Deformities of fingers with resultant limited ROM. *Risk Factors- Oropharyngeal dysphagia, vascular dementia, hx of significant weight loss, hospice status. During an interview on 1/25/24 at 8:50 A.M., Certified Nurse's Assistant (CNA)#2 said that the Resident requires supervision while eating and sometimes needs help with utensils. During an interview on 1/25/24 at 8:53 A.M., Nurse #4 said Resident #12 requires setup assistance only and does not need to be supervised at all times during meals. Nurse #4 said residents should not eat alone if they require supervision or assistance during meals. During an interview on 1/26/24 at 9:13 A.M., the Assistant Director of Nursing (ADON) said residents who require supervision and queuing should not be left alone during meals. During an interview on 1/26/24 at 10:06 A.M., The Director of Nursing (DON) said residents who require supervision and queuing should not be left alone without supervision during meals. The DON said Resident #12 should not be left alone while eating. The DON said he would expect the plan or care to be followed.

Based on observations, records reviews, policy review and interviews for one Resident (#322) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5% . One out of three nurses observed made two errors out of 27 opportunities resulting in a medication error rate of 7.41%. Specifically, Nurse #2 crushed an extended release diltiazem (a blood pressure lowering medication), which should not have been crushed and administered the incorrect dose of vitamin d3. Findings include: Review of the facility policy 'Administering Medications', undated, indicated, but was not limited to: 4. Medications must by administered in accordance with the orders, including any required time frame. Review of the facility policy 'Crushing Medications', undated, indicated, but was not limited to: -Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. 2. The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric coated medications). The attending physician or consultant pharmacist must identify an alternative or the attending physician must document (or provide the nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident. 4. The resident's medications administration record (MAR) should reflect the physicians or nurse practitioners order to crush medications. Resident #322 was admitted to the facility in January 2024 with diagnoses including hypertension, vitamin d deficiency, and dysphagia (difficulty swallowing). On 1/25/24 at 8:47 A.M. the surveyor observed Nurse #2 prepare, crush, and administer the following medications to Resident #322: -Diltiazem HCl (hydrochloride) ER (extended release) 120 milligrams (mg), 1 tablet -Vitamin D3 Oral Tablet 25 (micrograms) mcg, 1 tablet Review of Resident #322's active physician orders indicated the following: -Diltiazem HCl ER Oral Capsule Extended Release 24 Hour 120 MG, give 1 capsule by mouth one time a day *do not crush*, initiated 1/12/24 -Vitamin D3 Oral Tablet 25 mcg, give 2 tablet [sic] by mouth one time a day, initiated 1/12/24 According to the National Institutes of Health (NIH), diltiazem hydrochloride extended-release tablets should be swallowed whole and not chewed or crushed. During an interview on 1/25/24 at 8:47 A.M., Nurse #2 said Resident #322 always takes his/her medications crushed because he/she is unable to swallow whole pills. Nurse #2 he was administering one vitamin d3 tablet and surveyor visualized one vitamin d3 tablet in Resident #322's medication administration cup prior to administration. During an interview on 1/25/24 at 10:23 A.M., Nurse #2 said Resident #322 has an order for diltiazem extended release capsules, but that the facility changed pharmacies and now sends tablets. Nurse #2 said he used to soak the capsule in applesauce, but since tablets won't soften like the capsule did he crushed it. Nurse #2 said the order for diltiazem extended release capsules indicated not to crush. During an interview on 1/26/24 at 10:57 A.M., Unit Manager #1 said the diltiazem extended release tablet for Resident #322 should not have been crushed. Unit Manager #1 said the nurse should have clarified the order for diltiazem extended release being sent in incorrect tablet form with either the provider or the pharmacy. During an interview on 1/26/24 at 11:52 A.M., the Director of Nursing (DON) said he was unsure if this diltiazem extended release should be crushed, but that the medication nurse should follow the facility guidelines for crushing medications.

Based on observation and interview, the facility failed to 1.) ensure Residents were provided a dignified experience during meals on the 1st floor and 2.) failed to ensure staff were not storing their personal belongings in a Resident's closet (#49) out of a total of 19 sampled Residents. Findings include: 1. On 11/29/22 at 8:05 A.M., 11/30/22 at 7:52 A.M., and 12/1/22 at 8:00 A.M., the surveyor observed staff standing over Resident #22 while assisting the Resident with his/her meal. No other staff prompted the staff assisting to get a chair and sit while feeding Resident #22. On 11/29/22 at 8:17 A.M., the surveyors heard multiple staff refer to Residents as feeders while passing breakfast trays. During observations of the lunch meal on 11/29/22 at 12:04 P.M. on the 1st floor dinning room, multiple residents were eating their meals while their others at their tables had not received a their meal. Residents watching their table mates eat could be heard saying, where's my food? why is it taking so long. One staff person was observed standing while assisting a Resident and upon seeing a surveyor stopped and, retrieved a chair and then sat down to continue assisting the Resident. Multiple staff were heard referring to Residents as feeders During observations of the dinner meal on 11/29/22 at 4:55 P.M., the surveyor observed CNA #2 feeding a Resident with one hand while she held her cell phone in another hand keeping her focus on her phone. Upon seeing the surveyor, she immediately placed the cell phone on the Resident's lap and then focused on assisting the Resident. When asked what was placed on the Resident's lap, CNA #2 said she had placed her cell phone on the Resident's lap. CNA #2 then removed the cell phone and promptly left. During an interview with the Director of Nursing on 12/1/22 at 9:45 A.M. he said that he had been made aware of the above concerns. 2. On 11/29/22 at 8:16 A.M. the surveyor observed a CNA enter a resident room wearing her winter jacket. At 8:19 A.M., the surveyor observed the CNA still in the room, but no longer wearing her winter jacket and making up a bed. At 8:42 A.M. the surveyor entered the room and observed the CNA's winter coat and scarf stored in Resident #49's closet. During an interview with the Director of Nursing on 12/1/22 at 9:45 A.M., he acknowledged the act of staff using Resident closet space to store personal items.

Based on observation, interview and policy review, the facility failed to ensure expired medications were not available for administration in 3 of 3 medication carts observed. Review of the facility policy titled, Medication Administration, dated 1/21, indicated: - check the date on the package/container, no expired medications will be administered - nurse will record date opened on medications, certain products such as multi-dose vials (insulin) and ophthalmic (eye drops) have specified shortened end-of-use dating. Position statements from the American Society of Ophthalmic Registered Nurses and American Society of Cataract & Refractive Surgery state that multi-dose eye drops should be disposed of within 28 days after initial use. *During the medication pass observation on South Cart 2 on 11/30/22 at 9:30 A.M., surveyor observed: -[MEDICATION(S)] (an ophthalmic eye drop used to treat allergies), dated as opened on 10/20/22 (opened for 41 days). Review of the manufacturer's guidelines [MEDICATION(S)] is good for 4 weeks (28 days) once opened. -one multi-dose inhaler labeled as [MEDICATION(S)] and salmeterol inhalation powder medication used to treat [CONDITION(S)]), opened and undated. Review of the manufacturer's guidelines indicate that once [MEDICATION(S)] and salmeterol inhalation is removed from the foil pouch, write the opened date and use by date on the label. The use by date is one month from the date opened for the first dose. During an interview with Nurse #8, she said she was not aware that the eye drops had expired and was not aware the [MEDICATION(S)] and salmeterol inhalation needed to have a date opened and use by date. During an interview on 11/30/22 at 9:37 A.M., the Unit Manager said that eye drops are good for 60 days and the [MEDICATION(S)] and salmeterol inhalation comes from the pharmacy open and not in the foil packaging and said the [MEDICATION(S)] and salmeterol inhalation needs to have dates opened and use by dates. *During and observation on the North Cart 1 on 11/30/22 at 12:00 P.M., the surveyor with Nurse #4 observed: - one [MEDICATION(S)] insulin (medication used to treat diabetes) pen, dated as opened 10/5/22 and expired 11/3/22 - one [MEDICATION(S)] insulin (medication used to treat diabetes) pen, dated as opened 11/2/22 and expired 11/29/22 - one [MEDICATION(S)] insulin (medication used to treat diabetes) pen, opened and undated - one multi-dose inhaler labeled as [MEDICATION(S)] and salmeterol inhalation powder, opened and undated - one bottle of [CONDITION(S)]-Stat (urinary tract protection medication used to treat urinary tract infections), opened and undated. Review of the manufactures guidelines indicate to discard 3 months after opening. During an interview on 11/30/22 at 12:08 P.M., Nurse #4 said she would remove the expired medications from the medication cart. Nurse #4 said that medications should be dated once opened. *During and observation on the North Cart 2 on 11/30/22 at 12:19 P.M., the surveyor with Nurse #7 observed: -one multi-dose inhaler labeled as [MEDICATION(S)] and salmeterol inhalation powder, opened and undated During an interview on 11/30/22 at 12:25 P.M., Nurse #7 said she wasn't aware that [MEDICATION(S)] and salmeterol inhalation powder required to be dated when opened and said she would review manufactures guidelines.

Based on records reviewed and interviews the facility failed to keep an accurate medical record related to advanced directives for two Residents (#27 and #41) and failed to accurately document the administration of as needed (PRN) medication for one Resident (#11) out of a total sample of 19 Residents. Findings include: Review of the facility policy titled Medical Records, undated, indicated the facility will maintain an accurate medical record for each resident. 1.) For Resident #27 the facility failed to maintain an accurate medical record related to his/her advanced directives specifically code status. Resident #27 was admitted to the facility in [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Minimum Data Set assessment, dated [DATE], indicated that he/she makes self understood and he/she could understand others. Review of Resident #27's active physician's order, dated [DATE], indicated: -Full Code (if a person's heart stops beating and/or they stop breathing, all resuscitation procedures, such as cardiopulmonary resuscitation (CPR) will be provided to keep them alive) Review of Resident #27 Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form dated [DATE], indicated: -Do Not Resuscitate (DNR) (no cardiopulmonary resuscitation (CPR). During an interview on [DATE] at 4:24 P.M., the Director of Nursing said that the MOLST should match the active physician's order and he would review Resident #27's code status. 2.) For Resident #41 the facility failed to maintain an accurate medical record related to his/her advanced directives specifically health care proxy. Resident #41 was admitted to the facility in [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #41's Quarterly Minimum Data Set assessment, dated [DATE], indicated he/she had a severe cognitive impairment and his/her Health Care Proxy had been invoked (when the resident lacks the ability to make their own medical decisions and the health care agent makes medical decisions for the resident). Review of Resident #41's Decree on Special Proceeding for Health Care Proxy, dated [DATE], indicated Resident #41's health care proxy was affirmed in court. The document indicated that Resident #41 lacked the capacity to make healthcare decisions. Review of a physician's order dated [DATE], indicated his/her health care proxy was not invoked. Review of the the Social Services notes, dated [DATE], [DATE] and [DATE], indicated that Resident #41's health care proxy was invoked. Review of Resident #41's plan of care related to advanced directives, dated as reviewed [DATE], indicated his/her health care proxy was invoked on [DATE]. During an interview on [DATE] 8:51 A.M., Resident #41's Health Care Agent said she was Resident #41's health care proxy and it was court affirmed. The health care proxy said she was making Resident #41's medical decisions. During an interview on [DATE] at 4:30 P.M., the Director of Nursing reviewed the physician's order that indicated Resident #41's Health Care Proxy was not activated. The Director of Nursing said he would review Resident #41's advanced directives. 3.) The facility failed to ensure the administration of an as needed (PRN) [MEDICATION(S)] (narcotic medication used to treat pain) was documented as administered accurately in Resident #11's Medication Administration Record (MAR). Resident #11 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated he/she scored a 6 out of a 15 on the Brief Interview for Mental Status indicating he/she is moderately cognitively impaired and requires assistance with bathing, dressing and toileting. The MDS also indicated that Resident #11 reported he/she had a 6 out of 10 on the pain scale and had reported occasional pain over the past 7 days and received as needed pain medications in the past 5 days. Review of Resident #11's physician's orders indicated: [MEDICATION(S)] (a narcotic used to treat pain): 50 milligrams (mg) tablet, Give 1 tablet by mouth 3 times a day as needed for pain. Review of Resident #11's [DATE] MAR and the Narcotic Book indicated: *On [DATE], he Narcotic Book indicated Resident #11 received 1 dose of [MEDICATION(S)]. The MAR indicated that Resident #11 did not receive any [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 2 doses of [MEDICATION(S)]. The MAR indicated Resident #11 only received 1 dose of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 1 dose of [MEDICATION(S)]. The MAR indicated that Resident #11 did not receive doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 only received 2 doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 2 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 only received 1 dose of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 1 dose of [MEDICATION(S)]. The MAR indicated that Resident #11 did not receive any doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 1 dose of [MEDICATION(S)]. The MAR indicated that Resident #11 did not receive any doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 1 dose of [MEDICATION(S)]. The MAR indicated that Resident #11 did not receive any doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 2 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 1 dose of [MEDICATION(S)]. Review of the [DATE] MAR and Narcotic Book indicated: *On [DATE] the Narcotic Book indicated Resident #11 received 2 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 did not receive any doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 1 dose of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 2 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 1 dose of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 2 doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 2 doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 1 dose of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 2 doses of [MEDICATION(S)]. *On ,d+[DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 2 doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 2 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 1 dose of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 2 doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated that Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 received only 2 doses of [MEDICATION(S)]. *On [DATE] the Narcotic Book indicated that Resident #11 received 3 doses of [MEDICATION(S)]. The MAR indicated that Resident #11 did not receive any [MEDICATION(S)]. During an interview with the Director of Nursing on [DATE] at 9:45 A.M. he was unaware of the discrepancies between the Narcotic Book and the MAR. The Director of Nursing said that nursing should document the [MEDICATION(S)] on both the Narcotic Book and the MAR.

Based on records reviewed, observation and interviews the facility failed to implement the plan of care for 2 Residents (#8 and #46), 1). For Resident #8 the facility failed to implement a physician's order for floor mats; and 2). For Resident #46 the facility failed to implement a physician's order and a care plan for air mattress settings, out of a total sample of 19 Residents. Findings include: Review of the facility policy titled, Comprehensive Person Center Care Planning, undated, indicated staff will implement a person centered care plan. 1.) Resident #8 was admitted to the facility in 12/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #8's Significant Change of Status Minimum Data Set assessment, dated 9/4/22, indicated he/she had a vision impairment, required one person assistance for ambulation, and had a fall with major injury. Review of physician's order, dated 8/28/22, indicated: -shock absorbent floor mat to left side of bed. During an observation on 11/29/22 at 8:04 A.M. Resident #8 was in his/her bed eating breakfast. The surveyor did not observe a floor mat on the left side of the bed. The surveyor was unable to observe any floor mats for Resident #8 in his/her room. During an observation on 11/30/22 at 6:59 A.M. Resident #8 was in his/her bed sleeping. The surveyor did not observe a floor mat on the left side of the bed. The surveyor was unable to observe any floor mats for Resident #8 in his/her room. During an interview on 11/30/22 at 2:54 P.M., Certified Nurse Aide (CNA) #1 said that she was not aware that Resident #8 required a floor mat. During an interview on 11/30/22 at 4:51 P.M., CNA #5 said she was not aware that Resident #8 required a floor mat. During an observation on 11/30/22 at 2:46 P.M., the surveyor accompanied by the Director of Nursing (DON) observed Resident #8 sitting on the side of his/her bed. There was no floor mat to the left side of his/her bed. The DON said that the floor mats are large and would be visible in the room. The DON was unable to find the floor mat. 2.) Resident #46 was admitted to the facility in April 2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Quarterly Minimum Data Set assessment, dated 10/5/22, indicated he/she was at risk for skin break down and was dependent on staff for bed mobility. Review of the physician's order, dated 4/5/21, indicated: -Monitor low air loss, alternating pressure mattress every shift for proper function. Ensure every shift that weight setting is at 100 pounds (lbs). Review of Resident #48's plan of care related to skin breakdown, dated as reviewed on 10/12/22, indicated: -Monitor low air loss, alternating pressure reducing mattress every shift for function. -Make sure the setting is at 100 lbs. During an observation on 11/29/22 at 3:59 P.M., Resident #46 was in his/her bed and the air mattress was set to 150. During an observation on 11/30/22 at 7:00 A.M., Resident #46 was in his/her bed and the air mattress was set to 150. During an interview on 12/1/22 at 7:29 A.M., Nurse #2 said she checks the air mattress settings on the night shift (11:00 P.M. to 7:00 A.M.). Nurse #2 said sometimes the settings accidentally change. During an interview on 11/30/22 at 2:50 P.M., the Director of Nursing said the air mattress should be set to the physician's order.

Based on records reviewed, observation and interviews, the facility failed to ensure nursing implemented physician's orders for obtaining reweighs and monitoring a significant weight loss in one Resident (#27) out of 19 sampled residents. Findings included: Review of the facility policy titled Weight Loss Policy, undated, indicated the following: -A five percent weight loss in 30 days and a 10 percent weight loss in 180 days are considered a significant weight loss. - The registered dietitian will review and update the resident ' s record with a progress note. - The physician will be notified of any recommendations made by the dietitian Resident #27 was admitted to the facility in September 2022 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Admission Minimum Data Set Assessment, dated 9/26/22, indicated that he/she makes self understood and he/she could understand others. The MDS indicated he/she required supervision with meals and did not have weight loss. Review of Resident #27's Admission Nutritional Assessment, dated 9/26/22, indicated his/her usual body weight is 155-160 pounds. Review of Resident #27's plan of care related to nutrition, dated 9/26/22, indicated he/she will not experience significant weight loss through the goal target date. Review of the physicians order, dated 9/19/22 indicated the following: -re-weigh for weight fluctuations of 3 pounds in one week and document the re-weigh -re-weigh for weight fluctuations of 5 pounds in one month and document the re-weigh Review of the physician's order, dated 11/2/22, indicated the following: -monthly weights on the the 11th during the day shift (7:00 A.M. to 3:00 P.M.) -re-weigh for weight fluctuations of 3 pounds in one week and document the re-weigh. Notify the physician, dietitian, and the health care agent. -re-weigh for weight fluctuations of 5 pounds in one month and document the re-weigh. Notify the physician, dietitian, and the health care agent. Review of Resident #27's weights indicated the following: 9/20/2022 160 pounds (lbs) 9/21/2022 151.4 lbs 9/26/2022 156.8 lbs 10/3/2022 155.8 lbs 10/10/2022 154.2 lbs 10/17/2022 151.2 lbs 10/24/2022 150 lbs 10/31/2022 148.8 lbs 11/11/2022 140 lbs, a loss of 8.8. lbs in 11 days Review of the weight record indicated that Resident #27 had a weight loss from 9/26/22 at 156.8 pounds to 148.8 pounds on 10/31/22, which is an 8 pound loss and a 5% significant weight loss in one month. Resident #27 then lost another 8.8 pounds on 11/11/22, which was a 5.9% significant weight loss. Review of the clinical record indicated that Resident #27 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initiated on 9/26/22. There is no indication in the clinical record that any additional interventions to prevent further weight loss were attempted. Review of the physicians note, dated 12/1/22 recorded as a late entry for 11/15/22, indicated that there was no documentation to support the physician addressed Resident #27's significant weight loss. During an interview on 11/30/22 at 4:53 P.M., Certified Nurse Aide #5 said that Resident #27 is a picky eater and doesn't always like his/her meals and he/she looked like he/she lost weight. During an interview on 11/30/22 at 3:28 P.M., the Dietitian said she noticed the weight loss for Resident #27. The Dietitian said she made nursing aware on 11/11/22, 11/14/22 and 11/28/22 that Resident #27 required a re-weigh. The Dietitian said she did not implement any new recommendations or recommendations for prevent further weight loss for Resident #27's because she was waiting on the re-weigh. The Dietitian said the re-weigh has not been obtained. During an interview on 11/30/22 at 4:31 P.M., Nurse #1 said Resident #27 is not a big eater and he/she is picky. Nurse #1 said she was aware that the dietitian had requested re-weighs for Resident #27 and was not sure why the weights were not obtained. During an interview on 11/30/22 at 3:55 P.M., the Director of Nursing (DON) said nursing should follow physician's orders for weights. The DON said that nursing should have obtained a re-weigh for Resident #27. During a follow up interview on 12/6/22 at 9:12 A.M., the Dietitian said that she had she had missed something on my end regarding Resident #27's documented weight loss on 10/31/22 and acknowledged that no interventions were implemented to address the weight loss.

Based on record review and staff interview, the facility staff failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain body weight and prevent weight loss for two Residents (#33 and #22) in a total sample of 15 residents. Findings include: Review of the facility policy titled, Weight Loss Policy, undated, indicated the following: *All residents' weights will be reviewed on a weekly basis by the dietician. Any significant weight losses will be re-checked for accuracy. Any residents with significant weight loss will be reported at the interdisciplinary meeting and a new MDS will be generated when determined appropriate. *A five-percent (5%) weight loss in thirty (30) days and ten-percent (10%) weight loss in one hundred and eighty (180) days are considered a significant weight loss. *The registered dietician will be notified by the nursing department in the communication book. *The registered dietician will review and update the resident's record with a progress note. *The physician will be notified of recommendations made by the registered dietician. *The nursing care plan will be updated. *The resident will be weighed weekly. 1. Resident #33 was admitted to the facility in February 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #33 had a Brief Interview for Mental Status of 14 out of a possible 15, which indicated that Resident #33 was cognitively intact. The MDS also indicated that Resident #33 required extensive assistance from staff for all activities of daily living. Further review of section D, titled Mood, of the same MDS indicated that Resident #33 did not have a poor appetite. Review of Resident #33's physician orders dated 2/24/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the weight record for Resident #33 indicated the following: *2/25/21 - 120 lbs (pounds) *3/1/21 - 112.8 lbs (a 6% weight loss) *3/2/21 - 110.8 lbs *3/8 - resident refused taking his/her weight *3/9/21 - 107.4 lbs *3/22/21 - 105.4 lbs (a 6.56% weight loss from 3/1/21) *There was no weight taken on Monday, 3/29/21 Review of Resident #33's nursing progress note written a month after his/her admission and dated 3/22/21 indicated the admission weight of 120 lbs was inaccurate. The note failed to indicate why or how it was determined that this admission weight was inaccurate. During an interview on 3/31/21 at 8:13 A.M., Resident #33 said that his/her weight is typically around 120 lbs. Resident #33 said that he/she knows that he/she has had some weight loss, possibly 5 lbs., but was unaware of his/her current weight. The surveyor told Resident #33 that his/her most recent weight at the facility was 105 lbs. Resident #33 said that this weight was scary because it was well below his/her previous stable weight when he/she was home. When asked about his/her eating habits, Resident #33 said he/she likes to eat and has requested vegetables from the kitchen because he/she knows that is a healthy way to eat and will help him/her feel better. Resident #33 said that he/she never refuses to eat. Resident #33 said he/she would like to have spoken with staff about this weight loss. Review of physician orders dated 2/24/21, indicated that the following dietary interventions were ordered: *Decubi Vite 1 capsule daily *Protein supplement 30 ml *House supplement 1 3 x/day Review of physician orders dated 3/3/21, indicated that the following dietary interventions were put in place after Resident #33's initial nutrition assessment: *Ground, super cereal with breakfast, ice cream with lunch and sherbet with dinner Review of Resident #33's current physician's orders failed to indicate additional dietary interventions after the 6.56% weight loss on 3/21/21. Review of Resident #33's nutrition care plan dated 3/3/21, indicated the following intervention: *Monitor and evaluate weight. Notify MD/NP, RD and family of any significant weight changes. During a review of Resident #33's medical record, there was no evidence to indicate that Resident #33's weight loss was reported to the physician or the dietician. During an interview on 3/30/21 at 1:39 P.M., Nurse #2 said that Resident #33 is a slow eater but was unaware of any weight loss. Nurse #2 said that the facility policy is that a significant weight loss is 3 lbs in a day or 5 lbs in a week. Nurse #2 looked at the weight history for Resident #33 and Nurse #2 said that because the weight loss was spread over a month, it was not significant, and she would not have notified the dietician or physician. Nurse #2 said that if she were to identify a significant weight loss, she would notify the physician but was not required to notify the dietician. Nurse #2 said that the nursing staff only notifies the physician because the dietician runs her own report and monitors weights for everyone herself. When asked if Resident #33 eats well, Nurse #2 said that Resident #33 never refuses to eat. During an interview on 3/31/21 at 12:39 P.M., Unit Manager #1 said that Resident #33 is a slow but good eater and does not refuse to eat. Unit Manager #1 said that any significant weight loss is communicated to the dietician weekly. Unit Manager #1 said that Resident #33 did have a significant weight loss and is not sure why it was not communicated to the dietician. During an interview on 3/31/21 at 10:31 A.M., the Dietitian said that she works at the facility one day a week. She said that at the start of each working day, she runs a report to view all weights of every resident in the facility. The Dietician said that the report automatically identifies significant weight loss over a month but does not identify significant weight loss within a month (over three weeks) and she would have to calculate that herself. The Dietician said that Resident #33 had an initial nutrition assessment one week after admission and had interventions put in place at that time to prevent weight loss. The Dietician said that she believes Resident #33's admission weight was inaccurate but was unable to say the reason for inaccuracy or why it took 3 weeks to determine it was wrong. The Dietician acknowledged that from 3/3/21 to 3/21/21, Resident #33 had a significant weight loss of 6.56%. She said that she had worked at the facility on 3/24/21 and would have seen Resident #33's most recent weight but must have missed it. In addition, the Dietician said that nursing had not notified her and that no new interventions had been put into place. The Dietician said that a new dietary intervention would have been helpful to prevent further weight loss. 2. For Resident #22, the facility failed to identify and assess a significant weight loss. Resident #22 was admitted to the facility in 10/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #22's most recent Minimum Data Set assessment dated [DATE] indicated that he/she was severely cognitively impaired and required assistance with bathing. On 3/30/21 at 9:37 A.M., the surveyor observed Resident #22 in his/her room. Resident #22 appeared thin and frail. Review of Resident #22's most recent Quarterly Nutritional Evaluation dated 2/10/21, indicated that Resident #22's weight was 97 lbs. Review of Resident #22's recorded weights for March 2021 indicated the following: 3/5/21 97.6 lbs (pounds) 3/12/21 94.4 lbs 3/19/21 92.6 lbs 3/26/21 91.6 lbs (a 5.12% weight loss in one month) Review of Resident #22's Nutritional Risk Care Plan, dated 10/11/17 indicated the following: Weight 97 lbs (2/10/21) Goal: No significant weight loss X 1 Month (Target Date 5/18/21) During an interview with Unit Manager #2 on 3/31/21 at 9:17 A.M., she said that if a resident has a weight loss, the Dietitian is notified, but the Dietitian is also able to run a report and would do that math to calculate a significant weight loss. Unit Manger #2 said that if a resident has a weight loss of more than 5 lbs, she would ask for a reweigh and would alert the physician and the Dietitian. During an interview with the Dietitian on 3/31/21 at 10:31 A.M., she said that she is in the facility weekly and reviews all the weights in a report. The Dietitian said that the facility does not have weekly risk meetings but that staff do call her and notify her of changes in resident weights when she is not in the building. The Dietitian said she would expect staff to notify her of changes of 3 lbs in resident weights. The Dietitian said the last time she assessed Resident #22 was on 2/10/21. She said she was unaware that Resident #22 experienced a significant weight loss.

Based on record review and interview, the facility staff failed to administer emergency care as required prior to the arrival of emergency medical personnel for 1 Resident (#78) from a total sample of 2 closed records. Findings include: Resident #78 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] indicated Resident #78 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4 from a possible score of 15. The nursing progress note dated [DATE] at 4:45 P.M. described a change in the resident's respiratory condition. The physician was notified and orders were obtained for a chest X-ray and blood tests. At 8:14 P.M. blood test results were reported to the physician with no new orders. At 10:24 P.M. a nursing progress note indicated the resident continued with a wet cough, crackles were heard on auscultation (abnormal assessment findings), blood pressure was ,[DATE], pulse was 98, respirations were rapid at 26 and temperature was 96.5 degrees Fahrenheit. The progress note indicated the resident refused an albuteral nebulizer treatment to help his/her breathing. The chest x-ray that had been ordered was not completed as of yet. A nursing progress note dated [DATE] at 12:06 A.M. indicated the resident was noted to have difficulty breathing and calling for help. His/her pulse had increased to 130 beats per minute. The resident's oxygen saturation was 80% on room air with labored breathing and gasping for air. Oxygen was applied. The body temperature reading was 100.6 degrees Fahrenheit. Nurse #1 called for an ambulance to take Resident #78 to the hospital. The progress note indicated that ambulance personnel arrived at 12:15 A.M. and after intense labored breathing for 10 minutes, he/she took his/her last breath. The physician was notified that the resident was unresponsive, no apical pulse and no respirations for 1 minute. An order was obtained for RN pronouncement. The resident expired at 12:15 A.M. [DATE]. There was no document to indicate that cardio-pulmonary resuscitation was initiated after Resident #78 experienced what was documented as a witnessed arrest in a resident with a full code status. Interview with Nurse #1 on [DATE] at 7:38 P.M., Nurse #1 said she was the nurse on duty the shift that Resident #78 died . The resident was in respiratory distress and would not keep the oxygen or nebulizer in place. His/her temperature was climbing, respirations were at 32 and the heart rate increased to 140 beats per minute. Nurse #1 said she called the ambulance service to take the resident to the hospital. Nurse #1 did not call 911 services. Nurse #1 said the resident stopped breathing and the heart stopped, she did not initiate CPR. She said the resident died at the same time the ambulance emergency medical technicians (EMTs) arrived. Nurse #1 said no CPR was initiated by the EMTs because the resident would not survive. Nurse #1 said she did not know the code status of the resident during the change in condition. Review of the ambulance report dated [DATE] indicated the facility called at 12:00 A.M. for an emergency transport to the hospital for Resident #78 due to shortness of breath. The EMTs arrived at the facility at 12:12 A.M. Upon arrival the nurse reported to the EMTs that Resident #78 was a do not resusitate and expired. The EMTs left the building without resident contact. Interview with the Director of Nursing (DON) on [DATE] said that the resident had experienced flash [MEDICAL CONDITIONS] on [DATE] into [DATE]. A nursing progress note dated [DATE] at 12:06 A.M. indicated the nurse attempted to treat the resident with oxygen. The resident would not allow the nurse to place the oxygen on. When the nurse did apply the oxygen, the resident kept removing it. The resident was alert and confused at 7:45 P.M. The DNS said in reviewing the event, the nurse did not anticipate the resident's needs timely and that the nurse knew the resident's symptoms were not reversible therefore, did not initiate CPR. The DNS said the nurse did not realize the resident was a full code status at the time of the event.

Based on record review and interview, the facility staff failed to comprehensively assess and provide care in accordance with professional standards for 1 Resident (#78) from a total sample of 2 closed records. Findings include: Resident #78 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] indicated Resident #78 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4 from a possible score of 15. The resident had a physician order [REDACTED].>A physician interim order was documented [DATE] for cough medicine 3 times daily for 3 days and check vital signs every shift for 3 days. There was no corresponding nurse progress note. A nursing progress note dated [DATE] at 4:45 P.M. indicated a new order for [MEDICATION NAME] nebulizer (breathing treatment) every 6 hours as needed for wheezing, a chest x-ray for cough and wheezing and stat (immediate) blood tests. On [DATE] at 7:54 P.M. a nursing progress note indicated a change in physical condition, the resident was alert and confused. Blood pressure was elevated at ,[DATE], heart rate was rapid at 97, oxygen saturation was 90%, respirations 24 and elevated temperature of 100.5. Tylenol was given for the temperature with positive results. A late entry ([DATE] at 3:19 P.M.) nursing progress note indicated at 8:14 P.M. the blood test results (no critical results) were reported to the physician. The chest x-ray had not been completed at this time. The chest x-ray had not been ordered stat and there was no indication that the nursing staff attempted to clarify the order with the physician. A late entry ([DATE] at 3:30 P.M.) progress note by Nurse #1 on [DATE] at 10:24 P.M. indicated the resident vital signs as blood pressure ,[DATE], heart rate 98, respirations 26, temperature 96.5 and oxygen saturation 90% on room air. The resident continued to have a wet cough and crackles on auscultation. The nurse attempted to administer the [MEDICATION NAME] nebulizer but the resident refused to wear the mask. No [MEDICAL CONDITION] was present and awaiting chest x-ray. There was no documentation in the medical record that the nursing staff had performed an assessment of Resident #78's breathing, congestion or heart rate from 10:25 P.M. on [DATE] to 12:00 A.M. on [DATE]. A nursing progress note by Nurse #1 dated [DATE] at 12:06 A.M. indicated the resident had difficulty breathing and was calling for help at 12:00 A.M. His/her heart rate was 130, oxygen saturation was 80% on room air and temperature 100.6. Audible crackles, oxygen was applied but the resident kept removing. The resident then developed labored breathing and gasping for air. The nursing progress note continues that the resident was a full code and an ambulance was called. There is no documentation that 911 services were called or that oxygen was applied in response to Resident #78's worsening condition and potentially life threatening symptoms. On [DATE] at 12:15 A.M. Nurse #1 documented the emergency ambulance arrived for transport to the hospital but after intense breathing for 10 minutes, the resident took his/her last breath, was unresponsive, no apical pulse for 1 minute, pupils were fixed and dilated and no response to painful stimuli. The physician was notified after respirations were absent for 5 minutes. Cardiopulmonary resuscitation was not initiated. On [DATE] the surveyor spoke with the ambulance service. The trip report received [DATE] indicated that a call was received from the Armenian Home on [DATE] at 12:00 A.M. When the ambulance service arrived at the facility, they were informed that the resident was a do not resuscitate and he/she had expired in the facility. The service call was terminated at 12:42 with no service provided to the resident.

Based on record review and interview for two of three sampled residents (Resident #1 and Resident #2), who had poor safety awareness, the Facility failed to ensure they received adequate supervision. - On 1/18/15, Resident #1, who had a history of [REDACTED].M. and was located by a housekeeper three blocks away at 2:00 P.M. - On 3/8/15, Resident #2, went out the front door in his/her wheelchair and fell down three steps, landing on the concrete walk, where he/she remained for twenty-six minutes until a visitor exiting the front door found him/her and summoned help. Resident #2 transferred to the hospital, when he/she was diagnosed with [REDACTED]. Findings include: 1. The Hospital Psychiatry Discharge Note (Discharge Note), dated 1/14/15, indicated Resident #1 was admitted to the Hospital because he/she kept trying to leave home and had his/her bag packed. The Discharge Note indicated Resident #1 had been wandering outside for the last two years, but this behavior became worse over the two weeks prior to his/her admission to the hospital on [DATE]. The Health Care Proxy Activation Form, dated 1/14/15, indicated the physician determined Resident #1 did not have the capacity to make decisions due to dementia. The Surveyor interviewed the Administrator at 9:25 A.M. on 3/9/14. The Administrator said due to Resident #1's history of elopement, staff placed a Wanderguard (an exit alert device designed to activate a door alarm if Resident #1 attempted to leave the Facility) on Resident #1's ankle. The Nurse's Note, dated 9:26 P.M. on 1/18/15 and written by Nurse #1, indicated Resident #1 was last seen in the Facility between 12:30 P.M. and 12:45 P.M. and was noted to be missing at 1:15 P.M. The Note indicated Resident #1 was found at 2:00 P.M. a few blocks away. The Surveyor interviewed Nurse #1 at 2:10 P.M. on 3/9/15. Nurse #1 said she heard the Facility door alarm sound around the time Resident #1 left the building, but thought the alarm was triggered by visitors. Nurse #1 said she turned the alarm off, but did not go outside to see if a resident left the building. 2. Resident #2's Care Plan for Cognition, dated 2/26/15, indicated Resident #2 had moderate impairment. Resident #2's Care Plan for Safety, dated 3/8/14, indicated Resident #1 was at risk for injury due to decreased safety awareness, mobility, strength and endurance, and a history of falls. The Surveyor observed that there were two sets of double doors with an interior landing between them at the front exit of the Facility. The Administrator said Resident #2 liked to sit between the doors in the sun. The Administrator said at 5:15 P.M. on 3/8/15, visitors found Resident #1 outside on the ground, so she reviewed video tapes to determine what happened. The Administrator reviewed a video recording and summarized her observations in a Narrative, dated 3/9/15. According to the Narrative, at about 4:35 P.M., Nurse #2 helped Resident #2 to the area between the two sets of doors. The camera next captured Resident #2 struggling to open the front door to go outside. Resident #2 had difficulty opening the door and propelling himself/herself over the threshold. Resident #2 eventually obtained the momentum necessary to go through the door to the outside. The Narrative indicated that evidently, he/she was unable to stop himself/herself and the recording captured his/her wheelchair rolling across the landing. Resident #2's wheelchair being propelled down the stairs onto the the walk was not visible in the recording; once he/she landed on the concrete walk, he/she was completely out of sight of the camera and of anyone inside the building. Resident #2 was on the ground for twenty-six minutes before a visitor exiting the front door found him/her and summoned help. The Incident Report, dated 3/8/15, indicated Resident #2 sustained a hematoma on the left forehead. Nurse's Note, dated 1:43 A.M. on 3/9/15, indicated Resident #2 transferred to the hospital, where he/she was diagnosed with [REDACTED].