Every finding on record at Sacred Heart Nursing Home

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Maintain the main kitchen and kitchen extension on the second floor in a clean and sanitary condition; and2. Maintain four of four kitchenettes in a clean and sanitary condition.Findings include: Review of the facility's policy, dated 2025, indicated but was not limited to the following: Food Storage: all food items should be labeled with the date of preparing or opening and used within the recommended timeframe. Implement a routine cleaning schedule for all kitchen surfaces, equipment, and dining areas. Use approved sanitizing solutions and follow the manufacturer's instructions for use. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following:(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. 1. On 8/7/25 at 8:15 A.M., the surveyor made the following observations in the main kitchen and the second-floor main kitchen extension: Main kitchen first floor: -Refrigerator and freezer reach-in units, the door handles and front panels were visibly soiled. -Storage cabinet drawer and cabinet panels were visibly soiled and sticky in places. -Hood filters were visibly dirty with a buildup of dust. -The transparent top door to the ice cream freezer was visibly dirty. -Reach-in freezer top left shelf, the boxes were encased in ice, and frozen to the top of the back left box was a bag of wonton noodles and a frozen pie. The surveyor was unable to separate the items on the top left shelf due to the ice encasement of the packages. -Food items stored in transparent bags on the left side of freezer, the contents inside the bag were encased in ice, along with the outside of the bag. -Multiple magnetic clips on the front of the refrigerator, holding plastic sleeves with dietary instructions were visibly soiled inside and out. Main kitchen extension located on the second floor: -The floor in the dish room, steam table serving area, around the door jams, and the prep area (two refrigerators and coffee stand) were all visibly soiled along the edges with at least one one-inch buildup of black substance with visible food particles. - In front of the three refrigerator units was visible buildup of black substance and food particles. Underneath the silver reach-in refrigerator the floor was visibly dirty with dirt, debris, and food particles. -Floor under the dish machine was observed to be visibly dirty with dirt, debris, and food particles. -Cabinet doors and drawers located by the dishwasher were visible dirty. -Cabinet drawers, doors and bottom shelf of the cabinets located at the coffee station were visibly stained with dirt and coffee spills. Cups and lids were stored on dirty shelves, with the packaging open. The plastic round container on top of the cabinet which contained plastic lids was visibly stained brown. -Two white refrigerators, the shelves, produce drawers and underneath the produce drawers were dirty with spilt liquids and food debris. Both refrigerators were visibly dirty with food remnants. -The floor in front of one refrigerator was soft and split, which depressed leaving a hole in the floor. There was visible buildup of dirt and food particles where the floor had a hole. The surveyor reviewed the findings above with the Food Service Manager (FSM). During an interview on 8/13/25 at 8:10 A.M., the FSM said when the surveyor entered the kitchen on the first day of survey, the kitchen was not as clean as it should have been. He said the kitchen does not have a cleaning policy but showed the surveyor a cleaning check list to be completed by staff daily. The FSM said we have cleaned the floors, but they still need to be power washed to clean them. He said maintenance needs to look at the soft spot/hole in the floor. 2. On 8/13/25 at 7:39 A.M, the surveyor observed the following in the Saint Joseph's unit kitchenette: -A white granular substance spilled in the cabinet where plastic lids, plastic spoons, and hot chocolate were stored and utilized for residents; -Large dark brown stains on 14 ceilings tiles, a strand of a pink caulking-like substance hanging from the ceiling over the kitchenette area where food is kept and stored; -A white Styrofoam cup of coffee filled with a brown substance open to air stored in a cabinet, brown granular substance spilled on the bottom of the shelf where cookies, peanut butter and bread were kept; -Multiple brown tacky areas inside of a drawer storing plastic utensils, straws, and condiment packages. On 8/13/25 at 7:40 A.M., the surveyor observed housekeeping staff mopping the floor, cleaning the microwave, and wiping the counter surfaces. On 8/13/25 at 8:30 A.M., the surveyor observed the same spills and stains in the kitchenette area after the area was done being cleaned by housekeeping. On 8/13/25 at 7:55 A.M., the surveyor observed the following in the 2PY unit kitchenette: - A spoon wrapped in a paper towel left on top of the sink; - A brown granular substance scattered over the bottom of two of the cabinets that were used to store drinks for resident use; - A cabinet with three soiled shelf liners with brownish and red substances visible with bread, undated peanut butter, a bag of snack mix, and packages of jelly; and - A cabinet containing bread, a jar of open and undated peanut butter, a bag of snack mix and individual packages of jelly which were stored on three shelves where the shelf liner was soiled/discolored with a sticky visible brown substance. On 8/13/25 at 8:08 A.M., the surveyor observed the following in the 3PY unit kitchenette: -Two drawers that were visibly soiled containing debris and crumbs. -A jar of open and undated peanut butter. On 8/13/25 at 8:16 A.M., the surveyor observed the following in the Saint [NAME] unit kitchenette: -Accessible drawers that opened and had rusted holes and flakes of rust loose inside of the drawer. -A drawer containing hot chocolate, keys, and dirt/debris. -A jar of open, undated peanut butter with visible peanut butter on the outside of the container. -A layer of brown debris built up in drawers containing food and snacks for residents, and two cabinets with a white granular substance on the bottom. During an interview on 8/13/25 at 8:33 A.M., Nurse #1 said she has not observed staff cleaning inside of the drawers or cabinets. She said housekeeping does a surface clean and the dietary department stocks the kitchenette. She said she was aware the kitchenette cabinets and drawers were dirty but did not know who was responsible for cleaning them. During an interview on 8/13/25 at 8:40 A.M., Housekeeper #1 said the housekeeping department is responsible for cleaning the kitchenette floors, countertops, and microwaves. She said housekeeping does not clean inside of drawers or cabinets and was not sure whose responsibility it was to clean them. During an observation with an interview on 8/13/25 at 9:05 A.M., the Food Service Manager (FSM) said the dietary department does not clean the drawers or cabinets in the kitchenettes. He said food items should be labeled with the date they were opened and if not, then they should be thrown away. The FSM said food items are dated that he takes from his rotation and brings to the unit. He said the item should be labeled by nursing (or whichever department) when it is opened on the unit. During an interview on 8/13/25 at 9:30 A.M., the Administrator said her expectation is for the kitchenettes to be kept in a clean and sanitary manner. She said there is no assigned process for cleaning the cabinets and drawers but there should be.

Based on record review and interview, the facility failed to ensure one Resident (#2), out of a total sample of 24 residents, received the necessary care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed to ensure a Resident at risk for skin breakdown with a contracted left upper extremity (LUE) did not develop a Stage 4 Pressure Injury (full thickness skin and tissue loss, potentially exposing muscle, tendons, ligaments, cartilage, or bone, with a high risk of infection and slow healing) to the LUE.Findings include: Review of the facility's policy titled Wound and Skin Care Protocol Policy, dated as last revised 1/2025, indicated but was not limited to the following:-Identify outcome-based approaches for the care of residents identified as at risk.-Interventions must be care planned and implemented during the admission process and revised as needed. Review of the facility's policy titled Prevention and Management of Contractures, dated as last revised 9/24, indicated but was not limited to the following:-It is imperative to be able to determine any change in motor loss, note any new onset or worsening weakness, stiffness, or any other change in the normal functional status.-Position the resident in accordance with standards of body mechanics to prevent muscle contractures and loss of joint function.-Reposition every 2 hours to prevent pressure areas, encourage joint flexibility and to prevent flexion contractures.-Encourage and assist residents to perform passive and active exercises to maintain and improve muscle strength, maintain optimal joint function, and prevent other deformities.-Document repositioning, therapy, and adaptive equipment on the resident's care plan and on the Certified Nurses Aide (CNA) care plan for easy access and follow through. Resident #2 was admitted to the facility in October 2023 with diagnoses which included hemiplegia (paralysis on one side) and hemiparesis (weakness/partial paralysis on one side) following a cerebral infarction (CVA-stroke) affecting left dominant side, restlessness and agitation, and spastic hemiplegia affecting left dominant side. Review of the Minimum Data Set (MDS) assessment, dated 5/27/25, indicated he/she did not complete the Brief Interview for Mental Status (BIMS) due to memory problems. Further review indicated Resident #2 was dependent for care, had impairment on one side, was at risk for pressure ulcers, had a stage 4 pressure ulcer, and a surgical wound. Review of the Occupational Therapy (OT) Evaluations, Progress Notes, and Discharge Summaries preceding the development of the Stage 4 Pressure Ulcer indicated but were not limited to the following:-Progress Report 1/26/24-2/12/24: Patient will have decreased pain in the LUE and tolerate passive range of motion (PROM). He/she will tolerate PROM routine for LUE at shoulder, elbow, wrist, and hands. Caregiver will appropriately don (put on) and doff (take off) left hand roll orthotic and monitor skin condition for effective contracture management.- Progress Report 2/28/24-3/12/24: Patient has discomfort with PROM routine for LUE at shoulder elbow, wrist, and hands, and had been refusing PROM routine and wearing of left-hand orthotic.-discharged from OT March 2024.-Evaluation and Treatment Plan: Start of Care 12/4/24: Patient will tolerate PROM routine for LUE shoulder, elbow, wrist, and hands to decrease risk of further contracture and skin breakdown. Resident referred to OT services due to increased difficulty with self-feeding. RUE weakness impacting self-feeding. Also noted with increased tone and decreased ROM to LUE placing patient at increased risk for skin breakdown. Nursing reports the hand roll had been discontinued because he/she was refusing to wear it. Additional impairments: Patient with left hemiplegia, LUE shoulder, elbow, and hand flexion pattern contracture (persistent bent arm). Risk Factors include due to the documented physical impairments and associated deficits patient is at risk for further decline in function, increased pain, increased tone, and decreased skin integrity.-OT Treatment Encounter Notes 12/4/24-1/27/25 (24 visits): Patient participated in PROM to bilateral upper extremities including shoulder extension, shoulder adduction, shoulder abduction, elbow extension, and elbow flexion. He/she declined to participate in PROM x1. Discharge Assessment on 1/27/25 indicated he/she tolerated PROM to LUE with no signs/symptoms of pain. Caregiver education completed focusing on patient contracture management.-OT Discharge Summary 1/27/25: Patient/Caregiver Education: Caregiver education initiated and completed focusing on contracture management for LUE. The facility was unable to provide the Caregiver Education referenced in the 1/27/25 OT Discharge Summary. The facility provided a Caregiver Education Sheet, dated 11/30/2023, regarding a left-hand roll orthotic. The in-service was signed by one staff member. Instructions: Hygiene, dry thoroughly, PROM to hand and fingers, coupled with gentle stretch, application of orthotic, and to monitor for symptoms of precautions. Precautions: Monitor for signs of redness, irritation, discomfort, or abrasion. Review of the Comprehensive Care Plan failed to indicate the LUE contracture, a PROM treatment plan for the LUE contracture, or preventative skin integrity treatment/monitoring of the LUE contracture to prevent skin breakdown at the contracted left elbow/acromioclavicular (AC) area. Further review of the Comprehensive Care Plan indicated but was not limited to the following:-A treatment plan was in place for the Left-Hand contracture, he/she had a hand roll, and they frequently refused it.-He/she was at risk for skin breakdown due to decreased mobility and interventions included repositioning/weight shift in chair, weekly skin checks, monitor palm to ensure fingernails don't dig into palm.-Stage 4 pressure ulcer to Left AC. Review of the CNA electronic documentation of task records failed to indicate the LUE contracture, a PROM treatment plan for the LUE contracture, or preventative skin integrity treatment/monitoring of the LUE contracture to prevent skin breakdown at the contracted left elbow/AC area.Review of the Medication and Treatment Administration Records (MAR/TAR) failed to indicate the LUE contracture, a PROM treatment plan for the LUE contracture, or preventative skin integrity treatment/monitoring of the LUE contracture to prevent skin breakdown at the contracted left elbow/AC area. Review of the nursing progress notes from January and February 2025 indicated but were not limited to the following:-1/2/25, 1/9/25, 1/19/25, 1/23/25, 2/13/35: At risk for pressure ulcers: YES.-1/5/25, 1/19/25, 2/16/25: Refused checking left hand/left hand assessment.-2/19/25: Refused nail trim, medicated and then allowed it. Nails long, hard, hand odorous and moist. The progress notes failed to indicate the skin integrity at the contracture site had been assessed or that he/she had been encouraged to participate in PROM, refused PROM, or refused inspection of the skin integrity at the contracture site. Review of the Nursing Progress Note, dated 2/24/25, indicated a new wound measuring 2.5 centimeters (cm) x 3 cm x 0.7cm to the Left AC with slight sour odor, beefy red granulation tissue (rough grainy surface), moderate sanguineous (bloody)drainage, seropurulent (yellow cloudy) drainage, macerated edges (skin breakdown due to prolonged exposure to moisture-becomes white and soggy), with surrounding tissue darkened and non-blanchable (persistent redness indicating tissue damage). Review of the weekly skin checks from January through March 2025 failed to indicate any new pressure areas. Review of the Weekly Wound Management Detail report failed to indicate the documentation was done weekly. The initial report was completed on 2/24/25 when the wound was first noted, and not again until 3/28/25. Resident was status post tendon release (surgical cutting on the tendon to restore movement) on 4/29/25 with surgical wound closure. The wound was resolved/healed on 5/23/25. Review of the nursing progress notes from March 2025 indicated but were not limited to the following:-3/21/25: Wound Clinic Consult appropriate at this time.-3/26/25: Wound Clinic recommend referring to Orthopedics for tendon release.-3/30/25: Visible Tendon and Deep wound bed. Two staff needed for the dressing change. MD to address pain management next visit. Review of the MD/NP, Clinic/Specialist and Hospital notes from January thorough April indicated but were not limited to the following:-1/28/25: MD/MP: CVA with left hemiplegia, Musculoskeletal: Weakness, limitation of motion, stiffness, joint deformities, and needs assistance with all activities of daily living.-2/25/25: Wound left arm: Wound noted yesterday by nursing. Patient with contractures to arm, keeps elbow bent. Musculoskeletal: Weakness, limitation of motion, stiffness, joint deformities scattered/multiple. Skin: Abnormal findings include open wound left arm AC. Wound bed with slough (yellow stringy, non-viable tissue accumulated in wound), mild surrounding redness, moderate serosanguinous (thin watery pink/red) drainage.-3/21/25:MD: Patient has severe bilateral contractures.-3/26/25: Wound Clinic: Refer to orthopedics for question of tendon release. Pressure ulcer of the left elbow stage 4.-3/27/25:MD/NP Note: Asked by staff to evaluate resident due to clinical finding which are significant for wound clinic follow up. Seen by ortho today, wound with exposed tendon. Refer to Ortho for evaluation.-4/8/25: Orthopedic Surgery: Patient has a degenerating ulcerative type wound involving the anterior elbow as a result of his/her severe flexion contracture that has been present for a long time. He/she had a stroke two years ago, became contracted, wound developed three weeks ago. Left elbow is contracted at 130-135 degrees, can pull passively to about 120 degrees flexion contracture. There is exposed bicep tendon and muscular tissue in the wound, unable to see if it involves the joint. Consulted wound specialist and patient would probably require contracture release in order to address and evaluate the wound itself.-4/29/25: admitted to the hospital for Left Elbow Soft Tissue release. Wound was surgically closed during the procedure. During an interview on 8/12/25 at 4:18 P.M., Nurse #3 said Resident #2 was admitted with a contracture. She said they were not doing any treatments or preventative skin care to the area until the wound developed. During an interview on 8/13/25 at 10:20 A.M., Nurse #4 said Resident #2 was admitted with the contracture, it got tighter, and he/she was resistive to letting you open it up. She said Resident #2 would hold the LUE up by their collar bone regularly. She said they did not do any preventative skin care to the area and only did routine weekly skin checks like they did on everyone. She said there was no specific skin inspection for the elbow contracture area only the hand contracture. She said that after the pressure ulcer was discovered dressing changes were difficult because you could not open the arm a lot to get in there and dressings didn't stay well. She said after he/she went to the wound clinic it was recommended he/she have a tendon release. She said when they did the tendon release they closed the wound, so it healed well. She said it probably would never have healed if they did not do they surgery because it was so tight at that point, dressing changes were difficult, and it was painful. During an interview on 8/13/25 at 10:46 A.M., Unit Manager #1 said Resident #2 was very contracted and not cooperative with care. He said therapy was trying to prevent the contracture from getting worse, but I don't think he/she tolerated it well. He said Resident #2's nails would dig into their palm and that it why they frequently monitored the palm area. He said they did not do any monitoring of the LUE/elbow contracture site, just the routine weekly skin checks. He said often he/she would not allow care to be done and it could be difficult. Additionally, he said sometimes they do additional preventative skin checks or dressings to an area to prevent skin breakdown, but Resident #2 did not have any orders, interventions on the care plan, or anything on the CNA flow sheets for that. During an interview on 8/13/25 at 12:09 P.M., with the Director of Rehab Occupational Therapist (DOR/OT) #1 and OT #2, OT #2 said Resident #2 was declining in his/her self-feeding in December 2024 and when the evaluation was done it was noted the LUE contracture was tighter. PROM was done and orthotic management (hand roll) to the LUE. She said he/she was tolerating the PROM well with skilled OT visits. She said caregiver goal was for the handroll and monitoring/management of the contracture. She said the education would have consisted of PROM to the hand, wrist, elbow, and shoulder. She said usually CNAs do that after the education is done, and the nurse would write the orders for the specific time frame. She said OT only write the orthotic orders. The DOR/OT #1 was unable to provide the surveyor with the education that should have been completed in January 2025. She said the other therapists thought it was done, but it was not in the binder in the Rehab Office or on the unit. Additionally, she said we (therapy dept) do the education, and the specifics would be on the education sheet. She said a copy stays in the office usually, and then one goes to the floor do they can continue education and write the orders. She said PROM should have been daily and when you do that you would inspect the skin. OT #2 said referencing the education sheet from 2023, that the education from January 2025 would have been like this one, stating part of the PROM to LUE would include skin inspection of the entire arm, especially due to the elbow crevasse where moisture would build up. OT #2 said she did the OT Discharge Summary but did not do the education herself and was unable to provide a copy of it. She said the OT Assistant would complete the education with the CNAs, Nurses, and Unit Manager on multiple shifts and then leave a copy on the unit so the Unit Manager can ensure the treatment plan in being followed and put the original in the Rehab Office. During an interview on 8/13/25 at 12:49 P.M., the Assistant Director of Nurses (ADON)/Wound Nurse said he/she developed the wound in February 2025, the wound got worse, the tendon was exposed, and the Wound Clinic was consulted at the end of March, and then he/she went to Ortho, who recommended a tendon release. She said OT education would have been done with the Unit Manager and the staff on the unit, she said PROM orders would be written as a physician's order, it would go on the flow sheets, the CNAs would complete it, and document in the computer. She said he/she did not have any orders/tasks associated with the LUE contracture for PROM. She said if it was something Nursing had to do it would go on the treatment sheets and it was not there either. Additionally, she said the contracture and management plan for the contracture should have been on the care plan and it was not. She said additional skin inspections to a certain area would have been written as an order, like the hand/palm order that was in place. During an interview on 8/13/25 at 12:53 P.M., Unit Manager #1 said he could not recall any education from OT regarding the LUE contracture, PROM, or skin inspections/management being done this year. During an interview on 8/13/25 at 2:00 P.M., the Director of Nurses (DON) said Resident #2 was on OT in December 2024 and January 2025. She said she would expect the education and Discharge plan of care to be documented. She said if there should have been PROM with skin inspections there would have been an order, and she did not see any. She said sometimes communication between departments has been challenging, and she did not get copies of the therapy education. She said it was kept in the Rehab office and on the units. She said the PROM would have been on the CNA flow sheets and documented in the computer and it was not. She said everyone gets general ROM with care, but anything specific to a certain extremity would be written as an order. She said it was not specifically written on the OT Discharge Summary, but if it was on the education sheet, she would expect the orders to be written. She said they did not have a specific contracture process for additional skin inspections. She said there was an order for his/her hand because of the finger nails. She said Resident #2 was difficult at times with care, but she thought he/she could open the arm if he/she wanted to.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one Resident (#85), out of a sample of 24 residents. Specifically, the facility failed to ensure staff utilized the appropriate personal protective equipment (PPE) when entering the room of Resident #85 who had an active diagnosis of Clostridioides difficile (formerly known as Clostridium difficile and often called C. diff, which is a bacterium (germ) that causes diarrhea and colitis (inflammation of the colon) and was on contact plus precautions. Findings include:Review of the facility's policy titled Contact Precautions, dated 4/2025, indicated but was not limited to the following:-To prevent the transmission of infection agents which are spread by direct or indirect contact with the resident or the resident's environment.Contact Precautions shall be used in conjunction with Standard Precautions when resident has a suspected or confirmed case of: Clostridium difficile (C-Diff).-Personal protective equipment:-Gloves shall be donned upon entering the resident's room or cubicle and worn whenever touching the resident's intact skin, environmental surfaces, and articles in close proximity to the resident. Change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material or wound drainage).-Gown shall be donned upon entering the resident's room or cubicle. Remove gown and observe hand hygiene before leaving the resident-care environment. After a gown removal, ensure clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganisms to other residents or environmental surfaces.Resident #85 was admitted to the facility in December 2022 with a diagnosis of Enterocolitis due to C-Diff, recurrent-per lab results.Review of Resident #85's Physician's Orders indicated but were not limited to the following:-7/30/25- C Diff.-Maintain contact precautions for C diff. Review of Resident #85's care plan included, but was not limited to the following:-C Diff: I have an infection of my gastrointestinal system. I have a communicable infection.-Be sure to use contact precautions when entering my room/caring for me.-Teach my visitors what they need to do not to catch my infection when visiting.On 8/7/25 at 1:34 P.M., the surveyor observed signage posted outside Resident #85's room, titled Contact Plus Precaution, Massachusetts Department of Public Health dated 9/2022, which indicated the following:- In addition to Standard Precautions, Staff and Providers MUST:-Clean hands before entering resident's room-Gown-Gloves-Wash hands with soap and water before exiting resident's roomOn 8/12/25 at 2:12 P.M., the surveyor observed Activity Staff #2 in Resident #85's room not wearing any PPE, holding Resident #85's television remote control assisting the Resident in changing the channel. During an interview on 8/12/25 at 2:12 P.M., Activity Staff #2 said she did not need to wear any PPE because she was not doing any personal care. She said she was only assisting Resident #85 with his/her television. During an interview on 8/13/25 at 8:00 A.M., the Director of Nursing (DON) said if a resident was on contact plus precautions, she would expect the staff to be donning (putting on) the appropriate PPE before entering the room and doffing (removing) the PPE before exiting the room. The DON said if a resident has C-Diff, the staff should be wearing PPE when they enter the room for any reason.

Based on observation, record review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean equipment and ensured that food was stored properly, in three out of four kitchenettes. Findings include: Review of the facility's policy titled Kitchen/Pantry Cleaning Schedule, undated, indicated but was not limited to the following: -Check/Clean & sanitize microwave (inside & out) -Check all cabinets, shelving, drawers in good repair -If any equipment is in need of repair, please inform supervisor On 6/20/24 at 9:49 A.M., the surveyor observed the following in the Third Floor Unit kitchenette: -Inside the microwave, the bottom outer panel of the microwave was rusted, and peeling off. -Inside the microwave, on the right-side wall, there was food particle spatter and a dark brown stain. -Inside the microwave on the bottom left front corner was a brownish, sticky, crusted substance. -A toaster, three clear plastic serving bowls, a coffee machine, and two packages of drinking cups were stored under the sink next to plumbing piping. On 6/24/24 at 8:03 A.M., the surveyor observed the following in the Saint Michael's Unit kitchenette: -Inside the microwave on the upper left side wall was a brownish, orange crusted stain. -Inside the microwave on the back top right and left corners were areas of rust. -An aluminum foil food serving pan, one bottle of prune juice, and one plastic coffee mug were stored under the sink next to plumbing piping. On 6/24/24 at 11:27 A.M., the surveyor observed the following in the Saint Joseph's Unit kitchenette: -Inside the microwave on the top center, there were two areas of rust peeling off, food particle spatter and dark brown stains. -Inside the microwave on the top right and left corners were areas of rust. -A coffee pot and multiple bags of coffee in a bucket were under the sink next to plumbing piping. During an interview with observation of the Saint Michael's Unit kitchenette on 6/25/24 at 8:26 A.M., Unit Manager #1 said the dietary staff were responsible for stocking and cleaning the kitchenettes. UM #1 and the surveyor observed the microwave and she said she has never noticed the rusted areas before and will notify maintenance. The surveyor and UM #1 observed the cabinet under the sink and noted an aluminum foil food serving pan, one bottle of prune juice, one plastic coffee mug. She said nothing is supposed to be stored under the sink and removed the items. During an interview with observation of the Saint Joseph's Unit kitchenette on 6/25/24 at 8:39 A.M., the Food Service Director (FSD) said the microwaves are supposed to be cleaned and sanitized daily. The surveyor and FSD observed the microwave, and he said the areas on the top of the microwave appear to be rusted and flaking off, and it needed to be replaced. The FSD and surveyor observed the cabinet under the sink and noted a coffee pot, and multiple bags of coffee stored in a bucket. He said no food items should ever be stored under the sink due to the high risk of contamination. FSD said the dietary staff are responsible to check the cabinets daily and ensure nothing is placed in the cabinet, under the sink. During an interview with observation of the Saint Michael's Unit kitchenette on 6/25/24 at 8:48 A.M., the FSD and surveyor observed the microwave. He said the microwave appears to be rusted and needed to be replaced. The FSD and surveyor looked in the cabinet under the sink, and all items had been removed. The surveyor informed the FSD of the findings on 6/24/24 and 6/25/24 earlier in the morning, and he said no items are to be stored under the sink. During an interview with observation of the Third-Floor kitchenette on 6/25/24 at 8:48 A.M., the FSD and surveyor observed the microwave and noted that the inside, bottom outer panel was rusted, and peeling off, and continued to have food particle spatter and a dark brown stain on the right inside wall. He said it was in disrepair and should not be in use. He said the dietary staff never made him aware, and it needs to be replaced. The FSD and surveyor looked in the cabinet under the sink and noted a toaster, three clear plastic serving bowls, coffee machine, two packages of drinking cups. He said nothing is supposed to be stored under the sink, and the dietary staff should have removed the items when they do the daily cleaning of the kitchenette.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program Policy, last revised 11/2023, indicated but was not limited to the following: - it is the policy of the health facility to implement an antibiotic stewardship program which will promote the appropriate use of antibiotics while optimizing treatment of infections - facility action: an antibiotic review process, also known as a time out for all antibiotics prescribed in the facility - antibiotic time out (ATO) prompts clinicians to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer - ATO can be considering a stop order of an antibiotic when diagnostic test results or symptoms of the resident do not support the diagnosis of infection During an interview on 6/20/24 at 10:45 A.M., the Infection Preventionist (IP) said the facility uses the pre-defined McGeer criteria to determine if an illness or set of symptoms rise to the level of an infection. She said antibiotic usage is tracked on the facility illness surveillance sheets which also indicate whether or not an illness meets infection criteria. Review of the facility surveillance sheets for April and May 2024 indicated but were not limited to the following: APRIL: Resident #73 had a skin concern with an onset date of 4/30/24, the surveillance indicated the issue did not rise to the level of an infection as determined by the facility criteria, however an antibiotic was prescribed for 7 days. Review of the progress notes, including physician and nurse practitioner notes for Resident #73 from 4/25/24 through 5/20/24, failed to indicate an ATO was performed for Resident #73's continued antibiotic use, even though the symptoms did not meet infection criteria. MAY: Resident #106 had a urinary issue with an onset date of 5/11/24, the surveillance indicated the issue did not rise to the level of an infection as determined by the facility criteria, however an antibiotic was prescribed for 7 days. Review of the progress notes, including physician and nurse practitioner notes for Resident #106 from 5/5/24 through 5/25/24, failed to indicate an ATO was performed for Resident #106's continued antibiotic use, even though the symptoms did not meet infection criteria. Further review of Resident #106's medical record indicated a urinalysis and culture was obtained related to a fall the Resident had and there were no symptoms of a potential illness or infection prior to the diagnostic test being obtained and the Resident completed a 7-day course of antibiotics and remained without urinary symptoms for the entirety of the treatment. During an interview on 6/20/24 at 3:29 P.M., the IP said the facility is supposed to complete a time out and document that in the medical record for all residents on antibiotics in the facility that do not meet infection criteria. She reviewed the information for Resident #73 and Resident #106 and said there was no evidence that an ATO had occurred for either Resident as it should have. She said neither Resident #73 or #106 met McGeer infection criteria and an ATO should have been documented in their medical records in accordance with the facility policy and it was not. During an interview on 6/25/24 at 11:54 A.M., the Director of Nurses said residents on antibiotic therapy are discussed daily in morning meeting. She said she was aware of the concerns discussed with the IP regarding the antibiotic stewardship. She said the expectation is that the policy is followed and an ATO is completed as it is required to be and it is not being done in accordance with the facility policy at this time.

Based on observation and interview, the facility failed to ensure a functional, safe, and clean environment on two (2PY and 3PY) of four units in the facility. Specifically, the facility failed to ensure sharps containers were replaced when two thirds to three-quarters full to decrease the risk of needlestick injuries and exposure to bloodborne pathogens. Findings include: Review of the facility's policy titled Sharps Container Weekly Check Policy/Procedure, revised July 2018, indicated but was not limited to the following: -It will be the responsibility of the maintenance and nursing department to inspect and dispose of any sharps containers that are two thirds to three-quarters full. -Sharps containers will be checked weekly and disposed of according to department policy. -The maintenance department will routinely check/replace containers on a scheduled day, usually Monday, once a week -Sharps containers in resident rooms will be replaced on an as needed basis. Nursing staff will submit a request to the maintenance department indicating which rooms need new containers. Review of the Occupational Safety and Health Administration (OSHA) web-based fact sheet titled, Protecting Yourself When Handling Contaminated Sharps, indicated but was not limited to the following: - A needlestick or a cut from a contaminated sharp can result in a worker being infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other bloodborne pathogens. The standard specifies measures to reduce these types of injuries and the risk of infection. Careful handling of contaminated sharps can prevent injury and reduce the risk of infection. Employers must ensure that workers follow these work practices to decrease the workers' chances of contracting bloodborne diseases. Sharps Containers: - The containers must be replaced routinely and not be overfilled, which can increase the risk of needlesticks or cuts. Occupational Safety and Health Administration. (2011, January). Protecting Yourself When Handling Contaminated Sharps. https://www.osha.gov/sites/default/files/publications/bbfact02.pdf On 6/25/24, during a tour of the 2PY and 3PY Units, the surveyors observed wall mounted sharps containers in the following residents' rooms filled above the three-fourths (3/4) full line marking with various sharps inside including but not limited to contaminated syringes, needles, and razors: 3PY Unit: 9:50 A.M. room [ROOM NUMBER] 2PY Unit: 10:33 A.M. room [ROOM NUMBER] (unoccupied after terminal clean) 10:34 A.M. room [ROOM NUMBER] 10:35 A.M. room [ROOM NUMBER] 10:37 A.M. room [ROOM NUMBER] 10:40 A.M. room [ROOM NUMBER] The sharps containers were all filled above the three-fourths (3/4) full line marking increasing the potential for needlestick injuries and exposure to bloodborne pathogens. Review of the Monthly Facility Inspection document, provided by the Maintenance Director, indicated monthly resident room checks were last completed in May 2024. No other documents were provided by the Maintenance Director including a sharps container weekly checklist to indicate that maintenance was routinely checking the containers on a scheduled day, once a week, per facility policy. During an interview on 6/25/24 at 9:59 A.M., Nurse #1 said maintenance was responsible for changing the sharps containers and, as far as she knows, it is not done on a schedule. She said the staff either verbally tell maintenance if they are on the unit or the staff can complete a maintenance slip to notify maintenance of the need for a needle box change. She said they request a change from maintenance if they notice it's at the line or if they use it and it seems that the needle doesn't fall freely, or if they have to jiggle it. During an interview on 6/25/24 at 10:35 A.M., Nurse #5 said if a sharps container is full, they would notify maintenance to replace it. She said a repair slip is completed then attached to a clip outside the maintenance office. She said the containers should not be filled above the fill line as it could be a potential hazard. She said she was aware the sharps container in room [ROOM NUMBER] was full yesterday but didn't notify maintenance yet. During an interview on 6/25/24 at 10:42 A.M., Certified Nursing Assistant (CNA) #3 said she wasn't sure who she would notify if the containers were full. She said the aides and nurses monitor them and said she had not seen any that were full this day. During an interview on 6/25/24 at 11:06 A.M., the Maintenance Director said nursing monitors the sharps containers on the units and if one is full and needs to be replaced then nursing makes out a request for maintenance to empty it. He said if maintenance staff are in a room and notice a container is full, they'll switch it out. The surveyor reviewed the repair slips with the Maintenance Director and Maintenance Staff #1 who said they had not received any for the observed rooms. The Maintenance Director said if the containers are too full there is a potential for needlestick injuries. During an interview on 6/25/24 at 1:09 P.M., the Maintenance Director said sharps containers should also be replaced if full during a terminal room clean or on an as needed basis. He said maintenance doesn't routinely check the residents' rooms, just once a month for the most part. He said he only has two staff for the whole facility, so they are not doing weekly checks. During an interview on 6/25/24 at 1:17 P.M., the surveyor reviewed the Monthly Facility Inspection document with the Maintenance Director and Maintenance Staff #1 who said resident room checks were last completed in May but wasn't sure what day.

Based on record review and interviews, the facility failed to develop and implement a person-centered plan of care which included care for residents who had experienced trauma and the identification of potential triggers to be avoided to help prevent potential re-traumatization for two Residents (#120 and #30), out of a total sample of 24 residents. Findings include: 1. Resident #120 was admitted to the facility in March 2024 with diagnoses including Parkinson's disease. Review of the most recent Brief interview for Mental Status (BIMS), dated 3/27/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 6/21/24 at 10:52 A.M., Resident #120 said he/she had a trauma in which he/she was robbed and sexually assaulted that occurred quite a few years ago. The Resident said the event had a lasting impact on him/her and he/she can be jumpy or reactive at times. The Resident said he/she shared the trauma with the facility. During an interview on 6/21/24 at 11:06 A.M., Certified Nurse Aide (CNA) #2 said she was familiar with Resident #120 but was not aware of any behaviors, traumas or potential triggers the Resident may have that would cause a behavior or reaction. During an interview on 6/21/24 at 11:31 A.M., CNA #1 said she knows Resident #120 well and cares for them frequently. She said she had never known the Resident to have behaviors or a history of trauma and she was unaware of any triggers or things that should be avoided to help prevent the Resident from having a negative reaction. Review of the Social History and Assessment for Resident #120, dated 3/27/24, indicated but was not limited to the following: - Resident is alert and oriented and able to communicate their needs and desires - Resident does not exhibit any behaviors - Resident enjoys sharing stories about their life - Mental health history: Resident reports being robbed and sexually assaulted in the past - Trauma: Does the Resident report or the record reflect any history of trauma: No - Does the Resident have disturbing memories or thoughts from a stressful experience in the past: No Review of the current care plans for Resident #120, as of 6/21/24, indicated, but were not limited to the following: PROBLEM: Mood/Behavior: I have a history of depression, can be stubborn and want things done a particular way, and it makes me upset if things go differently. I have a diagnosis of insomnia and am visually impaired with dry eyes. (6/21/24) GOAL: I would like to be free of acute emotional distress and feel safe and comfortable in my environment by evidence of no crying, sadness, or unacceptance of placement during the next 90 days. (6/21/24) INTERVENTIONS: Administer medications at the lowest effective dose, monitor for side effects of antidepressants and report significant findings, encourage me to participate in activities, if I appear upset talk to me to find out where I am from, I enjoy attending mass and family friends on the same unit, I have a tablet I play games on, refer to social services and psych services as needed, use a slow calm approach introduce yourself tell me what you are going to do and allow me to express myself and process what you have said (6/21/24) The current active care plans failed to indicate the Resident had suffered a trauma, or that his/her mental health history included a traumatic event or to identify any potential triggers to be avoided to help prevent potential re-traumatization to the Resident. During an interview on 6/21/24 at 4:32 P.M., Nurse #2 said she was not aware of any traumas in Resident #120's past, or any behaviors or potential triggers to be avoided while caring for the Resident. During an interview on 6/21/24 at 4:34 P.M., Nurse #3 said she knows the Resident well and cares for them often. She said she was unaware the Resident had any trauma or mental health history and she does not know of any behaviors the Resident has or any triggers to be avoided to ensure the Resident does not have a negative reaction. During an interview on 6/21/24 at 4:40 P.M., the Director of Social Services said residents have a social history and assessment completed upon admission and residents with a known trauma or history of a trauma would have a care plan developed and implemented to alert the staff to the concern and potential things to be avoided or behaviors to monitor. She reviewed the assessment for Resident #120 and said although the Resident indicated a history of sexual assault and being robbed, they declined psychotherapy. She said she did not indicate the Resident's experiences of sexual assault or being robbed as a trauma and that was an error. She reviewed the care plans for Resident #120 and said a care plan should have been developed and implemented to alert staff to the trauma and things to avoid or behaviors to be on the look out for but that did not happen. She said it is imperative that staff understand potential triggers to avoid any potential re-traumatization to the Resident and that process was not implemented for this Resident as it should have been. 2. Resident #30 was admitted to the facility in November 2019 with diagnoses including: schizoaffective disorder, bipolar disorder and generalized anxiety. Review of the most recent BIMS, dated 5/14/24, indicated the Resident was cognitively intact with a score of 14 out of 15. Review of the medical record for Resident #30 indicated but was not limited to the following: - a recent hospitalization in April of 2024 in which he/she had reported a history of trauma, but due to being in the hallway at the hospital chose not to elaborate - Resident was on services and received psychotherapy routinely at the facility During an interview on 6/18/24 at 9:17 A.M., the Resident said he/she has a history of trauma and bad thoughts that come up regarding that trauma but he/she did not want to speak to the surveyor about it in detail at that time and appeared suspicious of the surveyor. Review of the psychotherapy notes from May 2024 indicated, but were not limited to the following: - 5/10/24: Diagnoses: post-traumatic stress disorder (PTSD); precipitants and triggers of feelings and behaviors were explored, others report a suspicious demeanor and paranoia - 5/24/24: Diagnoses: PTSD; others have observed a suspicious demeanor, paranoia has improved, precipitants and triggers for feelings and behaviors were explored Review of the current care plans for Resident #30, as of 6/21/24, indicated, but were not limited to the following: PROBLEM: Mood/Behavior: I have schizoaffective disorder, manic episodes, bipolar disorder, anxiety, depression and insomnia. I am visually impaired and hard of hearing. I can be obsessed with my health and any changes that occur. My last severe manic episode was in 2023; in 2024 I have been more paranoid and hearing things from my inner voice. There are times I want to stay up late at night to watch television, eat snacks and write letters. (edited: 6/11/24) GOAL: I would like to be free of acute emotional distress and feel safe and comfortable in my environment as evidenced by not packing my items and no excessive worrying over my health conditions during the next 90 days. (edited: 5/13/24) INTERVENTIONS: Administer medications at the lowest effective dose, monitor for side effects of antidepressants, anxiolytics, mood stabilizers, and antipsychotics and report significant findings, encourage me to participate in activities, I enjoy attending mass, I often like to have a confessional to bring me comfort when my negative thoughts are overpowering, I see a psychotherapist, monitor me during times of excessive charity as it may be a sign of mania, reassure me that we are monitoring my health, refer to psych services and social services as needed (5/13/24); remind me the importance of having a good wake-sleep cycle (6/11/24) Review of the current care plans for Resident #30 failed to indicate the Resident had a trauma history, what the trauma entailed or what triggers should be avoided to help avoid potential behaviors and feelings or re-traumatization to the Resident. During an interview on 6/21/24 at 4:32 P.M., Nurse #2 said she knows Resident #30 and was aware the Resident had an extensive psychiatric history. She said she was not aware of any trauma or potential triggers that should be avoided to help the Resident avoid a negative reaction or behavior. During an interview on 6/21/24 at 4:34 P.M., Nurse #3 said she knows the Resident well and cares for him/her often. She said the Resident had delusional behaviors and a recent psych hospitalization . She said she was not aware of any trauma or any potential triggers to avoid when caring for the Resident to help potentially eliminate behaviors or negative feelings on the Resident's part. During an interview on 6/21/24 at 4:50 P.M., the Director of Social Services said she knows the Resident well and is aware the Resident has a history of trauma related to abandonment and not feeling good enough. She reviewed the current care plans for Resident #30 and said there was no indication of the trauma, potential triggers and what should be avoided to potentially prevent a behavior or re-traumatization to the Resident. She said there should be a care plan in place and it is not. During an interview on 6/25/24 at 11:58 A.M., the Director of Nurses (DON) said the facility should be developing and implementing a care plan for any resident with a known history of trauma which includes any triggers or potential triggers to help mitigate a potential negative consequence or outcome for the resident in the future.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for one Resident (#57), out of a total sample of 24 residents. Specifically, the facility failed to ensure the Resident's foam dressing to the left heel unstageable deep tissue injury (DTI- pressure injury where the depth of the ulcer is obscured by a layer of dead tissue, or slough and/or eschar, covering the wound bed) was changed in accordance with the physician's order. Findings include: Review of the facility's policy titled Dressing Changes and Changing a Clean Dressing, revised November 2023, indicated but was not limited to the following: Purpose: -To promote wound healing. -Cleanse and rinse wound as ordered. Resident #57 was admitted to the facility in April 2024 and had diagnoses including peripheral vascular disease, displaced articular fracture of head of the right femur, and bilateral paralytic syndrome following cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 4/19/24, indicated that Resident #57 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, was at risk for developing pressure ulcers, was dependent on staff for mobility, and had two unstageable DTIs present upon admission. Review of the Skin Issue care plan, initiated 6/19/24, indicated Resident #57 had an unstageable area on the left heel upon admission which had gotten smaller in size. Care planned interventions included applying Allevyn foam dressing (used to keep the wound moist and clean, providing an optimal environment for healing) as ordered (6/19/24). Review of current Physician's Orders indicated the following: -Foam dressing -Cleanse left heel with normal saline, pat dry, cover with foam dressing, change every three days, and as needed for intactness/soilage. Monitor for pain with every dressing change, once a day every three days 7:00 A.M. - 3:00 P.M. (6/5/24) On 6/25/24 at 8:29 A.M., the surveyor observed Nurse #5 perform a dressing change to Resident #57's left heel unstageable DTI who was lying in bed. Nurse #5 removed the old dressing exposing the Resident's wound for observation. The wound was approximately 2 centimeters (cm) in length x 1 cm width with a dark wound bed in the center. There was no drainage or open areas. The surrounding skin was pink. Resident #57 denied any pain or discomfort. Nurse #5 measured the wound then applied a new foam dressing. Nurse #5 did not cleanse the wound with normal saline or pat dry prior to applying the new foam dressing per physician's orders. Nurse #5 said she performed the dressing change that was due for the night. During an interview on 6/25/24 at 8:35 A.M., the surveyor reviewed Resident #57's medical record with Nurse #5 who said the physician's order said to cleanse the wound with normal saline and pat dry before applying the foam dressing. She said she did not do that but should have and would have to go back and do it over again. During an interview on 6/25/24 at 12:43 P.M., the Director of Nursing (DON) said Resident #57 came in with heel issues and discoloration. The Assistant Director of Nursing (ADON) said she was the facility's wound care nurse, and the Resident came in with a left heel DTI. The ADON said the foam dressing was started on 6/4/24. She said the Resident was at risk for developing pressures because he/she did not move and was dependent on care. The ADON said wound dressing changes should be done per physician's orders.

Based on observation, interview, and record review, the facility failed to ensure two Residents (#57 and #96), out of a total sample of 24 residents, received care and treatment to prevent and to promote the healing of pressure injuries consistent with professional standards of practice. Specifically, the facility failed: 1. For Resident #57, who had an existing left heel unstageable deep tissue injury (DTI- pressure injury where the depth of the ulcer is obscured by a layer of dead tissue, or slough and/or eschar, covering the wound bed), to consistently implement physician's orders to offload the Resident's heels and adjust the low air loss (LAL) mattress (distributes body weight over a broad surface area to help prevent skin breakdown) per physician's orders and care planned interventions; and 2. For Resident #96, who had an existing unstageable DTI on his/her coccyx, to ensure the Resident's LAL mattress settings were programmed in accordance with the physician's order. Findings include: Pressure Injury Care: -Make sure the patient's heels don't rest on the bed. Apply heel protection devices, as required, to prevent heel pressure injuries. The devices should completely offload pressure from the heels. If you're placing pillows under the patient's calves to decrease pressure, place each pillow longitudinally underneath the calf with the heel suspended in the air. Wolters Kluwer. Lippincott Nursing Procedures, Eighth edition, [Philadelphia: Wolters Kluwer, [2019]. Page 632. Review of the facility's policy titled Wound and Skin Protocol Policy, revised January 2024, indicated but was not limited to the following: -Interventions must be care planned and implemented during the admission process and revised as needed. Review of the facility's policy titled Low Air Loss Mattress, last reviewed March 2024, indicated but was not limited to the following: Purpose: -To treat and prevent wounds by facilitating blood circulation and decreasing pressure of each tissue's contact area. -If determined that the resident requires a low air mattress an order will be obtained by the physician to include low air loss mattress: Check accuracy of weight setting. Monitor for bottoming out. Check that the static button is set in the off position. -Check the resident's weight and adjust the low air loss mattress accordingly. This should be done weekly with the weekly weights and documented. -Caregivers should always perform a hand check by placing their hands underneath patient's pelvis area to check if there is sufficient air support to ensure the patient is not bottoming out. 1. Resident #57 was admitted to the facility in April 2024 and had diagnoses including peripheral vascular disease, displaced articular fracture of head of the right femur, and bilateral paralytic syndrome following cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 4/19/24, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, was at risk for developing pressure ulcers, was dependent on staff for mobility, and had two unstageable DTIs present upon admission. Review of the Skin care plan, initiated 4/25/24, indicated Resident #57 was at risk for skin problems secondary to his/her incontinence and decreased mobility and was admitted with areas of DTI on the heels and buttock. Care planned interventions included the following: -Offload the heels, 4/24/24 -Low air loss mattress on the bed, 4/23/24 Review of current Physician's Orders indicated the following: -Offload the heels every shift three times a day, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M., 4/13/24 -Low air loss mattress, check accuracy of weight setting. Monitor for bottoming out. Check that static button is set in off position every shift 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M., 4/18/24 During an observation with interview on 6/18/24 at 8:55 A.M., the surveyor observed Resident #57 lying in bed with a pillow underneath the left calf. The Resident's left heel was in contact with the mattress and not offloaded per physician's orders. The Resident's LAL mattress static mode button was in the on position indicating the mattress was distributing a constant level of air pressure evenly distributed across the mattress surface. Resident #57 said he/she had a sore on the left heel but wasn't sure how it got there and described his/her current pain level as a 7 out of 10 and stinging. The Resident said he/she had a history of a stroke and had limited range of motion in the upper extremities and difficulty speaking. During an interview on 6/18/24 at 12:35 P.M., Resident Representative #1 said Resident #57 had a bedsore on the back of his/her left heel. Resident Representative #1 said it was better, but still sore, and said sometimes he/she comes to visit in the middle of the night and the Resident's heels are flat on the bed, not elevated, so he/she will put a pillow or something underneath. During an interview on 6/20/24 at 9:53 A.M., Nurse #5 said the Resident had a 1.0 centimeter (cm) x 1.5 cm DTI on the left heel and interventions included to keep the heels offloaded. She said the Resident had not complained of pain. On 6/24/24 at 9:03 A.M., the surveyor observed Resident #57 lying in bed with a pillow underneath the left calf. The Resident's left heel was in contact with the mattress and not offloaded per physician's orders. The Resident's LAL mattress static mode button was in the on position. During an interview on 6/25/24 at 8:23 A.M., Certified Nursing Assistant (CNA) #5 said she was assigned to the Resident this day but didn't know if he/she had any wounds. CNA #5 asked CNA #4 who said he/she didn't have any wounds or pressure areas that she knew of but said the Resident was at risk for developing pressure ulcers. CNA #4 said the Resident had an air mattress and his/her heels were supposed to be elevated while in bed. On 6/25/24 at 8:17 A.M., the surveyor observed Resident #57 lying in bed with a pillow underneath the left and right calves. The Resident's left heel was in contact with the mattress and the right heel in contact with the pillow. The heels were not offloaded per physician's orders. The Resident's LAL mattress static mode button was in the on position. During an observation with interview on 6/25/24 at 8:27 A.M., the surveyor and Nurse #5 observed Resident #57 lying in bed. The Resident's LAL mattress static mode button was in the on position. The surveyor observed the Resident's left heel wound with Nurse #5. The wound was approximately 2 centimeters (cm) in length x 1 cm width with a dark wound bed in the center. There was no drainage or open areas. The surrounding skin was pink. Resident #57 denied any pain or discomfort. Nurse #5 said it was a DTI. She said the mattress was set at 200 pounds on static pressure and wasn't sure if that was the order but would check. She said the Resident's heels should be offloaded to treat the current left heel DTI and to prevent others from forming. She said the Resident was at risk for developing pressure ulcers. During an interview on 6/25/24 at 8:35 A.M., the surveyor reviewed the medical record with Nurse #5 who said the LAL mattress should not have been on static mode and said she didn't know the difference between static mode and alternating mode for air pressure or the benefit to the static mode being turned off. She said mattresses should be set per physician's orders but wasn't sure how to adjust the settings. During an interview on 6/25/24 at 12:42 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the Resident was admitted with a left heel DTI and was at risk for developing pressure ulcers due to immobility and dependence on staff for care. The DON and ADON said care planned interventions should be consistently implemented. They further said the static pressure cycle holds the air pressure, it doesn't alternate it, and should have been turned off per physician's orders. They further said the Resident's heels should have been consistently offloaded while in bed. The DON and ADON said nursing or maintenance sets up the air mattresses, but nursing adjusts the settings. 2. Resident #96 was admitted to the facility in May 2024 and had diagnoses including muscle weakness, abnormalities of gait and mobility, and altered mental status. Review of the MDS assessment, dated 5/11/24, indicated Resident #96 had severe cognitive impairment as evidenced by a BIMS score of 0 out of 15, was dependent on staff for mobility, was at risk for developing pressure injuries, and had one unhealed unstageable DTI present upon admission. Review of a Nursing Progress Note, dated 5/6/24, indicated but was not limited to the following: -coccyx 1.0 x 2 cm open area, new Allevyn dressing applied, right buttock 3 x 1 cm excoriation, coccyx 7 x 10 cm dark pink/purplish in color. Review of current Physician's Orders indicated the following: -Low air loss mattress: Check accuracy of weight setting. Monitor for bottoming out. Check that static button is set in off position, 5/6/24 Review of the Skin care plan, initiated 5/20/24, indicated Resident #96 was at risk for skin problems secondary to incontinence and decreased mobility. Interventions included a low air loss mattress on his/her bed (5/8/24). Review of the Vitals Summary indicated the following weights for Resident #96: 6/12/24 - 130.0 pounds (lbs.) 6/19/24 - 133.0 lbs. On 6/20/24 at 9:48 A.M., the surveyor observed Resident #96 sitting in a recliner in his/her room. A LAL mattress was inflated on the bed with the weight setting programmed at 325 pounds. The static mode button was in the on position. On 6/24/24 at 8:49 A.M., the surveyor observed Resident #96 lying in bed. The LAL mattress weight setting was programmed at 325 pounds. The static mode button was in the on position. On 6/25/24 at 8:09 A.M., the surveyor observed Resident #96 lying in bed. The LAL mattress weight setting was programmed at 150 pounds. The static mode button was in the on position. Resident #96 was non-verbal but shook his/her head yes when asked if there was a wound on his/her coccyx. During an interview on 6/25/24 at 8:51 A.M., Certified Nursing Assistant (CNA) #4 said she was familiar with the Resident who didn't have any wounds or pressure injuries she knew of. She said other than repositioning, there were no other interventions to prevent pressure injuries that she knew of. During an observation with interview on 6/25/24 at 8:55 A.M., the surveyor entered the Resident's room with Nurse #7 and observed the LAL mattress settings programmed at 150 pounds, static pressure. Nurse #7 said the Resident had a small open area on his/her coccyx and was getting a wound treatment to the area. She said she wasn't sure what the correct settings would be for the mattress but would look. Nurse #7 said Resident #96 was at risk for developing pressure ulcers and interventions included the LAL mattress. On 6/25/24 at 9:15 A.M., the surveyor reviewed the medical record with Nurse #7 who said Resident #96 had an unstageable wound on his/her coccyx and the physician's order was to make sure the air mattress was not bottoming out, check the weight settings, and make sure the static mode setting was off. She said the Resident's current weight was 133.0 pounds. She said the weight setting should be adjusted to the Resident's weight with the static mode button in the off position per physician's orders. During an interview on 6/25/24 at 9:46 A.M., the Maintenance Director said nursing is responsible for adjusting the settings on the air mattresses because maintenance staff doesn't know what the residents' needs are, so they always defer back to nursing if the settings need to be adjusted. During an interview on 06/25/24 at 12:59 P.M., the DON and ADON said the Resident had a pressure ulcer on his/her coccyx when admitted from the hospital, but it was healing. They said the Resident was at risk of developing pressure ulcers and had a LAL mattress on the bed. They said the Resident's weight is considered when adjusting the settings and the weight should have been set per physician's orders and static mode turned off.

Based on record review and interviews, the facility failed to identify the potential triggers to be avoided in two Residents (#120 and #30), with a history of trauma, to help prevent potential re-traumatization out of a total sample of 24 residents. Findings include: During an interview on 6/24/24 at 3:33 P.M., the Director of Nurses (DON) and Administrator said the facility does not have a policy on trauma informed care and there is no specific policy or procedure they follow. 1. Resident #120 was admitted to the facility in March 2024 with diagnoses including Parkinson's disease. Review of the most recent Brief interview for Mental Status (BIMS), dated 3/27/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 6/21/24 at 10:52 A.M., Resident #120 said he/she had a trauma in which he/she was robbed and sexually assaulted that occurred quite a few years ago. The Resident said the event had a lasting impact on him/her and he/she can be jumpy or reactive at times. The Resident believes a trigger would be someone coming up from behind him/her quietly or touching him/her from behind which would cause him/her to be frightened and likely lash out physically. The Resident said he/she shared the trauma with the facility but no one else had asked him/her about potential triggers that could cause upset. The Resident said it would be good for the facility to know his/her trigger so it can be avoided. During an interview on 6/21/24 at 11:06 A.M., Certified Nurse Aide (CNA) #2 said she was familiar with Resident #120 but was not aware of any behaviors, traumas or potential triggers the Resident may have that would cause a behavior or reaction. During an interview on 6/21/24 at 11:31 A.M., CNA #1 said she knows Resident #120 well and cares for them frequently. She said she had never known the Resident to have behaviors or a history of trauma and she was unaware of any triggers or things that should be avoided to help prevent the Resident from having a negative reaction. Review of the Social History and Assessment for Resident #120, dated 3/27/24, indicated but was not limited to the following: - Resident is alert and oriented and able to communicate their needs and desires - Resident does not exhibit any behaviors - Resident enjoys sharing stories about their life - Mental health history: Resident reports being robbed and sexually assaulted in the past - Trauma: Does the Resident report or the record reflect any history of trauma: No - Does the Resident have disturbing memories or thoughts from a stressful experience in the past: No Review of the current care plans for Resident #120, as of 6/21/24, failed to indicate the Resident had suffered a trauma, or that his/her mental health history included a traumatic event or to identify any potential triggers to be avoided to help prevent potential re-traumatization to the Resident. During an interview on 6/21/24 at 4:32 P.M., Nurse #2 said she was not aware of any traumas in Resident #120's past, or any behaviors or potential triggers to be avoided while caring for the Resident. During an interview on 6/21/24 at 4:34 P.M., Nurse #3 said she knows the Resident well and cares for them often. She said she was unaware the Resident had any trauma or mental health history and she does not know of any behaviors the Resident has or any triggers to be avoided to ensure the Resident does not have a negative reaction. During an interview on 6/21/24 at 4:40 P.M., the Director of Social Services said residents have a social history and assessment completed upon admission and residents with a known trauma or history of a trauma would have a care plan developed and implemented to alert the staff to the concern and potential things to be avoided or behaviors to monitor. She reviewed the assessment for Resident #120 and said although the Resident indicated a history of sexual assault and being robbed, they declined psychotherapy. She said the facility psychotherapist would typically help any trauma residents with psychotherapy sessions. She said she did not indicate the Resident's experiences of sexual assault or being robbed as a trauma and that was an error. She said since that was not documented, the Resident was not asked if he/she had any potential triggers. She reviewed the care plans for Resident #120 and said a care plan should have been developed and implemented to alert staff to the trauma and things to avoid or behaviors to be on the look out for but that did not happen. She said it is imperative that staff understand potential triggers to avoid any potential re-traumatization to the Resident and that process was not implemented for this Resident as it should have been. 2. Resident #30 was admitted to the facility in November 2019 with diagnoses including: schizoaffective disorder, bipolar disorder and generalized anxiety. Review of the most recent BIMS, dated 5/14/24, indicated the Resident was cognitively intact with a score of 14 out of 15. Review of the medical record for Resident #30 indicated but was not limited to the following: - a recent hospitalization in April of 2024 in which he/she had reported a history of trauma, but due to being in the hallway at the hospital chose not to elaborate - the last social services assessment had been completed since November of 2019 at the time of the Resident being admitted and failed to indicate a history of trauma or potential triggers - Resident was on services and received psychotherapy routinely at the facility During an interview on 6/18/24 at 9:17 A.M., the Resident said he/she has a history of trauma and bad thoughts that come up regarding that trauma but he/she did not want to speak to the surveyor about it in detail at that time and appeared suspicious of the surveyor. Review of the psychotherapy notes from May 2024 indicated, but were not limited to the following: - 5/10/24: Diagnoses: post-traumatic stress disorder (PTSD); precipitants and triggers of feelings and behaviors were explored, others report a suspicious demeanor and paranoia - 5/24/24: Diagnoses: PTSD; others have observed a suspicious demeanor, paranoia has improved, precipitants and triggers for feelings and behaviors were explored Review of the current care plans for Resident #30 failed to indicate the Resident had a trauma history, what the trauma entailed or what triggers should be avoided to help avoid potential behaviors and feelings or re-traumatization to the Resident. During an interview on 6/21/24 at 4:32 P.M., Nurse #2 said she knows Resident #30 and was aware the Resident had an extensive psychiatric history. She said she was not aware of any trauma or potential triggers that should be avoided to help the Resident avoid a negative reaction or behavior. During an interview on 6/21/24 at 4:34 P.M., Nurse #3 said she knows the Resident well and cares for him/her often. She said the Resident had delusional behaviors and a recent psych hospitalization . She said she was not aware of any trauma or any potential triggers to avoid when caring for the Resident to help potentially eliminate behaviors or negative feelings on the Resident's part. During an interview on 6/21/24 at 4:50 P.M., the Director of Social Services said she knows the Resident well and the Resident recently requested to be hospitalized psychiatrically related to paranoia and delusions that were felt to be uncontrolled. She said she checks in regularly with the Resident and is aware the Resident has a history of trauma related to abandonment and not feeling good enough. She reviewed the medical record and said there were no available social history and assessments completed since admission. She said the Resident is followed by psychotherapy who she believes manages the Resident's trauma and is aware of the Resident's triggers. She reviewed the current care plans for Resident #30 and said there was no indication of the trauma, potential triggers and what should be avoided to potentially prevent a behavior or re-traumatization to the Resident. She said there should be a care plan in place and it is not. On 6/25/24 at 9:06 A.M., the surveyor called and left a message for the facility psychotherapist to discuss the Resident's care but the call was not returned. During an interview on 6/25/24 at 11:58 A.M., the DON said the facility usually performs social history and assessments on admission and they need to consider a reassessment period to determine if things may have occurred or if the residents are triggered by an old trauma they now wish to share. She said the facility should be care planning for any resident with a known history of trauma and any triggers or potential triggers to help mitigate a potential negative consequence or outcome for the resident in the future. She confirmed the facility did not have a policy on trauma informed care or the care of residents with PTSD.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, frequently incontinent but able to made his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 03/18/24, Certified Nurse Aide (CNA) #1 spoke to Resident #1 in degrading and insulting manner Findings include: Review of the Facility Resident Rights Policy, undated, indicated residents had the right to reasonable accommodation of their needs and preferences. Resident #1 was admitted to the Facility in July 2021, diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or paralysis on one side of the body) following a non-traumatic intracranial hemorrhage. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 2/20/24, indicated he/she had intact cognitive function, was able to make his/her care needs known and was frequently incontinent. Review of Resident #1's Point of Care History, dated 3/01/24 through 3/31/24, indicated Resident #1 had episodes of being both continent and incontinent of bowel. The Point of Care History indicated Resident #1 was continent of bowel 20 days during the month of March 2024. Review of the Facility's Internal Investigation Summary, dated 3/20/24, indicated that on 3/18/24, in response to Resident #1's request to be put on the bedpan, CNA #1 told Resident #1 just go in your pants and I'll change you later. During a telephone interview on 04/24/24 at 10:15 A.M., CNA #2 said that around 3:30 P.M. on 3/18/24, she approached Resident #1, who was in bed, to provide incontinence care. CNA #2 said that Resident #1 told her that during the prior (7:00 A.M. to 3:00 P.M.) shift that guy (later identified as CNA #1) told him/her to shit in his/her pants and he would come back and clean him/her up. CNA #2 said that CNA #1 was the only male CNA who worked the previous shift and that CNA #1 had been assigned to care for Resident #1. CNA #2 said that Resident #1's bed was completely soiled with urine and feces and she had to completely change the linen on Resident #1's bed to clean him/her. CNA #2 said feces had dried onto Resident #1's skin, that it had to be scrubbed off and his/her skin was red and irritated. CNA #2 said that Resident #1 told her that he/she did not ring his/her call light again during the prior shift because he/she did not want to get CNA #1 in trouble. CNA #2 said Resident #1 cried when he/she talked with her about the incident with CNA #1 and complained that he/she paid a lot of money to get this type of treatment. CNA #2 said she reported Resident #1's statement and condition to Nurse #1. During a telephone interview on 4/18/24 at 2:30 P.M., Nurse #1 said that on 3/18/24 around 8:30 P.M., CNA #2 told her that Resident #1 had complained to her about care that he/she received during the 7:00 A.M. to 3:00 P.M. shift. Nurse #1 said she spoke to Resident #1 and he/she told her that when he/she asked CNA #1 to put him/her on the bedpan, CNA #1 told him/her to shit in his/her pants and he would come back and clean him/her later. Nurse #1 said Resident #1 told her that CNA #1 never came back to clean him/her. Nurse #1 said she reported Resident #1's allegation to Nurse #3, who was the supervisor that night. During a telephone interview on 04/17/24 at 1:10 P.M., CNA #1 said on 3/18/24 while he/she was passing lunch trays, Resident #1 asked to use the bedpan. CNA #1 said that he told Resident #1 that he/she was going to have to wait until after lunch to be put on the bedpan and Resident #1 said oh man. The Surveyor asked CNA #1 about statements Resident #1 reported to staff (CNA #2 and Nurse #1) that he (CNA #1) told him/her to shit in his/her pants and CNA #1 acknowledged that he had said that to Resident #1. During an interview on 04/16/24 at 12:55 P.M., the Administrator said that she spoke to CNA #1 on 3/20/24 about Resident #1's allegation and CNA #1 told her that on 3/18/24 when Resident #1 asked to use the bedpan, he told Resident #1 to move his/her bowels in his/her incontinence brief. During a telephone interview on 04/24/24 at 10:30 A.M., the Assistant Director of Nurses said that she spoke to CNA #1 on 3/20/24 about Resident #1's allegation and CNA #1 told her that on 3/18/24 when Resident #1 asked to use the bedpan, he told Resident #1 to shit in his/her pants. On 4/16/24, the Facility was found to be in past non-Compliance and presented the Surveyor with a plan of correction that addressed the area(s) of concern as evidenced by: A) On 3/20/24, Resident #1 was interviewed about the alleged incident by the Administrator, the Assistant Director of Nursing and the Director of Social Service and an investigation of his/her allegation was initiated. B) On 3/20/24, the Director of Social Service initiated a plan for offering Resident #1 on-going support. C) On 3/25/24, the Facility terminated CNA #1. D) On 03/20/24, the Assistant Director of Nursing and the Director of Social Service interviewed alert and oriented residents who resided on Resident #1's unit to surveil for other unreported allegations of potential abuse or neglect. E) On 03/20/24, the Administrator and Director of Nursing provided education to Nurse #1 and Nurse #3 regarding timelines and procedures for reporting allegations of abuse and neglect. F) Between 3/20/24 and 3/26/24, the Facility Administrator, Director of Nursing and Staff Development Coordinator educated all staff on the Facility Patient Abuse Policy and timelines of and mechanisms for reporting allegations of abuse and neglect. G) The Corrective Action Plan will be reviewed during the April 2024 QAPI meeting. H) The Administrator and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 3/18/24, Resident #1 told Certified Nurse Aide (CNA) #2 and Nurse #1 that CNA #1 had made an inappropriate and insulting statement to him/her, and although Nurse #1 told her supervisor (Nurse #3), about Resident #1's allegation and provided Nurse #3 with a written statement about the allegation, Nurse #3 did not immediately notify the Administrator and/or Director if Nurses (DON), but instead placed Nurse #1's written statement in the DON's mailbox where it was not seen or brought to Administration's attention for around 36 hours. Findings include: Review of the Facility Abuse Prohibition Policy and Procedure, dated as last reviewed 1/2024, indicated that allegations of abuse will be immediately reported to the Administrator and Director of Nurses. Resident #1 was admitted to the Facility in July 2021 and his/her diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or paralysis on one side of the body) following a non-traumatic intracranial hemorrhage. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 2/20/24, indicated he/she had intact cognitive function, was able to make his/her needs known and was frequently incontinent. Review of Resident #1's Point of Care History, dated 3/01/24 through 3/31/24, indicated Resident #1 had episodes of being both continent and incontinent of bowel. The Point of Care History indicated Resident #1 was continent of bowel 20 days during the month of March 2024. Review of the Facility's Internal Investigation Summary, dated 3/20/24, indicated that on 3/18/24, in response to Resident #1's request to be put on the bedpan, CNA #1 told Resident #1 just go in your pants and I'll change you later. During a telephone interview on 04/24/24 at 10:15 A.M., CNA #2 said that around 3:30 P.M. on 3/18/24, she approached Resident #1, who was in bed, to provide incontinence care. CNA #2 said that Resident #1 told her that during the prior shift that guy (later identified as CNA #1) told him/her to shit in his/her pants and he would come back and clean him/her up. CNA #2 said that CNA #1 was the only male CNA who worked the 7:00 A.M. to 3:00 P.M. shift and that CNA #1 had been assigned to care for Resident #1. CNA #2 said that when Resident #1 told her about the incident, he/she cried and complained about being treated in that way. CNA #2 said she reported Resident #1's statement to Nurse #1 on 3/18/24. During a telephone interview on 4/18/24 at 2:30 P.M., Nurse #1 said that on 3/18/24, CNA #2 told her that Resident #1 had complained to her about care that he/she received during the 7:00 A.M. to 3:00 P.M. shift. Nurse #1 said she spoke to Resident #1 and he/she told her that when he/she asked CNA #1 to put him/her on the bedpan, CNA #1 told him/her to shit in his/her pants and he would come back and clean him/her. Nurse #1 said she reported Resident #1's statement to Nurse #3, who was the supervisor, on 3/18/24. During a telephone interview on 4/24/24 at 10:40 A.M., Nurse #3 said that she worked during the 3:00 P.M. to 11:00 P.M. shift on 3/18/24 and was the supervisor. Nurse #3 said that around 10:30 P.M., Nurse #1 reported to her that Resident #1 alleged that during the prior shift, when he/she asked CNA #1 to assist him/her to the bathroom, CNA #1 told him/her to go in his/her incontinence brief and CNA #1 would clean him/her later, but never returned. Nurse #3 said that Nurse#1 provided her with a written statement documenting Resident #1's allegation and she (Nurse #3) placed the written statement in the Director of Nurse's mailbox. During an interview on 04/16/24 at 12:55 P.M., the Administrator and Director of Nurses (DON) said that because the DON did not work on 3/19/24 or 3/20/24, Nurse #1's written statement about Resident #1's allegation was not brought to the attention of Administration until later in the morning on 3/20/24 (about the 36 hours after Resident #1 initially reported the allegation). On 4/16/24, the Facility was found to be in past non-Compliance and presented the Surveyor with a plan of correction that addressed the area(s) of concern as evidenced by: A) On 3/20/24, Resident #1 was interviewed about the alleged incident by the Administrator, the Assistant Director of Nursing and the Director of Social Service and an investigation of his/her allegation was initiated. B) On 3/20/24, the Director of Social Service initiated a plan for offering Resident #1 on-going support. C) On 3/25/24, the Facility terminated CNA #1. D) On 03/20/24, the Assistant Director of Nursing and the Director of Social Service interviewed alert and oriented residents who resided on Resident #1's unit to surveil for other unreported allegations of potential abuse or neglect. E) On 03/20/24, the Administrator and Director of Nursing provided education to Nurse #1 and Nurse #3 regarding timelines and procedures for reporting allegations of abuse and neglect. F) Between 3/20/24 and 3/26/24, the Facility Administrator, Director of Nursing and Staff Development Coordinator educated all staff on the Facility Patient Abuse Policy and timelines of and mechanisms for reporting allegations of abuse and neglect. G) The Corrective Action Plan will be reviewed during the April 2024 QAPI meeting. H) The Administrator and/or designee is responsible for overall compliance. .

Based on observations and interviews, the facility failed to ensure residents on 2 of 4 units had a comfortable and homelike dining experience. Specifically, residents were provided meals on overbed tables while still on the food tray and inside heating elements, residents seated in the same area were provided meals at different times, staff stood while assisting residents with eating and residents not in a common area were placed in the doorway of their room to eat. Findings include: During dining observations throughout survey from 3/28/23 through 3/31/23, the surveyors observed the following on St. Michael's and St Joseph's units (identified by staff as secured units for residents with dementia). 1. St. Michael's Unit: During an interview on 3/28/23 at 9:40 A.M., Nurse #3 said the dining room was not being used and had not been used for many months. Nurse #3 said residents ate meals in the television area or their own room. On 3/28/23 at 11:49 A.M., the first meal truck arrived on the unit. Nine residents were seated in the television room. All residents were seated in either a wheelchair or dining chair and all had overbed tables placed in front of them. Eight residents were served their meals directly from the food truck and observed to eat lunch off the serving trays on the overbed tables. The heating element and food covers remained on the tray. One resident, seated in the television area, remained without a tray as the other eight residents ate. At 11:51 A.M., two residents were seated in a reclined position in recliner chairs, outside the television area, near the elevator. At 11:59 A.M., one resident, who was seated outside the television room, was served their meal directly from the food truck to the overbed table The heating element and food cover remained on the tray as a staff member stood beside the resident and fed him/her. At 12:08 P.M., the other resident who was seated outside the television room was offered a pudding thick drink by a staff member as the resident's tray was not provided on the first meal truck. At 12:09 P.M., the second meal truck arrived to the unit and staff were observed to pick up meal trays from other residents who finished their meals served from the first truck. At 12:19 P.M., the resident who was seated in the television room without a meal as the other eight residents ate, was provided a sandwich as staff removed trays from the eight residents who had completed their lunch. At 12:20 P.M., the resident who was seated outside the television room, who had previously been provided a pudding thick drink, was served a meal tray. The tray was placed on the overbed table. The heating element and food cover remained on the tray as a staff member stood beside the resident and fed him/her. On 3/29/23 at 11:49 A.M., four residents were seated in the television room. All residents were seated in either a wheelchair or dining chair and all had overbed tables placed in front of them. During an interview on 3/29/23 at 11:49 A.M., Certified Nurse Aide (CNA) #2 said the dining room had not been used for a long time and was unsure when residents would eat in the dining room again. CNA #2 said some residents ate in the television room and others ate in their room or seated in the doorway of their room. During an interview on 3/29/23 at 11:57 A.M., Nurse #3 said the dining room was not used, perhaps because of staffing, or the need to encourage residents to wear masks which made it difficult for residents to eat. At 12:00 P.M., the four residents seated in the television room were served their meals directly from the food truck and observed to eat lunch off the serving trays on the overbed tables. The heating element and food covers remained on the tray At 12:05 P.M., one resident was seated in a wheelchair in the doorway to his/her room and served their meal directly from the food truck and placed on an overbed table. The overbed table was observed to be crooked and leaned downward. The heating element and food cover remained on the tray as a staff member stood beside the resident and fed him/her. At 12:10 P.M., three additional residents were observed seated in wheelchairs in the doorway of their rooms, eating lunch from trays placed on overbed tables. The heating element and food covers remained on the trays. 2. St Joseph's Unit On 3/29/23 at 8:05 A.M., a resident was observed seated in a wheelchair in the doorway of his/her room with an overbed table placed in front of the resident. The resident was served a breakfast tray and observed to eat breakfast from the tray placed on the overbed table. On 3/30/23 at 8:01 A.M., a resident was observed seated in a chair in the doorway of his/her room with an overbed table placed in front of the resident. The resident was served a breakfast tray and observed to eat breakfast from the tray placed on the overbed table. During an interview on 3/30/23 at 10:31 A.M., Unit Manager #1 said the dining room on the St. Joseph Unit was opened only for lunch time. She said staff would have some residents sit in their bedroom doorways for breakfast and dinner as the dining room remained closed for those meals. On 3/30/23 at 4:40 P.M., the surveyor observed eight residents seated in the television room in either a wheelchair or dining chair and all had overbed tables in front of them. Five residents were served their meals directly from the food truck and observed to eat dinner off the serving trays on the overbed tables. Three residents continued to wait for dinner trays. One resident who waited for the dinner tray was observed to touch the utensils and food on the tray of a resident seated next to him/her who was eating. During an interview on 3/30/23 at 4:50 P.M., CNA #7 said the first food truck arrived on the unit at approximately 4:30 P.M., and the second truck arrived at approximately 5:00 P.M. CNA #7 said the dining room had not been opened for dinner since the COVID-19 pandemic began and she had not been told to resume meals in the dining room. CNA #7 said residents eat in the television room or in their own room. At 5:07 P.M., the second truck arrived at the unit and staff were observed to pick up meal trays from the five residents who had completed the dinner meal. The three residents who had not been provided the dinner meal from the first truck, were provided meal trays at this time, which were placed on the overbed tables. On 3/31/23 at 12:05 P.M., the surveyor observed the dining room on unit 2PY. The dining room was set for 15 residents. The tables had white table clothes, draped with a purple overlay and a floral centerpiece. The settings for the 15 residents included cloth napkins, silverware, and water. During an interview on 3/31/23 at 12:15 P.M., the Director of Nurses said St. Michael's Unit had not opened the dining room yet, St. Joseph's Unit had the dining room opened for lunch only and the main dining room on unit 2PY was opened for units 2PY and 3PY. The surveyor reviewed the dining observations. The Director of Nurses said it was a slow process to get all the facility dining rooms up and available for the residents and said all residents should have a comfortable and homelike dining experience.

Based on interviews and record review, the facility failed to ensure two Residents (#73 and #116), in a sample of 24 residents, had been seen by a physician every 30 days for the first 90 days of admission and then every 60 days thereafter and that required visits alternated between the Physician and the Nurse Practitioner. Specifically, the facility failed to ensure for 1. Resident #73, required visits alternated between the Physician and the Nurse Practitioner; and 2. Resident #116, visits occurred every 30 days for the first 90 days of admission. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated 10/13/22, indicated the waiver for Physician Delegation of Tasks was terminated on 5/7/22. 1. Resident #73 was admitted to the facility in September 2017. Review of the Physician's Progress Notes indicated all visits from 5/17/22 through 1/31/23 were conducted by the Nurse Practitioner. The Primary Physician conducted a visit with the Resident on 2/8/23, five months after the required visits were to have been conducted. During an interview on 3/30/23 at 2:24 P.M., the Director of Nurses said she had been provided all of the Physician Progress Notes from the office of the Primary Physician and the Nurse Practitioner. She said the Primary Physician and the Nurse Practitioner should have been alternating visits. 2. Resident #116 was admitted to the facility in September 2022. Review of the Physician's Progress Notes indicated Resident #116 was seen for an initial visit on 10/3/22, the next 30-day visit on 11/8/22 and the next visit was conducted on 2/21/23, over 90 days after the previous visit. During an interview on 3/31/23 at 12:18 P.M., the Director of Nurses said the Physician or Nurse Practitioner should conduct visits every 30 days for the first 90 days of admission.

Based on observations and interviews, the facility failed to provide food that was palatable and at a safe and appetizing temperature. Findings include: On 3/29/23 at 12:00 P.M., the surveyor observed the second meal truck arrive to the St. Joseph unit. At 12:27 P.M., four resident lunch trays remained on the meal truck. At 12:45 P.M., three lunch trays remained on the meal truck. The surveyor observed staff continue to take the lunch trays directly to residents, without reheating the food. On 3/29/23 at 12:58 P.M., two surveyors and the Assistant Director of Nurses (ADON) conducted food temperatures of the last lunch tray on the meal truck. The results were as follows: -roasted potatoes: 90 degrees Fahrenheit (F) -mixed vegetable (broccoli, cauliflower, carrots) 94 degrees F, cool to touch -chicken salad sandwich: 75 degrees F -chocolate milk in a cup: 60 degrees F -small carton of whole milk: 59 degrees F During an interview on 3/29/23 at 1:05 P.M., the ADON said the expectation was not for the meal to take one hour to be delivered to residents. She said staff should have been re-heating the hot portion of the lunch trays if the meals were still on the meal truck. On 3/30/23 at 11:59 A.M., the surveyor observed the second meal truck arrive on the St. Joseph unit. At 12:25 P.M., there were four lunch trays remaining on the meal truck. On 3/30/23 at 12:27 P.M., two surveyors and Unit Manager #1 conducted food temperatures of a lunch tray on the meal truck. The results were as follows: -carrots: 102 degrees F, lukewarm to taste -roasted potatoes: 100 degrees F, tepid, not hot, with good flavor -chicken salad sandwich: 65 degrees F, lukewarm to taste, not cool -chocolate milk: 58 degrees F, cool, not cold -small carton of whole milk: 52 degrees F, cool, not cold to taste During an interview on 3/30/23 at 12:35 P.M., Unit Manager #1 said there were seven residents on the unit who needed assistance with eating, which was causing delays in the distribution of lunch trays. She said the dining process was a work in progress. During an interview on 3/30/23 at 1:40 P.M., the Food Service Director said the one-hour food delivery time on 3/29/23 was too long. He said he has conducted test trays with staff in the past and meal delivery takes about 18 minutes. He said when the food leaves the steamtable the internal temperature is about 160 to 165 degrees F and that he has educated the staff that the food can get to 130 to 135 degrees F in 15 minutes. He said he would not expect the food to hold their temperatures for an hour or even for the 25 minutes it took to distribute trays on this day.

Based on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#15), out of 24 sampled residents. Specifically, the facility failed to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment. Findings include: Resident #15 was admitted to the facility in November 2019 with diagnoses including dementia, generalized anxiety disorder, and psychosis. Review of the 1/10/23 Minimum Data Set (MDS) assessment indicated Resident #15 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating a severe cognitive impairment, had anxiety, depression, psychotic disorder, and received psychotropic medication daily. Review of March 2023 Physician's Orders indicated the following psychotropic medications: -Wellbutrin HCI (antidepressant) 150 milligrams (mg) once a day (8/23/21) -Remeron (antidepressant) 15 mg at bedtime (8/23/21) -Klonopin (antianxiety) 1 mg three times a day (9/7/21 to 3/21/23) -Klonopin 1 mg twice a day (3/21/23) -Seroquel (antipsychotic) 12.5 mg twice a day (11/22/22 to 3/21/23) -Seroquel 12.5 mg once a day (3/21/23) Review of comprehensive care plans included, but was not limited to: -Problem: Mood/Behavior/Communication: I have a diagnosis of anxiety and depression. I have a history of suicidal ideation with attempts. I frequently will refuse care as I state I can take care of myself. (last revised 1/9/23) -Approach: Administer my medications at their lowest effective dose; monitor for side effects of antidepressants, antipsychotic and anxiolytics; I may refuse care often; I take the following medication for my mood: Wellbutrin, Klonopin, Remeron, Seroquel (last revised 1/9/23) -Goal: I would like to be free of acute emotional distress and feel safe and comfortable in my environment during the next 90 days (last revised 1/9/23) Further review of the care plan failed to identify Resident specific targeted signs and symptoms for the use of Wellbutrin, Klonopin, Remeron and Seroquel and any specific non-pharmacological approaches and measurable goals to meet the Resident's needs. During an interview on 3/30/23 at 2:28 P.M., the surveyor reviewed Resident #15's medical record with Nurse #4 and Unit Manager #3. They said the care plan does not include targeted behaviors, non-pharmacological interventions, and measurable goals but should.

Based on observation, interview, and record review, the facility failed for one Resident (#70) to provide an ongoing activity program to meet and support the individual preferences of the resident, out of a total sample of 24 residents. Specifically, the facility failed to provide support for the Resident to pursue their one to one (1:1) preferred activities of choice in the Resident's room. Findings include: Review of the facility's policy titled Resident Daily Activity Program, dated December 2022, indicated but was not limited to the following: -Provide activities at appropriate times, morning, afternoon and some evenings and weekends. -Provide activities which stimulate the cardiovascular system and assist in range of motion. Such activities include exercise, movement to music, wheelchair balloon volleyball, etc. -Offer activities which are intellectually challenging. Such activities include discussion of current events, book clubs, or reminiscing. -Provide activities designated specifically for the confused or disoriented on a regular basis. -Provide small group activities on a regular basis. -Schedule cultural and religious programming representative of Resident population on a regular basis. -Provide inter-generational programs on a regular basis. -Regularly schedule creative and expressive programs. -Provide programs which promote cognitive, physical, and emotional health. -Enhance each Resident's physical and mental status and promote each Resident's self-respect by providing activities that allow for self-expression, personal responsibility, and choice. -Provide in-room activities in keeping with Resident's life-long interests, or in-room projects for independent enjoyment. -Offer activities that appeal to both men and women. -Schedule seasonal and special event activities. Resident #70 was admitted to the facility in December 2022 with diagnoses including vascular dementia, moderate with agitation and other behavioral disturbance. Review of the most recently completed Activity Assessment for Resident #70, dated 2/22/23, indicated the following: - Resident can concentrate fifteen plus minutes on one task if interested - Ability to make his/her needs known - Alert and oriented to person and place with confusion (Short Term: fair; Long Term: good) - Resident best tolerated group size of 1:1 - Resident is included in 1:1 visit for conversation, exercise games, and coloring Review of the Minimum Data Set (MDS) assessment, dated 3/2/2023, indicated Resident #70 was severely cognitively impaired, as evidenced by Brief Interview for Mental Status (BIMS) of 1 out of a possible 15. Review of Resident #70's medical record indicated he/she benefits from 1:1 visits and needs encouragement at times with minimum assist. Review of the Care Plan for Activities, dated 2/22/23, indicated the following: Problem: 1. I plan my day to be informed and invited to group programs of interest; 2. I'm functioning but can be a loner and prefer independent or one to one activity in my room Goal: 1. I would like to be invited to Bingo, games, special events: musical entertainment; 2. I may need to have modifications made to help me to participate as independently as possible due to hearing limitation; 3. I would like to be included in one to one stimulation/intervention/visits for social stimulation and emotional support; 4. I would like to receive independent items like coloring; and 5. I enjoy programs like massage, nails, reminiscing, discussion (2/22/23) Approach: 1. Invite me to attend group programs off unit i.e., Bingo, cards, and games; 2. Invite me to musical entertainment for a change of environment; 3. Invite me to special events; 4. Invite me in one-to-one stimulation, intervention, and visit for emotional and social support. During the survey visit from 3/28/23 through 3/29/23, the surveyor observed the following: On 03/28/23 at 09:57 A.M., Resident up in chair by his/her bedside, television off, no diversional activities. 03/28/23 at 3:45 P.M., Resident sitting up in chair by his/her bedside, no 1:1 activity observed. 03/29/23 at 09:46 A.M., Resident observed in the same position, no 1:1 activity was observed. 03/29/23 at 10:17 A.M., the surveyor asked the Resident about his/her daily activity of interest, and he/she replied, I have nothing to do. 03/29/23 at 12:01 P.M., Resident sitting in the chair by his/her bedside. Surveyor asked him/her why your radio and your television are off the Resident replied that he/she was blind. Further review of the medical record indicated no documented activity participation for Resident #70 that reflected: - 1:1 visit for conversation - exercise games and coloring Review of the Activities/Recreational Notes for Resident #70 indicated the Resident attended calendar delivery, coffee cart, creative time, exercise, magazine cart, conversation, social visits, walking; but no indication that anyone documented 1:1 visit, conversation, exercise games and coloring with the Resident. During an interview on 03/29/23 at 02:45 P.M., Activity Director #1 said she was familiar with the Resident. She said the Resident likes creative things, such as painting. She said she used to provide activities to the Resident, but since she changed her position, she had stopped seeing him/her. She said she would not know if the Resident was reassessed, and if the activity care plan was implemented to reflect his/her activities of interest. During an interview on 03/29/23 at 03:43 P.M., Activity Director #2 said a housekeeper on light duty was to visit the Resident every day. She said the housekeeper never reported to her what she had done with the Resident when visiting him/her and there was no documentation to indicate 1:1 visits had been provided to Resident #70. Activity Director #2 said that the Resident required more cueing and experienced hearing difficulty but was unable to elaborate on the type of cueing that could benefit the Resident during activities. During an interview on 03/29/23 at 4:05 P.M., the Director of Nurses said the Resident should have been re-assessed in order to implement activities that meet his/her needs.

Based on observation, record review, and interview, the facility failed to reassess and document a clinical rationale for continued antibiotic use for one Resident (#15), out of a total sample of 24 residents. Specifically, the facility failed to ensure the Physician re-evaluated the use of Mucinex (generic name guaifenesin; used to help clear mucus or phlegm from the chest when you have congestion) following a hospitalization for pneumonia. Findings include: Resident #15 was admitted to the facility in November 2019 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Review of the medical record indicated Resident #15 was hospitalized on [DATE] and treated with antibiotic therapy and guaifenesin for pneumonia of both lungs. Further review of hospital documentation indicated Resident #15's medications at discharge on 8/23/21 included guaifenesin 600 milligrams (mg) twice daily. Review of March 2023 Physician's orders included, but was not limited to: Mucinex extended release, 600 mg twice daily (8/23/21) Review of August 2021 through March 2023 Medication Administration Records indicated Mucinex extended release, 600 mg twice daily was administered as ordered by the physician. Further review of the medical record failed to indicate that from August 2021 to March 2023, Resident #15's Physician or Physician extender re-evaluated and documented a clinical rationale for continued use of guaifenesin 600 mg twice daily. During an interview on 3/31/23 at 12:54 P.M., the surveyor reviewed Resident #15's medical record with Unit Manager #3. He was unable to find any documentation to indicate the guaifenesin was re-evaluated by the Physician or Physician extender and had documented a clinical rationale for its continued use. During an interview on 3/31/23 at 1:00 P.M., the Assistant Director of Nursing said that she does rounds with Resident #15's Physician at every visit and said he had not re-evaluated the Resident's use of guaifenesin for continued use.

Based on observation, record review, document review, and interview, the facility failed for one Resident (#4), out of a sample of 24 residents to administer Eliquis timely and consistently per administration guidelines. Findings include: Resident #4 was admitted to the facility in December 2016 with diagnoses including paroxysmal atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Review of the Institute for Safe Medication Practices Eliquis Fact Sheet, dated 2018, included but was not limited to the following: -Eliquis is a high-alert medicine. This means that Eliquis has been proven to be safe and effective, but serious harm, such as severe bleeding or a stroke, can occur if it is not taken exactly as directed. -Take your Eliquis at the same time or times each day -Usual doses range from 2.5 milligrams (mg) to 10 mg twice daily (each dose taken 12 hours apart) Review of the Physician's Orders dated March 2023, indicated the following: 1.Tylenol (Pain Management) 500 Milligrams (MG) tablets, give two tablets to equal to 1,000 MG (9:00 A.M. and 7:00 P.M.) 2. Atorvastatin (decrease cholesterol level)20 MG tablets, give one tablet (7:00 P.M.) 3. Depakote (used for partial seizures) 125 MG tablets, give one tablet (7:00 P.M.) 4. Depakote 250 MG tablets, give one tablet (7:00 P.M.) 5. Eliquis (blood thinner) 5 MG tablets, give one tablet (9:00 A.M. and 7:00 P.M.) 6. Fenofibrate (reduce and treat high cholesterol) 48 MG tablets, give one tablet (7:00 P.M.) 7. Melatonin (used for sleep) 3 MG, give one tablet (7:00 P.M.) 8. Mirtazapine (antidepressant) tablets, give 7.5 MG tablet (7:00 P.M.) 9. Senna Plus (used to treat constipation) 8.6 MG tablets, give two tablets (7:00 P.M.) 10. Prosource Complete (used for protein deficiency), give 30 milliliters (5:00 A.M. and 7:00 P.M.) On 3/29/23 at 5:14 P.M., the surveyor observed Nurse #8 pouring the following medications to administer to Resident #4: 1. Tylenol 500 Milligrams (MG) tablets, give two tablets to equal to 1,000 MG 2. Atorvastatin 20 MG tablets, give one tablet 3. Depakote 125 MG tablets, give one tablet 4. Depakote 250 MG tablets, give one tablet 5. Eliquis 5 MG tablets, give one tablet 6. Fenofibrate 48 MG tablets, give one tablet 7. Melatonin 3 MG, give one tablet 8. Mirtazapine 7.5 MG tablet, give one tablet 9. Senna Plus 8.6 MG tablets, give two tablets 10. Prosource Complete, give 30 milliliters On 3/29/23 at 5:30 P.M., during medication reconciliation, the surveyor noticed that the above medications were initiated on 2/25/23 and were due to be administered at 7:00 P.M., specifically the Eliquis that must be administered at the same time was administered at 5:14 P.M., one hour and 45 minutes prior to the scheduled time. During an interview on 3/29/23 at 5:40 P.M., the Director of Nurses (DON) said medications are administered in accordance with prescriber orders, including required timeframes. The Director of Nurses said medications are to be administered according to the standard of professional practice an hour before and an hour after.

Based on observations, interviews, and review of current COVID-19 guidance, the facility failed to ensure staff implemented infection control guidance to mitigate the potential transmission of COVID-19 within the facility. Specifically, the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) for a facility with COVID-19 cases in the last 14 days. Findings include: Review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated September 10, 2021, indicated the following: Ensure everyone is aware of recommended Infection Prevention Control (IPC) practices in the facility. Post visual alert (e.g., signs, posters) at the entrance and in strategic places with instructions about current IPC recommendations. Review of the in-use posted precaution sign for Facility with COVID-19 cases in the last 14 days indicated the following: -clean hands when entering and exiting -eye protection (goggles or face shield) -gown for high contact care, change between each resident -gloves, change between each resident -mask, N95 for aerosol generating procedures (AGPs) -*examples of high contact care activities include a. dressing b. bathing/showering c. transferring d. providing hygiene e. changing linens f. changing briefs or assisting with toileting g. device care or use h. wound care i. vital signs During an observation with interview on 1/5/22 at 11:45 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 in the room of Resident #1A sitting beside his/her bed having a conversation without any eye protection in place. The signage Facility with COVID-19 cases in the last 14 days was posted on the door frame of the Resident's room door. CNA#1 said she knows she needs to have goggles on but forgot them in her car and figured someone would provide her with a new pair. She said she is not following the posted sign for PPE use and broke the rules. During an observation with interview on 1/5/22 at 11:52 A.M., the surveyor observed Rehab Staff #1 transfer a Resident from a sitting to standing position and then assist the Resident with ambulating in the hallway by holding onto a gait belt (support belt worn for safety with transfers and ambulation) that was secured around the Resident. Rehab Staff #1 was not wearing a gown. She said the transfer and hands on ambulation was high contact care and when they were in the Resident's room she wore a gown, but she didn't think she was allowed to wear a gown in the hallway. During an interview on 1/5/22 at 11:54 A.M., Unit Manager #1 observed the transfer and ambulation activity of Rehab staff #1 with surveyor and said the sit to stand transfer, which occurred three times, was high contact care and a gown should be worn as part of the required PPE. She said all residents on her unit require gowns for high contact care, but she thinks it is confusing for the staff, because they are not used to wearing PPE in the hallways. She was made aware of the surveyor's observations of CNA #1 and said, she too observed CNA #1 without eye protection. She said both CNA #1 and Rehab Staff #1 did not follow the facility process for wearing PPE per the posted signs. During an interview on 1/5/22 at 12:20 P.M., the Assistant Director of Nurses (ADON) was made aware of the surveyor's observations of PPE breaches and said CNA #1 should have had eye protection on when entering the unit and should not have been in a resident room without eye protection. She said Rehab Staff #1 did not follow the posted sign guidance for PPE use with high contact care and said ambulating a resident with a gait belt and the sit to stand transfer were high contact care activities. During an interview on 1/5/22 at 2:58 P.M., the Infection Preventionist said she was aware of the observed PPE breaches and said both the CNA and Rehab staff did not follow the facility's posted guidelines for PPE use.

Based on observation, record review, and staff interview, the facility failed to ensure that for 1 Residents, (#[AGE]), of a total sample of 35 residents, to uphold the residents' rights to self-determination in regards to services provided at the facility or services obtained outside of the facility. For Resident #[AGE], the facility failed to uphold the Resident's wish not to be seen by the facility's psychiatric consultant. Findings include: 2. Resident #[AGE] was admitted in 8/2018, with [DIAGNOSES REDACTED]. The Resident was observed to be alert and oriented and able to make his/her own decisions. On 4/1/19, at 10:46 P.M., the 3:00 P.M. to 11:00 P.M. nursing supervisor sent an email to the administrator, Director of Nursing, and Food Service Supervisor detailing several complaints made by the Resident. One of the complaints made by the Resident was that the consultant psychiatrist would stop by his/her room, say Hello, and then bill him/her for a visit. The Resident told the nursing supervisor that he/she was going to call Medicare to confirm this and report it as fraud. The Resident further explained to the nursing supervisor that he/she had spoken to the MDS (Minimum Data Set) person about this and was assured that someone would meet with him/her to discuss his/her concern. He/She said that three weeks had gone by and he/she had still not seen anyone. On 4/2/19, the administrator went to speak to the Resident about his/her multiple concerns that were voiced to the 3:00 P.M. to 11:00 P.M. nursing supervisor on 4/1/19. The administrator indicated that she discussed the Resident's concern about the consultant psychiatrist. The administrator informed the Resident that the psychiatrist would no longer be involved with the Resident's care, per the Resident's request. The Resident was interviewed on 10/25/19 at 12:30 P.M. The Resident said to the surveyor that he/she never authorized care or services from the consultant psychiatrist and that he/she made this clear to the administrator during a discussion they had several months earlier. The Resident said, when asked about consenting to the psychiatrist's care or treatment, he/she indicated, Never ever. The Resident's record was reviewed on 10/25/19 and other days throughout the survey. Record review indicated, that since the interview the Resident had with the administrator on 4/2/19, when the administrator assured that the psychiatrist would no longer provide care to the Resident, progress notes for four psychiatric visits were observed in the Resident's medical record. The psychiatrist documented psychiatric evaluation/treatment sessions with the Resident on 4/15/19, 6/3/19, [DATE], and 10/21/19. Each of the visits was conducted without the consent of the Resident. On 10/29/19 at 3:16 P.M., the administrator was interviewed about the facility's failure to respect the Resident's right to not receive care or treatment from the psychiatrist. The administrator acknowledged the notes detailing care/treatment from the psychiatrist on 4/15/19, 6/3/19, [DATE], and 10/21/19, following the administrator's meeting with the Resident on 4/2/19, when the administrator assured the Resident that he/she would no longer receive the services of the psychiatrist. The administrator said to the surveyor that she failed to communicate to the psychiatrist that the Resident did not want him to treat him/her, and failed to honor the Resident's right to not receive care or treatment from the psychiatrist. The psychiatrist was interviewed by the surveyor on 10/29/19 at 3:40 P.M. The psychiatrist said, I see him/her regularly. Nice stable gentleman/lady. I do the psychopharmacology piece. The psychiatrist said to the surveyor that he was never told by the Resident or the facility that the Resident did not want to receive care or services from him. The psychiatrist said, That's the first I've heard of it. No one said anything to me. On 10/29/19, during interview with the administrator, the administrator said that the Resident was provided services from the psychiatrist, services that the Resident did not give consent for.

Based on record review, observation and staff interview, the facility failed to ensure for 1 Resident (# 3,) of 28 sampled residents to provide adequate supervision and ensure that safe swallowing strategies were implemented to prevent a choking episode, Findings include: For Resident #3, the facility failed to provide adequate supervision and ensure that safe swallowing strategies were implemented to prevent a choking episode, Resident #3 was admitted in 11/2013 with [DIAGNOSES REDACTED]. Review of the clinical record on 3/30/15 indicated on 4/25/14 a Nursing Request / Screening Form was sent to the Speech and Language Pathologist (SLP) because the resident was "totally non compliant with honey thick liquids and drinking from the water bubbler." The SLP (who also previously treated Resident until 1/2014) recommended to "obtain a modified barium swallow to assess oropharyngeal integrity and recommendations for advancing diet safely." Review of the existing SLP recommendations in place for Resident #3 at the time of the nursing service 4/25/14 request for consult included the following: - Honey thick liquids, allow 4 ounces thin water twice daily for quality of life - Use the following strategies and or maneuvers during oral intake: rate modification, bolus sized modifications, alternation of liquids / solids, hard throat clear/swallow, no straws, Fraizier water (free water) protocol upright posture during meals and upright posture for greater than 30 minutes after meals - Close supervision for oral intake On 5/2/14, a modified barium swallow examination was completed at a local hospital to assess the resident's dysphagia indicated that the resident had a slight decline in swallow function since the resident's previous swallow study completed 6 months earlier, while hospitalized with aspiration pneumonia. The hospital's recommendations included: - Pureed diet, half spoonfuls, chin tuck, 2 swallows per bite - Honey thick liquids, half spoonfuls, chin tuck, 2 swallows per bite - Medication crushed with puree - Aspiration precautions - Given the patient's cognitive status, the above strategies may not be effective for him/her unless he/she is supervised one to one and cued consistently throughout his oral intake to use a chin tuck and to modulate his/her bite size The hospital's recommendations were a reiteration of the safe swallowing and safety precautions already instituted by the facility's SLP in 1/2014. The SLP indicated that the resident and primary caregivers were educated on safe swallow strategies and safety precautions necessary to prevent the potential for choking and aspiration. On 8/28/14, another nursing request for screening was sent the the SLP who indicated on 8/30/14 that no evaluation was required because "SLP recommendations in place - resident non compliant with recommendations and liquid modifications as well as lower salt / anti reflux diet and aspiration precautions. Resident re-educated regarding risks." Review of the 10/20/14 Dysphagia / Respiratory Care Plan indicated the following: "I have controlled texture and thickened liquids as I have dysphagia and also have problems with my airway." Approaches dated 10/20/14 included: "assist me with safe choices for my meals, remind me of safer choices." The care plan failed to identify that the resident was on aspiration precautions or that the Resident required close supervision for oral intake. Review of the existing Certified Nurse Aide (CNA) care card (not dated) indicated that the resident was an independent eater and could have breakfast in the residents room and lunch and dinner in the dining room. The CNA care card failed to identify that the resident was on aspiration precautions and required close supervision for all oral intake. According to the significant change (due to decline) Minimum Data Set (MDS) assessment with a reference date of 12/28/14, Resident #3 was cognitively impaired and was dependent on facility staff for most activities of daily living including supervision and physical assistance at meals. Review of the Nurse's Note of 3/20/15 at 10:30 A.M. indicated that a CNA summoned the nurse to the resident's room who observed the resident "purple and unable to cough no sound from the resident." Unsuccessful attempts with the Heimlich maneuver, need for mouth sweep and suctioning were necessary to eventually clear the Resident's airway. The resident had an emergency transfer to the hospital. The resident returned from the hospital the same day on antibiotics following a chest X-ray which indicated a possible left sided aspiration. On 3/20/15, the Dysphagia / Respiratory Care Plan problem statement indicated that the resident "had a choking episode that sent me to the hospital." On 3/20/15, the following additional approaches were added: "I should be in supervised area in the dining room for meals ....remind me frequently of my texture and thickened liquids." The care plan failed to identify that the resident was on aspiration precautions. On 3/22/15, the Resident was seen in consultation by the same SLP who had previously treated the resident. The SLP recommended the following safe swallowing strategies for all meals which resulted in new physician orders: slow rate; small bolus sizes; upright and out of bed and positioned with supervision for all oral intake; all textures to be cut into small pieces before presenting to the resident; all liquids to be thickened prior to presenting to the resident and other residents' liquids should be kept out of reach while in the dining room. The Speech and Language Pathologist (SLP) interviewed on 3/30/15 at approximately 1:00 P.M. said had previously treated the resident following admission through discharge from speech therapy in 1/2014. The SLP said that the resident was at high risk for aspiration and she repeatedly educated the resident and staff on safe swallowing / positioning strategies and the need for close supervision for all oral intake in order to prevent aspiration. The SLP said she requested that the physician order [REDACTED]. The SLP said that the resident has remained at high risk for aspiration since admission in 2013 and requires meal set up, close supervision and cueing but that the resident's compliance remains an issue. The SLP said that she began treating the resident again following the choking episode on 3/20/15. The SLP said that she was told that the resident was eating french toast (which the SLP said was allowed on the Resident's diet) in bed at the time the resident choked. The SLP said that the resident should have been seated in a chair in a supervised setting so the resident could be cued when needed. UM #2 interviewed on 3/30/15 at 1:35 P.M., was asked about Resident #3's choking episode said that prior to the choking episode the resident was eating independently and could have breakfast in his/her room but that the physician gave new orders on 3/22/15 (as stated above) following the SLP's recommendations. UM #2 was asked if Resident was at high risk for aspiration prior to the choking episode. UM #2 said that she was not sure and would have to check. UM #2 reviewed the dysphagia / respiratory care plan last updated on 3/27/15 and said that the care plan did not reflect that the resident was high risk for aspiration or needed close supervision for all oral intake. UM #2 also reviewed the existing CNA care card (undated) which indicated that the resident could eat independently and take meals in the room and said that she needs to update the CNA care card.

Based on interview and record review for two of three cognitively impaired, sampled residents (Resident #1 and Resident #2), the Facility failed to provide adequate supervision to prevent Resident to Resident altercations. -On 5/13/14, Resident #2 walked into Resident #1's room; staff heard yelling and observed Resident #1 pulling Resident #2's hair. Resident #2 sustained a bruise on the right hand. -On 9/13/14, Resident #2 wandered into Resident #1's room and Nurse #1 saw Resident #1 grab Resident #2 by the hair and pull Resident #2's head up and down on the bed; another resident reported seeing Resident #1 hit Resident #2 with a lamp before Nurse #1 entered the room. Resident #2 received a 2.5 centimeter laceration on the right lower cheek. Findings include: The quarterly Minimum Data Set ( MDS) assessment, dated 7/21/14, indicated Resident #1 had severely impaired cognitive skills. The MDS indicated Resident #1 had physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) four to six days a week The quarterly Minimum Data Set (MDS) assessment, dated 7/28/14, indicated Resident #2 had severely impaired cognitive skills. The Incident Report Form, dated 5/16/14, indicated that on 5/13/14, Resident #2 walked into Resident #1's room and staff heard yelling. Staff observed Resident #1 pulling Resident #2's hair. Resident #2 sustained a bruise on the right hand, where he/she was observed holding the footboard of the bed. The Surveyor interviewed the Director of Nurses at 8:15 A.M. on 9/29/14. The Director of Nurses said Resident #1 did not like other residents entering his/her room. The Director of Nurses said interventions, including a review of Resident #1's medication and the installation of a motion detector on the doorway to Resident #1's room were put in place after the incident of 5/13/14. The Director of Nurses said Resident #1 removed the motion detector and members of the interdisciplinary team thought it caused increased anxiety to Resident #1, so it was discontinued in June 2014. There were no new care plan interventions implemented. The SBAR (Situation, Background, Assessment and Request) Form for Resident #1, dated 9/14/14, indicated Resident #1 was difficult to approach, territorial and combative daily. The Form indicated Resident #1 was found with a handful of Resident #2's hair and pulling Resident #2's head up and down. According to the Form, a glass lamp was found on the bed and removed. The SBAR Form, for Resident #2, dated 9/13/14, indicated Resident #1 pulled Resident #2's hair and pulled his/her head up and down. Resident #2 yelled "oh my God." The Form indicated Resident #2 had a 2.5 centimeter bleeding scratch on the right cheek and Resident #2 was fearful. The Surveyor interviewed Nurse #1 at 10:00 A.M. on 9/29/14. Nurse #1 said another resident called her to Resident #1's room. Nurse #1 said she found Resident #2 lying on Resident #1's bed curled up like a pretzel. Nurse #1 said Resident #1 held onto Resident #2's hair and was banging his/her head on the bed. Nurse #1 said the other resident told her that he/she saw Resident #1 hit Resident #2 with a lamp and hit him/her in the eye. Nurse #1 said she did not see this, but noticed that there was a lamp on the bed. Resident #1 grabbed Resident #2's hair in an altercation on 5/13/14. The Facility failed to prevent a similar incident, which took place on 9/13/14. A reasonable person would experience psychological and emotional harm as a result of the actions of Resident #1.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff checked the secure placement of the sling clips two times per Facility policy, once in bed or chair and a second time when raised in the sling, to ensure the clips were hooked in place once tension was applied to the sling clips. Resident #1 slid out of the pad onto the floor, and Resident #1 was transferred to the emergency room for evaluation. The emergency room Report indicated that Resident #1 sustained a hematoma (a swelling or mass of blood confined to tissue or space that was caused by a break in the blood vessel) on the head, and a laceration to the back of the head that required 5 sutures due to a fall from the mechanical lift. Findings include: The Maxi-Lift (mechanical lift) policy, revised August 2004, indicated that the mechanical lift transfer must be done by two staff members while using an appropriate size sling, and to make a second check that all clips were hooked in place securely. The Surveyor interviewed the Director of Nurses (DON) at 8:15 A.M. and 4:00 P.M. on 3/27/13. The DON said staff were expected to check the secure placement of the sling clips two times per Facility policy, once in the bed or chair and a second time when raised in the sling to ensure the clips were hooked in place once tension was applied to the sling clips. The DON said the clips moved into a secure position when tension was placed on the clips once staff raised the resident in the sling. The Surveyor interviewed the mechanical lift company Quality Complaint Specialist #1 at 1:15 P.M. on 3/27/13. Quality Complaint Specialist #1 said staff should check for secure placement of the sling clips when initially attached, once tension is applied to the clips as the resident is raised, and anytime the resident independently or with staff assistance was re-positioned while in the sling to ensure proper tension remained on all 4 sling clips to prevent falls from the sling. Quality Complaint Specialist #1 said it was the tension on the clip that maintained proper placement. The Face Sheet indicated that Resident #1's admitted was April 2009, and his/her [DIAGNOSES REDACTED]. The Surveyor interviewed the Rehabilitation Coordinator at 8:45 A.M. on 3/27/13. The Surveyor interviewed Occupational Therapist (OT) #1 at 8:55 A.M. on 3/27/13. The Rehabilitation Coordinator and OT #1 said residents were assessed by rehabilitation for transfer needs. The Surveyor interviewed CNA #1 at 11:25 A.M. on 3/27/13. The Surveyor interviewed CNA #2 at 10:40 A.M. on 3/27/13. CNA #1 and CNA #2 said they were not taught to check the secure placement of the 4 sling clips more than one time. CNA #1 and CNA #2's education forms indicated they were taught to connect the clips to the mechanical lift before lifting the resident in the lift with no further direction indicated to re-check the clips during the transfer. CNA #2 said she routinely checked the placement of the 4 sling clips more than one time, per her own judgment, to ensure they were secured in place once a resident was raised in the lift over a bed or chair and before they moved a resident off a bed or chair to ensure a safe transfer. The plan of care, updated 10/15/12, indicated that Resident #1 required the use of a mechanical lift for all transfers. The physical therapy annual screen, dated 11/13/12, indicated that Resident #1 remained totally dependent on staff for all activities of daily living that included transfers and mobility. The Quarterly Minimum Data Set (MDS) assessment, completed on 12/28/12, indicated that Resident #1 was sometimes understood and he/she rarely understood others. The MDS indicated that Resident #1 had poor recall and a poor memory. The MDS indicated that Resident #1 had no behaviors. The MDS indicated that Resident #1 had signs and symptoms of delirium that included inattention and disorganized thinking. The MDS indicated that Resident #1 was nonambulatory. The MDS indicated that Resident #1 was totally dependent and required extensive assistance of 2 staff for bed mobility and transfer activities. The MDS indicated that Resident #1's [DIAGNOSES REDACTED]. The MDS indicated that Resident #1 received no pain medication during the last five days and had no signs of pain during the last five days. The fall risk assessment, dated 1/25/13, indicated that Resident #1 had no falls in the previous three months. The fall risk assessment indicated that Resident #1 was at low risk for falls. The certified nurse assistant (CNA) kardex (care plan) indicated that Resident #1 was totally dependent on 2 staff for all activities of daily living and transfer activities. The Surveyor interviewed Unit Manager #1 at 7:15 A.M. and 4:15 P.M. on 3/27/13. Unit Manager #1, CNA #1, and CNA #2 said Resident #1 was unable to assist with the mechanical lift transfer and required 2 staff members for all transfer activities. CNA #1 said she was floated to Resident #1's unit and had previously been assigned to Resident #1's personal care. CNA #1 said she was aware that Resident #1 required 2 staff for transfers because she had reviewed Resident #1's CNA care plan. CNA #1 said she had previously been told by nursing staff that Resident #1 used the ARJO mechanical lift and required the physical assistance of two staff for transfers. CNA #1 said she had been educated on the use of the mechanical lift but had not previously been educated to check the clips once they were initially attached to the pad. CNA #1 said she did not routinely check the clips after she initially attached them to the pad because she assumed they would stay attached during the transport. CNA #1 said she asked CNA #2 to assist her with Resident #1's transfer from the bed to the wheelchair while using the mechanical lift because Resident #1 required the physical assistance of 2 staff and CNA #2 was experienced in transferring Resident #1 as she was assigned to Resident #1's unit. CNA #2 said she had previously transferred Resident #1 with the assistance of a second staff member while using the mechanical lift and there were no issues. CNA #2 said she was summoned to assist CNA #1 with Resident #1's transfer. CNA #2 said when she entered Resident #1's bedroom she observed CNA #1 attach the four clips to the sling pad while Resident #1 laid in bed. CNA #2 said she moved the wheelchair closer to the bed while CNA #1 raised Resident #1 in the mechanical lift over the bed. CNA #2 said CNA #1 had not checked the clips a second time once Resident #1 was raised in the sling over the bed or when he/she leaned to the right while seated in the sling, but rather, CNA #1 moved the mechanical lift to position Resident #1 above his/her wheelchair, the left leg clip (which secured the pad to the ARJO lift) became unattached, and he/she slid out of the pad onto the floor. Unit Manager #1 said she was summoned to Resident #1's bedroom due to a fall and found Resident #1 lying on the floor by his/her bed. Unit Manager #1 said Resident #1 was bleeding from a laceration on the back of his/her head, denied any pain, and had no other sign of injury. Unit Manager #1 said first aid was given; Resident #1 was examined by Physician Assistant #1, who was on the unit, and Resident #1 was transferred to the emergency room for further evaluation. The nurse's note, dated 1/25/13, indicated that Resident #1 was assessed at approximately 9:50 A.M. on 1/25/13 due to a fall from the mechanical lift. The nurse's note indicated that Resident #1's cognitive status remained unchanged. The nurse's note indicated that Resident #1 was bleeding from a laceration on the occipital (back of the head) area, and first aid was given. The nurse's note indicated that Resident #1 was assessed by Physician Assistant #1, and was transferred to the emergency room for further evaluation and care. The emergency room Report, dated 1/25/13, indicated that Resident #1 sustained a hematoma and a laceration on the back of the head due to a fall from a mechanical lift. The emergency room Report indicated that Resident #1 was provided five sutures to close the laceration, no other injuries were found via diagnostic testing, and he/she was transferred back to the Facility with no new recommendations. Unit Manager #1 said Resident #1 returned to the facility on the same shift and was provided monitoring of the injury and the suture line. The Staff Development Coordinator (SDC) was interviewed at 10:45 A.M. on 4/1/13. The SDC said when she educated staff regarding mechanical lift transfers she had educated staff to check the clips one time because she had not previously viewed the mechanical lift policy. The SDC said she had been employed at the Facility for approximately eight years. The DON said since the incident new sling pads with more secure clips had replaced the type of sling pad that was used at the time of the incident. The DON and SDC said staff would be educated to follow the mechanical lift policy to ensure the clips were checked two times and as needed if re-positioning in the sling occurred during mechanical lift transfer. The DON said there had been no other falls out of the mechanical lift.