Every finding on record at Saint Vincent Rehabilitation & Nursing Center

Based on observation, interview and policy review, the facility failed to ensure that food was stored and dishwares were sanitized in accordance with professional standards for food service safety for 1 of 1 kitchen observed and 3 of 3 kitchenettes observed. Findings include:Observation on 7/14/26 at approximately 9:15 a.m. the facility's main kitchen with Staff D (Cook) revealed the following:1 container of opened chicken base, 1 opened beef base, and 1 opened whipped cream piping bag with no open date or discard date in the reach in refrigerator.1 blue covered pitcher containing a powdered substance with no identification, no open date or discard date on the kitchen food preparation shelf.1 opened bulk container of flour and 1 opened bulk container of sugar with no open date or discard date under the kitchen food preparation shelf.Observation on 7/15/26 at approximately 10:05 a.m. with Staff E (Dietary Services Manager) revealed one opened and undated whipped cream piping bag in the reach in refrigerator. Interview on 7/15/26 at approximately 10:30 a.m. with Staff E revealed that he/she does not date the bulk sugar and bulk flour.Observation on 7/14/26 at approximately 9:35 a.m. with Staff D of the first floor kitchenette refrigerator revealed that there was clear liquid in the bottom left drawer. The drawer contained closed sealed plastic containers. Further observation revealed a kitchen prepared plate with ham salad, tomatoes and lettuce covered in cling wrap without a resident name, prepared date, or a discard date. Observation on 7/14/26 at approximately 9:45 a.m. with Staff D of the second-floor kitchenette revealed a blender container with a pink thick liquid that had no prepared date or discard date.Interview on 7/14/26 at approximately 10:12 a.m. with Staff D confirmed the above observations in the second-floor kitchenette. Review on 7/16/26 of the facility's Food Storage and Labeling policy with revised date 6/29/23, revealed, Refrigeration .4. All opened or leftover items must have a visible label that identified the item, the date it was prepared or opened on, and the use by date 5. The use by date may vary per product. A chart is available to determine the acceptable length of storage.Review on 7/14/26 of the second and third-floor kitchenette refrigerator temperature logs revealed temperatures were greater than 41 degrees F (Fahrenheit) on the following dates:6/19/26 50 degrees F (with a notation that refrigeration was not closed),6/20/26 (a.m.) 44 degrees F, 6/22/26 (a.m.) 42 degrees F,6/23/26 (a.m.) 42 degrees F and 7/10/26 42 degrees F.Interview on 7/14/26 at approximately 10:12 a.m. with Staff D confirmed the above temperatures were out of range.Observation of Staff D conducting the testing of the in-use three-part sanitation sink revealed no color change on the test strip, with a result of zero parts per million (PPM). Further observation revealed that the test strips expired on 9/15/25, a second attempt at testing the three-part sanitation sink, revealed no color change on the test strip, with a result of no PPM, and these test strips expired on date of 8/30/24. Interview at approximately 9:30 a.m. with Staff D confirmed the above findings. Review on 7/16/26 of the manufacturer's instruction for Super San Food Service Sanitizer, copyright 2024 Eco lab incorporated, revealed, To sanitize food processing, equipment, utensils, and other hard, non-porous, food contact articles .in a three compartment sink: 4 .Super San Food Service Sanitizer . (150-400 ppm active quat) or equivalent dilution for 60 seconds

Based on interview, observation, and record review, the facility failed to update the water management plan annually and to implement monitoring measures to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens in a facility with a census of 59 residents. Findings include: Review on 7/15/26 of the facility's water management plan, revised 5/5/2025, revealed the plan did not identify or have in place control measures for eye-wash stations. Interview on 7/15/26 at approximately 1:00 p.m. with Staff F (Director of Maintenance) and Staff G (Infection Preventionist) confirmed the facility's water management plan was last reviewed 5/5/25. Interview on 7/16/26 at approximately 11:00 a.m. with Staff G, revealed the facility had two eye-wash stations. Staff G revealed that the U.S. Centers for Disease Control and Prevention (CDC) standards was used for water management. Staff G confirmed that the eye wash stations were not included in the water management plan. Review on 7/16/26 of the CDC website, Controlling Legionella in Potable Water Systems | Control Legionella | CDC, revealed the following guidance: .Flush low flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. 07/16/2026 11:02 AM

Based on interview and record review, the facility failed to follow physician orders for 1 of 3 residents reviewed for nutrition in a final sample of 15 residents. (Resident identifier was #10.)Findings include: Standard:[NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 20212, Chapter 19, page 267 revealed the following Communication with other health providers needs to be timely, accurate, and relevant to the patient's clinical situation. Review on 7/16/26 of Resident #10's physician's order dated, 4/8/26 revealed: daily weight (CHF (Congestive Heart Failure) protocol) report 3 pounds weight gain overnight or 5 pounds in one week, Notify provider if weight increases by 3 pounds in one day or 5 pounds in one week. Review on 7/15/26 of Resident #10's Weights and Vitals Summary revealed the following:6/11/26 weight 222.9 lbs. (pounds)6/12/26 weight 230.5 lbs. (7.6 lbs. weight gain in one day)6/24/26 Resident #10's weight was not obtained. Interview on 7/16/26 at approximately 9:18 a.m. with Staff A (Registered Nurse) confirmed the above findings. Further interview revealed that there was no notification to the physician for the weight gains on 6/12/26. Interview on 7/16/26 at approximately 12:17 p.m. with Staff B (Director of Nursing) confirmed the physician's orders were not followed for notification of weight gain. Review on 7/16/26 of the facility's policy Resident Weights, revised 8/20/19, revealed, 8. The licensed nurse is responsible for validating the weight. If the resident's weight is plus or minus three (3) pounds from the previous weight, the resident must be reweighed within 24 hours and verified by the nurse 10. The following members of the interdisciplinary team are notified upon licensed nurse validation of significant weight change. Physician .12. If the resident cannot be weighed, there must be a documented medical reason that prevents the resident from being weighed. Notify Physician .

Based on observation, record review, and interviews, the facility failed to ensure that medications were stored according to the manufacturer's instructions for 2 of 2 medication refrigerators reviewed. Findings include:Review on 7/14/26 of manufacturer's instructions for Lantus Solostar, Zepbound, Tuberculin Purified Protein, Novolog Flex Pen, Novolog 70/30 flex pen, Latanoprost Ophthalmic, and Prolia revealed that unopened medications should be stored at 36 F to 46 F.Observation on 7/14/26 of the 2nd floor medication refrigerator revealed the following medications:Lantus Solostar 100 unit, three vials (insulin)Zepbound 7.5 mg/0.5 ml, two pens ( Do Not Freeze)Tuberculin Purified Protein (tuberculin testing)NovoLog Flex Pen 3 ml, one penNovoLog 70/30 Flex Pen, one pen (insulin)Review on 7/16/26 of the 2nd floor Medication Refrigerator Temperature Checklist for May, June, and July 2026 revealed missing temperatures or unacceptable temperatures on the following dates:5/14, 5/15, 5/17, 5/18 had no temperatures listed.5/23: 32 F, 5/28: 33 F with no corrective action taken. 6/16, 6/17, 6/23 had no temperatures listed.6/1: 32 F with no corrective actions taken.7/2, 7/3, 7/5, 7/7, 7/13 had no temperatures listed.Interview on 7/14/26 at 9:25 a.m. with Staff H (Licensed Practical Nurse) confirmed the above findings that the temperatures were out of range, logs were incomplete and that no corrective actions were documented. Observation 7/14/26 at 9:45 a.m. of the 3rd floor medication refrigerator revealed the following medications:Lantus Solostar 100 unit, one vialLatanoprost Ophthalmic Solution 0.005%Prolia 60 mg/ml syringe ( Do Not Freeze), one syringeReview on 7/16/26 of the 3rd floor Medication Refrigerator Temperature Checklist for May, June, and July 2026 revealed missing temperatures or unacceptable temperatures on the following dates:5/2, 5/3, 5/4, 5/20, 5/21, 5/24, 5/26, 5/29, 5/30, 5/31 had no temperatures listed.5/10: 35 F, with no corrective actions6/1, 6/2, 6/14, 6/15, 6/17, 6/18, 6/22, 6/24 had no temperatures listed.6/28: 34 F, 6/29: 35 F, with no corrective actions 7/4, 7/5, 7/9, 7/11 had no temperatures listed.7/2: 30 F, 7/3: 35 F, 7/12: 33 F, and 7/13: 35 F, with no corrective actionsInterview on 7/14/26 at 9:45 a.m. with Staff I, MNA (Medication Nursing Assistant) confirmed the temperature logs were incomplete, some temperatures were out of range and no corrective actions were documented.Further review of the facility policy titled Medication Storage (dated 1/21) revealed in Section 4.1: Medications requiring 'refrigeration' or 'temperatures between 2 C (36 F) and 8 C (46 F)' are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that temperature has remained within the acceptable limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily.

Based on record review, and interview, it was determined that the facility failed to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 16 residents. (Resident identifier is #2.) Findings include: Review on 6/18/25 of Resident #2's physician orders revealed an order for Sertraline (antidepressant) 50 milligrams (mg) daily for Depression, dated 9/14/23, and an order for Seroquel (antipsychotic) 25 mg daily at bedtime for delusions, dated 9/14/23. Review on 6/18/25 of Resident #2's medical record revealed no attempts to perform a GDR or documentation of clinical necessity of either Sertraline or Seroquel. Interview on 6/19/25 at approximately 2:00 p.m. with Staff E (Corporate Nurse) confirmed there was no documentation of a GDR attempt or of a contraindication for a GDR to be attempted. Review on 6/19/25 of facility policy titled Utilization and Documentation of Psychotropic Medications revised 7/20/17 revealed .Residents who use psychotropic medications receive gradual dose reductions .unless clinically contraindicated, in an effort to discontinue these drugs .

Based on interview and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had necessary treatment and services, which included documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer for 1 out of 3 residents reviewed for pressure ulcers (Resident Identifier is #29). Findings include: Review on 6/19/25 of Resident #29's progress note, dated 3/15/25, revealed that Resident has two wounds to bilateral heels. Right inner heel is black/blue and reddened area . No measurements or wound stage were indicated. Further review of Resident #29's medical record revealed nurse's notes with descriptions and measurements of Resident #29's wounds on the following dates: 3/17/25, 4/2/25 (two weeks from prior assessment), 5/16/25 (6 weeks from previous assessment and is from wound clinic note), 5/23/25, and 6/4/25 (2 weeks from prior assessment and wound clinic note). Review on 6/19/25 of wound clinic note, dated 6/4/25, revealed Resident #29 had Active problems Unstageable pressure ulcer R heel. Interview on 6/19/25 at approximately 10:50 a.m. with Staff B (Director of Nursing) confirmed that there were no weekly assessments to include descriptions and measurements of Resident #29's wounds. Interview on 6/19/25 at approximately 11:25 a.m. with Staff A (Unit Manager) revealed wounds are not monitored weekly. Review on 6/19/25 of facility policy titled Skin Care Guidelines revealed Documentation The Weekly Pressure Ulcer Flow Sheet . is completed immediately after skin rounds are conducted . The weekly Management Wound Report is also completed during rounds .

Based on observation, interview, and record review, it was determined that the facility failed to obtain physician's orders for oxygen for 1 of 1 residents reviewed for respiratory care in a final sample of 16 residents (Resident identifier is #54). Findings include: Observation on 6/17/25 at approximately 7:15 p.m. of Resident #54 revealed that Resident #54 was lying in bed using oxygen via nasal canula. Observation on 6/18/25 at approximately 2:45 p.m. of Resident #54 revealed he/she was in bed with the head of bed elevated and oxygen on at 1 liter via nasal canula. Observation on 6/19/25 at approximately 11:45 a.m. Resident #54 revealed he/she was in a wheelchair in the dining room with a portable oxygen tank via nasal canula. Review on 6/19/25 of Resident #54's clinical notes dated 6/14/25 revealed the following: Resident returned from hospital in wheelchair .Resident was admitted for acute bronchitis, UTI [urinary tract infection], early pneumonia and reactive airway disease . Resident is on 1L [liter] on NC [nasal canula] .Resident is currently sleeping nasal canula in place at 1 liter at 95%. Orders will be initiated, MD [medical doctor] will be notified. Review on 6/19/25 of Resident #54's physician orders revealed that there was no orders for oxygen. Interview on 6/19/25 at approximately 12:00 p.m. with Staff A (Unit Manager) confirmed Resident #54 was receiving continuous oxygen and there were no physician orders in place for oxygen.

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Transmission Based Precautions (TBP) to prevent the potential spread of infection for 1 of 1 residents reviewed for TBP in a final sample of 16 residents. (Resident identifier is #44.) Findings include: Observation on 6/18/25 between 8:46 a.m. and 8:52 a.m. of Resident #44's room revealed a sign on the door of the room stating Enteric Contact Isolation . Prior to entering the room*: Clean Hands, Gown, Gloves, Clean Hands With Soap + [and] Water on Exit. Further observation revealed Staff F (Laundry) standing inside of Resident #44's room at the doorway holding empty hangers. Staff F exited Resident #44's room without washing his/her hands with soap and water and proceeded to push the laundry rack down the hallway and enter the residents room. Interview on 6/18/25 at 8:50 a.m. with Staff F confirmed the above findings. Staff F was not aware that Resident #44 was on contact precautions. Interview on 6/18/25 at 8:53 a.m. with Staff G (Licensed Nursing Assistant) revealed that Staff G thought that Resident #44's contact precautions were removed. Interview on 6/18/25 at 9:09 a.m. with Staff H (Registered Nurse) revealed that Resident #44 was on contact precautions for Clostridioides difficile (C. diff). Interview on 6/19/25 at 8:20 a.m. with Staff B (Director of Nursing) and Staff C (Infection Preventionist) confirmed that Resident #44 finished his/her treatment regime for C. diff but remained on contact precautions. Staff C stated Resident #44 was still having loose and/or watery bowel movements and it was hard to contain. Further interview revealed that all staff should wear a gown along with gloves prior to entering a room with contact precautions and wash their hands prior to entering and exiting the room. Review on 1/17/25 of the facility policy, Isolation-Categories of Transmission-Based Precautions, Revision Date September 2022, revealed: .Contact Precautions .7. Staff and visitors wear gloves (clean, non-sterile) when entering the room [ROOM NUMBER]. Staff and visitors wear a disposable gown upon entering the room .

Based on interview and record review, it was determined that the facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine for 4 of 5 residents reviewed for immunizations (Resident Identifiers are #22, #29, #36, and #39). Findings include: Review on 6/19/25 of the current CDC immunization guidelines retrieved from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html revealed People ages 65 years and older .are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. Resident #22 Review on 6/19/25 of Resident #22's vaccination records revealed Resident #22, born in 1933, received the COVD-19 Bivalent Booster (Pfizer) on 10/17/24. There was no documentation of Resident #22 being offered or educated about the next dose recommendations. Resident #29 Review on 6/19/25 of Resident #29's vaccination records revealed Resident #29, born in 1932, received the COVID-19 Bivalent Booster (Pfizer) on 10/17/24. There was no documentation of Resident #29 being offered or educated about the next dose recommendations. Resident #36 Review on 6/19/25 of Resident #36's vaccination record revealed Resident #36, born in 1939, received the COVID-19 Bivalent Booster (Pfizer) on 10/17/24. There was no documentation of Resident #36 being offered or educated about the next dose recommendations. Resident #39 Review on 6/19/25 of Resident #39's vaccination record revealed Resident #39, born in 1931, received the COVID-19 Bivalent Booster (Pfizer) on 10/17/24. There was no documentation of Resident #39 being offered or educated about the next dose recommendations. Interview on 6/19/25 at approximately 9:30 a.m. with Staff C (Infection Preventionist) confirmed the above findings. Review on 6/19/25 of facility policy dated 3/1/2025 revealed . Eligibility: All residents are eligible for COVID-19 vaccination, as per CDC guidelines, unless contraindicated . Ongoing Updates: The facility will monitor CDC updates to adjust vaccination schedules accordingly .

Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed, in writing, the items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for 2 of 3 residents reviewed for Beneficiary Notices who remained in the facility (Resident identifiers are #44 and #45). Findings include: Resident #44 Review on 6/18/25 of the Beneficiary Notice - Resident discharged within the last 6 months form, completed by the facility, revealed Resident #44 was discharged from Medicare services and remained in the facility. Resident #44's last covered day was 5/15/25. Review on 6/18/25 of Resident #44's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) dated 5/13/25 revealed that beginning on 5/15/25, Resident #44 will no longer require Physical Therapy, Occupational Therapy, Skilled Nursing Care, and will no longer be covered by Medicare. Further review revealed the SNF ABN did not contain the services that the facility offers and for which the resident may be charged, and the amount of charges for those services. Instead the SNF ABN stated No cost estimate available as the per day/item or service. Resident #45 Review on 6/18/25 of the Beneficiary Notice - Resident discharged within the last 6 months form, completed by the facility, revealed Resident #45 was discharged from Medicare services and remained in the facility. Resident #45's last covered day was 3/24/25. Review on 6/18/25 of Resident #45's SNF ABN dated 3/21/25 revealed that beginning on 3/25/25, Resident #45 will no longer require Physical Therapy, Occupational Therapy, Skilled Nursing Care, and will no longer be covered by Medicare. Further review revealed the SNF ABN did not contain the services that the facility offers and for which the resident may be charged, and the amount of charges for those services. Instead the SNF ABN stated No cost estimate available as the per day/item or service. Interview on 6/18/25 at approximately 1:10 p.m. with Staff D (Social Services) confirmed the above findings and that Staff D stated it was his/her practice to write No cost estimate available instead of the estimated cost. Review on 6/18/25 of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055 (2024) section D. Estimated Cost Section revealed .The SNF should enter an estimated total cost .SNFs must make a good faith effort to insert a reasonable cost estimate for the care .If for some reason the SNF is unable to provide a good faith estimate of projected costs of care at the time of the SNF ABN delivery, the SNF should indicate in the cost estimate area that no cost estimate is available, This should not be a routine or frequent practice .

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 7 of 92 days reviewed between October 1, 2023 and December 30, 2023. Findings include: Review on 5/5/24 of the facility's Payroll Based Journal Staffing Data Report for Quarter 1 2024 (October 1-December 1, 2023) revealed that there were no RN hours for the following days: 10/7/23, 10/21/23, 12/16/23, and 12/17/23. Review on 5/7/24 of the facility's daily nursing time sheets for October and December 2023 revealed the following: On 10/7/23 there were only 6 RN hours worked; On 10/8/23, 10/21/23, 10/22/23 there were no RN hours documented as worked; On 12/16/23 and 12/17/23 there were no RN hours documented as worked; On 12/31/23 there were 2 RN hours worked. Interview on 5/6/24 at 3:15 p.m. and on 5/7/24 at 1:58 p.m. with Staff J (Human Resources) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing antibiotic use for 6 of 12 months reviewed for antibiotic use. Findings include: Review on 5/6/24 of the facility's line listing for antibiotic use from May 2023 through April 2024 revealed that the facility did not track antibiotic use within the facility from December 2023 through April 2024. Interview on 5/7/24 at 2:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview further revealed that the facility did not have monthly antibiotic monitoring, tracking, or review documented from December to present, including documentation that antibiotics met criteria for use. Staff A confirmed that the facility had residents with infections and who were on antibiotics from December 2023 through April 2024. Review on 5/7/24 of the facility's policy titled, Antibiotic Stewardship, revised 2/11/22, revealed: .The Infection Preventionist, in conjunction with the Director of Nursing, will have primary oversight of the Antibiotic Stewardship Program. The Infection Preventionist has key expertise and data to inform strategies to improve antibiotic use. This includes: tracking of antibiotics, starts adherence to evidence-based published criteria, including utilizing the McGreers criteria during the evaluation and management of related infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organism .The Infection Preventionist is responsible for infection surveillance and MDRO [Multidrug Resistant Organism] tracking . 43408 Interview on 5/7/24 at approximately 2:30 p.m. with Staff A (Director of Nursing) revealed that the facility could not provide documentation or evidence of regular reporting on antibiotic use and antibiotic resistance to relevant staff such as prescribing clinicians and nursing staff.

Based on observation, interview, and record review, it was determined that the facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 3 of 3 residents reviewed for activities (Resident Identifiers are #45, #55, and #63). Findings include: Observation on 5/5/24 at approximately 2:00 p.m. of the Second Floor Unit revealed Resident #45 sitting in his/her wheelchair in the hall with eyes closed. Further observation of the second floor unit revealed that there were no activities in place on the unit. Review on 5/5/24 of the Second Floor Unit posted activity calendar for 5/5/24 revealed that the afternoon activity scheduled was a lemonade cart at 2:00 p.m. Observation on 5/6/24 at approximately 10:00 a.m. of the Second Floor Unit revealed Resident #45 with approximately five other residents sitting in their wheelchairs in the hall at the nurse's desk. Further observation revealed no activities occurring on the unit. Observation on 5/6/24 at approximately 12:00 p.m. of Second Floor Unit revealed Resident #45 pointing at Resident #26 and verbalizing their discontent with them as Resident #26 continued to self propel in their wheelchair through the halls, crying and verbally escalating. Further observation revealed no diversional activities on the unit in place. Observation on 5/7/24 at approximately 10:10 a.m. of the Second Floor Unit revealed Resident #45 to be sitting slumped in his/her wheelchair in the hall asleep. Interview on 5/7/24 at approximately 10:10 a.m. with Staff E (Licensed Nursing Assistant (LNA)) revealed that an activity occurs one day every other week on the Second Floor Unit and other than that the residents need to be brought to other floors to attend activities. Staff E stated that Resident #45 used to be very involved and active in activities, but due to some behaviors, they stopped bringing him/her off the unit for activities and he/she only attends ones on the unit now. Review on 5/7/24 of the activities calendar for 5/7/24 revealed the activities scheduled were hairdresser visits, 10:00 a.m. resident council, and 2:00 p.m. bean bag toss in the dining room. Review on 5/7/24 of Resident #45's medical record revealed a diagnosis of vascular dementia. Review on 5/7/24 of Resident #45's activities participation documentation for April 2024 and May 2024 revealed the following was documented as attended: 4/1/24-Mass; 4/8/24-Mass; 4/9/24 music entertainment; 415/24 Mass; 4/21/24 Mass; 4/22/24 Mass; 4/30/24-Gardening. Further review of Resident #45's activities participation documentation for April 2024 and May 2024 revealed that there were no activities documented as attended for May 2024. Interview on 5/7/24 at approximately 11:00 a.m. with Staff F (Activities Director) confirmed that Resident #45 had 7 activities documented as attended for the month of April 2024 and no documented activity attendance thus far in May 2024. Resident #55 Interview on 5/5/24 at 2:30 p.m. with Resident #55's Representative revealed that he/she was concerned that the activities in the facility were not engaging for Resident #55. [Pronoun omitted] stated that Resident #55 has dementia and was unable to participate in a lot of the activities scheduled. Interview further revealed that Resident #55 loved music. The family had purchased an iPad and headphones for Resident #55 to listen to music but Resident #55 was unable to turn it on themselves due to their cognitive impairment. Observation on 5/6/24 at 9:00 a.m. revealed Resident #55 was sitting in wheelchair with his/her eyes closed. Further observation revealed headphones lying on Resident #55's dresser. Observation on 5/6/24 at 2:00 p.m. revealed Resident #55 was sitting in his/her wheelchair in his/her room. Further observation revealed the TV was on but Resident #55 was not facing the TV. Review on 5/7/24 of Resident #55's Care Plan last revised 9/11/23 revealed that Resident #55 enjoyed activities such as animals, arts and crafts, TV, music, reading, talking on the phone, doing group activities, games, cards, and going outside. Review on 5/7/24 of Resident #55's activities participation documentation for April 2024 and May 2024 revealed that Resident #55 attended Mass 3 times and music 2 times in April. Further review revealed no documentation of activity participation for May. Interview on 5/7/24 at approximately 11:00 a.m. with Staff F confirmed the above. Staff F stated that Resident #55 attends activities when his/her spouse brings him/her. Resident #63 Observation on 5/5/24 at 2:15 p.m. on the third Floor revealed that Resident #63 was sitting in the hallway in a wheelchair against the wall in front of the nursing station. Further observation revealed that Resident #63 said, I am bored, I want to go to bed. Interview on 5/5/24 at 2:20 p.m. with Staff K (Registered Nurse) revealed that Resident #63 has aggressive behaviors with staff and gets easily agitated when he/she is bored. Observation on 5/5/24 at 3:00 p.m. of Resident #63 revealed that Resident #63 was in bed with his/her eyes closed. Observation on 5/6/24 at 2:30 p.m. of Resident #63 revealed that Resident #63 was in the hallway in a wheelchair. Resident #63 was yelling at a staff member. Further observation revealed a staff member wheeled Resident #63 into his/her room. Observation on 5/6/24 at 2:45 p.m. of Resident #63 revealed that Resident #63 was in his/her room in a wheelchair facing the bed, no television or music was on. Resident #63 was trying to get out of his/her wheelchair. Review on 5/7/24 of Resident #63's medical record revealed that Resident #63 was admitted to the facility in 2/2024 with a diagnosis of Alzheimer's disease and Dementia with agitation. Review on 5/7/24 of Resident #63's Leisure Interest assessment dated [DATE] revealed that Resident #63 liked animals, TV, fishing, playing chess and sudoku, the outdoors and liked his/her independence and going to religious services or practices. Review of the Activity Calendars for March, April and May 2024 revealed that Mass was offered every Monday. Review on 5/7/24 of Resident #63's activities participation documentation for April 2024 and May 2024 revealed that there was no documentation that Resident #63 attended any activities in April or May. Interview on 5/7/24 at approximately 11:00 a.m. with Staff F confirmed the above findings. Staff F stated that Resident #63 had behaviors and did not attend group activities. Staff F could not provide an individualized activity program for Resident #63.

Based on interview and record review, it was determined that the facility failed to ensure residents were offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza Vaccination for 2 of 5 residents reviewed for vaccinations (Resident Identifiers are #29 and #59). Findings include: Resident #29 Review on 5/7/24 of Resident #29's medical record revealed that there was no record that the influenza vaccination had been offered for the 2023/2024 flu season. Interview on 5/7/24 at 3:10 p.m. with Staff G (Regional Clinical Director) confirmed the above finding. Review on 5/7/24 of the facility's policy titled, Immunizations: Influenza (Flu) Vaccination of Residents, Staff and Volunteers dated 2015, revealed: .II. Administration Procedure: A. Current and newly admitted residents, all staff, and volunteers will be offered the influenza vaccine from October of each year through the end of March the following year . Resident #59 Review on 5/7/24 of Resident #59's medical record revealed that Resident #59 was admitted to the facility in June 2023. Further review on 5/7/24 of Resident #59's medical record revealed that a consent was signed by Resident #59 upon admission to administer the pneumococcal vaccine. Further review revealed that there was no documentation that the pneumococcal vaccine had been given. Review on 5/7/24 of Resident #59's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/24 revealed under Section O Is the resident's Pneumococcal vaccination up to date was coded No. Interview on 5/7/24 at 3:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated Resident #59 had not received the pneumococcal vaccine. Review on 5/7/24 of the facility's policy titled, Pneumococcal Vaccination of Residents revised 6/9/22, revealed: .III. Policy: a. All residents age [AGE] years or older will be offered appropriate pneumococcal vaccination, if applicable, based on their prior pneumococcal vaccine status and new 2022 CDC recommendations .VI. Administration Procedure: .c. Informed consent in the form of a discussion regarding the risks and benefits of vaccination will occur prior to vaccination . g. Vaccine will be administered according to standing order .

Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed timely of the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN) for 2 out of 3 residents reviewed for beneficiary notices (Resident Identifiers are #5 and #65). Findings include: Resident #5 Review on 5/6/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #5 was discharged from Medicare Services on 2/28/24 and remained in the facility. Review on 5/6/24 of Resident #5's SNF Beneficiary Notification Review form, completed by the facility, revealed that Resident #5's last covered day of Medicare Part A Skilled Services was 2/27/24 and that the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review on 5/6/24 of Resident #5's SNF ABN revealed that it was signed by Resident #5 on 2/27/24. Review on 5/6/24 of Resident #5's NOMNC revealed that it was signed by Resident #5 on 2/27/24. Resident #65 Review on 5/6/25 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #65 was discharged from Medicare Services on 3/26/24 and discharged home. Review on 5/6/24 of Resident #65's SNF Beneficiary Notification Review form, completed by the facility, revealed that Resident #65's last covered day of Medicare Part A Skilled Services was 3/25/24 and that the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review on 5/6/24 of Resident #65's NOMNC revealed that it was signed by Resident #65 on 3/25/24. Interview on 5/6/24 at 2:58 p.m. with Staff H (Social Worker) confirmed the above findings for Resident #5 and Resident #65. Interview on 5/7/24 at 2:46 p.m. with Staff G (Regional Clinical Director) and Staff I (Director of Clinical Reimbursement) revealed the facility does not have a policy for issuing beneficiary notices. Review on 5/7/24 of Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 retrieved from https://www.cms.gov/medicare/medicare-general-information/bni/downloads/instructions-for-notice-of-medicare-non-coverage-nomnc.pdf revealed, . The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily .

Based on interview and record review, it was determined that the facility failed to ensure that the required committee members attended meetings at least quarterly for 2 of the 4 quarterly meetings reviewed. Findings include: Review on 5/7/24 of the Quality Assurance Performance Improvement (QAPI) meeting attendance sheets revealed the following required members were not in attendance: Quarter 2 - Medical Director and Infection Preventionist; and Quarter 3 - 1 other member of the facility's staff. Interview on 5/7/24 at approximately 2:30 p.m. with Staff A (Director of Nursing) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to provide sufficient staffing numbers to meet the residents' needs for 12 out of 32 days reviewed. Findings include: Interview on 10/27/23 at approximately 12:00 p.m. with Staff I (Anonymous) revealed: . normal staffing was one nurse to first floor no LNA [Licensed Nursing Assistant], second floor 1 nurse and 1 LNA and third floor 1 nurse and 1 to 1 and 1/2 LNAs on average. This means 3 nurses and 2 and 1/2 LNAs to care for 63 residents. This is not safe. Review on 11/29/23 of the facility Nursing Schedule from 10/28/23 through 11/28/23 revealed: 10/28/23 3:00 p.m. until 7:00 p.m. there were 2 nurses, 1 Medication Nursing Assistant (MNA) and 2 LNAs, from 7:00 p.m. until 11:00 p.m. there was no nurse in the facility and 1 MNA and from 11:00 p.m. to 7:00 a.m. there was no nurse, 2 MNAs and 1 LNA in the facility. Facility census was 63. 10/29/23 7:00 a.m. until 3:00 p.m. there was 1 nurse and 1 MNA and from 7:00 p.m. until 11:00 p.m. there was no nurse and 2 MNAs. Facility census was 63 residents. 11/5/23 3:00 p.m. until 7:00 p.m. there was 3 LNAs in the facility. Facility census was 63 residents. 11/6/23 7:00 a.m. until 3:00 p.m. there were 4 LNAs in the facility. Facility census was 63 residents. 11/7/23 3:00 a.m. until 7:00 a.m. there was 1 LNA in the facility. Facility census was 63 residents. 11/10/23 7:00 a.m. until 7:00 p.m. there was 1 nurse and 1 MNA in the facility. Facility census was 65 residents. 11/11/23 7:00 a.m. until 3:00 p.m. there was 1 nurse, 1 MNA and 4 LNAs in the facility. Facility census was 65 residents. 11/13/23 3:00 p.m. until 11:00 p.m. there was 1 nurse and 1 MNA in the facility. Facility census was 65 residents. 11/14/23 11:00 a.m. until 3:00 p.m. there was 1 nurse and 1 MNA in the facility. Facility census was 65 residents. 11/16/23 3:00 p.m. until 7:00 p.m. there was no nurse in the facility. Facility census was 65 residents. 11/25/23 7:00 a.m. until 3:00 p.m. there was 1 nurse in the facility. Facility census was 66 residents. 11/26/23 7:00 a.m. until 3:00 p.m. no nurse, 1 MNA, and 3 LNAs, 3:00 p.m. until 11:00 p.m. no nurse, 3:00 until 7:00 p.m. there was 1 MNA and from 7:00 p.m. until 11:00 p.m. there were 2 MNAs. Facility census was 65 residents. Interview on 11/29/23 at approximately 10:00 a.m. with Staff C (LNA) revealed, Staffing is horrible, last Sunday there was only 1 LNA on the entire third floor. Further interview revealed that when staffing is short meals are late being passed and the residents' care suffers. Sometimes there is only 1 nurse in the building for all 3 floors. Interview on 11/29/23 at approximately 10:45 a.m. with Resident #5, #6, and #7 revealed that sometimes it takes 20 minutes to get assistance when needed. All 3 residents confirmed that they feel the facility needs more staff. I time it and if it takes more than 20 minutes, I wheel myself to the hall and yell for someone, stated Resident #5. Interview on 11/29/23 at approximately 11:30 a.m. with Staff F (Director of Nursing) revealed that optimal staffing would be: 1st shift there would be 7 LNAs 2nd shift there would be 6 LNAs 3rd shift there would be 3 LNAs Interview on 11/29/23 at approximately 2:00 p.m. with Staff D (Administrator) and Staff F was unable to provide any evidence of additional staffing during the above noted time frames. Review on 11/29/23 of the facility assessment, updated on 10/31/23 revealed: . Staffing Plan 3.2. Staffing needs based on resident acuity and census . Licensed Nurses providing direct care 6-8 Nurse Aides 21-27 . Staffing plan 3.3 Primary assignments to establish continuity of care, primary scheduling of staff to each unit are used as much as possible. Group schedules are created based on acuity and reviewed periodically, determined by resident and unit needs. Staff assignments might be adjusted based on resident acuity and unit requirements.Every attempt will be made to provide adequate staffing, during times of inadequate staffing staff will rotate throughout the facility to assist each other.

Based on observation, interview, and policy review it was determined that the facility failed to ensure that medications were labeled and stored in accordance with the manufacturer's instructions for 2 of 4 medication carts observed (Resident identifiers are #1, #2, and #3). Findings include: Second Floor Observation on 11/29/23 at approximately 10:20 a.m. of the Second Floor [NAME] Wing medication cart with Staff B (Medication Nursing Assistant (MNA)) revealed the following: Resident #2's open Novolog insulin pen with a pharmacy sticker that read Discard 28 days after opening and a handwritten discard date of 10/11/23; Resident #2's other open Novolog insulin pen with no open or expiration date and a pharmacy sticker that read Discard 28 days after opening, and a pharmacy delivery date of 9/19/23; Resident #3's open Lantus insulin pen with a pharmacy sticker that read Discard 28 days after opening and a handwritten open expiration date of 11/24/23. Review of Resident #2's November 2023 Medication Administration Record (MAR) revealed they had received 4 units of Novolog insulin daily. Review of Resident #3's November 2023 MAR revealed they had received 25 units every morning and 15 units every evening of Lantus insulin. Interview on 11/29/23 at approximately 10:20 a.m. with Staff B confirmed the above findings. Review on 11/29/23 of the manufacturer's instructions for Novolog revealed . Keep at room temperature (below 86 [degrees] F [Fahrenheit]) or refrigerated for up to 28 days, keep away from direct heat and light, Dispose after 28 days, even if there is insulin left in the pen or vial . Review on 11/29/23 of the manufacturer's instructions for Lantus revealed .After 28 days, throw your opened Lantus pen away-even if it still has insulin in it . Review of the facility's policy titled Medication Storage, initiated January 2021 revealed .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin pens must be stored at room temperature . 38218 Resident #1 Observation on 11/29/23 at approximately 10:30 a.m. of the First Floor Medication Cart revealed the following: Resident #1's Levemir Flexpen opened and not labeled with an open date or open expiration date Resident #1's Victoza pen opened and not labeled with an open date or open expiration date. Interview on 11/29/23 at approximately 10:30 a.m. with Staff A (MNA) confirmed the above findings. Further interview revealed that Staff A administered both medications that morning to Resident #1. Review on 11/29/23 of Resident #1's November 2023 MAR revealed: Levemir FlexTouch Subcutaneous Solution [Insulin Detemir] Pen-injector 100 UNIT/ML [milliliter], Inject 12 units subcutaneously two times a day ., Start date 10/3/23. Victoza Subcutaneous Solution [Liraglutide] Pen-injector 18 MG [milligrams[/3 ML, Inject 1.2 mg subcutaneously one time a day, ., Start date 10/3/23. Review on 11/29/23 of the manufacturer's instructions of Levemir Flexpen, undated revealed: .Storage after use . Dispose after 42 days, even if there is insulin left in the pen or vial . Review on 11/29/23 of the manufacturer's instructions of Victoza pen, dated September 2022 revealed: . Use a Victoza pen for only 30 days; it should be thrown away after 30 days, even if some medication is left in the pen.

Based on observation and interview, it was determined the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for conducting COVID-19 testing for 1 of 1 unit observed. Findings include: Third Floor Memory Care Unit Observation on 11/29/23 at approximately 11:15 a.m. on the Third Floor revealed Staff G (Memory Care Coordinator) and Staff H (Licensed Nursing Assistant (LNA)) in the process of completing COVID-19 testing on residents. Further observation revealed that Staff G and Staff H were not wearing N95 masks during the process of collecting the sample for COVID-19 testing. Both Staff G and Staff H were wearing a surgical masks. Interview on 11/29/23 at approximately 11:25 a.m. with Staff G confirmed the above observation. Staff G stated they were not aware that an N95 mask would be needed when collecting COVID-19 samples. Interview on 11/29/23 at approximately 11:45 a.m. with Staff F (Director of Nursing) revealed that they would expect that an N95 is to be worn when collecting COVID-19 samples. Staff F stated they had an ample supply of N95 masks for staff use. Review on 11/29/23 of the facility policy titled Point of Care Antigen Testing Policy & Procedure, established 10/28/20, revealed .IV. Procedure .Prior to obtaining sample: wash hands; and Don [put on] PPE [Personal Protective Equipment]-Np5 [N95] respirator, surgical mask, gown, eye protection, gloves . Review on 11/29/23 of the CDC website titled Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, found at https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html, updated 7/15/22, revealed .For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown .

Based on interview and record review, it was determined that the facility failed to ensure that the daily nurse staffing data was posted for 25 of the 30 days reviewed. Findings include: Review of the last 30 days of Daily In House Nursing Staff postings revealed that the facility had the following daily postings available, 11/19/23, 11/26/23, 11/27/23, 11/28/23, and 11/29/23. Interview on 11/29/23 at approximately 11:30 a.m. with Staff D (Administrator) confirmed the above findings and revealed that the there were no other daily postings done within the last 30 days.