Every finding on record at Alliance Health at Braintree

Based on observations, 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: 1. Maintain the ice machine in a clean and sanitary manner in one out of three kitchenettes; and 2. Ensure staff implemented and followed their policy related to safe and sanitary storage, handling, and consumption of foods items stored in the Resident's personal refrigerator/freezer. Findings include: 1. Review of the facility's policy titled Ice Machine, last revised 4/11/22, indicated but was not limited to: - Policy: it is the policy of this Facility that the ice machine be maintained in a clean and sanitary manner. - Process: - Monthly 1. Empty ice from storage bin 2. Clean outside and inside with solution of 1 part bleach to 9 parts water 3. Discard the first batch of ice after cleaning 4. Check machine to ensure that ice is being made normally 5. The ice machine should be emptied and sanitized at least quarterly - Bi-annually 1. The ice machine vendor is responsible for cleaning the ice making components of the machine twice a year. 2. This preventative maintenance cleaning involves cleaning the water filters, checking components, making necessary repairs and ensuring the machine is functioning properly. 3. Maintenance is responsible for the documentation that shows the machine has been cleaned by the vendor on a timely basis. On 7/23/24 at 12:53 P.M., the surveyor observed the following in the Third-Floor kitchenette: - A large ice machine. Inside the ice machine on one of the plastic components there was pink and black discoloration. The discolored component had condensation dripping down into the ice cubes. - A sticker affixed to the front of the ice machine indicated but was not limited to: - Name of the company and their phone number that last serviced the ice machine. - Ice Machine Cleaned and Sanitized Date: 1/24; By: Consultant #1. - Ice Chest Cleaning Sheet indicated the ice machine was last cleaned on 7/15/24. On 7/24/24 at 8:39 A.M., the surveyor observed the following in the Third-Floor kitchenette: - A large ice machine. Inside the ice machine on one of the plastic components there was pink and black discoloration. The discolored component had condensation dripping down into the ice cubes. During an interview with observation on 7/24/24 at 8:58 A.M., the Director of Maintenance (DOM) said he cleans the ice machine himself once a month by removing the ice from the ice machine and wiping down the ice machine. The DOM and surveyor observed pink and black discoloration on the plastic components and there were water droplets sliding down the pink and black discoloration dripping into the ice. The DOM reviewed the Ice Chest Cleaning sheet and said the ice machine was last cleaned on 7/15/24. During an interview with observation on 7/24/24 at 9:26 A.M., the DOM said the pink and black mold comes back quickly, and that maybe the ice machine needed to be cleaned more frequently. The surveyor observed the DOM wipe the pink and black substance with a disposable cloth and close the cover to the ice machine. The pink and black substance was able to be wiped off and was not a permanent stain. The surveyor and the DOM observed water droplets touching the pink and black substance dripping into the ice and potentially contaminating it. During an interview with observation on 7/25/24 at 9:44 A.M., Consultant #1 said he worked for the company that last serviced the ice machine in January 2024. Consultant #1 said his company recommended the ice machine be serviced and sanitized quarterly, but the facility preferred to have it done every six months. Consultant #1 and the surveyor observed the inside of the ice machine and saw a pink and black substance on one of the plastic components, a black substance on the inside of the upper front panel, and a black substance on a sensor. Consultant #1 said the black and pink residue was mold. Consultant #1 said the DOM was responsible for contacting the company and setting up the cleaning. During an interview on 7/25/24 at 10:57 A.M., the Administrator said the Facility does not have a contract with the company that comes in to service the ice machine, but schedules service every six months. The Administrator reviewed the last two invoices for ice machine cleaning which indicated that the ice machine was last serviced on 1/11/24 and 4/19/23, indicating eight months between cleanings. The Administrator said the Facility had been late in cleaning the ice machine. During an interview on 7/25/24 at 12:37 P.M., Consultant #1 said if the ice machine has mold, then it should not be used. Consultant #1 said when there is mold, it is not good. During an interview on 7/25/24 at 12:53 P.M., the DOM said when he cleaned the ice machine, he would use a nine to one ratio of water to bleach. The DOM said he usually emptied the ice out of the ice machine, and he would only clean the ice bucket. The DOM said if he saw something on the top component then he would clean it but did not clean it regularly. The DOM said he did not remember if he saw any pink and black discoloration on the plastic components. The DOM said he probably did not check it right. 34145 2. Review of the dietary policy titled Food Storage, last revised 2/28/23, indicated but was not limited to the following: -Individual Resident refrigerators a. If the resident chooses to have their own individual refrigerators in their room, the following requirements must be met for sanitation and safety purposes: -The resident/family will assume sole responsibility to clean the refrigerator and keep it in a sanitary manner. -The resident/family will be responsible for ensuring any perishable food is stored at less than or equal to 41 degrees. -Open food must be dated and should not be kept in the refrigerator any longer than 48 hours. The resident/family will be responsible for discarding appropriately. -The facility reserves the right to ask for the refrigerator to be removed if practices on maintaining it are not sanitary and do not meet with industry standards. Resident #27 was admitted to the facility in October 2022 and had diagnoses including dementia and Parkinson's disease. Review of the Minimum Data Set assessment, dated 5/30/24, indicated Resident #27 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 6 out of 15. During an interview with observation on 7/23/24 at 9:12 A.M., with the Resident's permission, the surveyor inspected the Resident's personal refrigerator/freezer located in the corner of his/her room. The Resident opened the refrigerator/freezer and said he/she keeps food in it and takes care of it him/herself. The Resident said he/she could not remember when he/she put the food items in there. The surveyor observed the following in the Resident's personal Refrigerator/freezer: -there was no thermometer inside either the refrigerator or freezer; -the top shelf of the refrigerator was glass and had condensation dripping onto items on the glass shelf below; -the second shelf of the refrigerator was glass and had brown/yellow stains on the surface as well as pieces of cardboard stuck to the shelf; -the inside edges, gasket and floor of the refrigerator were covered in large spills and splatters of a brown/yellow sticky substance; and -the freezer had a thick build-up of ice on all surfaces including the floor which was also covered in a light pink substance. The surveyor observed the following food items in the refrigerator/freezer: -uncovered thermal cup of soup, undated; -a sandwich wrapped in cellophane, undated; -a small individually wrapped (clear cellophane original packaging), cheese pizza with black and dark green fuzzy material visible on the edges of the pizza, undated -a red plastic plate of partially eaten food (unidentifiable contents); and -a covered thermal cup, undated and unidentifiable contents. During an interview on 7/24/24 at 9:17 A.M., the Maintenance Director said for refrigerators that are brought into the facility by families, it is the family's responsibility to clean and maintain them. Review of the medical record indicated following surveyor inquiry on 7/24/24, the facility contacted Resident #27's Health Care Proxy (HCP) regarding maintenance of the refrigerator/freezer. The HCP said they are unable to maintain the refrigerator/freezer and requested it be removed. During an interview on 7/25/24 at 7:36 A.M., the Director of Nursing (DON) said it is the facility's policy that either residents or their families are responsible for maintaining personal refrigerators. The DON said she didn't know how the facility ensures that families are maintaining safe and sanitary storage of food and proper functioning of the refrigerator but the facility should ensure safe storage.

Based on observations, interviews, and record review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#38), out of a total sample of 18 residents. Specifically, the facility failed to ensure a resident specific care plan was developed to address the resident's medical, physical, mental and psychosocial needs following the Resident's recent suicide attempt at the facility. Findings include: Resident #38 was admitted to the facility in June 2024 with diagnoses including non-Alzheimer's dementia and had an activated Health Care Proxy (someone designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the Minimum Data Set assessment, dated 6/10/24, indicated Resident #38 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 11 out of 15, and had no behaviors. Review of a Nursing Note, dated 7/10/24, indicated at around 10:45 P.M., Resident #38 was very agitated and hit his/her right leg and right hand against the side rails. A lot of blood was noted on the floor and bed. The Nurse applied dressings to the injury, and 10 minutes later, while the Certified Nursing Assistant (CNA) was trying to change the linen and put a clean johnny (a gown usually made of cotton, with an open back that fastens with ties around the back and neck) on him/her, the CNA observed the Resident trying to choke him/herself with the johnny and stated he/she wanted to kill him/herself. 911 was called immediately, and the Resident was sent to the emergency room for evaluation. Review of the Health Care Facility Reporting System (web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) and a Accident/Incident Report and Investigation Form indicated Resident #38 had a suicide attempt in the facility on 7/10/24. Further review of the report indicated the Resident presented with an acute change in mental status and delirium on the 7:00 A.M. to 3:00 P.M. shift. When the Resident's family member was preparing to leave, the Resident began to cry and was repeatedly saying I want to go home with you, get me out of here. At approximately 10:45 PM, when a CNA was assisting the Resident to change his/her johnny the Resident pulled the johnny out of the CNA's hands and twisted the johnny around his/her neck. As the Resident was doing this, he/she stated, I'm going to kill myself. The Nurse called 911. The CNA's statement indicated she was sitting with the Resident and noted that the johnny was tied and knotted so badly, the police officer had to cut it off. The Resident was transferred to the hospital for evaluation. Review of the Emergency Department Encounter note, dated 7/11/24, indicated Resident #38 presented to the emergency department following a reported suicide attempt by tying a johnny around his/her neck. The Resident was admitted for attempted suicide, altered mentation, and a urinary tract infection. The discharge notes indicated in the Assessment/Plan: Principal Problem: Acute encephalopathy Active Problems: Hypotension, UTI, COVID, Suicidal Ideation Resident #38 was discharged back to the facility on [DATE]. Review of comprehensive care plans indicated, but was not limited to: -Problem: Mood State (6/19/24) -Approaches identified include: Encourage Resident to participate in activities of choice; encourage Resident to talk about recent life changes; monitor for mood or behavior changes; provide 1:1 visits as needed to provide support; refer to Psych as needed. -Problem: Behavioral symptoms (6/19/24) -Approaches identified include: Always approach Resident in a calm manner; involve psych services prn (as needed); labs/urine as ordered by MD to rule out medical cause -Problem: Resident has a urinary tract infection (7/18/24) -Approaches identified include: administer antibiotic therapy as ordered, monitor/document for side effects and efficacy; encourage adequate fluids; monitor/document/report to MD as needed for signs/symptoms of UTI: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes; obtain and document vital signs per MD order. Further review of comprehensive care plans failed to indicate an individualized care plan was developed that identified and addressed the Resident's new diagnosis of suicidal ideation. On 7/23/24 at 9:10 A.M., the surveyor observed Resident #38 lying on his/her left side in bed awake. The Resident wore a hospital johnny that was secured around his/her neck only. No other ties were secured in the back of the johnny. The Resident repeatedly pulled the johnny away from his/her body in an upward direction as if trying to pull it off his/her body. During an interview on 7/24/24 at 12:35 P.M., Social Worker (SW) #1 said Resident #38 had a suicide attempt at the facility on 7/10/24. She said the Resident has a history of delusions that he/she is pregnant but has never had suicidal ideation before. She said when a resident returns from the hospital for a psychiatric issue, she contracts for safety, makes a referral to psychiatric services, and updates the care plan upon their return. She said she did not develop a Resident centered care plan to reflect the Resident's suicide attempt and suicidal ideation. The Social Worker said the Resident's name was placed in the consultant psychiatric Nurse Practitioner's (NP) book to alert them that the Resident needed to be seen on their next visit. She said the NP was out of the country and did not see the Resident and they do not have another provider to come in. During an interview on 7/25/24 at 7:36 A.M., the Director of Nursing (DON) said a care plan was not developed to address the Resident's suicidal ideation and attempt because they believe it was due to delirium from a UTI. During an interview on 7/25/24 at 4:05 P.M., Resident Representative #1 said Resident #38 has a history of frequent urinary tract infections with delirium, and he/she has never had suicidal ideations or a suicide attempt prior to 7/10/24.

Based on record review, interview, and policy review, the facility failed to ensure residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic medications prior to their use for one Resident (#69), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Management, last revised on February 12, 2022, indicated but was not limited to: - Notify resident or responsible party of initiation of psychoactive medications, and with any changes to dose, and document in record. Resident #69 was admitted to the facility in August 2020, with diagnoses which included Parkinson's disease, bipolar disorder, adjustment disorder with mixed anxiety and depressed mood. Review of the clinical record indicated the Physician invoked Resident #69's Health Care Proxy on 8/5/2020. Review of Resident #69's current Physician's Orders, dated 3/31/2023 through review on 5/5/2023, indicated an order for: - Ativan (anti-anxiety) 1 milligram (mg) twice daily, started on 3/31/2023. - Ativan 1 mg every four hours as needed, started on 4/1/2023. Review of the Medication Administration Record indicated Resident #69 received medication as ordered from 3/31/2023 through review on 5/5/2023. Initial review of the clinical record indicated a signed Informed Consent Form completed by the facility and Health Care Proxy for a one-time dose of Ativan on 7/13/2021 prior to a medical procedure. Further review of the clinical record failed to show a signed Informed Consent Form was obtained from the Health Care Proxy for administration of the current physician's orders for the anti-anxiety medication. During an interview on 5/5/2023 at 8:49 A.M., the Infection Preventionist Nurse and surveyor reviewed the clinical record and were unable to locate the signed Informed Consent for the administration of Ativan medication. The Infection Preventionist Nurse said the previous Informed Consent Form was obtained for one-time usage prior to a medical procedure. The Infection Preventionist Nurse said all residents should have completed Informed Consents for psychotropic medications prior to initiation of current treatment orders.

Based on record review and interview, the facility failed to ensure the Resident Comprehensive Assessment accurately reflected the correct discharge status for one Resident (#86), out of a total of three closed sample residents' records. Findings include: Resident #86 was admitted to the facility in February 2023 with diagnoses which included abdominal pain, adult failure to thrive, and dementia with behavior disturbance. Review of Resident #86's clinical record indicated a Physician's Order, dated 3/6/2023, to transfer the Resident to the hospital for further evaluation. Review of the Discharge Minimum Data Set (MDS) assessment section A, dated 3/6/2023, indicated Resident #86 was discharged to the community. During an interview on 5/9/2023 at 11:32 A.M., the MDS Coordinator said the discharge status of Resident #86 was incorrectly coded and should have been coded as discharged to acute care hospital.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required total physical assistance from two staff members to meet his/her toileting needs, the Facility failed to ensure that based on his/her comprehensive assessment that his/her toileting care needs were met as needed. On 09/18/22 at the start of the day (7:00 A.M. to 3:00 P.M.) shift, Resident #1 informed nursing that he/she had not received incontinence care at all during the overnight shift. Resident #1 was assessed by nursing and his/her adult brief was noted to be saturated in urine and soiled with feces. It was determined by the facility that Resident #1 had not been provided with incontinence care by staff during the previous shift. Findings include: Review of Facility Policy titled, Activities of Daily Living (ADL'S), dated 1/01/21, indicated that a program of ADL'S are provided to each resident in order to prevent disability and to maintain or return each resident to their maximum level of independence. The Policy further indicated, for toileting and elimination, a schedule is maintained for regularity. Resident #1 was admitted to the Facility in February 2022, diagnoses included, arthritis, congestive heart failure, anemia, hypertension, and chronic obstructive pulmonary disease. Review of Resident #1's Care Plan tilted, Urinary Incontinence, dated 2/15/22, indicated that he/she required staff to physically toilet him/her, provide incontinence care and change his/her adult brief every two hours and as needed (PRN). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 7/28/22, indicated he/she was cognitively intact, able to make his/her needs known, and was able to understand others. The MDS indicated Resident #1 required total physical assistance of two staff members for toileting needs, was always incontinent of bowel and bladder, and had a stage two (partial thickness loss of dermis) pressure injury to his/her buttocks. Review of Resident #1's Certified Nurse Aide (CNA) Care Card, last updated 9/07/22, indicated he/she required the physical assist of two staff members every two hours to reposition him/herself, required the use of a mechanical lift for transfers in/out of bed, and required staff assistance with toileting care needs. Review of the 11:00 P.M. to 7:00 A.M. Assignment Sheet, dated 09/17/22, indicated CNA #1 and Nurse #2 were assigned to Resident #1 to meet his/her care needs. During an interview on 11/28/22 at 10:24 A.M., Resident #1 said sometime during the month of September (exact date overnight shift 9/17/22 into 9/18/22) he/she had waited a very long time to have his/her saturated and soiled brief changed by a staff member. Resident #1 said he/she had been last changed on the evening of 9/17/22 at approximately 10:00 P.M., and said on 9/18/22 at approximately 8:30 A.M. was the next time a CNA provided him/her with incontinent care after having being left in his/her urine saturated and feces soiled adult brief for approximately eight hours. During an interview on 12/01/22 at 10:48 A.M., Certified Nurse Aide (CNA) #1 said Resident #1 was on her assignment for her shift that started on 9/17/22 at 11:00 P.M. and ended on 9/18/22 at 7:00 A.M. CNA #1 said that day was the first time she cared for Resident #1, and that during change of shift report another staff member informed her that Resident #1 would ring the call light when he/she needed assistance. CNA #1 said toward the end of her shift that night, she knew she had yet to provide care to Resident #1, and meant to go check on his/her. CNA #1 said she before going to check on Resident #1, she asked Nurse #2 to sign a missed punch form for her, so she went into her purse to get the form, noticed that her wallet was missing and said she panicked. CNA #1 said she had started looking everywhere and could not find her wallet anywhere. CNA #1 said she left the building to look in her car, still could not find her wallet, and said she drove to her house to look for it. CNA #1 said she returned to work a short time later, but did not realize that she had not provided care to Resident #1. During an interview on 12/01/22 at 1:32 P.M., Nurse #1 said on 9/18/22 at 7:00 A.M., after she arrived for her shift, as she was doing her morning rounds, Resident #1's call light was on so she went in to see what he/she needed. Nurse #1 said Resident #1 informed her that he/she had not been changed since the night before. During an interview on 11/30/22 at 1:03 P.M., Nurse Supervisor #1 said on 9/18/22 at approximately 11:45 A.M. he received a call from an upset family member stating Resident #1 had not received care the night before. Nurse Supervisor #1 said he went directly upstairs to investigate the concern and spoke with both Resident #1 and his/her family member. Nurse Supervisor #1 said he was informed by both of them that Resident #1 had not been provided incontinence care from the previous overnight shift and had remained in a soiled adult brief for approximately eight to ten hours. During an interview on 11/28/22 at 3:44 P.M., Nurse #2 said on 9/18/22 at 3:00 P.M.,when she came into work she was informed by Nurse Supervisor #1 that Resident #1 and his/her family member were very upset that Resident #1 had not received incontinent care throughout the previous overnight shift. Nurse #2 said she then called CNA #1 to speak to her about the concern. Nurse #2 said after speaking to CNA #1, she determined that CNA #1 had not attended to or changed Resident #1's incontinent brief at all on the previous overnight shift. Nurse #2 said she did recall that CNA #1 had lost her wallet that night and had gotten preoccupied trying to find it. During an interview on 11/28/22 at 3:44 P.M., the Director of Nurses (DON) said on 9/18/22 at 1:30 P.M., Nurse Supervisor #1 had called her and informed her of the concerns expressed by Resident #1 and his/her family member. The DON said she called Nurse #2 to investigate the reported concern. The DON said Nurse #2 informed her that CNA #1 had lost her wallet and instead of finishing his/her assignment, CNA #1 left the floor, and CNA #1 had not attended to or provided incontinent care to Resident #1 at all on the overnight shift.

Based on observations, interviews, and policy review, the facility failed to ensure that staff implemented proper infection control measures to prevent the potential transmission of communicable disease, including COVID-19, within the facility. Specifically, the staff failed to properly don (put on) and doff (remove) personal protective equipment (PPE) for care of residents on transmission based precautions, perform hand hygiene when indicated, and properly clean shared equipment between residents. Findings include: During an interview on 3/2/2021 at 12:30 P.M., the Infection Preventionist (IP) said that the facility had no specific policy for donning and doffing PPE. However, the facility trained their staff to adhere to the step-by-step directions on the Centers for Disease Control and Prevention (CDC) poster titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, when donning and doffing personal protective equipment (PPE). The posters are placed outside the rooms of those residents on transmission based precautions. The posters indicate that to doff a gown, gloves are removed first, then the gown and hand hygiene is performed; to don a gown, the staff's backside is to be covered; PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. The instructional poster indicated that the PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (e.g. retying gown) while providing personal care or close contact with the resident. During an interview on 3/2/2021 at 7:50 A.M., the Assistant Director of Nurses said that staff wear face shields and/or goggles and a mask. Gowns are worn when any personal contact occurs and/or if there is a potential or actual COVID-19 positive resident in the building. Signage is posted on the entry door to residents' rooms if they are on transmission based precautions. On 3/2/2021 at 9:31 A.M., the surveyor observed certified nursing assistant (CNA) #1 don a gown prior to entering a resident's room who was on transmission based precautions. The surveyor observed the gown falling off CNA #1's shoulders and the back of the gown was fully open exposing her backside while performing resident care. After several minutes, CNA #1 tied the straps in the back near her neck. The backside remained open and she did not perform hand hygiene prior to touching the straps at the back of her neck. Failing to cover her clothing completely, increased the risk of her clothing becoming a potential vector of transmission for communicable disease, including the COVID-19 virus. CNA #1 continued to perform close contact resident care. On 3/2/2021 at 9:38 A.M., the surveyor observed physical therapy assistant (PTA) #1 don a gown. The back of her gown was open and exposed her backside. The gown was loose around her neck and shoulder areas. Failing to cover her clothing completely, increased the risk of her clothing becoming a potential vector of transmission for communicable disease, including the COVID-19 virus. PTA #1 performed close contact therapy with the resident. During an interview on 3/2/2021 at 9:45 A.M., the Charge Nurse said that the staff wear full PPE (gown, face mask, face shield/goggles, gloves) when there are any suspected cases of COVID-19 in the facility and/or quarantined and while performing close contact personal care. Posters are outside the residents' rooms with guidance on how to don/doff PPE appropriately. On 3/2/2021 at 9:48 A.M., the surveyor observed Physical Therapist (PT) #1 clean the Nurse on a Stick (vital sign machine, oral thermometers, blood pressure cuff, and oxygen saturation device) in a quarantined resident's room and then proceed to move the machine out of the resident's room to the hall. There was no additional cleaning of the equipment observed. On 3/2/2021 at 9:50 A.M., the surveyor observed Nurse Practitioner #1 exit a quarantined resident's room and remove her gown and then her gloves. This is not consistent with the Center for Disease Control and Prevention (CDC) posters that indicate PPE must be removed slowly and deliberately in a sequence that prevents self-contamination; gloves are removed prior to gown, mask, and goggles/face shield; and PPE is removed and discarded prior to exiting the resident's room.

Based on observations, staff interviews, and policy review, the facility failed to ensure that the staff implemented infection prevention and control measures to prevent the potential transmission of communicable diseases and infection, including Covid-19. Specifically, the staff failed to implement the facility's transmission based precautions protocols by: (1) failing to ensure a consultant wore personal protective equipment appropriately while administering a test to a resident, and (2) failing to follow facility protocol to ensure supplies used for activities were not shared among residents. Findings include: Review of the facility's policy titled Visitor Limitation during COVID-19 Outbreak, revised 9/14/2020, indicated the following: -Consulting services will now be allowed back in the facility. -Required PPE will be worn by the consultant as appropriate to the resident's condition at the time of the visit. Review of the facility's policy, which included the Department of Public Health guidance titled Comprehensive Personal Protective Equipment (PPE), dated January 6, 2021, indicated the following: Gowns should be prioritized for the following activities: -During the following high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of healthcare providers, such as: -Dressing, bathing/ showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care 1. On 2/3/21 at 9:30 A.M., the surveyor observed a consultant, identified as an echocardiogram technician, enter the facility's front door wearing a Tyvek suit (full body coverall) and a N95 mask with both straps secured around the back of his neck. On 2/3/21 at 9:36 A.M., the surveyor and Director of Nursing (DON) observed the consultant enter the elevator with them, wearing the Tyvek suit and an N95 mask with both straps secured around the back of his neck. After exiting the elevator, the Infection Preventionist (IP) met the consultant outside the resident's room and asked the consultant to: perform hand hygiene, put a surgical mask over the N95 mask (double masking), and put on a gown over the Tyvek suit (double layers of PPE) before entering the resident's room. On 2/3/21 at 9:40 A.M., the IP said that the consultant was going to perform an echocardiogram on the resident in the room. The consultant and IP entered the resident's room, and drew the curtain around the resident's bed. During interview on 2/3/21 at 10:49 A.M., the IP said that the Tyvek suit that the consultant wore into the building appeared to have been used before, and that is why he asked him to wear a gown over the suit. The IP said that he should have asked him to remove the Tyvek suit so he could wear one gown and he should not have had him put on a surgical mask over the N95 mask before entering the resident's room to perform the echocardiogram. The IP said that the consultant should have worn the N95 appropriately with one strap secured behind his neck and one strap secured behind his head. 2. Review of the facility's policy titled, Outdoor/Indoor Group Activities During COVID-19, revised 12/13/20, included the following: Purpose: To slowly and safely begin the process of resuming activities that were in place pre-COVID-19. The facility will be progressing through the structured phases of opening per DPH and CMS guidelines. Indoor Group Activities will be permitted: -Items used for activities should not be shared between or among residents -Hand hygiene will be practiced frequently On 2/3/21 at 10:16 A.M. on the Second Floor Unit, the surveyor observed the Activity Assistant, without gloves, place four playing cards on three residents' overbed tables drawn from the deck of cards in his hand. Two of the three residents were recovered from Covid-19 and one resident was negative (never been diagnosed with [REDACTED]. All three residents were observed touching their cards and repositioning them on their overbed tables. At the end of the game, the Activity Assistant collected the cards from each of the residents, shuffled them, and dealt each resident four new cards and placed them on their overbed tables. The Activity Assistant failed to ensure that the playing cards used for the activity were not shared between or among the residents. The surveyor did not observe hand hygiene being performed at any time during the activity. During an interview on 2/3/21 at 2:23 P.M., the Activity Assistant and Infection Preventionist said that the residents should not have shared the same deck of cards.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at high risk for falls and whose care plan indicated he/she required the assistance of two staff members with transfers, the Facility failed to ensure staff followed and implemented interventions from his/her plan of care, when on 11/29/20, Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her bed to the wheelchair, without the assistance of another staff member, Resident #1 fell during the transfer and sustained a right humeral neck (upper arm) fracture. Findings include: The Facility's Policy titled, Comprehensive Person-Centered Care Planning, revised 8/15/17, indicated that staff shall provide services in accordance with each resident's written plan of care. Review of the Facility's Investigation, dated 12/7/20, indicated that on 11/29/20, at approximately 11:35 A.M., Certified Nurse Aide (CNA) #1 provided transfer assistance, without the assistance of another staff member, to Resident #1, who required two staff members to assist with sit-to-stand transfers. The Investigation indicated that CNA #1 attempted to transfer Resident #1 from his/her bed to his/her wheelchair, but Resident #1 ended up falling onto the floor and sustained a right humeral neck (upper arm) fracture with displacement. The Investigation indicated that on 11/29/20, CNA #1 failed to follow Resident #1's Plan of Care while providing Resident #1 with transfer assistance prior to his/her fall. Resident #1 was admitted to the Facility in July 2019, [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was totally dependent on two staff members for assistance with transfers, and that he/she had a limited range of motion in his/her upper and lower extremities. Review of Resident #1's Plan of Care related to Activities of Daily Living / Functional Status, dated as initiated 12/2019 and reviewed during his/her care conference dated 10/22/20, indicated Resident #1 required the assistance of two staff members with transfers. Resident #1's Fall Risk Assessment, dated 10/12/20, indicated he/she was at high risk for falls. Review of Resident #1's Certified Nurse Aide (CNA) Care Card (also referred to as Kardex), dated 10/1/20, indicated that Resident #1 required the assistance of two staff members with transfers. Review of Resident #1's Activity of Daily Living (ADL) Flow Sheet, (used by CNA's to document daily care provided to residents) for November 2020, indicated that CNA's documented daily that two staff members provided assistance for Resident #1 with all transfers. During an interview on 12/21/20, at 1:05 P.M., the Unit Manager said that prior to providing care, CNA's check the resident Care Cards (Kardex), for each residents required level assistance for all care needs. The Unit Manager said Resident #1 required two staff members to assist him/her with transfers. During an interview on 12/21/20 at 12:22 P.M., Certified Nurse Aide (CNA) #1 said that on 11/29/20, she transferred Resident #1 from his/her bed into his/her wheelchair, without the assistance of another staff member. CNA #1 said she was aware that Resident #1 required two staff members for transfers and said she did not follow Resident #1's Plan of Care and/or Care Card. CNA #1 said Resident #1 lost his/her balance and she tried to help lower Resident #1 to the floor. During an interview on 01/07/21 at 1:40 P.M., Nurse #1 said that on the morning of 11/29/20, she was in the hall way passing medications when CNA #1 asked her for help with Resident #1. Nurse #1 said that when she walked into Resident #1's room, she saw Resident #1 on the floor near his/her bed. Nurse #1 said Resident #1 told her that CNA #1 had attempted to transfer him/her into the wheelchair at the time of his/her fall. Nurse #1 said Resident #1 complained of pain in his/her right arm, that she informed his/her physician and obtained an order for [REDACTED].>During an interview with the Director of Nurses (DON) on 12/21/20 at 2:12 P.M., she said that on 11/29/20, CNA #1 did not follow Resident #1's Care Plan (which required two staff members to assist with transfers) and attempted to transfer him/her independently. The DON said Resident #1 fell on to the floor and sustained an arm fracture.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members with transfers, the Facility failed to ensure he/she was provided with the appropriate level of staff assistance to maintain his/her safety to prevent incidents/accidents, when on 11/29/20 Certified Nurse Aide (CNA) #1 transferred Resident #1 out of bed to the wheelchair, unassisted by another staff member, Resident #1 fell , complained of right arm pain, was transferred to the Hospital Emergency Department for further evaluation, where he/she was diagnosed with [REDACTED]. Findings include: Review of the the Facility's Investigation, dated 12/7/20, indicated that on 11/29/20, at approximately 11:35 A.M., Certified Nurse Aide (CNA) #1 provided transfer assistance, without the assistance of another staff member, to Resident #1, who required two staff members to assist with sit-to-stand transfers. The Investigation indicated that CNA #1 attempted to transfer Resident #1 from his/her bed to his/her wheelchair, but Resident #1 ended up falling onto the floor and sustained a right humeral neck (upper arm) fracture and displacement. Resident #1 was admitted to the Facility in July 2019, [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was totally dependent on two staff members for assistance with transfers, and that he/she had limited range of motion in his/her upper and lower extremities. Review of Resident #1's Fall Risk Assessment, dated 10/12/20, indicated he/she was at high risk for falls. Review of Resident #1's Plan of Care related to Activities of Daily Living / Functional Status, dated as initiated 12/2019 and reviewed during his/her care conference dated 10/22/20, indicated Resident #1 required the assistance of two staff members with transfers. Review of Resident #1's Certified Nurse Aide Care Card (also known as Kardex), dated 10/1/20, indicated that Resident #1 required the assistance of two staff members with transfers. Review of Resident #1's Activity of Daily Living (ADL) Flow Sheet, (used by CNA's to document daily care provided to residents) November 2020, indicated that CNA's documented daily that two staff members provided assistance for Resident #1 with all transfers. During an interview on 12/21/20 at 12:22 P.M., Certified Nurse Aide (CNA) #1 said that on 11/29/20, she transferred Resident #1 from his/her bed into his/her wheelchair, without the assistance of another staff member. CNA #1 said she was aware that Resident #1 required two staff members for transfers and said she did not follow Resident #1's Plan of Care and/or Care Card. CNA #1 said Resident #1 lost his/her balance and she tried to help lower Resident #1 to the floor. CNA #1 said she stayed with Resident #1 and called out to Nurse #1 for help. Review of Resident #1's Nurse Progress Note, dated 11/29/20, indicated Nurse #1 had responded to Resident #1, who had fallen to the floor and that he/she complained of pain. The Note Resident #1's physician ordered him/her an urgent x-ray and medication to treat his/her pain. Review of the Hospital Report, dated 11/29/20, indicated Resident #1 presented to the emergency department with complaint of right arm pain. The Record indicated Resident #1's Physician ordered non-weight bearing status to the right arm, to wear a sling on his/her right arm at all times, and medications for pain management. Resident #1's Radiology Report, dated 11/29/20, indicated that he/she had a fracture involving the right humeral neck (upper arm) with displacement. During an interview on 01/07/21 at 1:40 P.M., Nurse #1 said that on the morning of 11/29/20, she was in the hall way passing medications when CNA #1 asked her for help with Resident #1. Nurse #1 said that when she walked into Resident #1's room, she saw Resident #1 on the floor near his/her bed. Nurse #1 said Resident #1 complained of pain in his/her right arm. Nurse #1 said Resident #1 told her that CNA #1 attempted to transfer him/her into the wheelchair at the time of his/her fall. The physician progress notes [REDACTED].#1 had significant right shoulder pain which was not responding to Tylenol, so he/she was placed on low-dose [MEDICATION NAME] (narcotic). During an interview on 12/21/20 at 2:12 P.M., the Director of Nurses (DON) said that on 11/29/20, CNA #1 did not follow Resident #1's Care Plan (which required two staff members to assist with transfers) and attempted to transfer him/her independently. The DON said Resident #1 fell on to the floor and sustained an arm fracture.

Based on observations, staff interviews, and record review, the facility failed to effectively implement and monitor 6 residents (#295, #42, #199, #7, #196 and #96,) who required transmission based precautions (TBP) to prevent cross contamination and possible spread of Multi Drug Resistant Organism (MDRO) infections related to inadequate use of personal protective equipment (PPE) from a total sample of 20 residents. Findings include: The following Residents required TBPs for MDRO infections: -Resident #7, [MEDICAL CONDITION] Resistant [DIAGNOSES REDACTED] Auras(MRSA)/[MEDICATION NAME] Resistant [MEDICATION NAME](VRE) in a wound, required contact precautions. -Resident #96, [MEDICATION NAME] Resistant [MEDICATION NAME](VRE) of the rectum, required contact precautions. -Resident #42 [MEDICAL CONDITION] Resistant [DIAGNOSES REDACTED] Aureus(MRSA) in a wound, required contact precautions -Resident #295 [MEDICAL CONDITION] required contact precautions -Resident #[MEDICAL CONDITION] of the nares, required droplet precautions -Resident #196-MRSA of the urine, required contact precautions TBPs must be used when a resident develops signs and symptoms of a transmissible infection and is at risk of transmitting the infection to other residents. According to the facility policy for TBP, the two categories of TBP that are implemented in the facility are contact and droplet precautions. Contact Precautions: Contact precautions are intended to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering (i.e., before making contact with the resident or resident's environment) the room. Prior to leaving the resident's room, the PPE is removed and hand hygiene is performed. Droplet Precautions: The use of droplet precautions applies when respiratory droplets [MEDICAL CONDITION] or bacteria particles which may be spread to another susceptible individual. Respiratory viruses can enter the body via the nasal mucosa, conjunctivae and less frequently the mouth. When a resident is placed on transmission-based precautions, the staff should implement the following: o Clearly identify the type of precautions and the appropriate PPE to be used; o Place signage in a conspicuous place outside the resident's room such as the door or on the wall next to the doorway identifying the CDC category of transmission-based precautions (e.g. contact, droplet, or airborne), instructions for use of PPE, and/or instructions to see the nurse before entering. Ensure that signage also complies with residents' rights to confidentiality and privacy; Make PPE readily available near the entrance to the resident's room; - Don appropriate PPE upon entry into the environment of the resident on transmission-based precautions (e.g., contact precautions); -Provide education to residents (to the degree possible/consistent with the resident's capacity) and their representatives or visitors on the use of transmission-based precautions. -PPE required is gowns, gloves and masks. Respiratory droplets are generated when an infected person coughs, sneezes, talks, or during procedures such as suctioning, endotracheal intubation, cough induction by chest physiotherapy, and cardiopulmonary resuscitation. The maximum distance for droplet transmission is currently unresolved, but the area of defined risk based on epidemiological findings is approximately 3-10 feet. The ICN (infection control nurse) indicated to the surveyors that there is a stop sign posted at the resident's door indicating that the resident has an infection and has been placed on precautions. A pink piece of paper is placed in the PPE cart which indicates the room, the type of precautions, mode of transmission and the PPE required. These pink papers are filled in by the staff as residents are placed on precautions or are admitted on precautions, 1). For Resident #7 the facility failed to follow the facility policy/standards of practice for Resident #7 who required contact TBP's for a [DIAGNOSES REDACTED]. Resident #7 was admitted to the facility in January/2020 with [DIAGNOSES REDACTED]. Record review indicated that the Resident had a physician's orders [REDACTED]. On 1/28/20 at 10:50 A.M. the following was observed: The pink slip in the PPE cart indicated the type of precautions [MEDICAL CONDITION]/VRE Mode of transmission: Right knee wound/incision The PPE required indicated gloves, mask, gown There were numerous breeches of infection control by staff and visitors entering and leaving the resident's room. This occurred during the entire survey (1/23/20 through-1/29/20) with no one donning gloves or performing after leaving the room. 2). For Resident #96 the facility failed to follow the facility policy/standards of practice for Resident #96 who required contact TBP's for a [DIAGNOSES REDACTED]. Resident #196 was admitted to the facility in December/2020 with [DIAGNOSES REDACTED]. The Resident was re-hospitalized and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review indicated that the Resident had a physician's orders [REDACTED]. On 1/28/20 at 10:49 A.M. the following was observed: The pink slip in the PPE cart indicated that type of precautions as VRE/Rectum Mode of transmission: contact PPE required: gloves, gowns and mask. On 1/29/20 at 9:30 A.M. there was a visitor noted in the resident's room, eating soup with the resident, touching objects within the environment with no PPE on. Both the Resident and the visitor were consuming soup. Staff made no attempt to educate the visitor as to the type of PPE required. 3). For Resident #196 the facility failed to follow the facility policy/standards of practice for Resident #196 who required contact TBPs for a [DIAGNOSES REDACTED]. Resident #196 was admitted to the facility January/2020 with [DIAGNOSES REDACTED]. Fecalis, the Resident had a Foley catheter (tube into the bladder to drain urine) in place. Record review indicated that Resident #96 did not have a physician's orders [REDACTED]. On 1/28/20 at 10:47 A.M. the following was observed outside the Residents room in the PPE cart: The pink slip indicated the type of precautions as contact with the gloves, mask and gown written next to the contact precautions Mode of transmission: direct contact PPE required: gloves and gown. While on Unit 3, Unit #3 manager also stated to the surveyors that the Resident had shingles on her upper lip. The surveyors asked her for documentation about the shingles and what type of MDRO did the resident actually have a [DIAGNOSES REDACTED].#3 could not provide any documentation as to the shingles, and indicated that I guess it is just [MEDICAL CONDITION] of the urine. On 1/29/20 at 9:14 A.M. the pink slip was again viewed and now indicated that the Resident was on contact precautions, Mode of transmission: urine PPE: gloves and gowns The survey team's observations of infection control breaches throughout the survey include: -Throughout survey from 1/23/20 through 1/29/20 the surveyors made frequent rounds to observe the residents who were on TBP. In 6 of 6 rooms the standard trash barrel was continually used for the discarded PPE. This barrel did not indicate that it was to be used for the PPE and potentially infectious waste, as it was the standard trash barrel used for all Residents' rooms regardless of TBPs or not. There were numerous observations of the barrels overflowing with discarded PPE and no trash liners in place. The facility barrel could hold the regular waste, however due to the larger volume in the amount of waste generated by the person on TBPs, they were overflowing on numerous occasions. -During the infection control interview on 1/29/20 is was brought to their (DON & ICN) attention by the surveyor that when Resident #62 returned from the hospital in December, the hospital discharge summary stated that [MEDICAL CONDITION] nasal swab was positive. There had been no follow-up of [MEDICAL CONDITION] as the ICN and the staff on Unit 2 were unaware of this [DIAGNOSES REDACTED]. -It was also brought to the attention of the DON and the ICN by the surveyor that the medical director had been on Unit 2 performing resident physicals (3 Residents) in the hall and had not performed any hand hygiene before, in between and after touching all 3 residents. 4.) For Resident #295, the facility failed to follow [MEDICAL CONDITIONS] an bacteria causing diarrhea) contact transmission based precautions. The following was referenced from the 2007 CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, revised July 2009, include but not limited to: -Prevention of transmission for a person who has [MEDICAL CONDITION] focuses on the application of Contract Precautions for patients with diarrhea, accurate identification of patients, environmental measures (e.g., rigorous cleaning of patient rooms) and constant hang hygiene. Use of soap and water, rather than alcohol based hand rubs, for mechanical removal of spores from hands. -Contact Precautions are intended to prevent transmission of infectious agent, which are spread by direct or indirect contact with the patient or the patient's environment. -Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. -Donning PPE (Personal Protective Equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., [MEDICAL CONDITION] and other intestinal pathogens). Resident #295 was admitted to the facility in January of 2020 with loose stools, nausea, urinary tract infection, and a history of recent laparoscopic assisted sigmoidectomy ( removal of all or part of the sigmoid colon) for recurrent diverticular bleeding. On 1/23/20 at 11:12 A.M., the surveyor observed Resident #295 lying in his/her bed. Signage on the wall indicated that you needed to check with the nurse before entering the resident's room. The surveyor observed a three plastic shelving precaution cart located outside his/her room with disposable gloves, yellow gowns, and masks located inside the drawers. There was also a bright pink piece of paper inside the top shelf which stated the following: -Resident's room number -Type of precaution: contact for [MEDICAL CONDITION] -Mode of transmission: direct/indirect -PPE required: gloves, gowns, mask While standing outside Resident #295's room beside the precaution cart on 1/23/20 at 11:12 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 walk down the corridor and enter Resident #295's room carrying the cordless telephone from the nurses station. The CNA handed the cordless telephone to Resident #295 as he/she had a phone call. The CNA was then observed to exit the room, the resident remained in her/his bed talking on the cordless telephone. The CNA failed to don/doff PPE while entering/exiting the resident's room who was on contact precautions for [MEDICAL CONDITION] infection. The CNA failed to perform hand hygiene upon exiting the room. The CNA was then observed to touch the key pad (potentially contaminating) to exit the stairwell and told the surveyor she was leaving for her lunch break. The surveyor observed CNA #1 re-enter Resident #295's room at 1:15 P.M., retrieved the cordless phone, and brought it back to the nurses station where it was placed back on the phone charger. The phone was not sanitized appropriately. The CNA was not observed to perform hand hygiene at any time during the above observations. The surveyor also observed one small white trash receptacle in the corner of the resident's room which was overflowing with a combination of trash from both A and B beds, and soiled yellow precaution gowns. There was no identified receptacle for potential infectious waste or contaminated materials/soiled PPE. During an interview with Unit Manager #2 on 1/23/20 at 11:15 A.M., Unit Manager #2 told the surveyor the resident was admitted to the facility on contact precautions for [MEDICAL CONDITION] infection. The unit manager said he/she was still symptomatic with diarrhea and a lab was being re-tested . During observation on 1/23/20 at 11:49 A.M., the surveyor observed a visitor enter Resident #295's room. The visitor was observed to sit in Resident #295's chair at their bedside. The visitor was observed leaning over the resident's bed, touching their bedside table, and other items the resident had potentially touched for over an hour. The visitor did not don/doff any appropriate PPE for contact precautions or perform hand hygiene. During a subsequent interview with Unit Manager #2 on 1/27/20 at 9:50 A.M., she said the resident's lab for [MEDICAL CONDITION] came back negative on 1/23/20, but the resident remained symptomatic, and said he/she would remain on [MEDICAL CONDITION] precautions. On 1/27/20 at 1:08 P.M., the surveyors observed Rehabilitation Services Staff #1 and #2 providing direct care to Resident #295. Both rehabilitation staff were observed only wearing disposable gloves, and both were assisting the resident into the bathroom. On 1/29/20 at 9:02 A.M. two surveyors toured the unit and observed a new pink paper inside the top shelf of the precaution cart which stated the following. -Resident's room number -Type of precaution: contact for stool (the word [MEDICAL CONDITION] was now removed) -Mode of transmission: direct/indirect -PPE required: gloves, gowns, mask Inside the top shelf of the precaution cart the surveyor's observed a soiled yellow gown, crumpled in ball on top of clean boxes of gloves. Nurse #5 said she could not identify why there was a soiled gown in the PPE cart. The white trash receptacle remained in the corner of Resident #295's room and was overflowing with a combination of yellow gowns, and other soiled unidentified debris. 5.) For Resident #42, the facility failed to follow [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) contact transmission based precautions. Resident #42 was admitted to the facility in November of 2019 with [DIAGNOSES REDACTED]. Review of the most recent admission MDS, with a reference date of 11/27/19, indicated Resident #42 was cognitively intact, as evidenced by a BIMS score of 13 out of 15. The resident received extensive to total dependence on staff for ADL's, except was independent with eating. During an initial observation on the second floor on 1/23/20 at 11:14 A.M., the surveyor observed Resident #42 lying in his/her bed. Signage on the wall indicated that you needed to check with the nurse before entering the room. The surveyor observed a three plastic shelving precaution cart located outside his/her room with disposable gloves, yellow gowns, and masks located inside the drawers. There was also a bright pink piece of paper inside the top shelf which stated the following: -Resident's room number -Type of precaution:[MEDICAL CONDITION] contact -Mode of transmission: contact -PPE required: gloves, gown During an interview with Unit Manager #2 on 1/23/20 at 11:16 A.M., Unit Manager #2 told the surveyor the resident was on precautions [MEDICAL CONDITION] in their infected wound. While standing outside Resident #42's room beside the precaution cart, the surveyor observed CNA #2 providing direct care while assisting the resident up out of bed and into a wheelchair without any appropriate PPE. The CNA was then observed to exit the resident's room and failed to perform hand hygiene. On 1/23/20 at 11:57 A.M., the surveyor observed CNA #2 enter Resident #42's room, remove the resident's dirty bed linens, and then exited the room with a pile of dirty bed linens in her hands. The CNA did not have gloves or other PPE on. The CNA was then observed to walk down the hall and after discarding the dirty linens in the linen barrel, CNA #2 was observed to exit the room with soiled hands. CNA #2 walked over to the clean linen cart and proceeded to collect clean linens to make Resident #42's bed. The CNA entered the resident's room, and dropped the linens on the bed. The CNA then saw the surveyor standing outside Resident #42's room, left the room and put on a yellow gown, gloves, and mask and re-entered the resident's room. The CNA was not observed to perform hand hygiene during any observation. On 1/27/20 at 11:23 A.M., the surveyor observed CNA #3 walk in and out of Resident #42's room with an iced coffee cup in her hand. The CNA was observed to take sips of her coffee as she exited the resident's room, then proceeded down the hallway and put her coffee at the nurses station. The CNA was observed and did not don/doff any appropriate PPE. The surveyor also observed one white trash barrel at the exit of the resident's room which was overflowing with unidentifiable debris. There was no designated container or receptacle identified as potential infectious waste or soiled PPE. 6). For Resident #199, the facility to follow appropriate droplet transmission based precautions [MEDICAL CONDITION] in the nares. The following was referenced from the CDC 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, revised July 2009 include but not limited to: -Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.-Healthcare personnel caring for patients on Contact Precautions wear a mask, the mask is donned upon room entry. Resident #199 was admitted to the facility in January of 2020 with a [DIAGNOSES REDACTED]. During an observation on the second floor on 1/27/20 at 11:14 A.M., the surveyor observed Resident #199 lying in his/her bed. Signage on the wall indicated that you needed to check with the nurse before entering the room. The surveyor observed a three plastic shelving precaution cart located outside his/her room with disposable gloves, yellow gowns, and masks located inside the drawers. There was also a bright pink piece of paper inside the top shelf which stated the following: -Resident's room number -Type of precaution:[MEDICAL CONDITION] contact -Mode of transmission: contact -PPE required: gloves, gown During an observation on 1/27/20 at 11:25 A.M., the surveyor observed Nurse #5 providing direct care in the resident's room. The nurse was observed to exit the room and return to her medication cart. The nurse was not observed to don/doff PPE appropriately or perform hand hygiene. During an interview with the DON on 1/28/20 at 10:32 A.M., the surveyor's asked for the facility policy [MEDICAL CONDITION] in the nares. The DON told the surveyors, that's been corrected, the resident should have been on droplet precautions all along, not contact precautions. On 1/28/20 at 11:29 A.M., the surveyors observed Resident in her/his bed. The resident had four visitors in their room, none of which were wearing PPE. One of the visitors was seated in the resident's wheelchair, another visitor was seated on the resident's left side of their bed, touching the resident's bedside table, and other items the resident had touched and potentially contaminated. During an interview with the Infection Control Nurse on 1/28/20 at 12:04 P.M., she told the surveyors the nurse who admitted Resident #199 did not know what type of infection or transmission based precaution Resident #199 should be receiving, so the nurse stuck them on contact precautions. The Infection Control Nurse said she realized the resident [MEDICAL CONDITION] in her/his nares on 1/27/20 at 2:45 P.M., and switched out the pink paper in the precautions cart to read droplet precautions. The resident had been in the facility for 2 days and was receiving the incorrect transmission based precaution [MEDICAL CONDITION] in the nares. On 1/28/20 at 1:52 P.M.,the surveyors observed Resident #199 lying in his/her bed. There was a visitor in the room who was observed with their bare feet propped up on the resident's bed sheets. The visitor was seated in the resident's chair next to their bedside table. The visitor was not observed to be wearing any appropriate PPE. At 1:55 P.M., CNA #1 entered the resident's room and was observed to touch and readjust the resident's bed sheets, touched her/his bureau and put 2 shirts away, conversed with the resident and family, touched the television remote, and then exited the room. The CNA was not observed to don/doff any PPE or perform hand hygiene during the above observations. During an interview with CNA #1 the surveyor asked CNA #1 if a mask needed to be worn when in the room. The CNA told the surveyor she thought she only needed to wear PPE if she was bathing a resident. During an observation on 1/29/20 at 1:15 P.M., the surveyor observed 2 family members visiting Resident #199 in her/his room. No PPE was donned appropriately. Throughout survey from 1/23/20 through 1/29/20 the surveyors made frequent rounds to observe the residents who were on TBP. In 6 of 6 rooms the standard trash barrel was continually used for the discarded PPE. This barrel did not indicate that it was to be used for the PPE and potentially infectious waste, as it was the standard trash barrel used for all Residents' rooms regardless of TBPs or not. There were numerous observations of the barrels overflowing with discarded PPE and no trash liners in place, The facility barrel could hold the regular waste, however due to the larger amount of waste generated by the person on TBP's they were overflowing on numerous occasions. During an interview with the DON and Infection Control Nurse on 1/29/20 at 10:19 A.M., the surveyors reviewed the multiple observations of breaches in infection control including both staff and visitors which were observed throughout all days of the recertification survey from 1/23/20 through 1/29/20.

Based on policy review, record review and staff interviews, the facility failed to have a facility wide, systemic approach to monitor antibiotic use that included staff education and protocols according to the Antibiotic Stewardship program. Findings include: The Facility policy for the Antibiotic Stewardship-Guidance (dated 11/19/17 and is reviewed annually)indicates that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotics Stewardship Program. The facility policy includes but not limited to: Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. Training and education will include emphasis on the relationship between antibiotic use and Gastrointestinal disorders, Opportunistic infections, Medication interactions and the evolution of drug resistant pathogens. Prescribers will provide complete antibiotic orders including the drug name, dose, frequency of administration, duration of treatment, start and stop date, number of days of therapy, route of administration and indication for use. When a nurse calls a physician/prescriber to communicate a suspected infection they should have the following information available: *Signs and symptoms *When symptoms were first observed *Residents hydration status *Current medication lost *Allergy information *Suspected Infection type *Any orders for [MEDICATION NAME](blood thinner) and results of last INR *Last creatinine clearance or serum creatinine if available *Time of the last antibiotic dose as applicable Antibiotics that are prescribed over the phone, the prescriber or designee will assess the resident within 72 hours of the telephone or as soon as possible. When a culture and sensitivity (C&S) results will be treated as a high priority. The lab results will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. Changes to antibiotic orders based on C&S will be reviewed by the facilities ICN and/or pharmacist on their review. Antimicrobial stewardship is the systematic effort to educate and persuade prescribers of antimicrobials to follow evidence-based prescribing in order to stem antibiotic overuse, and thus antimicrobial resistance. When antibiotics are prescribed inappropriately, bacteria become resistant to the drugs, diminishing the ability of providers to effectively treat patients with complex health care needs. Antibiotic stewardship programs can improve patient safety and ensure the continued efficacy of antibiotics. THE Centers for Disease Control and Prevention(CDC) indicate that the core elements of the Antibiotic Stewardship programs in nursing homes should include the following: 1. LEADERSHIP SUPPORT ESTABLISHED AT FACILITY 2. ACCOUNTABILITY 3. DRUG EXPERTISE 4. ACTIONS TO IMPROVE USE 5. TRACKING: MONITORING ANTIBIOTIC PRESCRIBING, USE, AND RESISTANCE 6. REPORTING INFORMATION TO STAFF ON IMPROVING ANTIBIOTIC USE AND RESISTANCE. 7. EDUCATION On 1/29/20 at 10:19 AM. to 12:23 PM the ICN and DON were interviewed: The surveyor asked The ICN specifically as to how the Antibiotic Stewardship program was implemented, monitored and how education was provided to the staff and physicians. She stated that the infections are monitored by the use of the line listings(tracking of a Resident's symptoms related to illness and antibiotic use including actual infections vs non infections, and antibiotics use). She states she reviews her daily reports each morning which indicates what residents have been placed on an antibiotic. She then begins the line listing for that resident. She completes the line listings for all three units. The facilities line listings required the following information: a. Resident name and room number b. Site of Infection c. Category based on McGeers Criteria (a surveillance tool to assist in the clinical presentation of the Resident and what would be considered a infection) d. Signs and symptoms-Date of Onset e. Culture site/Date/Results f. Chest X-Ray Results/Date g. Treatment/Interventions/Isolation/Comment h. Final Status-HAI, CAI, Chronic-Asymptomatic Infection I. Count in total (Y/N) j. Resolved (Y/N) k. Comments The Infection Control Line Listings from August 2019 through January 2020 reviewed by the surveyor and observed to be incomplete, i.e. several Resident Infections lacked information on Resident symptoms, date of onset of the infection, culture date, site, results of the culture, treatment, infection resolved (Y/N), final status, comments, etc. This information was required according to the Monthly Resident Infection report and the lack of documentation made it difficult to monitor for effective antibiotic use. The surveyor then asked the ICN for the facilities worksheet/surveillance tool (McGeers' criteria worksheet) which was to be completed for all the residents with an infection. The ICN indicated that she did not have any because once she completed the worksheet, she discarded them. The ICN said she would expect the nurse to follow the McGeers' algorithm but couldn't answer concrete way she would tract the criteria without the nurse filling out the McGeer criteria. The ICN had no information that indicated which category of infection was present based on the McGeer's criteria(One of the sections on the facilities line listings to be completed). The ICN further stated that the nurses are not documenting if the Resident meets McGeers criteria and that she has been completing the worksheet/surveillance tool after the fact. -An effective Infection Control Program must include accurately documenting, compiling, and tracking, all of the information listed on the Infection Line Listings and any tools or forms utilized to improve communication should become part of the residents medical record to improve documentation of decision making. On 1/29/20 at 3:00 P.M. with the Director of clinical operations said to the surveyor that the worksheets were supposed to be kept and not discarded. The Surveyor then asked the ICN about the facilities physicians and if they comply with the Antibiotic Stewardship program. She indicated that the medical director is compliant but that there are several physicians at the facility that indicate to her that they are basically going to do what they want because they know better as they have been doing this for years. I asked the ICN about re-education with the staff and the physicians and she indicated that education had been completed but could not provide any documentation of the education provided to staff and physicians since 2017. During interview with the ICN and DON on 1/29/10 at 12:30 P.M., they acknowledged that the facility failed to have a systemic approach to monitor antibiotic use that included staff education and protocols according to the Antibiotic Stewardship program.

Based on observation, interview, and record review, the facility failed to ensure that for 7 residents (#295, #42, #7, #199, #196 #62, and #6), that comprehensive care plans were developed and/or consistently implemented to address the resident's specific needs. Findings include: 1.) For Resident #295, the facility failed to develop a comprehensive care plan for [MEDICAL CONDITION] ([MEDICAL CONDITION] a bacteria that causes inflammation of the colon) contact transmission based precautions. Resident #295 was admitted to the facility in January of 2020 with loose stools, nausea, urinary tract infection, and a history of recent laparoscopic assisted sigmoidectomy ( removal of part or the whole sigmoid colon) for recurrent diverticular bleeding. During an interview with Unit Manager #2 on 1/23/20 at 11:15 A.M., Unit Manager #2 told the surveyor the resident was admitted to the facility on contact precautions for [MEDICAL CONDITION] infection. Review of the medical record failed to include any notation, baseline or comprehensive care plan developed that indicated Resident #295 had [MEDICAL CONDITION] infection and/or was on Contact Precautions, as observed with the precaution cart outside his/her room on all days of survey from 1/23/20 through 1/29/20. 2.) For Resident #42, the facility failed to develop a comprehensive care plan for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) transmission based precautions. Resident #42 was admitted to the facility in November of 2019 with [DIAGNOSES REDACTED]. During an initial observation on 1/23/20 at 11:14 A.M., the surveyor observed Resident #42 lying in his/her bed. The surveyor observed a three plastic shelving precaution cart located outside his/her room with disposable gloves, yellow gowns, and masks located inside the drawers. There was also a bright pink piece of paper inside the top shelf which stated the following: -Resident's room number -Type of precaution:[MEDICAL CONDITION] contact -Mode of transmission: contact -PPE required: gloves, gown During an interview with Unit Manager #2 on 1/23/20 at 11:16 A.M., Unit Manager #2 told the surveyor the resident was on precautions [MEDICAL CONDITION] in their wound. Review of the medical record failed to include any comprehensive care plan developed that indicated Resident #295 [MEDICAL CONDITION] and required transmission based precautions. During an interview with the DON on 1/29/20 at 3:45 P.M., she said a care plan should have been developed and implemented for Residents # 295 and #42 for the type of infection and transmission based precaution they were receiving. 3.) For Resident #7 the facility failed to develop a comprehensive care plan for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA)and and [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) of a wound which required transmission based precautions. Resident #7 was admitted to the facility in January/2020 with [DIAGNOSES REDACTED]. Record review indicated that the Resident had a physician's orders [REDACTED]. Further record review of the Interdisciplinary Care Plans did not include a care plan addressing the transmission based precautions that the resident required as ordered by the physician. 4.) For Resident #199 the facility failed to develop a comprehensive care plan for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) of the nares which required transmission based precautions. Resident #199 was admitted to the facility in January/2020 with [DIAGNOSES REDACTED]. Record review indicated that the Resident had a physician's orders [REDACTED]. Further record review of the Interdisciplinary Care Plans/48 hour care plan did not include a care plan addressing the transmission based precautions that the resident required as ordered by the physician. During an interview with the DON on 1/29/20 at 3:35 P.M., she said Resident #7 and #199 should have had a comprehensive care plan for the type of infection and transmission based precaution they were receiving. 5). For Resident #196 the facility failed to develop a comprehensive care plan for [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) of the rectum which required transmission based precautions. Resident #196 was admitted to the facility in December/2020 with [DIAGNOSES REDACTED]. The Resident was re-hospitalized and returned to the facility in late January with a [DIAGNOSES REDACTED]. Record review indicated that the Resident had a physician's orders [REDACTED]. Further record review of the Interdisciplinary Care Plans did not include a care plan addressing the transmission based precautions that the resident required as ordered by the physician. During an interview with the DON on 1/29/20 at 3:40 P.M., she said Resident #196 should have had a comprehensive care plan for the type of infection and transmission based precaution they were receiving. 6). For Resident #62, the facility staff failed to develop and implement care plans for his/her [MEDICAL CONDITION], anticoagulant drug therapy, and risk of infection [MEDICAL CONDITION]. Resident #62 was admitted to the facility in February of 2019, and had [DIAGNOSES REDACTED]. A. Record review indicated Resident #62 [DIAGNOSES REDACTED]. Review of the medical record, that included the Medication Administration Record [REDACTED]. During interview on 1/29/20 at 11:45 A.M., Unit Manager #2 was asked about the [MEDICAL CONDITION] disorder. The Unit Manager referred to the medical record and after review, said that she did not know how the facility was monitoring and treating the Resident's [MEDICAL CONDITION] disorder. B. Record review indicated Resident #62 was administered the anticoagulant medication Eliquis 5 mg, daily for his/her [MEDICAL CONDITION]. Review of the medical record, that included the Medication Administration Record [REDACTED]. The physician orders [REDACTED]. Review of the TAR for December 2019 and January 2020 indicated that staff signed that the weekly skin assessments were done. However, review of the medical record failed to locate any actual weekly skin assessments completed. On 1/28/20 at 12:00 P.M. and on 01/29/20 01:00 P.M., Resident # 62 was observed in room, lying in bed and watching television. The Resident was groomed and dressed in pants and a shirt. The Resident's left and right hands had multiple bruises on them. The right hand and forearm's bruises were more pronounced and the colors of the bruises varied from deep purple to lighter shades. The right hand and forearm were almost completely covered with bruises. (The medications Eliquis thins blood and side effects that are monitored for includes bruising.) During interview on 1/29/20 at 11:45 A.M., Unit Manager #2 was asked about the skin checks and monitoring of the anticoagulant medications. She reviewed the record and said that staff documented on the TAR that the weekly skin assessments were being done. After review of the record, Unit Manager #2 said the skin assessments were not done. On 1/29/20 at 4:00 P.M., the Director of Nurses said they were investigating Resident #62's bruises. No information was provided about the plan of care for symptoms and side effects associated with the anticoagulant therapy. C. Resident #62 was readmitted to the facility in mid-December, following a hospitalization for aspiration pneumonia. Review of the hospital's discharge summary dated 12/11/19, indicated a nasal swab had been obtained during the Resident's hospitalization and he/she was found to be positive for the [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). On 12/11/19, the physician's readmission progress note indicated the positive culture [MEDICAL CONDITION], but further review, fails to indicate the facility developed and implemented a plan of care for the bacteria. During interview on 1/29/20 at 11:30 A.M., the Infection Control Nurse and Director of Nurses were unaware that the Resident had a positive culture on 12/11/19. 7). For Resident #6, the facility failed to follow the plan of care to ensure the resident consumed at least 1500 CCs of fluid daily. Resident #6 was admitted to the facility in January of 2018 with [DIAGNOSES REDACTED]. The record indicated the Resident had a Foley catheter. Review of the medical record for Resident #6 indicated that care plans were initiated on 4/5/19, and updated on 1/23/20, that the Resident was at risk for the development of urinary tract infections [MEDICAL CONDITION], related to history of UTI and [MEDICAL CONDITION] that required a Foley catheter. The goals were to not have signs and symptoms of a UTI. The approaches listed on the care plan included, but not limited to, monitor daily for signs and symptoms of UTI, encourage clear fluid intake of at least 1500 cc per day, discourage caffeine containing beverages, as they irritate bladder walls, encourage cranberry juice, monitor intake and output. On 1/28/20 at 1:19 P.M., the surveyor observed Resident #6 in bed and was pleasant during observation. Resident #6 had no fluids on their tray table at the time of observation. On 1/29/20 at 12:34 P.M., Resident #6 the surveyor observed the noon meal for Resident #6. Observation of fluids included coffee, a caffeine beverage, that was on his/her tray table in a cup (6 to 8 oz) with a lid. Resident #6 was asked if he/she drank extra fluids and he/she said he/she was dependent on staff for them. Resident #6 said he/she was able to drink fluids by him/herself. Review of the annual nutrition assessment, dated 1/11/20, indicated the Resident was to have a sippy cup for fluids and that his/her fluids needs were 2010 cc daily and a minimum of 1500 cc. The assessment did not include the cranberry juice and/or the caffeine recommendations. Review of the medical record indicated that staff documented intake of meals, but do not specifically identify the Resident's fluid intake. The nursing staff documented output, each shift, but do not document input on the Treatment Administration Records (TAR). Unit Manager #2 was interviewed on 1/29/19 at 9:30 A.M. and was asked about who and how staff documented the Resident's intake. Unit Manager #2 referred to the medical record and said that she was unsure how the intake was documented. She said that the staff documented the meal intake and that the fluids were not separated from the amounts. She did not know about any recommendations of cranberry juice or limited caffeine, but said that the Resident was prone to urinary tract infections. On 1/29/20 at 11:00 P.M., the Director of Nurses and the Infection Control Nurse said that the Resident was not supposed to have a plan of care for intake and output and that the Resident was not prone to urinary tract infections. Neither the Director or the Infection Control Nurse provided additional evidence to contradict the current plan of care outlined in the Resident's record.

Based on documentation, observation and interview, the facility ensure that the medical records were complete and accurately documented for 2 Residents ( #195,and #62) from a total of 20 Residents: the facility failed to document and assess the death of a resident and documented inaccurately the status of a resident wearing a brace. Findings include: 1. Resident #195 was admitted to the facility in 1/2020 with [DIAGNOSES REDACTED]. The facility policy titled Registered Nurse Pronouncement of Death and Form Instructions, dated 5/29/18, indicates the nurse's note must include the following: - Absence of respirations, apical pulse and blood pressure - Lack of response to painful stimuli - Pupils fixed and dilated - Notification of next of kin - Notification to Funeral home There was no assessment of the Resident. Determination of Death includes observation and assessment that a person has ceased vital bodily functions irreversibly including, but not limited to, the following: pulse, respiration, heartbeat, and pupil reaction. Review of the documentation indicated that the nurse's note written on 1/24/2020 at 4:31 P.M. failed to include the absence of respirations, apical pulse and blood pressure, lack of response to painful stimuli, pupils fixed and dilated as required by facility policy and standards of practice. On 1/27/20 at 2:25 P.M. during an interview with Nurse Manager #1, the medical record was reviewed with Surveyor. Nurse Manager #1 said that she performed the Pronouncement of Death and was not aware of the information required by facility's policy and Professional Standards that are required in the pronouncement of death by a Registered Nurse. 2. Resident #11 was admitted to facility in 7/2019 with [DIAGNOSES REDACTED]. Resident is alert and oriented. The physician's orders [REDACTED]. May remove when eating, bathing and sleeping. On 1/23/20 and 1/24/20, the Surveyor observed Resident #11 without the brace throughout the day. Resident #11 was observed without either brace on 1/27/20 at 9:30 A.M., 1/27/20 at 1 P.M. and 2:44 P.M. and on 1/29/20 at 10:30 A.M. During an interview with Resident #1 on 1/27/20 at 2:44 P.M., the Surveyor inquired as to why the braces were on the chair. Resident #11 said that he/she wears the collar when he/she wants to. On 1/27/20 at 2:45 P.M. during an interview with Nurse Manager #1, she and the Surveyor reviewed the medical record for Resident #11. Nurse Manager #1 could not find any documentation on January 2020 MAR (medication administration record) that Resident #11 was refusing to wear the brace. Nurse Manager #1 did not know why staff were documenting that the braces were applied every shift. Nurse Manager #1 reviewed the MAR and the documentation which indicated that the brace was on every shift for the entire month of January, 2020.

Based on observation and interview, the facility failed to ensure medical treatment was provided in a private and dignified manner, for 1 sampled resident (#394) and for 2 other residents. The total sample included 20 residents, Findings include: On 1/29/20 at 9:15 A.M., the surveyor was seated at the nurses station and observing staff interaction with residents. Residents were being removed from the dining room and staff were leaving some of the residents in front of the nurses station. At the time of the observation, the area was congested with residents and staff. The nursing staff included 2 nurses on medication carts, 4 rehabilitation staff, the Unit Manager (#2), the Admission Director, the Medical Director, and others who were not identified, but observed removing food carts and providing house keeping services. A. On 1/29/20 at 9:15 A.M., Resident #394, had been observed leaving the dining room, propelling him/herself in a wheelchair. The Resident stopped near the nurses station and was reading a newspaper. The surveyor observed Resident #394's physician, approach him/her. The physician began an assessment of Resident #394, that included vital signs, palpation of the Resident's abdomen, exposing and assessing the Resident's bilateral lower legs, (which the Resident attempted to cover up, stating he/she did not have very nice looking legs to begin with). The physician continued to push down Resident #394's socks and assess the leg [MEDICAL CONDITION], at which time the Resident and a therapist who joined them, said the [MEDICAL CONDITION] had not been observed before and was pronounced (obvious). The Resident was asked how he/she was doing. The Resident reported his/her bottom was sore from a fall that had occurred. The physician said for Resident #394 to take care and walked away. B. On 1/29/20 at 9:25 A.M., Resident #344 was observed in the hallway with Therapist # 4. Resident #344 was seated in a wheelchair and was approached by his/her physician. The physician began assessing the Resident and asked a series of questions. The assessment included vital signs and listening to the Resident's heart. The therapist discussed recent problems with blood pressure and provided the physician with vital signs and other confidential information. The physician asked Resident #344 if he/she was drinking enough fluids and provided information of the importance drinking fluids. The Resident was asked if he/she felt light headed, had moved his/her bowels and if he/she was depressed or anxious. The physician said he would review medications and look at the Resident's medical record and walked off. The therapist proceeded to bring the resident to the elevator. At no time did she offer a more private setting for the assessment of the resident. C. On 1/29/20 at 9:40 A.M., observation of the second floor area surrounding the nurses station, indicated the area remained active with more that 12 residents seated in the area and multiple staff going about their duties. During this observation, an unidentified resident was seated in a wheelchair to the right of the nurses' station and facing the dining room. There were several other residents seated next to this resident and the Unit Manager (#2), as well as several other staff remained less than 4 feet from him/her, when the Resident was evaluated by the physician. The physician obtained vital signs and asked the resident to breath in and out. The resident was asked about a rash and before the resident responded, the physician said the rash was inflamed and most likely a fungal infection. The physician inspected the resident's skin and then said it might be dry skin. The physician said to the resident his/her nails looked like they needed a medication and that the staff would put a bandage on one of them as the nail was missing. The physician asked the resident how he/she was, but before the resident fully responded the physician left. During the observations on 1/29/20, no staff were observed offering any privacy and ensuring the residents' rights to confidentiality and privacy were maintained. On 1/29/20 at 11:00 A.M., the Director of Nurses was notified of the observations of residents receiving medical care and confidential information being shared in the hallway. The Director said that was not the expectation and confirmed the physician was the facility's medical director.

Based on observation and interview, the facility failed to inform the resident's physician was notified of a need to alter treatment as recommended by the facility's pharmacist and the dietician, for 2 Residents (#44 and #62), out of a total sample of 20 residents. Findings include: 1. For Resident #44, his/her physician was not notified of a recommendation for a supplement, by the dietician on 11/24/19, after determining Resident #44 's intake was between 20 to 50 % and the supplement would help increase his/her caloric intake Resident #44 was admitted to the facility in November of 2019 and had [DIAGNOSES REDACTED]. On 11/24/19, the initial nutrition evaluation indicated Resident #44 was at risk for inadequate intake. The assessment indicated the Resident's intake was 20 to 50 % of meals. The dietician recommended a nutritional supplement (120 ml) daily, to help increase Resident #44's caloric intake. Review of the physician orders [REDACTED]. ON 1/25/20 and 1/26/20, the nurses' notes indicated the Resident was taking supplements and ice cream. During interview on 1/29/20 at 10:30 A.M., Unit Manager #2 was asked about the supplement and ice cream. Unit Manager #2 reviewed the record and said that nutritional supplements were physician ordered. She said she could not find an order for [REDACTED]. During interview on 1/29/20 at 11:30 A.M., the Director of Nurses said the physician should have been notified after the dietician recommended the supplement on 11/24/19. 2. For Resident #62, the facility failed to notify the physician of recommendations made by the consulting pharmacist for 2 laboratory tests. Resident #62 was admitted to the facility in February of 2019, and had [DIAGNOSES REDACTED]. Record review indicated from 12/4/19 through 12/11/19, Resident #62 was hospitalized with ongoing symptoms that included fever (101 F) and oxygen saturation in the low 80's. The hospital discharge summary indicated the Resident had aspiration pneumonia and was treated with broad-spectrum antibiotics including [MEDICATION NAME]. Record review indicated that prior to Resident #62's readmission on 12/11/19, the hospital obtained a [MEDICATION NAME] trough on 12/10/19 (this test is used to monitor levels of the antibiotic [MEDICATION NAME] in the blood - a trough levels are collected thirty minutes prior to a patient's every fourth [MEDICATION NAME] dose). The Resident was readmitted to the facility on [DATE] and was to continue the [MEDICATION NAME], twice a day for an additional 3 days. On 12/13/19, the consultant pharmacist completed a review of Resident #62's medication upon his/her admission and recommended that the physician consider ordering a serum creatinine level and a [MEDICATION NAME] trough for the [MEDICATION NAME]. Record review failed to indicate the physician was notified of the recommendation made on 12/13/19. The pharmacy report has a section so that the Resident's physician can respond to the recommendation. The section provides evidence of notification, when notified and the physician's responses. Review of the 12/13/19 report indicated that someone initialed and dated a response on the bottom of the report. The notation was dated 12/24/19, 11 days after the pharmacy report was written, and indicated the medication was discontinued. Record review failed to provide any additional evidence that the laboratory tests were ordered or that the physician was made aware of the recommendations. On 1/29/20 at 10:00 A.M., the surveyor interviewed Unit Manager #2, who said she was unaware of the recommendations made by the pharmacist.

Based on observation, interview, and record review, the facility failed to review and revise the comprehensive care plans for pressure ulcer risk and constipation risk for 1 resident (#9), from a total sample of 20 residents. Findings include: Resident #9 was admitted to the facility in October of 2018 with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS), with a reference date of 10/17/19, indicated Resident #9 was NPO (received no food or liquid by mouth), he/she received all means of nutrition and hydration from an artificial feeding tube. Record review indicated a physicians order for Resident #9 to be NPO (nothing by mouth), the order was written on 11/1/18 and had no stop date. During an interview with Unit Manager #2 on 1/27/20 at 10:15 A.M., she confirmed Resident #9 remained NPO, and received all means of nutrition and hydration through their feeding tube. Further review of the medical record, indicated Resident #9's comprehensive care plans which stated the following: 1. Category: Resident is at risk for constipation due to decreased mobility. Approaches/interventions included: encourage the resident to eat high fiber food items, and encourage adequate fluid intake. 2. Category: Pressure Ulcer. Resident is at risk for pressure ulcers due to decreased mobility secondary to [MEDICAL CONDITION]. Approaches/interventions include: encourage the resident to eat high protein food items, and encourage fluids. Both care plans were developed on 5/6/19 and there was no indication that the care plans were reviewed or revised to be person-centered to address appropriate interventions for Resident #9 who does not eat or drink anything by mouth. During an interview with the Director of Nurses (DON) on 1/29/20 at 3:45 P.M., the surveyor reviewed Resident #9's comprehensive care plans which were not reviewed of revised by the interdisciplinary team since 5/6/19. The DON said Resident #9 is NPO, does not eat or drink anything by mouth, and the care plans listed above were not appropriate for Resident #9.

Based on documentation, observation and interview, the facility failed to perform the following tasks according to Standards of Practice for 2 Residents (#31 and #62) from a total of 20 Residents: failed to ensure they administered medication as physician ordered, documented inaccurately the status of a resident wearing a brace and failed to conduct weekly skin checks as ordered by the physician. Findings include: 1. Resident #31 was admitted to the facility in 12/2014 with a [DIAGNOSES REDACTED]. Resident is alert but confused with a Brief Interview Mental Status (BIMS) of 8, (indicating moderately impaired). Review of the facility policy titled Specific Medication Administration Procedures, dated 2017, indicated that the Five (5) rights are to be completed prior to administering medications. Licensed Staff are to check the medication label against the order on the medication administration sheet to confirm the correct medication, dose, route, frequency and resident. During the Medication Administration observation task on 1/27/20 at 9:26 A.M., the Surveyor observed Nurse #4 prepare the medication for Resident #31. Nurse #4 compared the Medication Administration Record [REDACTED]. The Surveyor questioned the [MEDICATION NAME] sulfate. The Physician's order, dated 11/1/18, was for delayed release [MEDICATION NAME] sulfate. The bottle of the medication was not labeled as delayed release. During a review of the medication bottle with Nurse #4, she said that the bottle was not labeled delayed release. Review of the Resident's Medication Administration Record [REDACTED]. The physician's order was dated, 11/1/18, for [MEDICATION NAME] sulfate tablet, delayed release 325 mg (65 mg iron), oral once a day. The Resident had received [MEDICATION NAME] sulfate table, 325 mg (65 mg iron), orally and once a day, but it was not delayed release. During an interview on 1/27/20 at 11:00 A.M. with the Director of Nurses, she said that this issue had surfaced previously and she thought it had been corrected. During an interview on 1/28/20 at 1:50 P.M., with the Director of Nurses, she said that the pharmacy was contacted and the facility was not administering the delayed release medication as ordered. 2. For Resident #62, the facility failed to conduct weekly skin checks as ordered by the physician. Resident #62 was admitted to the facility in February of 2019, and had [DIAGNOSES REDACTED]. Review of the current physician orders indicated that staff were to complete weekly skin assessments. Review of Treatment Administration Record (TAR) for December 2019 and January 2020 indicated that staff signed that the weekly skin assessments were done. Although, the TAR indicated a weekly skin assessment was complete, additional record review failed to locate any completed weekly skin assessments. On 1/28/20 at 12:00 P.M. and on 01/29/20 01:00 P.M., Resident # 62 was observed in room, lying in bed and watching television. The Resident was groomed and dressed in pants and a shirt. The Resident's left and right hands had multiple bruises on them. The right hand and forearm's bruises were more pronounced and the colors of the bruises varied from deep purple to lighter shades. The right hand and forearm were almost completely covered with bruises. During interview on 1/29/20 at 11:45 A.M., Unit Manager #2 was asked about the skin checks and if she could locate the weekly skin assessments. Unit Manager #2 reviewed the record and said that the skin assessments were not done and she did not know when the bruising on the Resident's bilateral arms had occurred. She said that the staff were only checking the TAR and not completing the actual assessment.

Based on record review, interview and observations, the facility failed for 1 Resident (#394) to provide care and treatment after the resident fell and called 911 for assistance. The total sample included 20 residents. Findings include: Resident #394 was admitted to the facility in January of 2020 and had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 1/14/20, indicated the Resident had no impairment of short and long term memory as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), and required extensive assistance from staff of activities of daily living. During observation and interviews on 1/24/20 at 9:20 A.M., Resident #394 said that he/she had fallen the night before while using the commode. Resident #394 said that a Certified Nursing Assistant (CNA) was with him/her, but did not make sure he/she was steady, when he/she said fell backwards. Resident #394 said that the CNA got another staff to assist him/her back to bed and that neither staff assessed me. The Resident said that the CNA told him/her that the resident could no longer use the commode at night, just a bed pan and a brief. Resident #394 said that one day he/she had called 911, because no one would help him/her get up out of bed. Resident #394 said the nurse heard the call and came in and said to the Resident he/she should not have called 911 and then told the 911 operated not to listen to the Resident. During interview on 1/24/20 at 9:49 A.M., the Infection Control Nurse was at the nursing station. The Infection Control Nurse reviewed the medical record, that included the nursing notes and said there was no indication that the staff were aware the Resident had a fall last night. The Nurse went to Unit Manager #2, who was on a medication cart. Resident #394 was sitting near the nurses in a wheelchair. The Infection Control Nurse and the Unit Manager had a discussion and the Infection Control Nurse said the Resident is claiming he/she had a fall last night and they will look into it. On 1/24/20 at 10:41 A.M., the Director of Nurses approached the surveyor and said the Night Supervisor had told her this morning at the end of his shift that the Resident had fallen. The Director said when she looked for the incident report there was none and therefore had called the supervisor at home and he said he had taken vitals and everything but did not document them. The supervisor said that he was coming in at 3:00 P.M. today and he was going to write in the incident report. The Director said she was aware of the fall but the Unit Manager and other nurses were not. Review of the medical record indicated on 1/14/20, a skilled nursing note indicated Resident #394 alert with confusion,and had become angry at a CNA for not getting him/her up out of bed early enough. The note indicated the Resident was informed the CNA was with another resident and that the CNA would be in next. Upon returning to the room the Resident was on the phone with 911 operator and telling them that he/she was not being taken care of. The nurse indicated he reassured the 911 operator that Resident was okay. The nurse said the Resident was then transferred to the commode. From 1/15/20 through 1/24/20, there were no additional notes indicating that the Resident's concerns about not receiving care or the fall were documented in the medical record. It was not until after the surveyor addressed the concerns that staff documented late entries in regards to the fall. On 1/24/20, the Nurse Practitioner assessed the Resident, and indicated the staff had reported the Resident was lowered to the floor (not fallen) and had a bruising on his/her arms. The progress note indicated there were conflicting reports and accounting of the incident. The progress note identified that the Resident had called 911 and thought it was a confabulation by the Resident. On 1/28/20 at 3:45 P.M., the surveyor conducted a follow up interview with Resident #394. the Resident provided the same accounting of the fall and 911 call as previously discussed. Resident #394 provided additional specific information regarding the 2 incidents and maintained that staff did not provide care and services as he/she had required. Resident #394 said when he/she had called 911 on 1/14/20, he/she had been seated at the edge of bed for than an hour with no pants on. Resident #394 said his/her top was just a night shirt and he/she felt vulnerable. The Resident said that staff told him/her that there were other residents that required care before him/her. The Resident said maybe he/she not have called 911, but the nurse had taken the phone from him/her and told the 911 operator that Resident #394 had memory loss. Resident #394 said that the facility staff never asked him/her about the incident and he/she felt that the nurse should not have said or responded as she had. Resident #394 was adamant that staff did not assess him/her following the fall. The Resident described the fall and said that the CNA had moved enough away from him/her that he/she might have caught his/her foot or lost balance, landing on his/her bottom. The Resident was able to identify both staff by name and said that he/she was placed in bed and assessed. The Resident reported he/she had several bruises and his/her bottom hurt. Resident #394 said that he/she had reported the concern about his/her bottom. On 1/29/20 at 9:15 A.M., the surveyor observed Resident #394's physician and the Medical Director of the facility, approach him/her in the hallway and complete a physical exam. The Resident was asked how he/she was doing. The Resident reported his/her bottom was sore from a fall that had occurred. The physician said for Resident #394 to take care and walked away. Review of the accident incident report indicated the fall occurred at 2:30 A.M. on 1/24/20. During interview on 1/29/20 at 1:00 P.M., the Director of Nurses was interviewed. She said that the Night Supervisor had said he had assessed the Resident, but had not documented or communicated the fall to anyone but her. She said she was unaware of the 911 call by the Resident, which indicated the Resident felt he/she was not receiving care and treatment he/she required. During the discussion, the Director said she will asks more questions and follow up on the care areas. No additional information was provided following the interview.

Based on observation, record review and interviews, the facility failed to ensure that for one resident (#44), who is currently on [MEDICAL CONDITION] medications, have a specific condition as diagnosed and documented for the use of the medication, out of a total sample of 20 residents. Findings include: Resident #44 was admitted to the facility in November of 2019 and had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/28/19, indicated Resident #44 was administered antipsychotic medication, anti-depressant medication and anti-anxiety medication daily. Review of the medical record indicated physician orders [REDACTED]. On 11/21/19, the physician assessment indicated the Resident had been on hospice services post subdural bleed at another facility. The progress note indicated he/she had improved from the bleed and subsequently fell and fractured his/her hip. During post operative care, the resident had exhibited [MEDICAL CONDITION] and had to be provided a 1 to 1 sitter during the hospitalization . The physician indicated [MEDICATION NAME] was administered at the hospital and the Resident improved and seemed calmer. The physician indicated that the Resident was admitted to the facility on the [MEDICATION NAME], and that post operative [MEDICAL CONDITION] had improved and he therefore he would taper and discontinue the medication. Review of the medical record indicated that 2 care plans for the use of [MEDICAL CONDITION] medication were initiated on 11/22/19. The care plans did not indicate what [DIAGNOSES REDACTED]. Additional review of the medical record indicated that 3 care plans for the following conditions were developed between 12/4/19 and 1/23/20: - behavioral symptoms (refusing care, medications, meals, and aggressive towards others) - behavioral symptoms related to depression - psychosocial well being related to anxiety. Resident #44 was observed on 1/28/20 and 1/29/20, throughout a 2 hour period. During both observations, Resident #44 was seated in a wheelchair. He/she was in the day room and in the hallway during the observations. Resident #44 was not observed restless and sat quietly during observation and contact from staff. During interview on 1/29/20 at 10:30 A.M., Unit Manager #2 was asked about the the use of the psychoactive medications and the Resident's behaviors that they were being administered for. The Unit Manager reviewed the record and said that the staff identified the behaviors associated with each type of medication and monitored for the behavior and for the side effect of each medication. After reviewing the record she could not find documentation identifying the medication administration use. The surveyor asked about psychiatric services, as the care plans indicated that they would evaluate the Resident. Unit Manager #2 said the Resident was on hospice and therefore did not receive those services. The Unit Manager said she did not know why the Resident was on the [MEDICATION NAME] and the other medications. She said sometimes the Resident refused care.

Based on record review and interview the facility failed to complete the Discharge Assessment MDS for 2 of 2 residents (Resident #2, and #3) within the timeframes prescribed. Findings include: 1. Review of the medical record indicated that Resident #2 was admitted to the facility in 9/2019 and was discharged the end of 9/2019. The Discharge Assessment MDS was not completed. 2. Resident #3 was admitted to the facility in 9/2019 and was discharged the end of 9/2019. The Discharge Assessment MDS was not completed. During an interview on 1/29/20 at 8:10 A.M. with MDS Nurse #2, she reviewed the facility's MDSs with the Surveyor. The MDS Nurse #2 agreed that neither Discharge Assessment MDS was completed.