Every finding on record at Alliance Health at West Acres

Based on observation, document 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. Ensure emergency water supply was discarded and replenished prior to the expiration date.2. Maintain safe and clean equipment in three out of three kitchenettes.Findings include:Based on observation, document 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. Ensure emergency water supply was discarded and replenished prior to expiration date; and2. Maintain safe and clean equipment in three out of three kitchenettes. Findings include: 1. Review of the facility's policy titled 4.0 Disaster Plan Policy, dated as last revised 1/5/2018, indicated but was not limited to the following:-Water will be maintained at all times, as follows: 3-day supply of potable water. On 9/16/25 at 8:39 A.M., the surveyor and the Food Service Director (FSD) observed the following in the Station Three main dining room closet:-23 cardboard boxes with the expiration date of 7/31/25 printed on the outside of the boxes. Inside the boxes were 6 one-gallon containers of water, for a total of 138 gallons of water. All had an expiration date of 7/31/25, printed on the outside of the plastic container. During an interview on 9/16/25 at 3:16 P.M., the FSD said she orders the emergency water for the facility but does not have a process to check the water supply or rotate it out prior to expiration. She said she should have been keeping track of the expiration dates. During an interview on 9/18/25 at 11:18 A.M., the Administrator said the expiration date should be checked when the water is received. The Administrator said the facility should have a process to track the emergency water supply. 2. Review of the 2022 Food Code by the Food and Drug Administration (FDA), indicated but was not limited to:-4-1 Materials for Construction and Repair 4-101 Multiuse 4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. -4-6 Cleaning of Equipment and Utensils 4-601 Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens Chapter 4 - 21 (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 9/16/25 at 10:10 A.M., the surveyor observed the following in the Station Three kitchenette:-Inside the microwave, it was noted to have brown stains and dried food particle spatter on the top and bottom right front corner of microwave. On the inside top right corner of the door, there were rusted brown areas above the black mesh screen.On 9/16/25 at 11:05 A.M., the surveyor observed the following in the Station One kitchenette:-Inside the microwave, there was dried food particle splatter covering the top, sides, and door. On the top was peeling silver residue.On 9/16/25 at 4:02 P.M., the surveyor observed the following in the Station Two kitchenette:-Inside the microwave, there was dried food particle splatter and rust brown areas on the top and left-hand side around the vent screen.During an interview with observation of Station One, Two and Three kitchenettes on 9/18/25 at 1:58 P.M., the FSD said the kitchen staff is responsible for cleaning and maintaining the kitchenettes. She said all the microwaves are dirty and need cleaning. The FSD said she can see rusted spots on the top of the microwave on the Station One unit, and it should not be in use.

Based on observation and interviews, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for two of two test trays. Findings include:During the initial resident screening on 9/16/25, the survey team identified the following concerns expressed by residents about food palatability:-Resident #53 said the food was often served cold.-Resident #103 said the food was cold 90% of the time, but the staff will reheat it, if you ask.-Resident #37 said the food was always cold and gross.On 9/17/25 at 11:15 A.M., 10 Residents attended the Resident Council Meeting. 10 out of 10 residents agree that the food temperatures are not always hot enough, and the food is lukewarm.On 9/17/25 at 11:55 A.M., the surveyor requested a test tray on the Station Two Unit. The tray arrived at the unit at 12:30 P.M.On 9/17/25 at 12:44 P.M., the surveyor and Certified Nursing Assistant (CNA) #1 completed the test tray together, 14 minutes after arrival on unit. The food temperatures were as follows:-Meatloaf 119.8 Fahrenheit (F); meatloaf was flavorful, but it is lukewarm-Puree meatloaf: 123.4 F; has good flavor and warmer than the other meatloaf, but still lukewarm-Mashed potatoes: 126.2 F; cold and lacking flavor-Mixed vegetables: 121.4 F; cold with no flavor-Coffee: 153.7 F; no concerns notedCNA #1 sampled food items on the test tray along with the surveyor and confirmed concerns related to temperature and palpability. On 9/18/25 at 7:40 A.M., the surveyor requested a test tray on Station Three Unit. The test tray arrived at the unit at 8:21 A.M.On 9/18/25 at 8:42 A.M., the surveyor and Nurse #1 completed the test tray together, 21 minutes after arrival on unit. The food temperatures were as follows:-Eggs 111.6 F; taste okay, but cold, just plain eggs-Hot cereal: 100.2 F; very cold, rubbery texture with a lot of cinnamon-Blueberry muffin: 95.2 F; good flavor-Milk: 43.6 F; no concerns noted-Juice: 44.7 F; no concerns noted-Coffee: 150.9 F; no concerns noted.Nurse #1 sampled food items on the test tray along with the surveyor and confirmed concerns related to temperature and palpability. During an interview on 9/18/25 at 8:42 A.M., Resident #22 said the eggs were lukewarm.During an interview on 9/18/25 at 8:42 A.M., Resident #123 said the eggs were warm, but would have liked them to be warmer.During an interview on 9/18/25 at 8:42 A.M., Resident #49 said the oatmeal was not good, it was barely warm, and he/she could only have one scoop.During an interview on 9/18/25 at 10:12 A.M., the Food Service Director (FSD) and the surveyor reviewed the observations and test tray results from the lunch and breakfast services observed. The FSD said hot foods need to be at least 135-140 F and cold foods need to be below 39 F when served to the residents. FSD said the meal trucks should be passed timely to ensure the food stays at an appetizing temperature. During an interview on 9/18/25 at 11:03 A.M., the Administrator, Regional Nurse and the surveyor reviewed observations and test tray results from the lunch and breakfast services observed. The Administrator said she is not sure what time frame it should take for the meals to be served once arriving on the unit, however over 40 minutes seems long for our typical process.

Based on interview and record review, the facility failed to ensure laboratory (lab) services were obtained for one Resident (#5), out of a total sample of 23 residents. Specifically, the facility failed to follow the physician's telephone order (T.O.) to obtain a CBC (complete blood count), CMP (comprehensive metabolic panel), and BMP (Basic Metabolic Panel) for Resident #5 who was on a blood thinner and experiencing nose bleeds. Findings include:Resident #5 was admitted to the facility in July 2020 with a diagnosis of atrial fibrillation (AFib, a common heart rhythm disorder) and was on a blood thinner to prevent blood clots.During an interview on 9/16/25 at 10:55 A.M., Resident #5 said he/she was on a blood thinner and had been having nose bleeds.Review of the current Physician's Orders for Resident #5 included the following:-Eliquis 2.5 milligrams (mg) twice per day-obtain labs as ordered by the physicianReview of the nursing progress notes for Resident #5 indicated the following:-8/16/25: moderate about of active bleeding from the left nostril, pressure dressing applied, Nurse Practitioner (NP) contacted and ordered to hold Eliquis evening dose-8/22/25: nosebleed with small amount of blood noted, pressure dressing applied, NP contacted and ordered to hold Eliquis evening dose-8/29/25: nosebleed from left nostril, pressure dressing applied, NP contacted and order for CBC, CMP and BMP labs to be completed on 9/2/25.-9/7/25: nosebleed from left nostril, pressure dressing applied, ice pack applied, NP contacted and subsequent two doses of Eliquis held.Review of the medical record on 9/18/25 failed to indicate the CBC, CMP or BMP labs had been obtained on 9/2/25.During an interview on 9/18/25 at 11:18 A.M., Nurse #2 reviewed the medical record for Resident #5 and said she could not locate lab results in the electronic medical record. She then checked the electronic lab portal and said labs were not obtained for Resident #5 in September 2025.During an interview on 9/18/25 at 1:41 P.M., Unit Manager #2 said the labs were not completed as ordered by the NP for 9/2/25 and that the nurse must have missed entering them in the lab portal.During an interview on 9/19/25 at 12:00 P.M., the Director of Nurses said there was no policy for obtaining labs as ordered and the nurses were expected to follow physician's orders.

Based on interviews and record review, the facility failed to ensure quality of care was provided, according to the plan of care and professional standards of practice for one Resident (#14), out of 23 total sampled residents. Specifically, the facility failed for Resident #14, to ensure wound care treatments to a right heel diabetic wound were reflective of recommendations from the Physician Wound Consultant. Findings include:Resident #14 was admitted to the facility in March 2025 with diagnoses including diabetes, peripheral artery disease and a non-pressure chronic ulcer (wound) on the right heel and midfoot.Review of the care plans indicated Resident #14 was at risk for skin breakdown related to impaired mobility, weakness, and diabetes with an approach including to have the wound team consult and treat as indicated.Review of the medical record indicated Resident #14 had multiple hospitalizations since being admitted to the facility in March 2025. Resident #14 had an infected right heel wound and had declined to have an amputation. Review of the medical record indicated the following treatment order was in place for the right heel upon re-admission in August 2025:-cleanse right heel wound with normal saline; pack with Alginate silver rope, cover with a dry protective dressing and Kerlix (gauze wrap) followed by ace wrap every 48 hours.Review of the Physician Wound Consultant Progress Note, dated 8/12/25, indicated the following treatment to the right heel wound:-cleanse with normal saline, apply calcium alginate with silver, lightly pack with a Q-Tip to base of wound, secure with ABD pad, rolled gauze, change daily and as needed.Review of the Physician Wound Consultant Progress Notes, dated 8/12/25, 8/20/25, 9/3/25, and 9/10/25, indicated the treatment was recommended daily and not every 48 hours.Review of the August and September 2025 Treatment Administration Records (TAR) indicated a treatment to the right heel was conducted every other day from 8/12/25 through 9/17/25 and not daily as indicated by the Physician Wound Consultant.During an interview on 9/19/25 at 9:39 A.M., the Medical Director and primary physician for Resident #14 said he defers wound treatment decisions to the Physician Wound Consultant. He said if the Physician Wound Consultant made changes to a treatment the nursing staff would call him for approval, and he had not declined any treatments for Resident #14.During an interview on 9/19/25 at 10:10 A.M., Unit Manager #1 said the Resident had not gone out to a wound clinic or podiatrist since re-admission from the hospital in August 2025 and was followed by the Physician Wound Consultant. The Unit Manager said Resident #14's right heel wound treatment was completed every other day. The Unit Manager reviewed the Physician Wound Consultant Progress Notes and said she was unaware the treatments were recommended to be completed daily. She said the Assistant Director of Nurses (ADON) completed wound rounds with the Physician Wound Consultant and would inform the unit nurses if there were any changes.During an interview on 9/19/25 at 11:10 A.M., the ADON said Resident #14 was seen by the Physician Wound Consultant weekly and the treatment to the right heel was to be completed every other day. She reviewed the Physician Wound Consultant Progress Notes and said she also had her own handwritten sheets with treatments from wound rounds. The ADON reviewed her handwritten notes and said she had not noticed that the Physician Wound Consultant had recommended for treatments to the right heel to be completed daily and the order had not been changed to reflect this.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to: 1. Perform a COVID-19 related investigation and conduct contact tracing for a single new resident case to prevent, to the extent possible, the onset and spread of infection and ensure staff and resident COVID-19 surveillance line listings were maintained; 2. Ensure proper COVID-19 outbreak testing procedures were implemented for four of four facility staff members reviewed representing two (Station 1 Unit and Station 3 Unit, both COVID-19 affected units) out of three units; 3. Ensure staff rapid antigen COVID-19 testing (BinaxNOW) was conducted in a manner that is consistent with current standards of practice and manufacturer's instructions for use for one of one staff member observed; and 4. Ensure staff performed appropriate hand hygiene and implemented appropriate use of personal protective equipment (PPE) for the care of a COVID-19 positive resident to prevent unnecessary exposure and the potential spread of COVID-19 infection. Findings include: During an interview on 8/26/24 at 2:12 P.M., the Assistant Director of Nursing (ADON) said the Infection Preventionist (IP) would not be present during the survey period, but she had a certificate of training and could speak to infection control policies and procedures in the IP's absence. The ADON said the facility used Massachusetts Department of Public Health (DPH), Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) guidance. Review of the current outbreak documentation (handwritten by the IP) provided by the ADON on 8/26/24 at 4:05 P.M. indicated the facility had 15 residents on the Station 1 Unit (short-term rehab) who were currently COVID-19 positive and one resident on the Station 3 Unit (long-term care) who had recovered on 8/23/24. The Station 2 Unit (long-term care) was unaffected. The documentation also indicated nine total staff members had tested positive for COVID-19. During an interview on 8/27/24 at 3:50 P.M. with the Administrator, Director of Nursing (DON), ADON, and Consulting Staff #1, the ADON said the facility was currently experiencing a COVID-19 outbreak which started on 8/15/24 on the Station 3 Unit when a resident had tested positive. They said all residents and staff on the Station 3 Unit were being tested as part of outbreak testing procedures. They said the Station 1 Unit became affected on 8/18/24 after a staff member had tested positive. The DON said unit-based testing was initiated on 8/19/24 and included all Station 1 residents, staff, and rehabilitation staff. She said outbreak testing for staff and residents was being conducted on the affected units starting within 48 hours after the potential exposure, then every 48 hours thereafter until the facility goes seven days without a new COVID-19 case. She said the Station 3 Unit completed outbreak testing on 8/20/24 with no new positives, however, the Station 1 Unit had not met the criteria yet. She said any resident or staff who had recovered from COVID-19 in the past 30 days were exempt from outbreak testing as long as they were asymptomatic. 1. Review of CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised May 2023, indicated but was not limited to the following: -Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. -A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. -Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Review of Massachusetts DPH Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated but was not limited to the following: -Close contact means being within 6 feet for 15 minutes or more (in a 24-hour period), of someone diagnosed with COVID-19, while that individual was potentially infectious. During an interview on 8/26/24 at 4:15 P.M., the surveyor reviewed handwritten documentation on an August 2024 calendar and on a separate piece of paper provided by the ADON stating it was the IP's notes as it pertained to the current COVID-19 outbreak in the facility. The documentation was unclear as to the events that had occurred at the start of the outbreak with the first case dated as 8/14/24 when a resident had tested positive on the Station 1 Unit. The documentation did not indicate a proper investigation or contact tracing for the new COVID-19 resident case was conducted to determine if any staff or residents were potentially exposed. The documentation also failed to indicate that a COVID-19 tracking report had been maintained for each staff and resident who were either symptomatic or positive to include symptoms and the date of onset or follow up. The ADON said the resident who had tested positive on 8/14/24 on the Station 1 Unit was admitted the day prior from the hospital into a private room but did not have an admitting diagnosis of COVID-19 so was not placed on isolation precautions until the day after when he/she had tested positive. The ADON said the facility did not do contact tracing to identify any potential staff that may have been exposed while the resident was potentially infectious prior to his/her diagnosis but would confirm with the IP over the phone. The ADON further said the documentation provided to the surveyor did not reflect an adequate COVID-19 line listing as the documentation was unclear as to the names listed, there were no symptoms listed for any of the staff or residents, if any, and there were no dates of onset or follow up. She said it was not proper surveillance for the current outbreak. The surveyor requested additional documentation pertaining to the current outbreak including surveillance line listings. During an interview on 8/26/24 at 4:53 P.M., the ADON and DON said they spoke to the IP who said the documentation provided to the surveyor was her line listing and there was nothing else. She said she just wrote it down on the calendar and piece of paper and did not list any symptoms or dates on onset. The ADON and DON said they could not answer if any of the COVID-19 positive residents or staff were symptomatic and, if so, when the symptoms began and could not speak to any follow up from looking at the documents provided. They said the documentation was not maintained to reflect a true surveillance line listing. During an interview on 8/28/24 at 10:31 A.M., the Administrator, ADON, DON, and Consulting Staff #1 said the start of the current COVID-19 outbreak at the facility was on 8/15/24 on the Station 3 Unit, not on 8/14/24 as that resident case was assumed to be hospital acquired. They said once positive on 8/14/24, the resident was placed on isolation precautions and staff were notified. They said they identified two rehab staff that may have been exposed but one always wore a surgical mask and the other tested negative that day at their other job, so they were not concerned. They said they did not do contact tracing for any other staff or residents who may have been identified as a close contact. They said at the time, staff were not wearing source control so there could have been potential exposure. They further said they could not speak to specific staff members that may have been potentially exposed and had nothing to show to indicate an investigation had been conducted or what the plan was. 2. Review of the Massachusetts DPH Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, Including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated but was not limited to the following: - Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. - If the long-term care facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago, then they should wait until 24 hours after any exposure, if known. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless the DPH epidemiologist directs otherwise. -Residents and staff who are recovered from COVID-19 in the last 30 days can be excluded from this testing. Review of the facility's policy titled Rapid Antigen Point of Care COVID-19 Testing, revised March 2023, indicated but was not limited to the following: Purpose: -To promptly identify potentially positive COVID-19 individuals and initiate swift treatment. Rapid antigen testing kits should be used for testing symptomatic staff and residents in the LTC facility, testing asymptomatic staff and residents at the facility as part of the required outbreak testing, and testing staff who feel they are at increased risk of exposure. -Once a new case is identified in the facility, following the requisite outbreak testing, the facility is required to test all residents and staff every 48 hours on the affected unit until the facility goes seven days without a new case or assigned epidemiologist directs otherwise. In addition, facilities should immediately test any symptomatic resident, staff member, or newly exposed resident or staff member. -Residents and staff who have recovered from COVID-19 in the last 30 days can be excluded from testing. -During an outbreak situation, testing is required every 48 hours until seven days without a positive case and then once a week until the facility goes fourteen days without a new case unless DPH epidemiology directs otherwise. On 8/27/24 at 4:19 P.M., the surveyor reviewed timecards and schedules worked with the ADON for four randomly sampled direct care staff (Staff #1, Staff #2, Staff #3, and Staff #4) who worked on the affected COVID-19 units and were to be included in the facility's current COVID-19 outbreak testing protocol. The staff were as follows: a. Review of Staff #1's August 2024 timecard indicated that he/she had worked on the following days since the start of the current COVID-19 outbreak that occurred on 8/15/24 on the Station 3 Unit after a resident had tested positive: -August 16th, August 17th, August 19th, on the Station 3 Unit Review of the staff August 2024 Testing Logs failed to indicate Staff #1 conducted COVID-19 outbreak testing as required for any of the dates worked. During an interview on 8/27/24 at 4:19 P.M., the DON said Staff #1 was eligible for outbreak testing and there were no test results for the days worked. She said Staff #1 did not complete outbreak testing as required. b. Review of Staff #2's August 2024 timecard indicated that he/she had worked on the following days since the start of the current COVID-19 outbreak that occurred on 8/18/24 on the Station 1 Unit after a direct care staff member had tested positive with the first resident testing positive on 8/19/24: -August 21st, August 22nd, August 23rd, August 26th, and August 27th, on the Station 1 Unit Review of the staff August 2024 Testing Logs failed to indicate Staff #2 conducted COVID-19 outbreak testing as required for any of the dates worked. During an interview on 8/27/24 at 9:23 A.M., Staff #2 said he/she tested that morning at the facility before the start of the shift but didn't document the results and was negative. Staff #2 said he/she doesn't usually document results and would go retest and document the results. During an interview on 8/27/24 at 4:22 P.M., the ADON said staff could test at home or at the facility, but the process was to document on the log if testing was done at the facility. She said staff will only notify them if they tested positive at home but there was no oversight to ensure home testing was being done or the results of the testing. The ADON said no one was keeping track. She said Staff #2 was eligible for outbreak testing and it was not done per protocol. c. Review of Staff #3's August 2024 timecard indicated that he/she had worked on the following days since the start of the current COVID-19 outbreak that occurred on 8/18/24 on the Station 1 Unit after a direct care staff member had tested positive with the first resident testing positive on 8/19/24: -August 18th and August 23rd, on the Station 1 Unit Review of the staff August 2024 Testing Logs failed to indicate Staff #3 conducted COVID-19 outbreak testing as required for the dates worked. During an interview on 8/27/24 at 4:25 P.M., the ADON said Staff #3 was eligible for outbreak testing and there was no documentation by Staff #3 on the testing logs to indicate that he/she had completed outbreak testing as required. d. Review of Staff #4's August 2024 timecard indicated that he/she had worked on the following days since the start of the current COVID-19 outbreak that occurred on 8/18/24 on the Station 1 Unit after a direct care staff member had tested positive with the first resident testing positive on 8/19/24: -August 22nd, August 23rd, and August 26th, on the Station 1 Unit Review of the staff August 2024 Testing Logs failed to indicate Staff #4 conducted COVID-19 outbreak testing as required for the dates worked. During an interview on 8/27/24 at 4:26 P.M., the DON said Staff #4 was eligible for outbreak testing and worked on the short-term rehab unit. She said Staff #4 did not test per protocol. 3. Review of the [NAME] BinaxNOW COVID-19 Ag Card product insert, revised April 2021, indicated but was not limited to the following: -The BinaxNOW COVID-19 Ag Card is a lateral flow immunoassay for the qualitative detection of the nucleocapsid protein antigen to SARS-CoV-2 directly from the anterior nasal (nares) swab specimens collected from individuals who are suspected of COVID-19 by their healthcare provider within seven days of the onset of symptoms. Precautions: -Proper sample collection, storage, and transport are essential for correct results. -Inadequate or inappropriate sample collection, storage, and transport may yield false test results. Test Procedure: -Read result in the window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly in 15 minutes, and not before. Results should not be read after 30 minutes. On 8/27/24 at 6:54 A.M., the surveyor observed Certified Nursing Assistant (CNA #1, orientee) perform COVID-19 outbreak testing prior to her shift at the testing station in the main lobby of the facility. CNA #2 was assisting. At 6:58 A.M., the surveyor observed CNA #1 insert her sample into the bottom hole of the testing card then seal the test card. CNA #1 did not label the card with her name, date, or time. A timer was observed on top of the testing cart but was not utilized. CNA #1 sat in the chair waiting for her results while CNA #2 left the testing area. At 7:07 A.M., nine minutes later, CNA #2 returned to the testing station and documented CNA #1's negative test result onto the testing log then disposed of the test card. During an interview on 8/27/24 at 7:07 A.M., CNA #1 said the test was done because there was a control line there and didn't know she had to wait 15 minutes. CNA #2 said they should have waited the full 15 minutes before reading the results. During an interview on 8/27/24 at 4:13 P.M., the ADON said the test should have been read at 15 minutes and not prior. 4. Review of the Massachusetts DPH Memorandum titled Comprehensive Personal Protective Equipment (PPE) Guidance, dated May 2023, indicated but was not limited to the following: -DPH recommends that a fit-tested N95 filtering facepiece respirator or alternative and eye protection be used when caring for patients with suspected or confirmed COVID-19. If there is any contact with potentially infectious material, an isolation gown and gloves should also be used. Review of the facility's policy titled Use of PPE- Post PHE, revised May 2023, indicated but was not limited to the following: -Appropriate PPE will be used to care for the residents during the various stages of their infectious disease process, this includes facemasks. -Staff will be required to use full PPE upon room entry (gown, gloves, facemask, eye protection). N95 filtering respirator should be used for residents who are presumed or confirmed infected with COVID-19. Review of the facility's policy titled The Infection Prevention Program, dated August 2017, indicated but was not limited to the following: When to Wash Hands: -Before and after entering isolation, precaution setting On 8/27/24 at 1:32 P.M., the surveyor observed Rehabilitation Services Staff (RSS) #1 enter a COVID-19 positive resident's room wearing a gown, gloves, face shield, and surgical facemask. An isolation contact/droplet precaution sign was posted outside the resident's room indicating that staff were required to wear eye protection, a gown, an N95 facemask, and gloves prior to entering the room. RSS #1 did not don (put on) an N95 respirator prior to entering the room. A PPE cart was located directly outside the resident's room stocked with N95 respirators. During an observation with interview on 8/27/24 at 1:35 P.M., the surveyor observed RSS #1 exit the resident's room still wearing the surgical facemask. RSS #1 did not perform hand hygiene upon exiting the room and did not change his surgical face mask before starting to proceed down the hallway. When stopped by the surveyor, RSS #1 said he had transferred the resident from the wheelchair to the bed and should have worn an N95 facemask in the room and should have changed his facemask and sanitized his hands upon exiting the room. During an interview on 8/27/24 at 3:50 P.M. with the Administrator, ADON, DON, and Consulting Staff #1, the ADON said full PPE with N95 facemask was required prior to entering COVID-19 positive resident rooms. She said all PPE should be doffed (taken off) inside the room at the entryway prior to exiting. The ADON said RSS #1 should have had an N95 facemask on, changed his surgical mask, and sanitized his hands when exiting the room. The Administrator said the facility was fully stocked with PPE.

Based on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for one Resident (#49), out of a sample of 23 residents. Specifically, the facility failed to ensure a medication to increase blood pressure was administered to the Resident as ordered by the physician. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised 4/11/18, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Medication Administration - General Guidelines, undated, indicated but was not limited to the following: - Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications. - Medications are administered in accordance with written orders of the prescriber. Resident #49 was admitted to the facility in September 2023 with diagnoses including paraplegia and hypertension. Review of Resident #49's active Physician's Orders indicated but was not limited to: - 9/18/23: Midodrine (used to treat low blood pressure) 2.5 milligram (MG) tablet, one tablet twice daily, hold for systolic blood pressure (SBP) over 130. Review of the July 2024 Medication Administration Record (MAR) indicated the Midodrine was given outside of physician prescribed parameters on the following days: - 7/20/24, 9:00 A.M. dose: Blood Pressure (BP) 132/76 - 7/20/24, 2:00 P.M. dose: BP 132/76 Review of the August 2024 MAR indicated the Midodrine was given outside of physician prescribed parameters on the following days: - 8/10/24, 9:00 A.M. dose: BP 136/82 - 8/10/24, 2:00 P.M. dose: BP 132/76 During an interview on 8/29/24 at 10:38 A.M., Resident #49 said he/she receives a BP medication twice a day. Resident #49 said he/she receives the medication to make sure his/her BP does not go too high or low when getting out of bed. During an interview on 8/29/24 at 10:45 A.M., the Assistant Director of Nursing (ADON) said Resident #49 receives Midodrine twice daily to ensure his/her BP values are stable when changing positions throughout the day. The ADON said the medication has parameters to ensure the Resident's BP does not increase too much during position changes. The ADON reviewed Resident #49's medical record and said the medication was given outside of parameters on 7/20/24 and 8/10/24. The ADON said she would expect the medication to be held if the SBP was greater than 130.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 4 errors out of 33 opportunities resulting in a medication error rate of 12.12%. Those errors impacted two Residents (#68 and #53), out of three residents observed. Findings include: Review of the facility's policy titled Medication Administration, dated as revised December 2019, indicated medications are administered as prescribed. 4. Five rights- Right Resident, right drug, right dose, right route and right time. Administration D. Documentation 1. The individual who administers the medication dose records the administration on the residents medication administration record directly after the medication is given. 1. For Resident #68, the facility failed to ensure Nurse #3 administered the correct form of aspirin (anti-platelet medication) and Bupropion hcl (anti-depressant medication). On 7/26/23 at 9:09 A.M., the surveyor observed Nurse #3 prepare and administer medications to Resident #68 including: -aspirin 81 milligrams (mg) enteric coated (absorbed in the small intestine), one tablet -Bupropion hcl 75 mg (regular release), two tablets Review of the Physician's Order, dated 11/1/18, indicated: -aspirin 81 mg chewable (absorbed in the stomach), one tablet by mouth daily Review of the Physician's Order, dated 6/5/19, indicated: -Bupropion hcl SR (sustained-release, slow release form of medication) tablet 150 mg, one tablet by mouth daily During an interview on 7/26/23 at 1:38 P.M., Nurse #3 said that she administered the incorrect form of aspirin and incorrect form of Bupropion. During an interview on 7/26/23 at 1:43 P.M., Unit Manager #2 said Nurse #3 should have administered the correct form of aspirin and Bupropion. 2. For Resident #53, the facility failed to ensure Nurse #4 administered acetaminophen and saccharomyces boulardii (probiotic). On 7/26/23 at 9:26 A.M., the surveyor observed Nurse #4 prepare and administer medications to Resident #53. Review of the Physician's Orders, dated 6/7/23, indicated: - Saccharomyces boulardii 250 mg, administer one capsule twice a day. - Acetaminophen 500 mg, administer two tablets once a day. On 7/26/23 at 9:40 A.M., during the medication reconciliation the surveyor observed that acetaminophen and saccharomyces boulardii were not administered. Review of the Medication Administration Record, dated July 2023, indicated Nurse #4 administered the acetaminophen and saccharomyces boulardii, but she did not. During an interview on 7/26/23 at 9:45 A.M., Nurse #4 said that Resident #53 did not receive his/her physician's ordered acetaminophen and saccharomyces boulardii. Nurse #4 said she should not have documented these medications as administered. During an interview on 7/26/23 at 11:30 A.M., Unit Manager #3 said that Nurse #4 should not have documented acetaminophen and saccharomyces boulardii as administered. During an interview on 7/27/23 at 11:58 A.M., the Director of Nursing said Nurse #3 should have followed the physician's orders and administered the correct aspirin and Bupropion. The DON said Nurse #4 should not have documented the acetaminophen and saccharomyces boulardii as administered.

Based on observations, record review, and interviews, the facility failed to ensure four Residents (#60, #7, #37, and #312), out of a sample of 25 residents received care consistent with professional standards of practice. Specifically, the facility failed: 1. For Resident #60, to implement a physician's order not to have straws; 2. For Resident #7, to document weekly skin checks accurately; 3. For Resident #37, to ensure nursing implemented new physician's orders and implemented the physician's order review policy as required; and 4. For Resident #312, to implement a physician's order for an ace wrap. Findings include: 1. Resident #60 was admitted to the facility in April 2022 with diagnoses including dysphagia (difficulty swallowing foods or liquids) and cerebral infarctions. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/31/23, indicated Resident #60 had severe cognitive impairment and was dependent on staff for hygiene, bathing, dressing, transfers, and bed mobility. Review of Resident #60's Physician's Order indicated the following: -order dated 4/11/22 for aspiration precaution -order dated 6/19/23 for puree diet, regular liquid, and no straws On 7/25/23 at 11:10 A.M., the surveyor observed Resident #60 in his/her room sitting in wheelchair with a large Styrofoam cup containing water with a straw in it. On 7/26/23 at 12:05 P.M., the surveyor observed Resident #60 in his/her room, sitting in a wheelchair with a large Styrofoam cup containing water with a straw in it. During an interview on 7/26/23 at 12:32 P.M., Unit Manager #2 said that nursing staff provides hydration to the residents by giving them cups of water. She said that Resident #60 is on aspiration precaution and should not be using straws with his/her drink. She said that she was not aware that the nursing staff had given Resident #60's water with straws. 43807 2. Review of the facility's policy titled 'Skin management Program', revised October 2022, indicated the following: *Based on comprehensive assessment of the resident the facility will ensure that the resident receives care consistent with professional standards of practice. *The purpose is to minimize the development of any type of ulcer or other additional skin concerns through the systematic and regular inspection of the resident's skin. *Certified Nursing Assistants will inspect the skin of each resident during daily care and whenever skin care is provided and report to the Licensed Nurse any changes to the Resident's skin. *The Licensed Nurse will respond to reports of skin problems and assess the Resident's skin as soon as possible. Resident #7 was admitted to the facility in August 2020 with diagnoses including dementia and schizoaffective disorder. Review of the MDS assessment, dated 6/28/23, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. On 7/25/23 at 9:15 A.M., the surveyor observed Resident #7 in his/her room with a purple bruise at the tip of his/her nose. Review of the July 2023 Physician's Orders indicated the following: *Weekly skin check Thursday 3-11 Review of the weekly skin checks, dated 7/20/23, 7/13/23, 7/6/23, and 6/29/23, did not indicate that the purple bruise on the tip of the Resident's nose was identified by staff. During an interview on 7/26/23 at 11:06 A.M., Certified Nurse's Assistant (CNA) #1 said CNAs are supposed to report new bruises they identify during care to the nurse. During an interview on 7/26/23 at 11:07 A.M., Unit Manager #1 said the CNAs are supposed to report any new skin concerns to the nurse, and the nurses are expected to complete the weekly skin assessments accurately. During an interview on 7/27/23 at 9:21 A.M., the Director of Nurses (DON) said the CNAs should be reporting any new skin concerns to the nurse, she expects the weekly skin assessments to be documented accurately by the nurses. 44095 3. Review of the facility's policy titled Physician' Order Review, dated 3/21/18, indicated a review of the orders will be done on the 11:00 P.M. to 7:00 A.M., shift to ensure new orders are recognized and transcribed appropriately and that necessary follow through has been initiated. Resident #37 was admitted to the facility in July 2023 with diagnoses including hypertension and gastro-esophageal reflux disease without esophagitis. Review of the MDS assessment, dated 7/14/23, indicated Resident #37 had a BIMS score of 15 out of 15 indicating intact cognition. Review of the Physician's Order, dated 7/24/23, indicated: - increase Norvasc (blood pressure medication) to 10 milligrams (mg) by mouth daily; - Dulcolax (medication for constipation) two tablets for one dose; and - Zofran (medication for nausea) 4 mg by mouth every morning for 1 week. On 7/26/23, the surveyor reviewed the Medication Administration Record (MAR), dated July 2023, and there was no documentation to support nursing implemented the physician's orders from 7/24/23. During an interview on 7/26/23 at 7:43 A.M., Unit Manager #1 said that the physician's orders were not implemented from 7/24/23 but they should have been. During an interview on 7/27/23 at 11:52 A.M., the DON said the physician's orders should have been implemented and the physician's order review policy should have been implemented. 4. Resident #312 was admitted to the facility in July 2023 with diagnoses including end stage renal disease and diabetes. Review of the MDS assessment, dated 7/18/23, indicated Resident #312 had a BIMS score of 15 out of 15 indicating he/she was cognitively intact. The MDS indicated Resident #312 required extensive assistance of one for dressing. Review of the Physician's Order, dated 7/14/23, indicated: -ace wrap to right ankle daily, remove at HS (bedtime) Review of the MAR, dated July 2023, indicated nursing applied Resident #312's physician's ordered ace wrap on: - 7/25/23 at 9:00 A.M. - 7/26/23 at 6:00 A.M. On 7/25/23 at 9:09 A.M., the surveyor observed Resident #312 out of bed participating with therapy and he/she was not wearing an ace wrap to the right foot. The ace wrap was on Resident #312's nightstand. On 7/26/23 at 8:26 A.M., the surveyor observed Resident #312 not wearing an ace wrap on his/her right foot. The ace wrap was on Resident #312's nightstand. On 7/26/23 at 11:04 A.M., the surveyor observed Resident #312 out of bed walking with therapy. Resident #312 was not wearing an ace wrap on his/her right foot. The ace wrap was on Resident #312's nightstand. During an interview with observation on 7/26/23 at 1:11 P.M., the surveyor observed Resident #312 not wearing an ace wrap to his/her right foot. Resident #312 said that staff do not put an ace wrap on his/her foot. The ace wrap was on Resident #312's nightstand. During an interview on 7/27/23 at 8:39 A.M., Unit Manager #1 said nursing should have implemented the physician's ordered ace wrap. During an interview on 7/27/23 at 11:56 A.M., the DON said nursing should have implemented the physician's ordered ace wrap.

Based on observations, record review, and staff interviews, the facility failed to implement care plans for three Residents (#7, #55, and #8), out of a sample of 25 residents. Specifically, the facility failed: 1. For Resident #7, to implement a nose picking behavior care plan; 2. For Resident #55, to apply Geri-sleeves (a device that helps protect extremities from abrasion, bruises, and skin tears), as ordered; and 3. For Resident #8, a. to apply Geri-sleeves, and b. to implement a fall mat (a device used to reduce risk of injury from impact) on the floor as ordered and ensure the Resident's bed was in a low position. Findings include: 1. Review of the facility's policy titled 'Skin management Program' revised October 2022 indicated the following: *Certified Nursing Assistants will inspect the skin of each resident during daily care and whenever skin care is provided and report to the Licensed Nurse any changes to the resident's skin. *A care plan will be developed, implemented and revised as necessary. Resident #7 was admitted to the facility in August 2020 with diagnoses including dementia and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment, dated 6/28/23, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. On 7/25/23 at 9:15 A.M., the surveyor observed Resident #7 in his/her room with a purple bruise at the tip of his/her nose. During an interview on 7/26/23 at 11:06 A.M., Certified Nurse's Assistant (CNA) #1 said the Resident has a history of picking the tip of his/her nose causing it to bruise. During an interview on 7/26/23 at 11:07 A.M., Unit Manager #1 said Resident #7 has a history of picking the tip of his/her nose off and on. She said this behavior should be personalized in the Resident's skin care plan. Review of the behavior care plan, edited on 6/26/23, did not indicate that the Resident's history of nose picking was care planned. During an interview with Social Workers #1 and #2 on 7/26/23 at 11:24 A.M., they both said the Resident's nose picking behavior should be personalized in the behavior care plan. During an interview with the Director of Nurses (DON) on 7/27/23 at 9:21 A.M., she said a personalized care plan detailing the Resident's nose picking should be added. 44095 2. Resident #55 was readmitted to the facility in June 2023 with diagnoses including peripheral vascular disease, heart failure, and anemia. Review of the MDS assessment, dated 5/2/23, indicated Resident #55 had a BIMS score of 15 out 15 indicating he/she was cognitively intact. The MDS indicated Resident #55 required assistance with dressing. Review of the Physician's Order, dated 6/26/23, indicated: - Geri-sleeves to both arms at all times, may remove for hygiene and skin checks. Review of the plan of care related to skin tears, dated 6/26/23, indicated: - Geri-sleeves to BUE (bilateral upper extremities) at all times, may remove for hygiene and skin checks. Review of the Medication Administration Record, dated July 2023, indicated nursing applied the Geri-sleeves on: - 7/25/23: 11:00 P.M to 7:00 A.M., 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M. - 7/26/23: 11:00 P.M to 7:00 A.M., 7:00 A.M. to 3:00 P.M., and 3:00 P.M. to 11:00 P.M. On 7/25/23 at 8:16 A.M., 7/25/23 at 12:41 P.M., 7/26/23 at 6:53 A.M., 7/26/23 at 7:53 A.M., 7/26/23 at 8:29 A.M., 7/26/23 at 1:19 P.M., 7/27/23 at 6:59 A.M., the surveyor observed Resident #55 without his/her physician's ordered Geri-sleeves. During an interview on 7/27/23 at 8:42 A.M., Resident #55 said she has not worn his/her Geri-sleeves in a few days but would if he/she had a pair. Resident #55 said the Geri-sleeves are down in the wash. During an interview on 7/27/23 at 8:44 A.M., CNA #2 said the nurse will apply the Geri-sleeves. During an interview on 7/27/23 at 8:43 A.M., Nurse #5 said that Resident #55 should wear his/her Geri-sleeves. During an interview on 7/27/23 at 10:14 A.M., Unit Manager #1 said that nursing should have implemented the Geri-sleeves. During an interview on 07/27/23 at 11:54 A.M., the DON said nursing should have applied the Geri-sleeves. 45763 3a. Resident #8 was admitted to the facility in July 2018 and had diagnoses that included dementia and repeated falls. Review of the most recent MDS assessment, dated 7/5/23, indicated that Resident #8 was assessed by staff to have severely impaired cognition. Review of Resident #8's current Physician's Orders indicated the following: * Geri-sleeves to BUE at all times, may remove for hygiene and skin checks, initiated 7/29/22. Review of Resident #8's medical record indicated the following care plan: *Geri-sleeves to bilateral upper extremities to minimize bruising. Staff to ensure placement and compliance. On 7/25/23 at 8:14 A.M., the surveyor observed Resident #8 in bed. The Resident's skin appeared fragile and he/she was not wearing Geri-sleeves on his/her arms. On 7/26/23 at 7:34 A.M., the surveyor observed Resident #8 dressed for the day. Resident #8 was wearing a short sleeve shirt and there were no Geri-sleeves in place. On 7/26/23 at 8:10 A.M., the surveyor observed a CNA and a Nurse entering Resident #8's room. One had a Hoyer lift (mechanical lift) and the other a breakfast tray. The surveyor continued to make the following observations: * At 8:17 A.M., the CNA and Nurse left the room and the Resident remained in a short sleeve shirt and was not wearing Geri-sleeves. On 7/26/23 at 11:49 A.M., the surveyor observed Resident #8 seated in a recliner chair in his/her room, wearing a short sleeve shirt, and no Geri-sleeves. On 7/26/23 at 11:53 A.M., the surveyor observed a CNA delivering lunch to Resident #8 in his/her room, then exiting the room. The Resident remained without Geri-sleeves on. On 7/27/23 at 8:04 A.M., the surveyor observed Resident #8 sleeping in bed without Geri-sleeves on. On 7/27/23 at 8:53 A.M., the surveyor observed two CNAs entering the Resident's room to transfer Resident #8 into a reclining chair. A third CNA entered the room to deliver Resident #8's breakfast tray. The Resident remained without Geri-sleeves on. During an interview on 7/27/23 at 10:59 A.M., Nurse #4 was unfamiliar with the term Geri-sleeves and was unaware of the physician order for Geri-sleeves to be worn at all times. During an interview on 7/27/23 at 11:04 A.M., Unit Manager (UM) #3 said the Resident has a long-standing behavior of removing and refusing Geri-sleeves, however, she would expect staff to replace the sleeves if they observe the Resident without them on. UM #3 said refusals should be documented but was unable to locate any documentation for refusal in the Resident's medical record. UM #3 said a care plan was developed to address this behavior today, but this should have been developed earlier as this behavior is not new. During an interview on 7/27/23 at 11:41 A.M., the DON said she would expect physician's orders and care plans to be implemented, and that Resident refusals should be documented. b. Review of the facility's policy titled Fall Management Program, revised 10/13/2022, indicated the following: *Residents identified at high risk for falls (score of 10 or higher on the assessment) will have an appropriate fall prevention care plan developed, implemented, and revised as necessary. Record review on 7/25/23 at 9:27 A.M., indicated the following: * A current Physician's Order, started 7/29/22, for: Fall mat to the right side of the bed when in bed, every shift, days evenings and nights. * A current care plan Resident at risk for falling R/T hx [history] of falls, poor safety awareness, anxiety, and use of high risk medication. The care plan included the following interventions: -Floor mats to right side of bed -Low Bed * The current CNA Care card (provides resident-specific care instructions) indicated the following: -Floor mats to (R) side when in bed -Special consideration: fall risk (checked as yes) and Geri-sleeves to R and L (right and left). * A Fall Risk Assessment, dated 7/3/23, indicated Resident #8 scored a 15, (score of 10 or higher indicates high risk for falls). * A nursing progress note, dated 7/19/23, indicated Resident screaming, yelling at staff, trying to get OOB [out of bed] multiple times. Ativan PRN given at 8:00Pm with no effect. CNA assigned did one-to-one observation to maintain client safety. Patient compliant with med administration. Fair appetite & Po intake. Call light in reach. We'll keep monitoring for safety. On 7/25/23 at 8:14 A.M., the surveyor observed Resident #8 lying in bed with his/her legs dangling toward the side of the bed. The bed was at a regular height and there was no fall mat in place. On 7/26/23 at 7:34 A.M., the surveyor observed Resident #8 alone in his/her room in bed. The bed was at a regular height, and there was no fall mat in place. On 7/27/23 at 8:07 A.M., the surveyor observed Resident #8 alone in his/her room in bed. The bed was at a regular height, and there was no fall mat in place. On 7/27/23 at 10:26 A.M., the surveyor observed Resident #8 alone in his/her room in bed. The bed was at a regular height, and there was no fall mat in place. During an interview on 7/27/23 at 10:27 A.M., Nurse #4 said Resident #8 is at a high risk for falls and that the Resident sometimes swings his/her legs out of bed. Nurse #4 said she would expect the care plan to be implemented, and that fall mats should be in place any time the Resident is in bed. During an interview on 7/27/23 at 11:41 A.M., the DON said she would expect interventions outlined in the resident's care plans to be followed, and that not implementing interventions for falls places the Resident at risk for major injury.

Based on observation, policy review, and interview, the facility failed to store and handle food in accordance with professional standards for food service safety. Findings include: Review of the facility's policy titled Food Storage, revised February 2023, indicated the following: *Dry Storage: -Storerooms and pantry areas are kept organized and clean. Food shall be protected from excessive dust, flies, and rodents. Review of the 2013 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) indicated If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 7/25/23 at 7:22 A.M., the surveyor made the following observations in the kitchen: *Four trays of cookies on sheet trays, partially covered by parchment paper, unlabeled and undated, in the dry storage area. There were small black flies landing directly onto the cookies. *Two trays of brownies on sheet trays, uncovered, unlabeled and undated in the dry storage area. There were small black flies landing directly onto the brownies. On 7/26/23 at 7:44 A.M. through 8:00 A.M., the surveyor observed staff working on the tray line during breakfast service as follows: *The cook contaminated his gloves by touching the bottom of bowls, the bottom of two sheet trays, and by grabbing various utensils. Using the same contaminated gloves the cook grabbed breakfast pastries and placed them directly onto residents' plates to be served. Breakfast pastries were included in the regular breakfast so the majority of resident meals observed were contaminated. During an interview on 7/26/23 at 1:07 P.M., the Food Service Director (FSD) said all food items should be covered, labeled, and dated. The FSD also said for items that are cooling, such as baked goods, the entire rack should be either covered or stored in the walk-in refrigerator to avoid contamination.

Based on observation, interview, and policy review, the facility failed to ensure medications were stored (refrigerated), and dated once opened, according to manufacturer's guidelines in 2 out of 3 medication carts. 1. On 7/25/23 at 1:00 P.M., the surveyor and Nurse #1 made the following observations of the Station 2, B medication cart: - one bottle of Latanoprost Ophthalmic eye drops, opened and undated - one bottle of Dorzolamide / Timolol eye drops, opened and undated - one bottle of Timolol Ophthalmic eye drops, opened and undated - one bottle of Latanoprost Ophthalmic eye drops, unopened and undated. Review of the packaging indicated keep refrigerated until opened. During an interview on 7/25/23 at 1:07 P.M., Nurse #1 said that the eye drops should be dated once opened and the eye drops should have been stored in the refrigerator until opened. 2. On 7/25/23 at 1:17 P.M., the surveyor and Nurse #2 made the following observations of the Station 1 medication cart 2: - one bottle of Prosource Plus, opened and undated. Review of the manufacturer's recommendations indicated discard once opened. During an interview on 7/25/23 at 1:21 P.M., Nurse #2 said that the Prosource Plus should have been dated once opened. During an interview on 7/27/23 at 12:00 P.M., the Director of Nursing said nursing should have dated the eye drops and Prosource once opened and should have kept the eye drops in the refrigerator.

Based on observation, policy review, and interview, the facility failed to provide supervision during meals for one Resident (#8), out of a total sample of 25 residents. Findings include: Resident #8 was admitted to the facility in July 2018 and had diagnoses that include dementia and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 7/5/23, indicated that Resident #8 was assessed by staff to have severely impaired cognition. Review of Resident #8's Activities of Daily Living Care Plan indicated the following intervention: *Resident #8 requires continual supervision (Ratio 1:8) with all meals. *Recliner with assist, assisted to meals and activities. Review of the current Certified Nursing Assistant (CNA) Care card (a staff reference which provides resident-specific care instructions) indicated the following: * Eating: cues, supervision. Review of the Palliative Care assessment, dated 6/14/23, indicated Resident #8 requires cueing for meals. On 7/25/23 at 8:32 A.M., the surveyor observed Resident #8 seated in a chair in the Resident's room which was reclined at a 45-degree angle. The Resident was attempting to lean his/her head forward to be able to see the food on the tray table in front of him/her. No staff were present to supervise or assist the Resident. On 7/25/23 at 12:33 P.M., the surveyor observed Resident #8 in his/her room. The Resident's recliner was positioned at a 45-degree angle and the Resident's food was on the tray table directly in front of him/her. No staff were present to supervise or assist the Resident. On 7/26/23 at 8:10 A.M., the surveyor observed two staff enter Resident #8's room. One had a Hoyer lift (mechanical lift) and the other a breakfast tray. The surveyor continued to make the following observations: * At 8:17 A.M., the nurse/cna left the Resident in the room alone with the breakfast tray directly on front of him/her. The Resident was eating breakfast and no staff were present to supervise the meal. On 7/26/23 at 11:53 A.M., the surveyor observed staff delivering lunch to Resident #8 in his/her room. The lunch was set-up on a tray table directly in front of the Resident and then the CNA left the room, leaving Resident #8 unsupervised. On 07/27/23 at 8:31 A.M., the surveyor observed Resident #8 eating in his/her room; no staff were present to supervise or assist the Resident. On 07/27/23 at 08:42 A.M., the surveyor observed Resident #8 coughing while eating in his/her room; no staff were present to supervise or assist the Resident. During an interview on 7/27/23 at 10:12 A.M., Certified Nursing Assistant (CNA) #4 said the CNAs will ask the nurses what level of assistance residents require for feeding. During an interview on 7/27/23 at 10:17 A.M., CNA #1 said CNAs get report from the nurses regarding the required level of assistance residents require for eating. CNA #1 said Resident #8 requires supervision with meals, and occasionally needs help. During an interview on 7/27/23 at 10:20 A.M., Nurse #4 said residents should receive the level of assistance outlined in their care plans. Nurse #4 also said if a resident requires continuous supervision, that resident must be supervised by staff from the moment the tray is delivered, until the resident is done eating. During an interview on 7/27/23 at 11:41 A.M., the Director of Nursing (DON) said the CNAs should reference the care cards to determine the level of assistance a resident needs, and that nurses should defer to the care plan to determine the level of assistance a resident needs. The DON said the care provided to residents should be consistent with their care plans, and that if a resident requires continuous supervision the resident must be supervised by staff throughout the entire meal period.

Based on observation, policy review, and interview, the facility failed to ensure a dignified dining experience for one Resident (#11), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Resident's [NAME] of Rights, revised 1/10/2022, indicated the following: *The Resident has the right to a dignified experience *The Resident has the right to be treated with respect and dignity Resident #11 was admitted to the facility in August 2022 and had diagnoses that included Alzheimer's disease and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 5/3/23, indicated Resident #11 scored 3 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated Resident #11 had no behaviors and required one person assistance with eating. On 7/25/23 at 8:57 A.M., the surveyor observed Resident #11 asleep at a table among peers in the unit's Main Dining Room (MDR). A staff person placed a plate of food in front of him/her, then without waking up Resident #11 walked away and continued passing out trays to other residents. The surveyor continued to make the following observations: * At 9:00 A.M., Resident #11 woke up, used a fork to pick up a piece of pancake and then dropped the food off the fork into his/her lap. * At 9:01 A.M., Resident #11 tried using the fork to spear food in his/her lap. * At 9:02 A.M., Resident #11 gave up attempts to use the fork and used his/her hands to pick up the food in his/her lap and feed self the wet and syrup covered pancakes with his/her hands. * At 9:06 A.M., Resident #11 stuck his/her hand and fork in food and tried to pick up food unsuccessfully. On 7/26/23 at 12:08 P.M., the surveyor observed Resident #11 seated in the dining room at a table with two tablemates. Both tablemates were served lunch and Resident #11 watched, waited and looked around the room as others were served. The surveyor continued to make the following observations: * At 12:14 P.M., Resident #11 reached for a tablemate's food, then sat back when he/she couldn't reach it. Resident #11 then began looking around the room, watching others eat. 15 of 18 residents in the room had been served. * At 12:20 P.M., a lunch was delivered to Resident #11, 12 minutes after his/her tablemates had been served their meal. All others in the room had been served. On 7/27/23 at 8:40 A.M., the surveyor observed Resident #11 seated in the dining room at a table with two tablemates. The Resident's tablemate was served lunch and Resident #11 watched, waited, and looked around the room as others were served. The surveyor continued to make the following observations: *at 8:44 A.M., Resident #11 reached over attempting to grab items off of his/her tablemate's meal tray. *at 8:55 A.M., the Resident's other tablemate received a meal tray *at 8:58 A.M., a lunch was delivered to Resident #11, 18 minutes after his/her tablemate had been served their meal. Resident #11's tablemate had already finished eating by the time the Resident received his/her lunch. During an interview on 7/27/23 at 10:12 A.M., Certified Nursing Assistant (CNA) #4 said when passing meal trays, all residents sitting together should be served at the same time. CNA #4 also said if residents are observed struggling with meals the CNAs would help the resident. During an interview on 7/27/23 at 10:20 A.M., Nurse #4 said during mealtimes all residents sitting together should be served at the same time to avoid residents having to watch their neighbors eat while not having access to food themselves. Nurse #4 said if a resident is struggling with meals, she would expect staff to intervene, even if the resident is not on that staff member's assignment. During an interview on 7/27/23 at 11:41 A.M., the Director of Nursing (DON) said she would expect staff to serve residents sitting together during mealtimes at the same time to avoid residents having to watch their neighbors eat while not having access to food themselves. The DON also said if a resident is struggling with meals, she would expect staff to intervene.

Based on observations, record review, policy review, and interviews, the facility failed to ensure for one Resident (#312), who required dialysis, he/she received such services consistent with professional standards of practice and the comprehensive person-centered care plan, out of 25 sampled residents. Specifically, the facility failed to ensure nursing implemented a physician's order for emergency equipment at the Resident's bedside (pressure dressing and clamp). Findings include: Review of the facility's policy titled Hemodialysis, dated as revised 12/15/22, indicated to provide transportation and comprehensive care to residents that received hemodialysis treatments at an outside dialysis center. -pressure dressing and non-serrated clamp are to be kept at the bedside. Resident #312 was admitted to the facility in July 2023 with diagnoses including end stage renal disease and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 7/18/23, indicated Resident #312 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact. The MDS indicated Resident #312 required dialysis. Review of the Physician's Order, dated 7/12/23, indicated: -Set up emergency equipment at bedside (pressure dressing and clamp) check placement every shift -Dialysis Fistula: if bleeding occurs from fistula, apply pressure dressing and call 911 On 7/25/23 at 9:09 A.M., 7/26/23 at 6:53 A.M., 7/26/23 at 8:26 A.M., 7/26/23 at 11:04 A.M., 7/26/23 at 1:11 P.M., and 7/27/23 at 8:39 A.M., the surveyor was unable to locate the physician's ordered emergency equipment at Resident #312's bedside. Review of the Medication Administration Record, dated July 2023, indicated nursing verified the emergency equipment was at the bedside on: 7/25/23: 11:00 P.M. to 7:00 A.M., 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. 7/26/23: 11:00 P.M. to 7:00 A.M., 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. During an interview on 7/27/23 at 8:39 A.M., Unit Manager #1 met the surveyor in Resident #312's room; there was no emergency equipment at the Resident's bedside. Unit Manager #1 said that there should be emergency equipment at the bedside. During an interview on 7/27/23 at 11:54 A.M., the Director of Nursing said nursing should have implemented emergency equipment at Resident #312's bedside.

Based on observations, interview, and policy review, the facility failed to identify vision decline in one Resident (#67), out of a sample of 25 residents. Specifically, the facility failed to identify that the Resident's activities of daily living were being affected due to a decline in vision. Findings include: Review of the facility's policy titled 'Quality of care', with no revision date, indicated the following: *Vision and Hearing: The facility will ensure the residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Resident #67 was admitted to the facility in February 2021 with diagnoses including legal blindness and glaucoma. Review of the Minimum Data Set (MDS) assessment, dated 5/17/23, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. On 7/25/23 at 9:11 A.M., the surveyor observed the Resident having a lot of difficulty finding his/her breakfast tray placed on the bedside table. Resident #67 told the surveyor his/her eyesight is completely gone. The Resident said when he/she was admitted , he/she could see shadows, but he/she is completely blind and would like if a staff member stayed with him/her until he/she finished his/her meal to direct him/her on where the food is located on the tray. Review of the Health Drive request for service consent, dated 5/25/21, indicated dental and podiatry as the only requested services, eye care services were not requested. During an interview on 7/25/23 at 12:39 P.M., the surveyor observed the Resident sitting out of bed eating cereal for lunch. The Resident said he/she was having difficulty eating without direction. The Resident said, Nobody helps to feed me. On 7/25/23 at 1:06 P.M., the surveyor observed the Resident eating an alternate lunch meal with his/her fingers. The Resident was having a hard time locating the position of the food with his/her fingers. Review of Resident #67's activities of daily living July care card indicated the following: *Eating: Independent with set up On 7/26/23 at 8:12 A.M., the surveyor observed staff deliver the Resident's meal tray, set it up, and provided longer supervision while the Resident asked for help locating the food on the tray. During an interview on 7/26/23 at 8:15 A.M., Certified Nurse's Assistant (CNA) #1 said she was not aware of the Resident's decline in vision; she mostly sets up the Resident's tray and leaves as the care card indicates. During an interview on 7/26/23 at 12:18 P.M., Resident #67 said he/she liked the extra assistance he/she got during the breakfast meal. During an interview on 7/27/23 at 8:02 A.M., Unit Manager #1 said the plan of care should be revised for residents who have had changes in condition. During an interview on 7/27/23 at 8:49 A.M., the Director of Nurses (DON) said Resident #67 should have been offered eye care services through Health Drive at admission to monitor his/her vision; the facility would have been able to pick up on her declining eyesight. She said his/her care plan should be revised and updated to accommodate the changes in his/her vision.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#97) was assessed for the ability to self-administer medications, out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Medication: Self-Administration, dated 1/15/22, indicated residents may self-administer their own medications, if requested, once the interdisciplinary team determines that this is safe practice. Resident #97 was admitted to the facility in June 2023 with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 7/7/23, indicated Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of the Physician's Order, dated 6/30/23, indicated: -Albuterol Sulfate Aerosol Inhaler, 90 micrograms, two inhalations every 6 hours as needed for shortness of breath. Further review of the Physician's Order indicated there was no documentation to support Resident #97 was assessed for self-administration. On 7/26/23 at 8:23 A.M., the surveyor observed Resident #97 sitting on the edge of his/her bed. Resident #97 said he/she was short of breath and was holding an inhaler in his/her hand and said that he/she needed a new inhaler and the inhaler was empty. On 7/26/23 at 8:25 A.M., Nurse #5 entered Resident #97's room and said Resident #97 had an albuterol inhaler at his/her bedside. Nurse #5 said that Resident #97 needed to be assessed to have medications at his/her bedside. During an interview on 07/26/23 at 8:29 A.M., Unit Manager #1 said Resident #97 should have been assessed for self-administration of medications. During an interview on 07/27/23 at 11:53 A.M., the Director of Nursing said Resident #97 should have been assessed for self-administration of medications.

Based on observations, interviews, and record review, the facility failed to complete a restraints assessment for one Resident (#94), out of a sample of 25 residents. Specifically, the facility failed to assess therapeutic devices (two pillows and two block floor mats) as restraints. Findings include: Review of the facility's policy titled 'Restraints' with a revision date of 1/1/21 indicated the following: *Therapeutic use of a device used as a restraint may be used when all other interventions or alternatives to a restraint are not effective. *If a restraint is used a licensed therapist and/or a nurse will assess the resident for appropriate interventions and a plan of care will be developed, documentation within the medical record will include verification that the resident has medical symptoms for which the restraint has been determined to achieve or maintain the highest level of mental, physical, and psychological well-being. *Rehab and Nursing will complete the assessment for the use of therapeutic devices form. *Nursing has informed the resident and/or their representative of the risk and benefits of the device and has completed the 'Restraints utilization informed consent'. Resident #94 was admitted to the facility in November 2022 with diagnoses including dementia and a history of falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/28/23, indicated a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severe cognitive impairment. On 7/25/23 at 8:49 A.M., the surveyor observed Resident #94 lying in a low positioned bed with two pillows tucked in on the left and right side, and two block floor mats on both sides of the bed at the same level with the low bed. Resident #94 was trying to swing his/her legs over the left side of the bed telling the surveyor he/she wanted to get out of bed; he/she was stuck. Review of progress notes, dated 7/14/23, indicated the following: *Resident with increased restlessness throughout the shift, Resident states isn't comfortable and I'm stuck. Further review of a Fall Incident Report, dated 2/24/23, indicated the following interventions: *Block mat placed at bedside to minimize attempts to get out of bed by self. On 7/26/23 at 6:46 A.M., the surveyor observed the Resident in a low positioned bed with two pillows tucked underneath both sides of his/her bed, and two block mats on both sides of his/her bed. He/she told the surveyor he/she wanted to get out of bed. On 7/27/23 at 6:43 A.M., the surveyor observed the Resident in a low positioned bed with two pillows tucked underneath both sides of his/her bed, and two block mats on both sides of his/her bed. He/she told the surveyor he/she wanted to get out of bed and was stuck. During an interview on 7/27/23 at 8:29 A.M., Certified Nurse's Assistant (CNA) #3 said the Resident can get very restless, the overnight staff tuck in pillows on both sides to try to stop him/her from getting out of bed. During an interview on 7/27/23 at 8:33 A.M., Unit Manager (UM) #3 said the overnight staff are trying to prevent the Resident from getting out of bed by tucking in the pillows on both sides of his/her bed. She said the block fall mats are an intervention for safety purposes and not to prevent the Resident from getting out of bed as indicated in the fall incident report dated 2/24/23. UM #3 said no restraints assessments have been completed for the two pillows or the two block fall mats. During an interview on 7/27/23 at 8:51 A.M., the Director of Nurses said pillows should not be tucked in the Resident's bed to prevent him/her from getting out of bed. She said the intention of the block fall mats are to keep him/her safe and not to prevent him/her from getting out of bed as indicated in the 2/24/23 fall incident report. The DON said restraints assessments should have been completed for both the two pillows and the two block fall mats to rule out the concerns of restraining the Resident's movements while in bed.

Based on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one Resident (#97), out of a total sample of 25 residents. Specifically, for Resident #97, the facility failed to ensure that staff coded the use of Oxygen on the Minimum Data Set (MDS) assessment. Findings include: Resident #97 was admitted to the facility in June 2023 with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation and generalized anxiety disorder. Review of the MDS assessment, dated 7/7/23, indicated Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS indicated Resident #97 did not utilize Oxygen. Review of the Physician's Order, dated 7/1/23, indicated: -O2 at 3LPM (oxygen at 3 liters per minute) via nasal cannula continuously. During an interview on 7/26/23 at 10:00 A.M., the MDS Nurse said that Resident #97 required Oxygen and she coded the MDS assessment incorrectly. During an interview on 7/26/23 at 12:35 P.M., the Director of Nursing said Resident #95 uses Oxygen and the the MDS assessment was coded incorrectly.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the facility failed to ensure that staff promptly notified Resident #1's Health Care Agent (HCA), when upon readmission to the Facility his/her antianxiety medication was discontinued because there was no current signed consent, his/her antipsychotic medication dose was decreased, and his/her HCA was not notified of the medications changes or to request and/or obtain new consents. Findings include: Review of Facility Policy titled [CONDITION(S)] Medication Management, dated [DATE], indicated its protocol to include: -Notify resident or responsible party of initiation of psychoactive medications, and with any changes in dose, and document in record; -Obtain and document informed consent for initiation of [CONDITION(S)] medications using the Massachusetts state specific form. Consent must be signed by the appropriate person prior to initiating the medication per State Regulations; Resident #1 was admitted to the Facility in [DATE], diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) dated [DATE], indicated he/she was significantly cognitively impaired. Review of Resident #1's Health Care Proxy form, dated [DATE], indicated his/her health care decision abilities were determined to be insufficient and the HCP was activated. The HCP form also indicated that there was an alternate agent chosen. 1. Review of Resident #1's Hospital Discharge Summary, dated [DATE], indicated he/she was to resume all previous medications upon readmission to the Facility, which included [MEDICATION(S)] (an antianxiety medication) 0.5 milligrams (mg) tablet by mouth daily. Review of Resident #1's Physician Orders, dated [DATE] through [DATE], indicated he/she had orders for the administration of [MEDICATION(S)] 0.5 mg by mouth daily Review of Resident #1's Nursing Progress Note, dated [DATE], indicated he/she returned from the Hospital at approximately 5:22 P.M. The Note indicated that medications and treatments were reviewed by the Nurse Practitioner (NP). Review of Resident #1's Physicians Order's, dated [DATE], indicated [MEDICATION(S)] 0.5 mg by mouth daily was discontinued. Further review of the medical record indicated there was no documentation to support that Resident #1's HCA was notified that the [MEDICATION(S)] was discontinued. Review of Resident #1's Nursing Progress Note, dated [DATE], indicated that nursing was waiting for his/her HCA to sign a new consent for [MEDICATION(S)] because the consent on record had expired. Review of Resident #1's Nursing Progress Notes, dated [DATE] and [DATE], indicate he/she went to a medical appointment with his/her daughter and nursing spoke with his/her daughter regarding another appointment. Although Nurses caring for Resident #1 spoke with his/her daughter on [DATE] and [DATE], there was no documentation to support nursing attempted to obtain the assistance of the daughter in contacting the HCA to obtain a signed consent to administer his/her antianxiety medication. During an interview on [DATE] at 9:00 A.M., Resident #1's HCA said she was not notified that his/her [MEDICATION(S)] had been discontinued. During an interview on [DATE] at 3:10 P.M., Nurse #3 said that she knew that there was not a signed current consent for Resident #1's [MEDICATION(S)]. Nurse #3 said she did not transcribe the [MEDICATION(S)] onto the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 5:29 P.M., Unit Manager #2 said he was aware they needed to have a signed consent form for Resident #1's [MEDICATION(S)], since the previous consent form had expired. Unit Manager #2 said that he did not call the Physician to inform him that Resident #1 had not been receiving [MEDICATION(S)] since his/her readmission. Unit Manager #2 also said he did not attempt to contact Resident #1's alternate HCA in an effort to contact the primary HCA or to assist with obtaining signed consent. 2. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medical Record, indicated that there was no documentation to support that the HCA was notified of the dose change of the [MEDICATION(S)] or that Nursing attempted to obtain a new consent for the dose change of his/her antipsychotic medication. During an interview on [DATE] at 9:38 A.M., Nurse #5 said she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #5 said the reasons for obtaining a [CONDITION(S)] consent form were, with an initiation of a new [CONDITION(S)] medication, a dose change, and annually. Nurse #5 said that she did not remember if she called to inform Resident #1's HCA or to obtain the HCA's consent for the newly prescribed dose of [MEDICATION(S)]. During an interview on [DATE] at 9:00 A.M., Resident #1's HCA said she was not notified of a change in his/her [MEDICATION(S)] on [DATE], when the dose was decreased. During an interview on [DATE] at 4:12 P.M., the Director of Nurses (DON) said that it is her expectation that nursing staff would inform her or the Assistant Director of Nurse within 24 hours if staff were unable to reach an activated HCA for a [CONDITION(S)] medication consent. The DON said it is her expectation that nurses would call and inform the Physician of the situation promptly and obtain any additional orders as needed.

Based on policy review, interview, and observations, the facility failed to implement their screening policy and allowed staff to screen themselves upon entry into the facility. Findings include: Review of the facility's policy titled Screening Process/ Required Testing for COVID-19 Compliance to F886, updated 10/11/21 indicated screening will be performed by a designated person; self-screening is not permitted. On 10/13/21 at 6:36 A.M., the surveyor entered the facility and did not observe a screener at the front desk. On 10/13/21 at 6:40 A.M., the surveyor observed Dietary Aide #1 enter the facility, perform hand hygiene, don a new mask, and complete the questionnaire for signs and symptoms of COVID-19. The Dietary Aide #1 then proceeded directly into the facility without anyone reviewing the screening questionnaire. On 10/13/21 at 6:46 A.M., the surveyor observed two Certified Nursing Assistants (CNA) in the entryway. They proceeded to perform hand hygiene, don new masks, and complete the questionnaire for signs and symptoms of COVID-19. Both CNAs then proceeded directly into the facility without anyone reviewing the screening questionnaires. During an interview on 10/13/21 at 12:55 P.M. with the Administrator and the Director of Nurses (DON), the DON said she usually arrives at 6:00 A.M. to perform the screening then another designated person relieves her at 7:00 A.M. The Administrator said that they do have a process in place and today was unusual.

Based on record review and interviews for 1 of 4 sampled residents (Resident #1), the Facility failed to ensure that food was prepared and served in a form to meet his/her individualized needs. On 2/14/15, Resident #1, whose plan of care indicated he/she was not to be served meatballs due to a choking incident in 2012, was served meatballs in error. Resident #1 choked as a result, required emergent care and was hospitalized . The Hospital Discharge Summary, dated 2/15/15, indicated Resident #1 died at 4:30 A.M. from an acute [MEDICAL CONDITION] after becoming hypoxic following a choking incident. Findings include: A Nutritional Assessment, dated 12/12/14, indicated Resident #1 was on a no added salt (NAS) ground diet, and he/she was not to be served meat balls due to his/her dysphagia (difficulty swallowing). A Speech Therapy Evaluation, dated 12/18/14, indicated Resident #1 tolerated a ground diet and there was an order to omit meatballs per his/her request. The physician's orders [REDACTED].#1 #1 was prescribed a NAS ground diet with "no meatballs." Resident #1's lunch time meal ticket, dated 2/14/15, indicated ziti with meatballs was circled as his/her selection for his/her main entree. The Surveyor interviewed the Hostess at 11:45 A.M. on 3/19/15. The Hostess said when she collected Resident #1's selected menu for 2/14/15, she noticed that meatballs were circled as the selection for the lunch time entree. The Hostess said she was aware that Resident #1 was not suppose to have meatballs but she assumed that a diet change had been made. The Hostess said she did not check with nursing staff to confirm if a diet change was made, and she entered Resident #1's selection for meatballs into the computer system used by Dietary staff. The Surveyor interviewed Dietary Aide #1 at 11:00 A.M. on 3/19/15. Dietary Aide #1 said she cooked the lunch time meal and saw that meatballs were selected for Resident #1's main entree. Dietary Aide #1 said she was not unaware that Resident #1 had an order indicating he/she was not to be served meatballs. The Surveyor interviewed Dietary Aide #2 at 11:25 A.M. on 3/19/15. Dietary Aide #2 said as she was plating the lunch time meal on 2/14/15, she saw that meatballs were selected as Resident #1's main entree. Dietary Aide #2 said she was aware Resident #1 was not supposed to be served meatballs and she asked the Cook if there had been a diet change. The Surveyor interviewed the Cook at 12:05 P.M. on 3/19/15. The Cook said according to Resident #1's meal ticket, he/she was on a ground diet and had selected meatballs as his/her main entree. The Cook said she could not recall if Resident #1 had an order not to have meatballs, she did not check to clarify if a diet change had been made and made the assumption it was okay to have meatballs as part of a ground diet. The Cook said she told Dietary Aide #2 to go ahead and put the meatballs on Resident #1's plate. Dietary Aide #2 said she placed 3 or 4 one and a half ounce meatballs on Resident #1's plate along with pasta and sauce. The Surveyor interviewed Nurse #1 at 3:00 P.M. on 3/18/15. Nurse #1 said Resident #1 choked on a meatball in the past and had a physician order [REDACTED]. Nurse #1 said she checked the lunch time meal trays against the meal tickets at approximately 12:30 P.M. on 2/11/15 before the Certified Nurse Aides (CNAs) passed out the trays. Nurse #1 said although she was aware Resident #1 was not to be served meatballs, she did not remove the meatballs or request a new tray when she saw the meatballs on Resident #1's plate. The Surveyor interviewed CNA #1 at 10:00 A.M. on 3/19/15. CNA #1 said she removed Resident #1's tray from the meal truck and brought it to Resident #1's table. CNA #1 said she asked Resident #1 if he/she would like her to cut up the meat balls and Resident #1 said yes. CNA #1 said she cut each meat ball into 4 bite size pieces, she asked Resident #1 if he/she needed any further help, and Resident #1 said no. CNA #1 said that a few minutes later, as she was assisting another resident, she heard a choking sound. CNA #1 said she turned around and saw Resident #1 turning a pale color and his/her eyes started to roll back in his/her head. CNA #1 said she ran over to Resident #1 and asked if he/she was okay, but Resident #1 did not answer. CNA #1 said she called out for help. Nurse #1 said Resident #1 was turning blue and was unable to speak (indicative of having a possible occluded airway). Nurse #1 said she stood behind Resident #1 and as she attempted the [MEDICATION NAME] maneuver, which was unsuccessful, Resident #1 started to go unconscious. Nurse #1 said at that point she and CNA #1 lowered Resident #1 to the floor, she called out for someone to bring the Code cart and to call a Code Blue (emergency response call). Nurse #1 said she she performed a finger sweep followed by upward chest compressions on Resident #1 at which point Resident #1 coughed up pieces of pasta and meat. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 1:15 P.M. on 3/18/15. The ADON said she called 911 Emergency Services and then helped Nurse #1 to suction Resident #1 removing more meat and past. The ADON said Resident #1 was placed on his/her left side, Oxygen was applied and Resident #1 was still breathing when the Paramedics transported him/her to the Hospital. The Hospital Discharge Summary, dated 2/15/15, indicated Resident #1's code status was Do not Resuscitate (DNR). The Summary indicated in the Emergency Department (ED) Resident #1 had agonal breathing (an abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED]), [MEDICAL CONDITION](irregular heart beat) and he/she was unconscious. The Summary indicated Resident #1 was placed on a [MEDICATION NAME] drip (narcotic [MEDICATION NAME] administered via intravenous injection) for care and comfort, and he/she died at 4:30 A.M. from an acute [MEDICAL CONDITION] after becoming hypoxic following a choking incident.

Based on record review and interviews for 1 of 4 sampled residents (Resident #1), the Facility failed to ensure that food was prepared and served in a form to prevent a choking incident. On [DATE], Resident #1, whose plan of care indicated he/she was not to be served meatballs due to a choking incident in 2012, was served meatballs in error. Resident #1 choked as a result, required emergent care and was hospitalized . The Hospital Discharge Summary, dated [DATE], indicated Resident #1 died at 4:30 A.M. from an acute cardiac arrest after becoming hypoxic following a choking incident. Findings include: A Nutritional Assessment, dated [DATE], indicated Resident #1 was on a no added salt (NAS) ground diet, and he/she was not to be served meatballs due to his/her dysphagia (difficulty swallowing). A Speech Therapy Evaluation, dated [DATE], indicated Resident #1 tolerated a ground diet and there was an order to omit meatballs per his/her request. The physician's orders [REDACTED].#1 #1 was prescribed a NAS ground diet with "no meatballs." Resident #1's lunch time meal ticket, dated [DATE], indicated ziti with meatballs was circled as his/her selection for his/her main entree. The Surveyor interviewed the Hostess at 11:45 A.M. on [DATE]. The Hostess said when she collected Resident #1's selected menu for [DATE], she noticed that meatballs were circled as the selection for the lunch time entree. The Hostess said she was aware that Resident #1 was not suppose to have meatballs but she assumed that a diet change had been made. The Hostess said she did not check with nursing staff to confirm if a diet change was made, and she entered Resident #1's selection for meatballs into the computer system used by Dietary staff. The Surveyor interviewed Dietary Aide #1 at 11:00 A.M. on [DATE]. Dietary Aide #1 said she cooked the lunch time meal and saw that meatballs were selected for Resident #1's main entree. Dietary Aide #1 said she was not unaware that Resident #1 had an order indicating he/she was not to be served meatballs. The Surveyor interviewed Dietary Aide #2 at 11:25 A.M. on [DATE]. Dietary Aide #2 said as she was plating the lunch time meal on [DATE], she saw that meatballs were selected as Resident #1's main entree. Dietary Aide #2 said she was aware Resident #1 was not suppose to have meatballs and she asked the Cook if there had been a diet change. The Surveyor interviewed the Cook at 12:05 P.M. on [DATE]. The Cook said according to Resident #1's meal ticket, he/she was on a ground diet and had selected meatballs as his/her main entree. The Cook said she could not recall if Resident #1 had an order not to have meatballs, she did not check to clarify if a diet change had been made and made the assumption it was okay to have meatballs as part of a ground diet. The Cook said she told Dietary Aide #2 to go ahead and put the meatballs on Resident #1's plate. Dietary Aide #2 said she placed 3 or 4 one and a half ounce meatballs on Resident #1's plate along with pasta and sauce. The Surveyor interviewed Nurse #1 at 3:00 P.M. on [DATE]. Nurse #1 said Resident #1 had choked on a meatball in the past and had a physician order [REDACTED]. Nurse #1 said she checked the lunch time meal trays against the meal tickets at approximately 12:30 P.M. on [DATE] before the Certified nurse Aides (CNAs) passed out the trays. Nurse #1 said although she was aware Resident #1 was not supposed to have meatballs, she did not remove the meatballs or request a new tray when she saw the meatballs on Resident #1's plate. The Surveyor interviewed CNA #1 at 10:00 A.M. on [DATE]. CNA #1 said she removed Resident #1's tray from the meal truck and brought it to Resident #1's table. CNA #1 said she asked Resident #1 if he/she would like her to cut up the meat balls and Resident #1 said yes. CNA #1 said she cut each meatball into 4 bite size pieces, she asked Resident #1 if he/she needed any further help, and Resident #1 said no. CNA #1 said that a few minutes later, as she was assisting another resident, she heard a choking sound. CNA #1 said she turned around and saw Resident #1 turning a pale color and his/her eyes started to roll back in his/her head. CNA #1 said she ran over to Resident #1 and asked if he/she was okay, but Resident #1 did not answer. CNA #1 said she called out for help. Nurse #1 said Resident #1 was turning blue and was unable to speak. Nurse #1 said she stood behind Resident #1 and as she attempted the Heimlich maneuver, which was unsuccessful, Resident #1 started to go unconscious. Nurse #1 said at that point she and CNA #1 lowered Resident #1 to the floor, she called out for someone to bring the Code cart and to call a Code Blue (emergency response call). Nurse #1 said she she performed a finger sweep followed by upward chest compressions on Resident #1 at which point Resident #1 coughed up pieces of pasta and meat. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 1:15 P.M. on [DATE]. The ADON said she called 911 Emergency Services and then helped Nurse #1 to suction Resident #1 removing more meat and pasta. The ADON said Resident #1 was placed on his/her left side, Oxygen was applied and Resident #1 was still breathing when the Paramedics transported him/her to the Hospital. The Hospital Discharge Summary, dated [DATE], indicated after arrival, Resident #1 was placed on a Morphine drip (narcotic analgesic administered via intravenous injection) for care and comfort, and Resident #1 died at 4:30 A.M. from an acute cardiac arrest after becoming hypoxic following a choking incident.

Based on record review and interviews for 1 of 4 sampled residents (Resident #1), the Facility failed to ensure Resident #1's plan of care was implemented. On [DATE], Resident #1, whose plan of care indicated he/she was not to be served meatballs due to a choking incident in 2012, was served meatballs in error. Resident #1 choked as a result, required emergent care and was hospitalized . The Hospital Discharge Summary, dated [DATE], indicated Resident #1 died at 4:30 A.M. from an acute [MEDICAL CONDITION] after becoming hypoxic following a choking incident. The Hostess said Resident #1's roommate's family members typically helped Resident #1 make his/her meal selections on [DATE], she observed that meatballs was selected for Resident #1's lunch time entree. The Hostess said although she was aware that Resident #1 was not to be served meat balls, she assumed that a diet change had been made. The Hostess said she did not check with nursing staff to confirm if a diet change was made, and instead, entered the selection for meatballs into the computer system used by Dietary staff. Findings include: Resident #1 was admitted to the Facility in April, 2009, and his/her [DIAGNOSES REDACTED]. An Emergency Department (ED) Report, dated [DATE], indicated Resident #1 was evaluated after vomiting up a meatball during a choking episode. A Physician Order, dated [DATE], indicated in response to the choking incident, Resident #1 was prescribed a ground diet with "no meat balls." The Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 had moderate cognitive impairment but could feed him/herself with setup help and supervision. A Nutritional Assessment, dated [DATE], indicated Resident #1 was on a no added salt (NAS) ground diet, and he/she was not to be served meatballs due to to his/her dysphagia (difficulty swallowing). A Speech Therapy Evaluation, dated [DATE], indicated Resident #1 tolerated a ground diet and there was an order to omit meatballs per his/her request. The physician's orders [REDACTED].#1's ground diet continued to consist of Resident #1 not being served meatballs. Resident #1's lunch time meal ticket, dated [DATE], indicated ziti with meatballs was circled as his/her selection for his/her main entree. The Surveyor interviewed the Hostess at 11:45 A.M. on [DATE]. The Hostess said Resident #1's roommate's family members would typically help Resident #1 make his/her meal selections from the daily menu. The Hostess said when she collected Resident #1's menu for [DATE], she noticed that meat balls were circled as the selection for the lunch time entree. The Hostess said she was aware that Resident #1 was not suppose to have meatballs but she assumed that a diet change had been made. The Hostess said she did not check with nursing staff to confirm if a diet change was made, and she entered Resident #1's selection for meatballs into the computer system used by Dietary staff. The Surveyor interviewed the Cook at 12:05 P.M. on [DATE]. The Cook said according to Resident #1's meal ticket, he/she was on a ground diet and had selected meatballs as his/her main entree. The Cook said she could not recall if Resident #1 had an order not to have meatballs. The Surveyor interviewed Nurse #1 at 3:00 P.M. on [DATE]. Nurse #1 said Resident #1 choked on a meatball in the past and had a physician order [REDACTED]. Nurse #1 said that on [DATE], she checked the lunch time meal trays against the meal tickets at approximately 12:30 P.M. before the Certified Nurse Aides (CNAs) passed out the meal trays to residents. Nurse #1 said although she was aware Resident #1 was not supposed to be served meatballs, she did not remove the meatballs or request a new tray when she saw the meatballs on Resident #1's plate. The Surveyor interviewed CNA #1 at 10:00 A.M. on [DATE]. CNA #1 said she was recently reassigned to the care unit on which Resident #1 resided and was not familiar with Resident #1. CNA #1 said she removed Resident #1's tray from the meal truck and brought it to Resident #1's table. CNA #1 said she asked Resident #1 if he/she would like her to cut up the meatballs and Resident #1 said yes. CNA #1 said she cut each meatball into 4 bite size pieces, she asked Resident #1 if he/she needed any further help, and Resident #1 said no. CNA #1 said that a few minutes later, as she was assisting another resident, she heard a choking sound. CNA #1 said she turned around and saw Resident #1 turning a pale color and his/her eyes started to roll back in his/her head. CNA #1 said she ran over to Resident #1 and asked if he/she was okay, but Resident #1 did not answer. CNA #1 said she called out for help. Nurse #1 said observed Resident #1's skin color was blue (indicative of inadequate oxygen), she stood behind Resident #1 and as she attempted the [MEDICATION NAME] maneuver (abdominal thrusts), which was unsuccessful in clearing Resident #1's airway. Nurse #1 said when Resident #1 began to become unconscious, she and CNA #1 lowered Resident #1 to the floor, she called out for someone to bring the code cart and to call a Code Blue (emergency response call). Nurse #1 said when attempting to clear Resident #1's airway, Resident #1 coughed up pieces of pasta and meat. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 1:15 P.M. on [DATE]. The ADON said she called 911 (Emergency Medical Response Services) and Resident #1 was transported to the Hospital. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 died at 4:30 A.M. from an acute [MEDICAL CONDITION] after becoming hypoxic following a choking incident.

Based on record review and staff interview, the facility failed to ensure for 1 resident (#13), of a total sample of 24, that adequate supervision and safety measures were provided to maintain the resident's safety. Findings included: Resident #13 was admitted with [DIAGNOSES REDACTED]. According to the most recent MDS (minimum data set), signed as being completed 12/27/12, the resident's BIMS score (Brief Interview for Mental Status) was 5 out of 15, which indicated deficits in memory and cognition. The MDS noted that the resident required extensive assistance with transfers, ambulation, dressing, hygiene, bathing, and was occasionally incontinent of bladder. The MDS also indicated that the resident had fallen once since the prior assessment. The fall was coded as a major injury (i.e. bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma, etc.). Record review on 3/14/13 revealed that on 9/16/12 at 8:45 A.M., the resident was found lying on the floor in the resident's room. The nurse's note indicated that the chair alarm was sounding and the resident fell while attempting to get back to bed. The resident was found on the floor with the right side of the body on the floor and the head against the wall. Bruising was noted the right side of the body by the nurse. The physician was notified of the fall and ordered the resident be sent to the hospital emergency room for evaluation. According to the report from the hospital, the resident sustained [REDACTED]. The Initial Fall Investigation Form, completed by the registered nurse on 9/18/12, indicated that the fall was unwitnessed and happened while the resident was alone in the room trying to get back to bed from the wheelchair. The registered nurse also documented that the "Bed was noted to be in high position." Review of the care plan, developed by the facility on 5/19/09 to address the resident's risk for falls, indicated that the resident was to be observed frequently and placed in a supervised area when out of bed, with the bed kept in the lowest position with the brakes locked. The DON (Director of Nursing) was interviewed about the fall on 3/15/13 at 9:30 A.M. The DON said she felt that the bed being in the high position may have contributed to the resident's fall. The DON also said that the resident's care plan indicated that the resident should have been kept in an area where he/she could be supervised while out of bed in the wheelchair. The updated care plan following the fall indicated that the resident was to be placed in the wheelchair in an area where staff could supervise the resident. The facility failed to consistently implement safety measures for this resident in order to maintain the resident's safety and prevent accidents and injury.

Based on record review and interview, the facility failed for one of one sampled resident (Resident #1) to address a radiology report, faxed to the facility on [DATE], which indicated that Resident #1 had a fractured left humerus and left elbow, until 8/27/10. Findings included: Nurse #1 was interviewed on 9/24/10 at approximately 3 PM. Nurse #1 said Resident #1 was in Nurse #1's care group during the evening shift of 8/22/10. Nurse #1 said Resident #1 first complained that Resident 1's left elbow hurt at supper time at approximately 5 PM. Nurse #1 said when Nurse #1 asked Resident #1 if something had happened to cause the pain, Resident #1 said that Resident #1 did not know what happened to cause the pain. Nurse #1 said at the time Resident #1 was in the dining room and wearing a long sleeve shirt and sweater. Nurse #1 said when Nurse #1 asked Resident #1 if Nurse #1 could check Resident #1's left arm, Resident #1, said, no. Nurse #1 said later, probably around 7:30 PM on 8/22/10, while receiving PM personal care Resident #1 complained of left elbow pain. Nurse #1 said Nurse #1 contacted the Physician and received a telephone order for Resident #1 to have a mobile X-ray. Nurse #1 said the mobile X-ray technician arrived at approximately 9 PM on 8/22/10. A Physician's Interim Order, dated 8/22/10 at 8:50 PM, indicated that the Facility was to obtain an X-ray of Resident #1's left elbow and left forearm. Nurse #1 said the mobile X-ray service practice was to telephone the Facility with the results in addition to faxing a hard copy of the written radiology report to the Facility. Nurse #1 said when Nurse #1 left the Facility sometime between 11:30 PM and 11:45 PM on 8/22/10, Nurse #1 had not known if the findings of Resident #1's X-ray were reported to the Facility. Nurse #1's shift note, dated 8/22/10, was consistent with the above statement. Additionally, Nurse #1's note indicated: ice was applied to Resident #1's left elbow; 650 milligrams (mg) of [MEDICATION NAME] (APAP), a non-opioid [MEDICATION NAME] medication, was administered to Resident #1; Resident #1's left elbow had a small bruise with some swelling, and Resident #1 was able to move the arm while yelling. Nurse #1's note, dated 8/22/10 at 11:30 PM, indicated that the findings of Resident #1's X-ray were still pending. Nurse #2 was interviewed on 10/28/10 at approximately 9:45 AM. Nurse #2 said Nurse #2 was the night nurse on Resident #1's unit on 8/22/10. Nurse #2 said Nurse #2 received the telephone call from the X-ray services and Nurse #2 was told that the X-ray results indicated that Resident #1 did not have any fractures, or dislocations, but Resident #1 did have [MEDICAL CONDITION]. Nurse #2 said Nurse #2 knew that the X-ray services sent a faxed written report in addition to the verbal report. Nurse #2 said Nurse #2 was very busy that night as many residents were awake. Nurse #2 said Nurse #2 did not have the time to get Resident #1's faxed radiology report as the fax machine was located upstairs on the second floor. Nurse #2 said in the morning of 8/23/10, Nurse #2 thought Nurse #2 asked the Unit Manager to get Resident #1's faxed radiology report, but was not sure. Nurse #2 said Nurse #2 did not see Resident #1's faxed radiology report on 8/23/10. Nurse #2 said it was days later that Nurse #2 heard that the 8/22/10 telephone report was incorrect. Nurse #2's note, dated 8/23/10, indicated that during the night shift: Resident #1 was yelling about pain in the left elbow; mobile X-ray service called and reported Resident #1 did not have a fracture, and nursing staff would continue to monitor Resident #1. Review of Resident #1's faxed written addendum radiology report, dated 8/22/10, indicated that the written addendum radiology report was faxed to the Facility as a final report on 8/22/10 at 11:24 PM. The addendum radiology report, dated 8/22/10, indicating the impression that there was no fracture or dislocation seen, was amended to indicate that Resident #1's left humerus had an extremely subtle impacted supracondylar humeral fracture and Resident #1's left elbow had an extremely subtle distal humeral supracondylar impacted fracture and [MEDICAL CONDITION]. A nurse's note, dated 8/23/10, indicated that during the day shift: Resident #1 complained of left elbow pain on exertion; Resident #1 did not complain of pain when resting; Resident #1's left elbow was swollen, and 650 mg of APAP medication was administered to Resident #1 with some effect. A nurse's note, dated 8/23/10, indicated that during the evening shift Resident #1 complained of left elbow pain; Resident #1's left elbow was still swollen, and APAP medication was administered to Resident #1 with good effect. A nurse's note, dated 8/24/10, indicated that during the day shift: Resident #1 complained of left elbow pain with activity; the elbow pain was reported to Resident #1's Physician, who gave a new order to administer extra anti-gout medication, [MEDICATION NAME], that day and tomorrow. The August 2010 Nursing Summary, dated 8/24/10 and signed by Nurse #2, indicated: on 8/22/10, Resident #1 complained of left elbow pain, but Resident #1 did not know what happened to cause the pain; Resident #1's left elbow was swollen; Resident #1's left elbow was X-rayed; the X-ray results indicated there was no fracture, no dislocation, that Resident #1 had [MEDICAL CONDITION], and Resident #1 was medicated with APAP medication. A nurse's note, dated 8/24/10, indicated that during the evening shift Resident #1 complained of left elbow pain with activity; Resident #1 refused the APAP medication stating that Resident #1 did not need the APAP medication as Resident #1 did not have any pain unless Resident #1 moved Resident #1's left arm. The Three Day Pain Assessment Screen in the clinical record indicated that on 8/24/10: at 6 AM, Resident #1 had no complaints of pain; at 10 AM, Resident #1's left elbow pain was rated as a 7, which was identified as severe pain, and at 5 PM, Resident #1's left elbow pain was rated as a 2, which was identified as mild pain. A nurse's note, dated 8/25/10 indicated that during the day shift Resident #1 complained of left elbow pain and at 11 AM, 650 mg of APAP was administered with positive effect. The Three Day Pain Assessment Screen in the clinical record indicated that on 8/25/10: at 6 AM, Resident #1 had no complaints of pain; at noon, Resident #1 had no complaints of pain, and at 7 PM, Resident #1's left elbow pain was rated as a 6, which was identified as moderate pain. Nurse #1 said when Nurse #1 returned to the unit for the evening shift on 8/25/10, Nurse #1 was told that Resident #1 was receiving medication for gout due to Resident #1's complaints of left elbow pain. Nurse #1's note, dated 8/25/10, indicated that Resident #1 complained of discomfort of the left elbow when being given PM care and Resident #1 refused offers of the APAP medication during the shift. Nurse #3 was interviewed on 9/24/10 at approximately 1:15 PM. Nurse #3 said for approximately five days, from 8/22/10 until 8/27/10, Resident #1 had complained of left elbow pain and Resident #1 received APAP medication for the pain. Nurse #3 said during the day shift on 8/27/10, one of the certified nurse aides (CNA) asked Nurse #3 to come and look at Resident #1's elbow, which Nurse #3 did. Nurse #3 said Resident #1's left elbow was swollen and bruised and Resident #1 was crying in pain. Nurse #3 said the Unit Manager also examined Resident #1's left elbow. Nurse #3 said Nurse #3 and the Unit Manager decided to check Resident #1's clinical record. Nurse #3 said Nurse #3 and the Unit Manager found the faxed radiology report, dated 8/22/10, which indicated that Resident #1 had a fractured left humerus and a fractured left elbow. Nurse #3 said Nurse #3 reported Resident #1's fractures to the Nurse Practitioner, who gave a verbal order to administer an opioid [MEDICATION NAME] medication, [MEDICATION NAME], to manage Resident #1's pain and a verbal order to send Resident #1 for an orthopedic consult. A nurse's note, dated 8/27/10, indicated at 10 AM, Resident #1 continued to complain of left elbow pain; the written radiology report, dated 8/22/10, was reviewed and indicated Resident #1 had an extremely subtle impacted supracondylar humeral fracture and an extremely subtle distal humeral supracondylar impacted fracture and [MEDICAL CONDITION]. The Director of Nurses (DON) was interviewed on 9/24/10 at approximately 8:50 AM and throughout the day. The DON said Nurse #2 said Nurse #2 had not retrieved the radiology report of 8/22/10 regarding Resident #1. The DON said the DON was not able to determine who retrieved the faxed radiology report or who filed the radiology report in Resident #1's record. The DON said the DON received a written statement from the mobile X-ray services' Consultant regarding Nurse #2 receiving the wrong information verbally from the mobile X-ray services. The DON gave the Surveyor a copy of the X-ray Consultant's written statement addressed to the DON. The X-ray services' Consultant was interviewed on 10/28/10 at approximately 5:25 PM. The Consultant said and the Consultant's statement, which was not dated, indicated: 1) on 8/22/10, the results of a skeletal exam on Resident #1 was verbally reported as negative to the Facility when the final results identified the exam as being positive; 2) the investigation determined that a hard copy of the final results was faxed to the facility on [DATE] at 11:24 PM, which was prior to the telephone call. On 8/22/10 at 11:30 PM, the X-ray representative telephoned Resident #1's nurse with the negative results as the representative failed to scroll through the entire report before telephoning the Facility, therefore, missing the positive note in the report addendum, and 3) the X-ray representative was re-educated in the importance of reviewing the entire results prior to Facility notification. The Consultant said this Consultant always toldl facilities to depend on the hard copy results. The Consultant said the purpose of the telephone call was to verify that the facility received the faxed hard copy. The Staff Development Coordinator (SDC) was interviewed on 9/24/10 at approximately 11:50 AM. The DON and SDC said a nurse was expected to review the hard copy of a resident's radiology report to know how to proceed including notifying the physician of the results.