Every finding on record at Care One at Holyoke

Based on observation, and interview, the facility failed to ensure that the medication storage room was locked when unattended for one unit ([NAME] Unit), out of four medication storage rooms observed. Specifically, the facility failed to ensure:-For the [NAME] Unit, that the medication storage room was locked when not in use and was under direct supervision of authorized personnel when unlocked, when facility staff permitted unauthorized Maintenance Personnel access to the medication storage room which contained medications and treatments that were not secured and easily accessible, and the Maintenance Personnel was observed to prop open the medication storage room door and leave it unattended and unsecured on two occasions. Findings include: Review of the facility's policy titled Medication Labeling and Storage, revised 2/23, indicated but not limited to: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 9/11/25 at 12:02 P.M., surveyor #1 conducted an observation of the medication room, which was located behind the nurse's station on the [NAME] Unit (3rd floor nursing unit). Surveyor #1 observed that the nursing station did not have a door or other partition, and a resident was observed walking around the area near the nurse's station and the medication storage room. Surveyor #1 observed a Nurse unlock the medication storage room door for the Maintenance Personnel, and walked away, leaving the Maintenance Personnel in the medication storage room unsupervised and the medication room door unlocked. Surveyor #1 observed the Maintenance Personnel exit the medication storage room and say he would need to get back in there. At that time, surveyor #1 observed the Maintenance Personnel use a piece of wood to prop open the medication storage room door and exit the area, leaving the medication storage room door unlocked. Surveyor #1 observed that no authorized personnel were at the nurse's station to provide supervision of the unlocked medication storage room. Surveyor #1 further observed residents and other staff walking around the nurse's station area. On 9/11/25 at 12:06 P.M. (four minutes later), surveyor #1 observed the Maintenance Personnel return to the medication storage room with the door propped open. On 9/11/25 at 12:07 P.M., surveyor #1 observed the Maintenance Personnel leave the medication storage room with the door propped open a second time and no authorized personnel supervision was present. On 9/11/25 at 12:08 P.M., surveyor #1 observed a resident ambulating around the nurses' station. During an interview on 9/11/25 at 12:10 P.M., Unit Manager (UM) #1 said the Maintenance Personnel should always be supervised by a Licensed Nurse when in the medication storage room, and the medication storage room door should not be propped open leaving the medication storage room unattended and/or unsupervised by Licensed Staff. UM #1 said it was not safe to leave the medication storage room open and unattended because anyone including residents could get in. On 9/11/25 at 4:49 P.M., surveyor #2 and Nurse #1 reviewed the medication storage room on the [NAME] Unit. Surveyor #2 observed that there were medications accessible on the storage room shelves, multiple over-the-counter medications were observed in a black container on the counter in the room, as well as syringes, and prescribed bubble pack medications (for specific residents) from the pharmacy. During an interview at the time, Nurse #1 said the only medications that were locked within another compartment in the medication storage room were Insulin and other narcotics. During an interview on 9/11/25 at 5:14 P.M., the Director of Nursing (DON) said Nurses were the only staff authorized access to the medication storage room. The DON said if Maintenance Personnel were in the medication storage room fixing things, a Licensed Nurse was to be present to supervise. The DON said the Nurses were not to leave the medication storage room unattended with unauthorized personnel. The DON also said that the medication storage room door should not be left propped open and unsupervised by licensed personnel and should be locked at all times for safety.

Based on observation, interview, and policy review, the facility failed to ensure its staff used proper hand hygiene techniques on one unit (Deerfield) out of four units observed, and for one Resident (#66) out of a total sample of 32 residents. Specifically, Nursing staff failed to: 1. properly handle medications in a way as to reduce the risk for the spread of possible contaminates from bare hands to pills being distributed to residents on the Deerfield unit, and 2. properly don (put on), doff (take off), and perform hand hygiene per facility policy when providing wound care treatments for Resident #66 who had multiple wounds and a diagnosed wound infection. Findings include: 1. Review of the facility policy titled Administering Medications, edited 5/21/19, indicated the following: -Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 4/3/23 at 8:13 A.M., on the Deerfield Unit, the Surveyor observed Nurse #5 transferring pills with her bare hands from one medication cup to another medication cup. During an interview following the observation Nurse #5 said she should not be touching pills with her bare hands and that she should have donned (put on) gloves if she needed to touch the pills. During a follow up interview on 4/4/23 at 3:00 P.M., the Director of Nursing (DON) provided the surveyor with the facility policy titled Administering Medications. She said the policy did not specifically address touching pills with bare hands, but it was facility practice that if pills needed to be handled with bare hands a nurse should don gloves to touch the pills. She further said touching pills with bare hands was an infection control issue and increased the risk of contaminating the pills with any contaminants that may have been on the nurse's hands. 44129 2. For Resident #66, the facility failed to ensure their staff provided wound care in such a way to avoid contamination putting the resident at risk for further infection. Resident #66 was admitted to the facility in May 2012. Review of the medical record indicated the Resident had three pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin, also known as bed sores) and was prescribed intravenous antibiotics to treat a wound infection. Review of the facility titled, Clean Dressing Change, revised 4/29/16 indicated the following: - Clean dressing change technique will be used as clinically appropriate - Purpose: to promote wound healing, prevent infection. Procedure: - Remove soiled dressing - perform hand hygiene, don clean gloves, loosen soiled dressing, inspect color, odor, consistency, appearance and quantity of drainage present, observe appearance of wound, place soiled dressing in moisture proof bag, remove gloves and discard in bag, perform hand hygiene. - Prepare supplies - once preparation of supplies is completed, perform hand hygiene and don (apply) clean gloves. - Clean the wound - after cleansing wound as indicated, remove gloves, perform hand hygiene and don a new pair of gloves. - Treat the wound - after treating wound remove gloves and wash hands with soap and water. During a wound care observation on 4/4/23 at 10:09 A.M., the Surveyor observed Nurse #1 perform hand hygiene, apply a pair of clean gloves, and position the Resident to his/her left side. She then removed the contaminated dressing that was saturated with drainage from the wound, cleansed the wound, then applied the new dressing as ordered. While still wearing the same gloves she applied prior to changing the first dressing, Nurse #1 then assisted the Resident to his/her right side. Nurse #1 then removed the contaminated dressing saturated with drainage from the second wound, cleansed the wound, then applied the new dressing as ordered. While continuing to wear the same gloves she applied prior to changing the first and second dressings, Nurse #1 then moved onto the third wound. The surveyor observed Nurse #1 remove the contaminated dressing saturated with drainage, cleanse the wound, then apply the new dressing as ordered. Throughout the process, the surveyor did not observe Nurse #1 performing appropriate hand hygiene and change into clean gloves between dressing changes, after handling soiled dressings, prior to cleansing the wounds or prior to applying clean dressings. During an interview on 4/4/23 at 10:35 A.M., Nurse #1 said she should have removed her contaminated gloves and performed hand hygiene after handling the soiled dressings. She further said she should have performed hand hygiene and applied new gloves prior to cleansing the wounds as well as prior to performing the dressing change, and she did not as required.

Based on record review, policy review, and interviews, the facility failed to ensure that its staff provided adequate supervision and clinical intervention for one Resident (#70), out of a sample of 32 residents. Specifically, the facility staff failed to provide one-on-one supervision and assessment by clinical staff to evaluate for level of risk following an expression of suicidal ideation by the resident. Findings include: Resident #70 admitted to the facility in June 2020 with diagnoses including Schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), Major Depressive Disorder and Anxiety. Review of Resident #70's progress note dated 1/2/23, indicated that the Resident was weeping and felt that his/her suicidal thoughts were being triggered. Further review of the Resident's clinical record did not reveal that the Resident was being monitored or assessed for suicidal ideation risk by staff following the suicidal statement. Review of the facility policy for Suicide/Self-Harm Precautions, last revised February 2023, indicated: -Any suicidal statement or acts of self-harm are to be taken seriously and are to be reported immediately to the nurse in charge or neuro-rehab supervisor. -The resident is not to be left unattended. -When a resident expresses a wish or intention to harm or kill him or herself, he or she will be placed on close visual supervision until the level of risk can be assessed. -The Program Director will assign a licensed/trained person to assess the Resident, interview staff and review chart. Review of Resident #70's Mood Care Plan, last revised 3/2/23, indicated that the Resident has a history of overdosing on prescription medication and tying a blanket to a bed rail in an attempt to self-harm. The care plan intervention indicated to follow the facility policy for self-harm behaviors. During an interview on 4/4/23 at 9:09 A.M., Social Worker #1 said that residents with suicidal ideation are to be supervised by staff until they can be assessed by a Clinical Therapist for their level of risk. During an interview on 4/4/23 at 11:56 A.M., Social Worker #1 said that a staff member should have clarified if Resident #70 was suicidal and written a progress note, which they did not. During an interview on 4/4/23 at 12:12 P.M., the Administrator said that they did not follow their policy for self-harm precautions and they did not document any follow-up regarding Resident #70's suicidal ideation being triggered, which should have been completed by a Social Worker or Clinician. He further said that the Resident should have been on one-to-one supervision per the facility's policy.

Based on interviews and record review, the facility failed to ensure its staff: 1) received consent from the activated Health Care Proxy (HCP- person designated to make health care decisions on behalf of a person determined to not be able to make those decisions) for one Resident (#129) out of a total sample of 32 residents, prior to administering a medication used to treat mood and behavior, and 2) have the designated HCP sign required written consents. Findings include: Review of the facility policy titled Psychotropic Medication Use, edited 2/2/23, included the following: -a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior -categories of medications that affect brain activity such as antihistamines (medications used to treat allergies), anti-cholinergic medications (drugs that block/inhibit activity of a neurotransmitter that inhibits involuntary muscle movements and other bodily functions), central nervous system (brain and spinal cord) medications that are prescribed as a substitute for or an adjunct to a psychotropic medication are monitored and managed as psychotropic medications -Residents, families and/or the representatives are involved in the medication management process; when a state requires, informed consent is obtained and documented in the medical record prior to the start of the therapy in accordance with state-specific requirements . Resident #129 was admitted to the facility in September 2020 with diagnoses including Paranoid Schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), psychotic disorder, Major Depression, Anxiety, Dementia and Anoxic Brain Injury (lack of oxygen to the brain resulting in the death of brain cells). Review of the facility form titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy, dated 3/2/21, indicated Resident #129's designated HCP was invoked (put into effect) by the Physician (or designee) for a duration of life long due to his/her diagnoses of Paranoid Schizophrenia and Dementia. 1) Review of a Psychiatric Consult and Medication Review, dated 2/23/23, indicated a recommendation to start Metoprolol (medication used to treat high blood pressure that can also be used off label [the practice of prescribing a medication for a different purpose then what it was approved for] to treat anxiety) 12.5 milligrams (mg) daily due to his/her paranoia and trust issues. Review of the February 2023 Physician's orders indicated the following: -Metoprolol 25.0 mg, give 1/2 tablet (12.5 mg) in the morning related to Paranoid Schizophrenia, initiated on 2/24/23. Review of the February 2023 Medication Administration Record (MAR) indicated that Metoprolol 12.5 mg was administered at 9:00 A.M. on 2/24/23. Review of the clinical record did not indicate that the Resident's activated HCP provided consent for the Metoprolol prior to its administration, as required. During an interview on 4/4/23 at 11:10 A.M., Nurse #5 said that consent would be obtained by the Resident or their guardian or responsible party if the Resident was not able to make their own healthcare decisions prior to administration of a psychotropic medication. Nurse #5 said when there was an order to start a new medication, the order would be entered into the electronic medical record (EMR) and put on hold until consent was obtained prior to administration of the medication. She further said that the Unit Manager (UM) was responsible for ensuring consent was obtained prior to administering psychotropic medications. During an interview on 4/4/23 at 11:13 A.M., UM #1 said consent must be obtained prior to administering a new psychotropic medication, and that the medication would be put on hold and not given until consent was obtained by the responsible party. During a follow-up interview on 4/4/23 at 2:41 P.M., UM #1 reviewed the February 2023 MAR with the surveyor. She said Metoprolol should not have been administered to Resident #129 on 2/24/23 without obtaining consent from his/her activated HCP. 2) Review of the April 2023 Physician's Orders included the following: -Clozaril (antipsychotic medication to treat Schizophrenia) at bedtime (HS) for Anxiety and Paranoid Schizophrenia -Lyrica (nerve pain medication used off label to treat anxiety) twice daily for psychotic disorder/delusions -Remeron (antidepressant) daily at HS for Depression Review of the Informed Consent for Psychotropic Administration Forms for the following medications: Clozaril, Lyrica and Remeron, indicated the following: -the forms did not indicate that the Resident/Resident Representative refused or consented to administration of the medications (the boxes to check off refusal of the medication or consent of the medication were unchecked), and -the forms were signed by Resident #129 even though his/her HCP was invoked 3/2/21. During an interview on 4/4/23 at 2:41 P.M., UM #1 reviewed the signed Informed Consent for Psychotropic Administration Forms with the surveyor. UM #1 said she was not aware that the Resident's HCP was invoked on 3/2/21. UM #1 said the Informed Consent forms for Remeron signed on 1/21/22, and Lyrica and Clozaril signed on 6/24/22, should not have been signed by Resident #129. During an interview on 4/4/23 at 3:05 P.M., the Director of Nurses (DON) said that Resident #129 should not have signed his/her paperwork after the HCP was invoked. She also said that consent should have been obtained by the Resident's HCP prior to the administration of Metoprolol on 2/24/23.

Based on observation, interview and record review, the facility failed to ensure its staff implemented a plan of care related to pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) for one Resident (#66) out of a total sample of 32 residents. Specifically, the facility staff failed to implement the Physician's orders for ensuring: A. treatment to prevent further skin breakdown was applied as ordered, B. weekly skin assessments were completed as ordered, and C. air mattress settings were set appropriately. Findings include: Review of the facility policy titled Prevention of Pressure Injuries, revised April 2020, indicated the following: -To conduct a comprehensive skin assessment .with each risk assessment, as indicated according to the resident's risk factors. Resident #66 was admitted to the facility in May 2012 with diagnoses including Parkinson's Disease, Hemiplegia (weakness of one entire side of the body), and malnutrition. Review of the most recent wound consult progress note dated 3/29/23 indicated the following: -Pressure ulcer of right and left buttock, Stage Four (involves full-thickness skin and tissue loss, exposing muscle, bone, and sometimes tendons, ligaments, or cartilage) -Pressure ulcer of left hip, Stage Four -Resident has chronic pressure ulcers -Resident has severe contractures A. Review of the April 2023 Physician's orders indicated an order to replace the lamb's wool between the Resident's right toes every day and evening shift for protection, initiated on 10/28/21. During an observation and interview on 4/3/23 at 9:57 A.M., the surveyor and Nurse #2 observed Resident #66 to not have lamb's wool in between his/her toes. She said that he/she should have lamb's wool in between his/her right toes for protection, but it was not there, as required B. Review of the April 2023 Physician's orders indicated an order to complete the skin observation tool (an observation tool utilized by licensed nursing staff and completed in the electronic medical record [EMR]) every day shift on Thursday, initiated on 7/15/21. Review of the EMR from 1/1/23 - 3/30/23, indicated only six of the 13 required skin observations were completed during this time. During an interview on 4/3/23 at 1:22 P.M., the Director of Nurses (DON) said that the skin assessments are completed only on the skin observation tool and are not noted anywhere else. The surveyor and the DON both reviewed the skin observation tools that were completed from 1/1/23 - 3/30/23. The DON said that from January to April, seven of the weekly skin observations had not been completed as required. During a follow up interview on 4/4/23 at 10:04 A.M., the DON said that when the staff performed a skin assessment it is from head to toe. She further said that when the wound doctor comes in to see a resident, they are typically only looking at what the facility staff have asked them to look at and it is not a full head to toe skin assessment. C. Review of the April 2023 Physician's orders indicated an order to check the air mattress setting every shift, keep it on therapy mode, soft setting second light from the bottom, every shift for pressure relief, initiated on 12/21/21. During an interview and observation on 4/4/23 at 2:11 P.M., Nurse #2 and the surveyor observed Resident #66's air mattress was set to the fifth light from the bottom (bottom indicating soft setting). Nurse #2 said that the air mattress should be set to the second light from the bottom per the Physician's orders, especially because Resident #66 currently has wounds, and the air mattress was not set as required.

Based on observations, interview, and record review, the facility failed to ensure its staff provided reasonable accommodations based on individual preferences for one Resident (#129), out of a total sample of 32 residents. Specifically, the facility failed to provide a footboard that would prevent the mattress from sliding down and off the resident's bed. Findings include: Review of the facility policy titled Work Orders-Maintenance, revised April 2010, indicated maintenance work orders shall be completed in order to establish a priority of maintenance services. The policy included the following: -work orders must be filled out and forwarded to the Maintenance Director -supply of work orders is maintained at each nurses' station -work order requests should be placed in the appropriate file basket at the nurses' station. -Work orders are picked up daily -emergency requests will be given priority in making necessary repairs Review of the Environmental/Safety Sheet, undated and provided by the facility on 4/4/23, included the following: -scan environment for safety concerns throughout shift! -does the identified issue pose a safety risk to the residents/staff? If so- correct immediately! -notify maintenance right away (as appropriate) . -for non-emergent issues, please fill out a maintenance slip including a detailed description, location and name of the person that identified issue. Resident #129 was admitted to the facility in September 2020 with diagnoses including Amblyopia (lazy eye: decreased eyesight due to abnormal visual development) and bilateral cataracts (cloudy area in the lens of the eye that leads to decreased vision). Review of the Minimum Data Set (MDS) Assessment, dated 2/24/23, indicated Resident #129 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15. On 3/30/23 at 1:48 P.M., the surveyor observed Resident #129 lying in bed. The mattress was observed hanging approximately one foot off the bed and the Resident's legs were angled towards the floor. On 4/4/23 at 9:24 A.M., the surveyor observed Resident #129 lying in bed. The head of the bed was elevated, approximately one foot of the bed frame was exposed at the head of the bed and the lower part of the mattress was observed hitting the floor. There was no foot board on the end of the bed. During an interview at this time, Resident #129 said that his/her bed had been this way for a while and that he/she always needed to move the mattress up onto the bed frame because it slides. Resident #129 further said that he/she would like to have this problem fixed. Review of the Resident's Care Plan and clinical record indicated no documented evidence that he/she requested to have the footboard to the bed removed. During an interview on 4/4/23 at 9:28A.M. and 9:40 A.M., Nurse #4 said she noticed that the Resident's mattress slides off the bed and that there was no footboard present. She said she noticed the footboard was not there weeks ago, had verbally mentioned it to someone and said there was someone going room to room checking equipment and beds at that time. Nurse #4 said maintenance requests should be written on a form in the maintenance book, which was located at the nurse's station, so that it can be followed up on. She further said that she was not sure what happened after she verbally mentioned the status of the Resident's mattress and footboard, but it was still not fixed. Review of the Maintenance Book located on the unit indicated no documented evidence that there was a request submitted relative to Resident #129's bed. During an interview on 4/4/23 at 10:16 A.M., Certified Nurses Aide (CNA) #1 said that she could not recall a time when Resident #129 had a footboard located on his/bed and that it had been this way (missing the footboard) as long as she could remember. During an interview on 4/4/23 at 11:13 A.M., Unit Manager (UM) #1 said that she was not aware of the status of Resident #129's mattress and footboard. She said that if the Resident had requested to have the footboard removed from the bed, it would be on the Resident's Care Plan. UM #1 said that if a maintenance concern or request arises, maintenance are notified and check in with the unit daily. During an interview on 4/4/23 at 11:33 A.M., the Director of Maintenance said that he was not made aware of the issue with Resident #129's bed until today when nursing notified him that a footboard was needed. He said a maintenance slip should have been completed when the issue was identified, that this was never completed, and that if he had been notified earlier, it would have been addressed immediately as it was a quick fix. During an interview on 4/4/23 at 3:05 P.M., the Director of Nurses (DON) said that she was made aware of the concern about Resident #129's bed. She said there was a process for maintenance requests and that the process was not followed as it should have been.

Based on observations, interviews, and policy review, the facility failed to ensure its staff maintained safe storage of medications. Specifically, facility staff failed to ensure: 1. an unattended medication cart was locked on one unit ([NAME]), out of four units, and 2. food was kept separate from medications in one unit (Deerfield), out of four medication storage rooms. Findings include: Review of the facility policy titled, Storage of Medications, revised November 2020 indicated the following: - Drugs and biologicals used in the facility are stored in locked compartments - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. - Medications are stored separately from food and are labeled accordingly. 1. On 3/31/23 at 11:34 A.M., the surveyor observed an unattended, unlocked medication cart on the [NAME] unit. The surveyor also observed a resident seated approximately four feet away from the cart and there was no staff within view of the medication cart at the time. At 11:36 A.M., the surveyor observed Nurse #6 quickly walk by the cart, engage the locking mechanism, and continue down the hallway. During an interview on 3/31/23 at 11:40 A.M., Nurse #6 said the unlocked cart was not within her view when she left it to attend to a resident. 2. During an observation and interview on 4/4/23 at 8:47 A.M., the surveyor accompanied Nurse #2 to the Deerfield unit medication room to look for a medication in the emergency medication kit. When Nurse #2 removed the emergency kit box off of the electronic medication dispensing system, the surveyor and Nurse #2 observed a takeout container with onion rings on top of the medication dispensing system. Nurse #2 said the onion rings should not have been there and there should not be food in the medication room.

Based on record review and interview, the facility failed to ensure that one Resident (#82), out of a total sample of 32 residents, was free of significant medication errors per facility policy and professional standards. Specifically, the facility staff administered unauthorized medications to Resident #82, that was intended for another resident. Findings include: Resident #82 was admitted to the facility in June 2015. Review of the facility policy for Adverse Consequences and Medication Errors, last revised February 2023, indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards of the professionals providing services. Professional standards in preventing medication errors that compromise patient safety are included in Nursing Rights of Medication Administration, authored by [NAME], A and [NAME], L. M (last updated September , 2022), https://www.ncbi.nlm.nih.gov/books/NBK560654/ The traditional 'five rights' or 'five R's' of medication administration are as follows: -Right patient - ascertaining that the patient being treated is the correct recipient for whom the medication was prescribed . -Right drug - ensuring the medication to be administered is identical to the drug prescribed . -Right route - how medications are safely delivered to patients -Right time - administering medications at a time that was intended by the prescriber . -Right dose - checking to ensure the dosage is the correct strength for the patient Review of Resident #82's progress note, dated 3/27/23 indicated that the Resident was administered another resident's medication, the Physician was notified and that the Resident's vital signs were to be monitored by staff for the following 72 hours. Review of the Medication Error Report, dated 3/27/23, indicated that Nurse #3 had administered the following medications to Resident #82 in error: -Eliquis 5 milligrams (mg) (anti-coagulant) -Pepcid 40 mg (gastric acid secretion reducer) -Percocet 5-325 mg (analgesic opioid oxycodone combination) -Olanzapine 5 mg (antipsychotic) During an interview on 4/4/23 at 7:15 A.M., the Director of Nurses (DON) said that Nurse #3 gave Resident #82 his/her roommate's medications without confirming who the Resident was prior to administration. She further stated that the Resident should have only received medications as ordered by the Physician.

Based on record review and interview, the facility failed to ensure the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, there was no evidence that the Infection Preventionist had attended three out of the five QAPI meetings, as required. Findings include: Review of the facility policy for Quality Assurance and Performance Improvement Committee, last revised July 2016, indicated that the following individuals will serve on the committee: -Committee chairperson -Administrator -Director of Nursing Services -Medical Director -Dietary Representative -Pharmacy Representative -Social Services Representative -Activities Representative -Environnemental Services Representative -Infection Control Representative During an interview on 4/05/23 at 3:58 P.M., the Administrator said that the Infection Preventionist did not attend the quarterly QAPI meetings as required. The Infection Preventionist missed the QAPI meetings held on 1/21/22, 10/29/22 and 1/24/23.

Based on interview, record review, and policy review, the facility failed to ensure its staff provided cumulative information on the number of confirmed COVID-19 cases within the facility to residents, their representatives, and families. Findings include: Review of the facility policy titled Coronavirus Disease (COVID-19)-Reporting Facility Data to Residents and Families, dated May 2020, indicated the following: -Cumulative information on the number of cases of confirmed COVID-19 or new onset of respiratory symptoms is included with the notice of confirmed case(s), or clusters of three or more residents or staff with respiratory symptoms occurring within 7 hours of each other. Cumulative updates are reported at least weekly. Review of the Voice Friend (program used by the facility to update residents, resident representatives, and families of COVID-19 cases within the facility) printed memo provided by the Administrator, dated 3/30/23, indicated no cumulative update on the total number of residents and/or staff cases of COVID-19 within the facility. Review of the Voice Friend printed memo provided by the Administrator, dated 4/1/23, indicated no cumulative update on the total number of residents and/or staff cases of COVID-19 within the facility. During an interview on 4/5/23 at 1:50 P.M., the Administrator said he was unaware that cumulative updates needed to be provided to residents, resident representatives, and families and that cumulative updates had not been put in the Voice Friend notifications the facility sent out to residents, resident representatives, and families. He further said he had reviewed the facility policy and cumulative updates should have been provided at least weekly, and that was not being done as required.

Based on observations, record reviews and interviews, the facility failed to ensure accurate and/or complete medical records for four sampled Residents (#23, #66, #57 and #35), out of a total sample of 30 residents. Findings include: 1. For Resident #23, the facility failed to ensure an accurate medical record relative to the administration of oxygen therapy. Resident #23 was admitted to the facility in March of 2016 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- condition involving constriction of the airways and difficulty or discomfort in breathing). On 7/27/21 at 9:27 A.M., the surveyor observed Resident #23 seated in a wheelchair in his/her room. Oxygen (O2) therapy was observed being administered to Resident #23, via a nasal cannula (tube inserted within the nose), which was connected to a concentrator set at a flow rate of 2 liters/minute or LPM (the percentage or concentration of O2 that a person inhales). Review of the Respiratory Care Plan, revised 3/24/16, indicated to administer oxygen as needed at 2 LPM to maintain an oxygen saturation level greater than 98% (O2 saturation measures the percentage of O2 in the blood). Review of the Certified Nurse Aide (CNA) Care Card, revised 6/9/20, indicated oxygen was to be administered at 2 LPM as needed to maintain an O2 saturation level greater than 92%. Review of the July 2021 Physician's Orders, indicated an order, initiated (2/5/21), for oxygen to be administered as needed (PRN) for O2 saturation levels less than 88%. During an interview on 7/30/21 at 10:11 A.M., the Director of Nurses (DON) said that the Respiratory Care Plan, Physician's Orders and CNA Care Card should match relative to when oxygen therapy was to be administered. 2. For Resident #66, the facility failed to ensure an accurate Physician's Order relative to the setting of an air mattress. Resident #66 was admitted to the facility in May of 2020 with diagnoses including traumatic brain injury and multiple contractures of the hips and knees. On 7/28/21 at 12:35 P.M. and on 7/29/21 at 8:42 A.M. and 12:02 P.M., the surveyor repeatedly observed Resident #66 lying in bed on an air mattress which was set at 5. Review of Resident #66's July 2021 Physician's Orders, indicated the following: -air mattress to be set at 6 (third light from the top), check every shift to assure appropriate comfort level. During an interview on 7/29/21 at 1:51 P.M. and subsequent interview at 2:32 P.M., the Director of Nurses (DON) said that that the company who supplied the air mattress for Resident #66 initially set it up for him/her. She later said that the company was contacted and indicated that the Resident's air mattress should be set at 5, not at 6. The DON said that the Physician's Orders would be adjusted to reflect to correct setting. 37700 3. For Resident #57, the facility failed to indicate a stop date for an, as needed (PRN), psychotropic medication. Resident #57 was admitted to the facility in February of 2020 with a diagnosis of Cerebral Infarction (a stroke). Review of the medical record indicated a Physician Order, dated 5/11/21, for Valium (an anti-anxiety) 5 milligram, give 0.5 tablet orally every 8 hours PRN for increased anxiety related to Generalized Anxiety Disorder. There was no stop date indicated in the Physician Order. Review of the medical record indicated a Consultant Pharmacist Recommendation, dated 5/28/21, for the Medical Doctor (MD) to address the Valium PRN order and please add a stop date after which the order can be re-evaluated. The form did not contain a response from the Physician to either agree, disagree or document a response. Review of the Medication Administration Records (MAR) indicated the Resident received the PRN Valium doses in May, June and July of 2021. During an interview on 7/30/21 at 1:12 P.M., the Director of Nurses (DON) gave a copy of the Consultant Pharmacist Recommendation form, dated 5/28/21, that indicated a response, dated 6/01/21, to review the PRN Valium order in 90 days. The DON said the stop date should have been indicated on the MARs and it was not. 4. For Resident #35, the facility failed to accurately document the pulse and blood pressure in relation to the administration of a medication which was dependent upon this data. Resident #35 was admitted to the facility in April of 2020 with diagnoses including dementia with behavioral disturbance. Review of the medical record indicated a Physician Order, dated 04/25/20, for propranolol (a medication used to treat high blood pressure, heart failure and irregular heartbeat which also can be used to manage anxiety symptoms) 10 milligrams (mg), give one tablet by mouth one time per day, hold for a systolic blood pressure less than 100 millimeters of mercury (mm/Hg) or a pulse less than 60 beats per minute. Review of the June 2021 Medication Administration Record (MAR) for the propranolol order indicated a dedicated area to document the Resident's blood pressure and pulse prior to the administration of the medication. Further review of the June 2021 MAR indicated Not Applicable (NA) under both the blood pressure and pulse column for a total of 10 out of 30 days. Review of the July 2021 MAR indicated NA under both the blood pressure and pulse column for a total of 17 out of 30 days. During an interview on 07/29/21 at 02:09 P.M., the surveyor asked Unit Manager (UM) #1 what NA indicated in the blood pressure and pulse column. She said it appeared that nursing staff entered NA meaning 'not applicable' because the nursing staff may have been obtaining the daily vital sign data that had already been recorded elsewhere in the medical record prior to administering the medication. The surveyor said the MAR data appears as though the medication was being administered without first checking the Resident's blood pressure and pulse to which UM #1 said the information was confusing. Review of the Resident's medical record indicated documented pulse and blood pressure after the medication administration time in 8 out of 30 days in June of 2021 and 13 out of 30 days in July of 2021. During an interview on 7/30/21 at 1:30 P.M., the surveyor asked the DON why the time of the recorded blood pressure and pulse readings were well after the administration of the medication. The DON said that the times listed in the computer are likely when the nurse gets around to data entering the information versus the time the information was obtained. She said the nurse generally keeps track of the information on a piece of paper and enters that information later on in the shift. The DON further said the electronic Medical Administration Record prompts the nurse to enter the blood pressure and pulse readings at the time of medication administration and they should have been doing this.

Based on policy review, observations and interviews, the facility failed to 1.) Ensure one medication cart on two of four units observed were clean and orderly and 2.) The facility failed to ensure one of two medication refrigerators inspected were at the required temperature setting. Findings include: Review of the facility Storage of Medications Policy, revised November 2020, included: - The facility stores all drugs and biologicals in a safe, secure and orderly manner. - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. - Drugs and biologicals are stored in packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1.) A. On 7/29/21 at 8:45 A.M., the surveyor observed the [NAME] Unit Medication Cart B with Nurse #1. The surveyor observed numerous different colored loose pills and white tabs (these tabs are punched out when a medication is removed from a blister card) found on the floor of a medication drawer. During an interview on 7/29/21 at 8:50 A.M., Nurse #1 said the medication drawer was not clean and should not have had the loose pills and white tabs in the drawer. B. On 7/29/21 at 8:55 A.M., the surveyor observed the Deerfield Unit Medication Cart B with Nurse #6. The surveyor observed one container of Anti-Itch Cream and numerous different colored loose pills and white tabs were found on the floor of a medication drawer. During an interview on 7/29/21 at 9:00 A.M., Nurse #6 said the Anti-Itch cream did not belong in the medication cart and she said the medication drawer was not clean and should not have had the loose pills and white tabs on the floor of the medication drawer. 2.) On 7/29/21 at 8:20 A.M., the surveyor observed the [NAME] Unit medication refrigerator with Nurse #3. The surveyor observed the refrigerator thermometer temperature to be 32 degrees Fahrenheit (F). The refrigerator contained numerous unopened insulin's and eye medications. Review of the Nursing 2016 Drug Handbook indicated: -Unopened insulin's should be stored in the refrigerator at 36-46 degrees Fahrenheit During an interview on 7/29/21 at 8:20 A.M., Nurse #3 showed the surveyor a Medication Room Refrigerator log sheet that indicated the refrigerator temperature reading should be between 35-41 degrees F. On 7/29/21 at 10:35 A.M., the surveyor observed the [NAME] Unit medication refrigerator with Nurse #3 and the refrigerator thermometer indicated the temperature to be 32 degrees F. During an interview on 7/29/21 at 10:45 A.M., the Director of Nurses (DON) said the refrigerator temperature range on the log sheet indicated an incorrect range and she further said the refrigerator temperature of 32 degrees was too low and not within the required range of 36 - 46 degrees Fahrenheit.

Based on record review, policy review and interview, the facility failed to prevent a significant medication error for one sampled Resident (Resident #35), out of a total sample of 30 residents. Findings include: Resident #35 was admitted to the facility in April of 2020 with diagnoses including dementia with behavioral disturbance. Review of facility Administering Medications Policy, revised in April of 2019, included: -Medications are administered in accordance with prescriber orders, including any required time frame. -The following information is checked/verified for each resident prior to administering medications: -Allergies to medications -Vital signs if necessary Review of the medical record indicated a Physician Order, dated 04/25/20, for propranolol (a medication used to treat high blood pressure, heart failure and irregular heartbeat which also can be used to manage anxiety symptoms) 10 milligrams (mg), give one tablet by mouth one time per day, hold for systolic blood pressure less than 100 millimeters of mercury (mm/Hg) or for a pulse less than 60 beats per minute. Review of the June 2021 Medication Administration Record (MAR) indicated administration of propranolol on 06/21/22 with a recorded systolic blood pressure of 93 mm/Hg which was outside of the parameters set forth in the physician's order. During an interview on 07/30/21 at 08:56 A.M., the surveyor asked Unit Manager (UM) #1 what the procedure would be if the resident's blood pressure or pulse were outside of the parameters ordered by the Physician. UM #1 said the medication should be held and the Physician should be notified. Upon review of the Resident's MAR for 6/23/21, UM #1 said the Resident should not have received the propranolol on that date based on the recorded blood pressure reading. Review of the MAR for 07/12/21 and 07/25/21 indicated the administration of propranolol with no recorded blood pressure or pulse readings. Further review of the Resident's clinical record indicated that there were no recorded vital signs, including blood pressure and pulse on 07/12/21. Review of the progress notes indicated the Resident refused having vital signs taken on 07/12/21. During an interview on 07/30/21 at 03:14 P.M., the surveyor asked the Director of Nursing (DON) what the procedure was if a medication was dependent upon vital sign parameters for administration and the resident refuses to have their vitals measured. She said the medication should not be given, the Physician should be notified and the clinical record noted. The DON further said the medication should not be given at all if the resident's blood pressure and pulse were not measured prior to medication administration.

Based on policy review, observations, record reviews and interviews, the facility failed to ensure infection control guidelines were maintained during 1.) The preparation of medications for an administration pass and 2.) A dressing change procedure. Findings include: 1. The facility failed to ensure medications were handled with gloved hands. Review of the facility Administering Medication Policy, edited 5/21/19, indicated: -staff follows established facility infection control procedures (ex. handwashing, antiseptic technique, gloves, isolation precautions, etcetera) for the administration of medication, as applicable. On 7/29/21 at 1:30 P.M., the surveyor observed the medication preparation for administration. The surveyor observed Nurse #4 place her hand behind each medication bubble card and push the medication out from the card while using her ungloved fingers to remove each pill from the bubble card and place each pill into the medication cup. Nurse #4 obtained four different medications in this same manner. She did not wear gloves and touched each pill with her ungloved fingers. During an interview on 7/29/21 at 1:35 P.M., Nurse #4 said she touched each pill with her bare hands and did not wear gloves, as required. 2. The facility failed to sanitize hands prior to donning (putting on) on new gloves during a wound clean dressing change procedure. Review of the facility Clean Dressing Change Policy, revised 4/29/16, indicated: -after removing a soiled dressing to remove gloves and perform hand hygiene according to local requirements. After cleaning a wound, to remove gloves, perform hand hygiene according to local requirements and don a new pair of gloves. On 7/30/21 at 11:08 A.M., the surveyor observed a clean dressing change procedure. The surveyor observed Nurse #5 remove her soiled gloves three times and, prior to donning a new pair of gloves, failed to sanitize her hands. During an interview on 7/29/21 at 11:15 A.M., Nurse #5 said the requirement was to sanitize her hands prior to donning new gloves during the dressing change procedure and she did not sanitize her hands for three opportunities during the procedure, as required.

Based on record reviews and interviews, the facility failed to notify the State Long Term Care Ombudsman when five sampled Residents (#19, #97, #32, #57 and #94), out of a total sample of 30 residents were transferred to the hospital. Findings include: 1. For Resident #19, the facility failed to notify the State Long Term Care Ombudsman of two hospitalization s. Resident #19 was admitted to the facility in October of 2015. Review of the nurse's note, dated 04/14/21, indicated the Resident was transferred to the hospital on 4/14/21. Review of the nurse's note, dated 4/25/21, indicated the Resident returned from the hospital on 4/24/21. Review of the nurse's note, dated 6/06/21, indicated the Resident was transferred to the hospital on 6/06/21. Review of the nurse's note, dated 6/10/21, indicated the Resident returned from the hospital on 6/10/21. Review of the clinical record indicated no evidence that the State Long Term Care Ombudsman was notified of the Resident's hospital admissions of 4/14/21 and 6/06/21. 2. For Resident #97, the facility failed to notify the State Long Term Care Ombudsman of two hospitalization s. Resident #97 was admitted to the facility in May of 2012. Review of the nurse's note, dated 6/02/21, indicated the Resident was transferred to the hospital on 6/02/21. Review of the nurse's note, dated 6/08/21, indicated the Resident returned from the hospital on 6/08/21. Review of the nurse's note, dated 6/19/21, indicated the Resident was transferred to the hospital on 6/19/21. Review of the nurse's note, dated 6/27/21, indicated the Resident returned from the hospital on 6/27/21. Review of the clinical record indicated no evidence that the State Long Term Care Ombudsman was notified of the Resident's hospital admissions of 6/02/21 and 6/19/21. 42690 3. Resident #32 was admitted to the facility in August of 2020. Review of a progress note, dated 4/29/21, indicated Resident #32 was transferred and admitted to the hospital on 4/28/21 due to a fall, resulting in leg pain. Review of the medical record indicated Resident #32 returned to the facility on [DATE]. Further review of the medical record did not indicate that the State Long Term Care Ombudsman was notified of the Resident's hospital admission of 4/28/21. 37700 4. Resident #57 was admitted to the facility in February of 2020. Review of the medical record indicated the Resident was transferred and admitted to the hospital from 5/07/21- 5/11/21 for hypotension (low blood pressure) and bradycardia (low pulse). Further review of the medical record did not indicate the State Long Term Care Ombudsman had been notified of the hospitalization . 5. Resident #94 was admitted to the facility in November of 2007. Review of the medical record indicated Resident #94 was transferred and admitted to the hospital from 4/27/21-5/01/21 for anemia (low blood count) and a Urinary Tract Infection (UTI). Further review of the medical record did not indicate the State Long Term Care Ombudsman had been notified of the hospitalization . During an interview on 7/29/21 at 3:25 P.M., the Director of Social Services (SW) said she was responsible to notify the State Long Term Care Ombudsman monthly of unplanned transfers to the hospital. She further said she had misunderstood and stopped notifying the State Long Term Care Ombudsman of monthly unplanned hospital transfers since August of 2020.

Based observations and interviews, the facility failed to adhere to infection control practices relative to hand hygiene and adhering to Transmission Based Precautions for management of COVID-19. Findings include: Review of the facility policy entitled Handwashing/Hand Hygiene, reviewed 2/28/20, indicated to use an alcohol-based hand rub .or, alternatively, soap and water for the following situations: -before and after direct contact with residents, -before and after preparing or handling medications, -before donning and doffing gloves, -before and after entering isolation precaution settings Review of the facility census/information sheet, provided to the surveyor on entrance to the facility on [DATE] at 7:30 A.M., indicated there were 20 residents who were COVID-19 negative. Of the 20 COVID-19 negative residents, 10 of the residents were co-horted in rooms with COVID-19 positive and recovered residents. Review of the facility Personal Protective Equipment (PPE) information sheet, undated, indicated for facility staff to don full PPE on room entry for residents who have never tested positive and are asymptomatic for COVID-19. The form indicated full PPE to include mask, goggles, gown and gloves. Review of the guidance provided by the assigned Department of Public Health (DPH) Epidemiologist, undated, indicated for the facility to maintain full PPE for COVID-19 negative residents until otherwise notified by the DPH. During the facility tour with the Director of Nurses (DON) conducted on 6/16/20 from 8:45 A.M. through 9:15 A.M., the surveyor observed the following: -Housekeeper #1 in a room that housed a COVID-19 negative resident cleaning the floor and side tables. A COVID-19 negative resident and a COVID-19 positive recovered resident were in the room and neither had on face masks. Housekeeper #1 was observed to have a face mask and gloves only on. Signage on the door to enter the room indicated full PPE required. The surveyor observed Housekeeper #1 exit the room without doffing gloves and face mask, and wheel cleaning bucket to the housekeeping closet down a separate hallway. -Nurse #1 in hallway near the nursing station observed providing medications to a resident who was seated in the hallway. Nurse #1 administered medications to this resident, then got a tissue to assist with wiping his/her nose, doffed gloves and donned new gloves without conducting hand hygiene. During an interview on 6/16/20 at 10:00 A.M., the DON said that Housekeeper #1 should have doffed gloves and conducted hand hygiene upon exiting the precaution room indicating full PPE. She further said that she did not think that Housekeeper#1 had to don full PPE when entering that room because she was not providing patient care. When the surveyor asked why full PPE was in place for COVID-19 negative residents, the DON said it was to protect the residents from possible exposure to COVID-19. She further said that the facility did have community spread and had direction from DPH epidemiology for guidance for PPE use. The DON said that Nurse #1 should have conducted hand hygiene after doffing gloves with direct patient care/administration of medications.

Based on observation, interview and record review the facility staff failed to ensure the manufacturer's instructions were followed for dishwasher temperatures. Findings include: The manufacturer's instructions were posted on the side of the dishwasher and indicated the required wash cycle temperature was 160 degrees Fahrenheit (F) and the the rinse cycle temperature was 180 degrees F. On 4/25/19 at 10:59 [NAME]M. the surveyor and the Food Service Director (FSD) observed the dishwasher operating. The wash cycle temperature was observed to be 152 degrees F, and the rinse cycle temperature was observed to be 180 degrees F. Review of the facility dishwasher temperature logs for February, (MONTH) and (MONTH) 2019 indicated that the wash cycle temperatures were recorded 3 times a day, after breakfast, lunch and dinner. The temperature logs indicated the wash cycle temperatures were below the manufacturer's guidelines during February, (MONTH) and April. The temperatures ranged between 153-159 degrees F, as follows: February - The breakfast wash cycle temperatures were recorded below the manufacturer's guidelines of 160 degrees F for 25 of 28 days. -The lunch wash cycle temperatures were recorded below the manufacturer's guidelines of 160 degrees F for 5 of 28 days. - The dinner wash cycle temperatures were recorded below the manufacturer's guidelines of 160 degrees F for 4 of 28 days. March - The breakfast wash cycle temperatures were recorded below the manufacturer's guidelines of 160 degrees F for 26 of 31 days. - The lunch wash cycle temperatures were recorded below the manufacturer's guidelines of 160 degrees F for 1 of 31 days. April - The breakfast wash cycle temperatures were recorded below the manufacturer's guidelines of 160 degrees F for 22 of 25 days. During an interview and review of the dishwasher temperature logs of February, (MONTH) and April, with the FSD on 4/25/19 at 3:25 P.M., she said that she was unaware of the manufacturer's guidelines for the wash cycle temperatures. She further said that the breakfast wash cycle temperatures did not meet the manufacture's guidelines.

Based on interview and record review the facility staff failed to provide the resident or resident's representative written notice of a transfer or discharge to a hospital for 6 residents (#21, #45, #61, #79, #129, #143) in a total sample of 31 residents. Findings include: 1. Resident #79 was admitted to the facility in 2/2015. Review of the clinical record indicated the resident was hosptalized on [DATE]. There was no indication a written notice of transfer was provided to the resident or the resident's representative. On 4/26/19 at 10:46 [NAME]M. during an interview with the Director of Nurses (DON), she said no written notice of transfer was provided to the resident or the resident's representative. 2. Resident #129 was admitted to the facility in 2/2015. Review of the clinical record indicated the resident was hospitalized [DATE]. There was no indication a written notice of transfer was provided to the resident or resident's representative. On 4/30/19 at 9:02 [NAME]M. during an interview with the DON, she said no written notice of transfer was provided to the resident or the resident's representative. 3. Resident #21 was admitted to the facility in 10/2012. Review of the clinical record indicated the resident was hosptalized on [DATE]. There was no indication a written notice of transfer was provided to the resident or the resident's representative. On 04/30/19 02:26 P.M. during an interview with the DON, she said no written notice of transfer was provided to the resident or the resident's representative. 4. Resident #45 was admitted to the facility in 11/1989. Review of the clinical record indicated the resident was hosptalized on [DATE]. There was no indication a written notice of transfer was provided to the resident or the resident's representative. On 04/30/19 02:26 P.M. during an interview with the DON, she said no written notice of transfer was provided to the resident or the resident's representative. 5. Resident #61 was admitted to the facility in 2/2017. Review of the clinical record indicated the resident was hosptalized on [DATE]. There was no indication a written notice of transfer was provided to the resident or the resident's representative. On 04/30/19 02:26 P.M. during an interview with the DON, she said no written notice of transfer was provided to the resident or the resident's representative. 6. Resident #143 was admitted to the facility in 5/2010. Review of the clinical record indicated the resident was hospitalized in 3/19/19. There was no indication a written notice of transfer was provided to the resident or the resident's representative. On 4/26/19 at 1:57 P.M. during an interview with the Director of Nurses (DON), she said no written notice of transfer was provided to the resident or the resident's representative.

Based on interview and record review the facility staff failed to administer the Physician ordered diet for one sampled resident (#18) out of a total sample of 31 residents. Findings include: Resident #18 was admitted to the facility in 12/2000 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) Assessment, dated 9/29/17, indicated the resident had impaired short and long term memory with moderately impaired decision making ability. Further review indicated the resident received a mechanically altered diet and required supervision for eating. Review of the 10/2017 physician's orders [REDACTED]. Review of Progress Note, dated 10/19/17, indicated that behavior staff reported the resident was choking and a small piece of food was removed from his/her mouth. Review of an Incident Report, dated 10/19/17, indicated the behavior staff reported the resident was coughing and choking when given a snack and a small piece of food was removed from his/her mouth. The Physician was notified and ordered a chest x-ray to be done 3 days later. Review of the Nursing Incident Follow-Up Report, dated 10/20/17, indicated that a member from the behavior team staff gave the resident a sandwich for a snack and the resident began to cough, not choke. Review of the chest x-ray results, dated 10/22/17, indicated the resident had Pneumonitis due to inhalation of other solids and liquids (aspiration). Review of the physician's orders [REDACTED]. Observation on 1/17/18 at 11:50 AM indicated the resident was asleep on the bed. Behavior Technician #1 was seated in a chair at the foot of the bed. During an interview on 1/17/18 at 12:15 PM Behavior Technician #1 said she had taken care of the resident for several years. She said that they were not technically supposed to give the residents food because they were not certified nurses aides. She said she used to cut up sandwiches and give them to the resident but she doesn't do that anymore because he/she choked easily. During an interview on 1/17/18 at 12:25 PM the Director of Nurses said that the behavior technicians were not supposed to assist with feeding. She said there was some confusion regarding this incident, communication breakdown between the nurse and the behavior team staff which resulted in the resident getting a sandwich when he/she wasn't supposed to.

Based on records reviewed and interviews, for one of two closed records (Resident #155), the facility staff failed to report an incident which seriously affected the health, safety, and well-being of the resident to the Department of Public Health (DPH) as required. Resident #155's death, which occurred within 6 hours of a resident-to-resident altercation, was not reported to the DPH. Findings include: Resident #155 was admitted to the facility in (MONTH) 2005 with [DIAGNOSES REDACTED]. The Progress Note, dated [DATE], indicated that Resident #155 fell forward out of his/her wheelchair due to a [MEDICAL CONDITION]. The note indicated that there were no visible signs of injury, but that Resident #155 was initially post-ictal (an altered state of consciousness following a [MEDICAL CONDITION]). The Neurological Check (an assessment of an individual's neurological functions to determine normal function and appropriate reaction to the performed tests) Flowsheet, dated [DATE] through [DATE], indicated that Resident #155 had a documented change in mental status for approximately 3.5 hours following the [MEDICAL CONDITION]. The Accident/Incident Report, dated [DATE], indicated that at approximately 5:35 P.M., Resident #155 bumped into a peer with his/her wheelchair, and the peer struck Resident #155 in the mouth with a fist, causing Resident #155 to bleed from the mouth. The Neurological Check Flowsheet, dated [DATE] through [DATE], indicated that on [DATE] between 5:35 P.M. and 7:35 P.M., Resident #155 presented with an unaltered mental status. The Flowsheet also indicated that Resident #155 refused to have complete neurological checks performed between 6:20 P.M. and 7:35 P.M., including checks of his/her pupils and vital signs. The Progress Note, dated [DATE], indicated that at approximately 7:40 P.M., a Certified Nurse Aide (CNA) observed Resident #155 lying face down in bed. The note indicated that Resident #155 did not have a palpable pulse (a pulse that could be felt), and a Code Blue and Emergency Medical Services were called. The note indicated that Resident #155 was transferred and admitted to the Hospital. The SBAR (Situation, Background, Assessment, Review) Note, dated [DATE], indicated that cardiopulmonary resuscitation (CPR) was initiated on Resident #155 because a Code Blue was called. The Hospital Discharge Summary, dated [DATE], indicated that Resident #155 was admitted to the Intensive Care Unit on [DATE] with issues including decreasing blood pressures and [MEDICAL CONDITION]. The Summary indicated that Resident #155 went into [MEDICAL CONDITION] and was pronounced dead at 11:58 P.M. on [DATE]. The facility's Incident Report Form indicated that the resident-to-resident altercation between Resident #155 and a peer occurred at 5:35 P.M. on [DATE]. The Form indicated that the incident was reported and submitted to the DPH on [DATE], 6 days after the altercation and Resident #155's death, but did not indicate that Resident #155 was deceased . The Surveyor interviewed the Director of Nurses (DON) at multiple times on [DATE] and [DATE]. The DON said she did not report Resident #155's death to the DPH as she did not attribute his/her death to anything other than a cardiac event. There was no documentation at the time of survey that Resident #155's death, which occurred approximately 6 hours after a resident-to-resident altercation in which he/she was struck in the face, was reported to the DPH.

Based on record review, interview, and observation for one out of four sampled Residents (Resident #1) the Facility failed to ensure that Resident #1 was treated with dignity when CNA #1 forcibly removed Resident #1 from the dining area by dragging his/her wheelchair backwards because Resident #1 became disruptive during snack time and then once in the hallway, CNA #1 taunted Resident #1 to the point that Resident #1's behavior escalated and he/she attempted to hit CNA #1. The Administrator and CNA #2 observed CNA #1 taunting Resident #1. Findings include: The Facility admitted Resident #1 in August, 2010. The face sheet indicated Resident #1's [DIAGNOSES REDACTED]. A mental health, mood, and behavior care plan, last updated on 1/3/12, indicated Resident #1 can become verbal with staff when redirected away from the elevator, patio, and food carts. The care plan indicated Resident #1 can become physically aggressive with staff when redirected regarding food and many incidents have occurred while being redirected or escorted out of the dining room. Care plan interventions included providing a structured routine, redirection to diversional activities as needed, and using a calm, supportive approach during redirection. A cognition care plan, updated on 1/3/12, indicated Resident #1 had cognitive deficits related to dementia and a [MEDICAL CONDITION]. Care plan interventions included: allowing Resident #1 time to express self and make needs or concerns known; speaking slowly and using a calm, friendly tone of voice; using diversional activities to redirect Resident #1 away from inappropriate or unsafe behaviors; and using a calm, patient approach to lessen the likelihood for agitation or anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 4/13/12, indicated Resident #1 had adequate hearing ability and moderately impaired vision. The MDS indicated Resident #1's speech was unclear and Resident #1 was only sometimes understood by others, but Resident #1 usually understood others. The MDS indicated Resident #1 scored 9 out of 15 points on a Brief Interview for Mental Status (BIMS) which represented moderate cognitive impairment. The MDS indicated Resident #1 displayed verbal behavior directed towards others. The MDS indicated Resident #1 used a wheelchair as a mobility device and required extensive staff assistance with locomotion. A nurse's note, dated 5/29/12, indicated Resident #1 had one physically aggressive episode during lunch and Resident #1 had intact skin, no injury and no ill effects. The nurse's note indicated Resident #1 was unable to process the incident. The Surveyor interviewed the Administrator at 8:30 A.M. and throughout the day on 6/20/12. The Administrator said he was coming down the hallway carrying a mattress and observed initially what he believed was CNA #1 joking around with Resident #1. The Administrator said CNA #1 was poking at Resident #1, not hard like a punch, but almost jokingly. The Administrator said CNA #1 then took Resident #1's hat and then put it back on Resident #1's head. The Administrator said Resident #1 then became agitated and started swinging at CNA #1. The Administrator said CNA #1 then moved behind Resident #1 and when Resident #1 tried to hit CNA #1, he grabbed Resident #1's arms and deflected the hits. The Administrator said Resident #1, who was in a wheelchair, then propelled the wheelchair backwards and tried to pin CNA #1 against the wall, but CNA #1 moved. The Administrator said he yelled CNA #1's name, but CNA #1 did not appear to hear him. The Administrator said CNA #1 then pointed at Resident #1 and said in a harsh tone, you stay out (meaning out of the the dayroom). The Administrator said CNA #1 then left the area. The Administrator said this incident occurred in the hallway near the elevator and dining room. The Administrator said CNA #2 was standing beside the elevator, so he then asked her what she observed. The Administrator said he then notified the Director of Nursing and had her address the issue and suspend CNA #1 pending an investigation. The Administrator said initially he believed CNA #1 was just joking around, but Resident #1 became very agitated and CNA #1 did not stop or walk away. The Administrator said he believed this became abusive, because Resident #1 clearly did not like the taunting and Resident #1's behavior escalated and he/she attempted to hit CNA #1, but CNA #1 still did not stop or walk away. The Surveyor interviewed CNA #2 at 1:00 P.M. on 6/20/12. CNA #2 said she went into the dining room to help with snacks and CNA #1 was wheeling Resident #1 out of the dining room. CNA #2 said Resident #1 then tried to hit CNA #1 and CNA #1 taunted Resident #1, by circling around Resident #1's wheelchair and holding his fists up like he was boxing with Resident #1. CNA #2 said CNA #1 then said to Resident #1, "put em up" like he was pretend boxing. CNA #2 said Resident #1 became more agitated and kept trying to turn around to follow CNA #1. CNA #2 said Resident #1 yelled and screamed at CNA #1, but CNA #2 was not able to understand what Resident #1 yelled. CNA #2 said CNA #1's behavior with Resident #1 was inappropriate. CNA #2 said the Administrator then came and told CNA #1 to stop. CNA #2 said she was pretty much right next to CNA #1 during this incident. Observations made by the Surveyor accompanied by the Administrator at 10:45 A.M. on 6/20/12, indicated that based on where the Administrator and CNA #2 said they were standing, they had a direct line of vision to CNA #1 and Resident #1. The Surveyor interviewed CNA #1 at 1:20 P.M. on 6/20/12. CNA #1 said he was doing 2:00 P.M. snacks in the dining room and Resident #1 wanted Goldfish snacks, but could not have them due to possible choking. CNA #1 said Resident #1 then became agitated. CNA #1 said when he tried to remove Resident #1 from the dining room, Resident #1 put his/her feet down and CNA #1 was unable to push Resident #1's wheelchair out of the dining room, so he turned the wheelchair around and pulled Resident #1 out backwards. CNA #1 said he then placed Resident #1 in the hallway and believed everything was fine. CNA #1 said when they called him down to the office, he believed it was about a performance evaluation, but it was about this incident. CNA #1 said he did not taunt, poke at, or take Resident #1's hat off. CNA #1 said if he was going to do something like this, why would he do it in the hallway where everyone could see him. CNA #1 said he did tell Resident #1 not to go back into the dining room, but he did not taunt Resident #1. CNA #1 said he did not believe there were any other residents or staff in the hallway when he brought Resident #1 out of the dining room. CNA #1 said the Behavioral Supervisor's office was right near the dining room and CNA #1 told the Behavioral Supervisor what had happened in the dining room and why he removed Resident #1 from the dining room. The Surveyor interviewed the Behavioral Supervisor at 1:18 P.M. on 6/26/12. The Behavioral Supervisor said he just got off the elevator and observed CNA #1 removing Resident #1 from the dining room. The Behavioral Supervisor said CNA #1 explained to him why he removed Resident #1 from the dining room. The Behavioral Supervisor said Resident #1 was very disruptive and upset, so he spoke with Resident #1 and explained why he/she was removed from the dining room. The Behavioral Supervisor said CNA #1 seemed upset that he had to remove Resident #1. The Behavioral Supervisor said he then closed the door to his office, because he had work to do, so he did not observe CNA #1 do anything inappropriate. The Surveyor interviewed Resident #1 at 11:00 A.M. on 6/20/12. When asked if he/she was treated okay by staff, Resident #1 replied, "all right"; however, Resident #1 replied "all right" to all questions. Resident #1 was not able to participate in the interview. The Surveyor assisted by the Administrator selected a sample of Residents (Resident #2, #3, & #4) on Resident #1's unit that were cognitively able to participate in an interview. The Surveyor interviewed Resident #2 at 11:10 A.M. on 6/20/12. When asked if he/she recalled CNA #1, Resident #2 replied yes. Resident #2 said CNA #1 sometimes taunted residents and he/she believed that CNA #1 sometimes crossed the line. Resident #2 said one example was when CNA #1 pretended to choke a resident and on another occasion Resident #2 observed CNA #1 throw a sandwich at a resident.