Every finding on record at Charlwell House Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure one Resident (#27) received treatment to pressure areas on the bilateral heels in accordance with professional standards to promote healing, out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to assess (including wound description, shape, measurements and condition), document and provide treatments as indicated to pressure ulcers on the bilateral heels. Findings include: Review of the facility's policy titled Wound Care, dated October 2010, indicated the following was to be documented in the medical record during wound care treatments: all assessment data including wound bed color, size, drainage obtained when inspecting the wound; if the resident refused the treatment and the reasons why. Review of the facility's policy titled Prevention of Pressure Injuries, dated April 2020, indicated the following: -conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors -during skin assessment, inspect: presence of erythema (redness); temperature of skin and soft tissue; and edema -inspect the skin on a daily basis when performing or assisting with personal care -evaluate, report and document potential changes in the skin -review the interventions and strategies for effectiveness on an ongoing basis Resident #27 was admitted to the facility in April 2025 with a diagnoses of diabetes, a stage 4 (full-thickness skin and tissue loss) pressure ulcer to the sacrum (base of spine), a history of a left transmetatarsal amputation (TMA- a surgical procedure where the forefoot (including the toes and part of the foot bones is removed to preserve the remaining part of the foot and ankle), and history of right foot first, second and third toe amputations. Review of the Minimum Data Set (MDS) assessment, dated 5/13/25, indicated Resident #27 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the medical record indicated Resident #27 was admitted to the facility following a two-month hospital stay for a stage 4 pressure ulcer on the sacrum and had multiple wounds to the bilateral lower extremities including pressure ulcers to the bilateral heels. Review of the care plans indicated Resident #27 had a pressure ulcer to the sacrum and heel and potential for pressure ulcer development related to limited mobility, initiated on 4/29/25. The goal was for the pressure ulcer to show signs of healing and remain free from infection with interventions of: weekly skin checks by licensed nurse, monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs or symptoms of infection; weekly treatment documentation to include measurement of each area of skin breakdown (width, length, depth, type of tissue and drainage); administer treatments as ordered and monitor for effectiveness. Review of the original admission hospital paperwork from April 2025 indicated Resident #27 had a pressure ulcer on the right heel since 2/25/25 and a pressure ulcer to the left heel since 4/2/25. The hospital summary indicated the left heel pressure ulcer wound bed was black with serosanguineous drainage (combination of blood and serous fluid, appearing as a light pink to red color). No further information was provided in the hospital discharge summary regarding the right heel pressure ulcer or treatments to either heel pressure ulcer. Review of the facility's document, Admission/readmission skin assessment, dated 4/27/25, indicated there was a pressure ulcer to the left heel and to the right heel. There was no additional information provided for either pressure ulcer including but not limited to the stage, measurement, description, or treatment. Review of the nursing admission progress note indicated aside from the wound on the sacrum, Resident #27 had four superficial wounds on the left leg, calf, ankle and heel and two superficial wounds on the right leg and heel. Review of the May 2025 Treatment Administration Record (TAR) included the following orders, dated 4/27/25, for wound care: -right leg and heel superficial wounds, normal saline cleanse and bacitracin (topical ointment to prevent skin infections from minor cuts and scrapes) with Mepore dressing daily (an adhesive absorbent dressing intended for treating lightly to moderately exuding wounds such as surgical wounds, cuts and abrasions.) -left leg, calf, shin, ankle and heel superficial wounds, normal saline cleanse and bacitracin with Mepore dressing daily. Review of the medical record indicated Resident #27 was sent to the hospital in May 2025. Review of the re-admission hospital paperwork, dated 5/7/25, indicated during the hospital admission Resident #27 had debridement (removal of dead tissue) of the necrotic (dead) tissue to the bilateral heel pressure ulcers and the pressure ulcers were unstageable likely stage 4 with plaques of adherent eschar (dead or devitalized tissue that is hard or soft in texture) and purulent drainage (a thick, milky, and often yellowish or greenish fluid). The discharge summary indicated to cover areas of the feet with Mepilex Border (an adhesive absorbent dressing intended to treat high exuding wounds) for protection or leave open to air and paint with Betadine solution to stabilize/dry the plaques of eschar daily. The hospital recommended a follow up with a podiatrist for further debridement. Review of the medical record, including the Resident Appointment Calendar, on 5/30/25 failed to indicate Resident #27 had an appointment scheduled with the podiatrist, 23 days after readmission. During an interview on 5/30/25 at 1:55 P.M., the Director of Nurses (DON) said Resident #27 did not have a scheduled appointment with the podiatrist at this time. Review of the facility's document, Admission/readmission skin assessment, dated 5/7/25 (signed as completed on 5/11/25 by Nurse #5), indicated Resident #27 had a pressure ulcer on the right heel and a pressure ulcer on the left heel. There was no additional information provided for either pressure ulcer including but not limited to the stage, measurement, description, or treatment. Review of the medical record from admission through review on 5/29/25 including nursing progress notes, nursing assessments and physician progress notes failed to include descriptions or measurements or changes to treatments of either pressure ulcer on the heels. Review of the Wound Evaluation and Management Summary dated 5/13/25 from the wound physician consultant failed to indicate the pressure ulcers on the bilateral heels were reviewed by the physician. During an interview on 5/30/25 at 9:26 A.M., the wound physician consultant said he had seen Resident #27 one time on 5/13/25. He said, If Resident #27 had pressure ulcers to the bilateral heels, I did not see them. Review of the medical record indicated Resident #27 was sent to the hospital a second time in May 2025. Review of the re-admission hospital paperwork, dated 5/25/25, indicated Resident #27 had pressure ulcers to the bilateral heels and the left heel pressure ulcer was surgically debrided during the admission with the following treatments: -Left heel: cleanse with normal saline, wet to dry dressing (type of wound dressing where moist gauze is applied to a wound and allowed to dry, creating a mechanical debridement) daily -Right heel: cleans with normal saline, apply Santyl (an ointment for chemical debridement) then dry sterile dressing Review of the facility's document, Admission/readmission assessment, dated 5/25/25, completed by Nurse #4 indicated Resident #27 had a left heel superficial wound and a right heel with a necrotic pressure ulcer. The comment section on the assessment indicated the left heel was to be cleansed with normal saline, apply gauze dressing daily and the right heel wound with necrotic skin was to be cleansed with normal saline, apply Santyl and cover with dry sterile dressing. The comment section failed to indicate the treatment of a wet to dry dressing to the left heel as indicated in the hospital discharge summary. Review of the May 2025 TAR indicated the previous treatment orders for wound care were reinstated on 5/26/25: -left leg, calf, shin, ankle and heel superficial wounds, normal saline cleanse and bacitracin with Mepore dressing daily -right leg and heel superficial wounds, normal saline cleanse and bacitracin with Mepore dressing Review of the medical record on 5/30/25 failed to indicate either treatment had been updated to reflect the treatments for the pressure ulcers of the left heel of a wet to dry dressing or the right heel for Santyl, as indicated in the hospital discharge summary. Review of the Weekly Skin Check, dated 5/25/25, completed by Nurse #5, indicted Resident #27 had wounds to the right and left heel, no additional information was provided regarding wound descriptions, measurements or treatments. During an interview on 5/30/25 at 9:30 A.M., the DON said the nurses should be documenting wound descriptions including the wound bed and drainage. She said the treatment order should not be clustered together to cover multiple wounds on a leg and each wound should have a separate treatment. She said, as far as she knew, Resident #27 had never refused treatment or care. On 5/30/25 at 10:40 A.M., the DON, the facility Wound Nurse, and the surveyor observed the lower extremity wounds of Resident #27. The bilateral lower portion of the legs were wrapped in Kerlix (gauze) from the feet up towards the knees. After removing the Kerlix, the surveyor observed the DON remove a square non-adhesive pad from the wound bed of the left heel. She said the left heel pressure ulcer measured 3 cm in length by 2.5 cm in width by 0.5 cm in depth, was a stage 3 (full-thickness loss of skin) pressure ulcer with 5% slough. The DON then removed a square non-adhesive pad, which was sticking to the eschar in the right heel and said the wound bed was necrotic. The Wound Nurse said the right heel pressure ulcer measured 3.3 cm in length by 1.3 cm in width by 0.1 cm in depth but was unstageable due to the necrotic tissue. During an interview at this time, the Wound Nurse and the DON said neither of them had previously seen Resident #27's bilateral heel pressure ulcers and had only seen the sacral wound. During an interview on 5/30/25 at 11:45 A.M., Nurse #4 said she had been the nurse providing care to Resident #27 on 5/29/25. She said on 5/29/25 both pressure ulcers to the heels had serosanguineous drainage so she applied the bacitracin and then put an ABD (abdominal- a medical pad used to absorb fluids and protect wounds) over the wound beds because of the depth of the wounds and the drainage. During an interview on 5/30/25 at 12:50 P.M., the Physician said she had reviewed the hospital discharge paperwork and knew Resident #27 had pressure ulcers on the bilateral heels and defers treatment options to the wound specialists and would follow the hospital treatment recommendations if they provided them. During an interview on 5/30/25 at 1:00 P.M., the DON said the facility had not been focused on the heels of Resident #27 and had been focused on the pressure area on the sacrum. She said she had never reviewed the treatment orders for the heels and could not say why the treatment orders were clustered for multiple areas or why said the heel wounds were superficial. She said the bilateral heels were not superficial wounds. She said the wound physician consultant had been at the facility on 4/29/25 but had not seen Resident #27 and the wound treatments for the heels were not reviewed. She said the nurses should be reviewing the hospital discharge summary with the physicians and entering treatments as indicated. During an interview on 5/30/25 at 1:10 P.M., the wound nurse said the process was for the nurses to be completing admission skin assessments and documenting the wound descriptions and contacting the physician to review the treatments. During an interview on 5/30/25 at 2:05 P.M., Nurse #5 said he worked on the unit three days per week and was the weekend supervisor. He said he often helped with new admissions and had been working when Resident #27 had originally been admitted . He said for the original admission he had completed entering the medications for Resident #27 in the electronic medical record and left it up to the nurses who were assigned to the Resident to complete the assessments. He said he had entered the orders for the right and left leg as a temporary treatment until the skin assessment was complete and the hospital discharge summary was reviewed. He said he would often come in and find that the assessments, including the skin assessments had not been completed and that was why he had completed the Weekly Skin Check form dated 5/25/25. He said Resident #27 had an open wound to the right heel with a daily dressing and the left heel was superficial and more like fragile skin. He said he had no idea there were pressure wounds on both heels, despite having documented completing the skin assessment on 5/25/25. He said the facility staff had been focusing on the Resident's sacral wound and not on the heels.

2. Review of the facility's policy titled Surveillance for Infections, dated as revised 9/2017, included but was not limited to: -The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare associated infections, to guide appropriate interventions, and to prevent future infections -The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The infection control committee and/or QAPI committee may be involved in interpretation of the data -The surveillance should include a review of any or all of the following information to help identify possible indicators of infections: a. Laboratory records, b. Skin care sheets, c. Infection control rounds or interviews, d. Verbal reports from staff, e. Infection documentation records, f. Temperature logs, g. Pharmacy records, h. Antibiotic review; and i. Transfer log/summaries -if laboratory reports are used to identify relevant information, the following find its merit further evaluation: a. Positive blood culture; b. Positive wound cultures that do not just represent surface colonization; c. Positive urine cultures with corresponding signs and symptoms that suggest infection; d. Positive sputum culture e. Other positive cultures; and f. All cultures positive for Group A streptococcus -for residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: a. Identifying information (resident name, age, room number, unit, and attending physician), b. Diagnoses, c. admission date, date of onset of infection d. Infection site e. Pathogens f. Invasive procedures or risk factors g. Pregnant remarks; and h. Treatment measures and precautions -Using the current suggested criteria for health care associated infections, determine if the resident has a healthcare associated infection - For targeted surveillance using facility created tools, follow these guidelines. a. Daily (as indicated): record detailed information about the resident and infection on an individual infection report form b. Monthly: collect information from individual resident infection reports and enter line listing of infections by resident for the entire month c. Monthly: summarize monthly data for each nursing unit by site and by pathogen d. Monthly/Quarterly: identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends e. Monthly/Quarterly: compare incidents of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period as the baseline. Compare subsequent rates to the average rate to identify possible increases in infection rates -Interpreting surveillance data: Analyze the data to identify trends Review of the February, March, and April 2025 line listings indicated but was not limited to: February 2025: -8 out of 15 residents had no documented signs and symptoms of an illness, and -3 out of 4 urinary tract infections treated failed to include culture results identifying the organism/bacteria March 2025: -6 out of 9 residents had no documented signs and symptoms of an illness, and -1 out of 1 urinary tract infections treated failed to include culture results identifying the organism/bacteria April 2025: -4 out of 5 urinary tract infections treated failed to include culture results identifying the organism/bacteria, and -Review of Resident #19's medical record indicated a urine culture and sensitivity report resulted on 4/25/25 which indicated extended spectrum beta lactamase (ESBL, an organism enzyme produced by certain bacteria that allows them to resist the effects of certain antibiotics) had been detected but these results were not recorded on the facility line listing During an interview on 5/29/25 at 10:57 A.M., the Regional Nurse and Infection Control Nurse said the facility utilizes McGeer criteria (a set of standardized definitions used in infection surveillance) to determine if an infection was present and collects data by reviewing new orders in the facility and communicating with staff. The Infection Control Nurse said residents with antibiotics were added to the line listing based on order review and reports from staff. The Regional Nurse and Infection Control Nurse said the culture results, lab review, and symptoms were not consistently put on the tracker/line listing. During an interview on 5/29/25 at 12:26 P.M., the Director of Nurses said infection surveillance should have included symptoms and organisms for accurate tracking/monitoring and should have been completed. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed: 1. For Resident #57, to follow infection control standards while completing a dressing change; and 2. To maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections. Findings include: 1.Review of the facility's policy titled Wound Care, revised October 2010, indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. -Wash and dry your hands thoroughly -Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites -Put on gloves, loosen tape and remove dressing -Pull glove over dressing and discard -Wash and dry your hands thoroughly Resident #57 was admitted to the facility in March 2025 with diagnoses including dementia and unstageable pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 4/16/25, indicated Resident #57 scored 99 on the Brief Interview for Mental Status, indicating he/she was severely cognitively impaired, and the Resident had an activated Health Care Proxy. Review of the Physician's Order indicated the following: -wound care: right medial foot: cleanse site with normal saline, pat dry, followed by calcium alginate (highly absorbent wound dressing) and silicone bordered super absorbent gelling fiber dressing every day shift. -wound care: left lateral foot: cleanse site with normal saline, pat dry, followed by calcium alginate and silicone bordered super absorbent gelling fiber dressing every day shift. On 5/29/25 at 1:38 P.M., the surveyor observed the following: -Nurse #6 washed her hands, applied a protective gown, surgical face mask, and gloves. -Nurse #6 removed the old dressing from the left lateral foot and placed it in the trash. -Nurse #6 did not perform hand hygiene or change her gloves. -Nurse #6 then cleansed the wound on the left lateral foot with normal saline soaked gauze pads. -Nurse #6 then removed the old dressing from the right medial foot and placed it in the trash. -Nurse #6 did not perform hand hygiene or change her gloves. -Nurse #6 then cleansed the wound on the right medial foot with normal saline soaked gauze. -Nurse #6 then removed her gloves, performed hand hygiene and applied the calcium alginate to the left lateral wound bed with the dressing extending over to the intact surrounding skin. -Resident #57 began moving his/her foot, and the calcium alginate fell onto the towel that was placed under his/her feet. -Nurse #6 picked up the calcium alginate from the towel and re-applied it to the wound bed, and the calcium alginate fell off the wound onto the bed linens. -Nurse #6 picked up the calcium alginate and re-applied it to the wound bed and then covered it with a silicone bordered dressing. -Nurse #6 did not perform hand hygiene or change her gloves -Nurse #6 then applied calcium alginate to the right medial foot wound bed and covered it with a silicone bordered dressing. -Nurse #6 then removed all the dressing supplies, removed her gloves, gown, and mask and performed hand hygiene. During an interview on 5/29/25 at 4:09 P.M., Nurse #6 said she should have changed her gloves and performed hand hygiene after removing the old dressings. She said once the calcium alginate fell off the wound onto the bed she should have applied a new clean one. Nurse #6 said the Resident was moving his/her leg so much during the dressing change it made it difficult for her. During an interview on 5/29/25 at 4:50 P.M., The Director of Nursing (DON) said you must change your gloves and perform hand hygiene, once you remove an old dressing, prior to cleansing the wound. She said once a dressing becomes contaminated, it must never be re-applied, as it increases the risk of the wound developing an infection. The DON said calcium alginate should only be placed over an open wound, not over the intact surrounding skin.

Based on observation and interview, the facility failed to ensure that medications in the refrigerator were stored under the proper temperature for 2 out of 2 medication rooms. Findings include: Review of the Facility's Medication Room Refrigerator Temperature Log indicated medications are to be stored between 36-46 degrees Fahrenheit. The Log further indicated temperature below 36 degrees (F) are too cold and temperature above 46 degrees (F) are too high. The facility requires staff to document any out-of-range temperatures then call the state or local health department immediately. On 5/28/25 at 10:39 A.M., the surveyor along with Nurse #6 entered the medication room on Unit A to perform a review of the medication room. Upon opening the refrigerator, the thermostat temperature was observed to read 70 degrees. Review of the refrigerator contents included three Mounjaros injection pens stored in the lock box, two insulin kits, suppositories, as well as unopened individual insulin pens and vials. During an interview on 5/28/25 at 11:05 A.M., Nurse #6 said the refrigerator temperature was extremely high. He said medications requiring refrigeration should be stored between 36°F and 46°F (2°C and 8°C). On 5/28/25 at 11:17 A.M., the surveyor along with Nurse #5 observed the medication storage room on Side B. Upon opening the refrigerator, the temperature on the thermometer read 59 degrees (F). Review of the refrigerator contents included: - 11 Lantus Insulin Pen (Glargine Injection 100 Units/Ml Exp (expiration) 4/30/27) ; - Two Novolog Insulin Injection Flex 100 units/ml for subcutaneous use Pen Exp 6/30/27; - Insulin Kit House Stock E-Kit Unit C delivered 5/27/25 Kit # I2105 Replace 5/27/26; - I2033 Insulin Kit B Unit; - I2233 B Unit; - Lantus Vial insulin glargine 100 unit/ml; and - Humulin Regular 10 ml multiple dose due for refill 6/1/2 During an interview at 9:50 A.M., Nurse #5 said the temperature of the refrigerator was in the danger zone. He said medications requiring refrigeration should be stored between 36°F and 46°F (2°C and 8°C). On 05/29/25 at 10:17 A.M., the surveyor observed Nurse #4 during a medication pass. Nurse #4 entered the medication room on side B to retrieve a medication. Upon entering the medication room on Side B, the surveyor rechecked the refrigerator's temperature in the medication room in the presence of the nurse and it was 30 degrees Fahrenheit (F). Review of the refrigerator contents included: - Insulin Kit I2033 dated 5/16/25; I2233 dated 5/3/25; - I2105 dated 5/23/25 were observed back in the refrigerator; - Risperidone dated 5/22/25; and - Unopened insulins previously stored in the refrigerator were observed back in it. During an interview at 10:40 A.M., Nurse # 4 said it is not appropriate to keep refrigerated medications in unstable temperatures. During an interview on 05/29/25 at 01:50 P.M., the Director of Nursing (DON) said she was not aware both refrigerators in the medication rooms were out of temperature range. She said she knew that the medications should be stored at the proper temperature but was not aware of the discrepancies of the two refrigerators. She said if the temperature is out of range on both refrigerators, it is an indication that something is wrong with them. On 05/29/25 at 02:10 P.M., the surveyor along with the DON reviewed the refrigerator temperature on Unit B and it was found to be 31 degrees Fahrenheit.

Based on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#38, #19), out of a total sample of 19 residents. Specifically, the facility failed, for Residents #38 and #19, to ensure pain medication was administered in accordance with the pain scale indicated in the Physician's order. Findings include: Review of the facility's policy titled Administering Medications, revised April 2019, indicated but was not limited to: - Medications are administered in a safe and timely manner, and as prescribed. - Medications are administered in accordance with prescriber orders, including any required time frame. Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice. 1. Resident #38 was admitted to the facility in September 2021 with diagnoses including osteoporosis and muscle weakness. Review of Resident #38's Minimum Data Set (MDS) assessment, dated 4/23/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Furthermore, the MDS assessment indicated Resident #38 had occasional pain, as well as received scheduled and as needed (PRN) pain medication. Review of Resident #38's Physician's Orders indicated but were not limited to: - 2/26/25: Oxycodone HCl (hydrochloride) (narcotic pain medication) Oral Tablet 5 MG (milligrams); give one tablet by mouth every eight hours as needed for pain 4-6. Review of Resident #38's Medication Administration Record (MAR) for March 2025 indicated but was not limited to the following: - Oxycodone 5 MG Tablet was given 15 times for a pain level score of less than four. Review of Resident #38's MAR for April 2025 indicated but was not limited to the following: - Oxycodone 5 MG Tablet was given eight times for a pain score of less than four. Review of Resident #38's MAR for May 2025 indicated but was not limited to the following: - Oxycodone 5 MG Tablet was given 17 times for a pain score of less than four. Further review of Resident #38's medical record failed to indicate nursing documentation related to the reason for medication administration for pain scale rating of less than four. During an interview on 5/29/25 at 2:45 P.M., Nurse #1 said Resident #38's PRN Oxycodone order is written so he/she will receive the medication when they report a pain scale between 4 to 6 out of 10. Nurse #1 said based on how the order is written the pain medication was administered outside of physician's orders when given for a pain scale rating of less than 4 out of 10. 2. Resident #19 was admitted to the facility in October 2024 with diagnoses including: spinal stenosis (narrowing of the spaces inside the spine) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the MDS assessment, dated 5/8/25, indicated the Resident was taking opioid (narcotic) pain medication and was cognitively intact with a BIMS score of 15 out of 15. Review of the Physician's Orders for Resident #19 indicated but were not limited to the following: -2/26/25: Tylenol tablet 325 MG, give two tablets (650 MG) by mouth every 12 hours as needed (PRN) for pain scale of 1-3. -2/26/25: Oxycodone 5 MG, give one tablet (5 MG) as needed (PRN) every six hours (Q6H) for pain scale of 3-6. During an interview on 5/28/25 at 11:09 A.M., Resident #19 said he/she asks for pain medication sometimes to manage breakthrough back pain. Resident #19 said when he/she requests the medication, the staff does not ask his/her pain level. Resident #19 said the nurse provides him/her with Oxycodone when he/she says they have pain. The nurses have never offered him/her Tylenol for pain. Review of the Numeric Pain Rating Scale indicated the following: - Rating of 0 indicates (=) no pain - Rating of 1-3 = mild pain, often described as annoying or distracting, but not significantly impacting daily activities. - Rating of 4-6 = moderate pain, which can interfere with daily activities and require some effort to manage. - Rating of 7-10 = severe pain, which significantly limits daily activities and can be debilitating Review of the MAR for both April 2025 and May 1st -29th, 2025 indicated, but was not limited to the following for Resident #6: April 2025: - Tylenol tablet 325 MG, give two tablets (650 MG) by mouth every 12 hours PRN, for pain scale of 1-3. > Not administered - Oxycodone 5 MG tablet (5 MG) Q6H PRN for pain (rating of 3 - 6) was administered outside of the ordered parameters 5 out of 9 times it was provided: > Twice for a rating of 0, > Once for a rating of 7, > Twice for a rating of 8. May 2025: - Tylenol tablet 325 MG, give two tablets (650 MG) by mouth every 12 hours PRN, for pain scale of 1-3. > Not administered - Oxycodone 5 MG one-tab Q6H PRN for pain (rating 3-6) was administered outside of the ordered parameters 13 of the 28 times it was provided. > Four for a rating of 0, > Four for a rating of 2, > Three for a rating of 7, > Once for a rating of 8, > Once for a rating of 10. During an interview on 5/29/25 at 3:42 P.M., Nurse #6 said when a resident requests PRN pain medication she asks them about their pain on a scale of 0-10. She said she administers the medication based on the pain scale the physician ordered. Nurse #6 said after the pain medication is administered, she follows up with the resident to ensure it was effective. Nurse #6 reviewed the April and May 2025 MAR for Resident #19 and said the pain medication was given outside of the physician's order, and it should not have been. She said when the pain scale is in between 1-3 Tylenol should have been administered, not Oxycodone. During an interview on 5/29/25 at 3:55 P.M., the Director of Nursing (DON) said as needed pain medications generally have a pain scale attached to them for medication administration. The DON said nurses should follow physician's orders when administering medications. The DON said pain medication should only be administered within the prescribed pain scale rating attached to the order.

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#66), out of a total sample of 19 residents. Specifically, the facility failed to ensure nail care was performed for Resident #66. Findings include: Review of the facility's policy titled Fingernails/Toenails, Care of, revised February 2018, indicated but was not limited to: - The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection. - Nail care includes daily cleaning and regular trimming. - If the resident refused the treatment, the reason(s) why and the intervention taken. - Notify the supervisor if the resident refuses the care. - Report other information in accordance with facility policy and professional standards of practice. Resident #66 was admitted to the facility in June 2024 with diagnoses including osteoarthritis and depression. Review of Resident #66's Minimum Data Set (MDS) assessment, dated 3/28/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Furthermore, the MDS assessment indicated Resident #66 was dependent for ADLs and mobility. During an interview with observation on 5/27/25 at 9:55 A.M., Resident #66 said their nails were long and he/she prefers them to be shorter. Resident #66 said staff do not ask him/her if they would like nail care to be performed. Resident #66 was observed by the surveyor to have long, jagged fingernails on both hands with a brown/red substance noted on the top and underneath his/her fingernails. During the following days and times, the surveyor made the following observations: - 5/28/25 at 10:06 A.M. and 12:35 P.M.: nails were long and jagged with a brown/red substance noted on the top and underneath his/her fingernails. - 5/29/25 at 9:55 P.M.: nails were long and jagged with a brown/red substance noted on the top and underneath his/her fingernails. Review of Resident #66's ADL self-care comprehensive care plan indicated but was not limited to the following: - The Resident has an ADL self-care performance deficit related to deconditioning, Parkinsonism. - Intervention: Check nail length and trim and clean on bath day and as necessary; report any changes to the nurse. (revised 6/20/24) Review of Resident #66's Certified Nursing Assistant (CNA) Kardex for bathing indicated to check nail length and trim and clean on bath day and as necessary. The CNA Kardex for bathing also indicated to report any changes to the nurse. Review of Resident #66's nursing progress notes failed to indicate he/she had refused nail care by staff. During an interview on 5/29/25 at 8:38 A.M., CNA #1 said nail care is performed on bath days for all residents in the building. CNA #1 said if a resident was noted to have longer or dirty nails they would be cared for before their next shower day. During an interview on 5/29/25 at 9:55 A.M., Resident #66 said no one has cared for his/her nails since he/she last spoke with the surveyor. Resident #66 said he/she did not know when his/her last shower was or what day he/she was assigned to have a shower. During an interview on 5/29/25 at 11:41 A.M., Nurse #2 said nail care can be done at any time when staff notice nails are long or dirty. Nurse #2 said some residents do not like their nail care to be completed. Nurse #2 was unsure where it would be documented if residents refused nail care. During an interview on 5/29/25 at 12:08 P.M., the Director of Nursing (DON) said her expectation was for nail care, including trimming and cleaning, to be a part of daily ADL care. The DON said a CNA should notify the nurse or supervisors if a resident is refusing or combative with ADL care, including nail care. The DON said nail care should be completed, and it should be documented in the medical record when it is not done.

Based on observation, interview, and record review, the facility failed to develop, implement and individualize a comprehensive care plan for one Resident (#58), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care was developed and implemented related to Resident #58's smoking status and preferences. Findings include: Review of the facility's policy titled Smoking Policy - Residents, dated 2024, indicated but was not limited to the following: - The facility shall establish and maintain safe resident smoking practices. - A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. - Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, indicated but was not limited to: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. - The interdisciplinary team reviews and updates the care plan: (d) at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. Resident #58 was admitted to the facility in April 2023 with diagnoses including quadriplegia and muscle weakness. Review of Resident #58's Minimum Data Set (MDS) assessment, dated 4/11/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Furthermore, the MDS indicated Resident #58 required assistance from staff for activities of daily living and currently used tobacco. Review of the list of smokers provided by the facility upon entrance indicated Resident #58 was a smoker residing in the facility. Review of Resident #58's Nursing Assessment, dated 4/9/25, indicated but was not limited to the following: - Resident requires a smoking apron. - Resident requires one to one assistance when smoking. - Resident smokes one to two times per day in evening. - Resident requires a staff person or family member present while utilizing the e-cigarette, vapor or any nicotine related device. Review of Resident #58's comprehensive care plans failed to indicate a smoking care plan was developed or implemented. During an interview on 5/29/25 at 2:42 P.M., Nurse #4 said she was uncertain of Resident #58's smoking status. Nurse #4 initially checked the electronic medical record to determine Resident #58's smoking status, but said she would have to check with the Certified Nursing Assistants (CNA). After discussion with a CNA, Nurse #4 said Resident #58 does smoke but mostly goes out in the evening with family. Nurse #4 said Resident #58 needs assistance with smoking tasks and family and/or staff would assist as needed. Nurse #4 said Resident #58's smoking preferences and needs should be identified in a care plan. Nurse #4 said she was unsure if a smoking care plan had been developed for Resident #58. Nurse #4 said any nurse or supervisor can update a care plan to reflect a resident's status, needs or preferences. During an interview on 5/29/25 at 3:47 P.M., the Director of Nursing (DON) said any resident in the facility who smokes should have a care plan developed and implemented related to his/her smoking status. The DON said she would expect any preference, assistance level and/or protective devices required during smoking to be listed in a resident's care plan. The DON said Resident #58 should have a care plan related to smoking.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#27) received treatment of a wound in accordance with professional standards for quality care, out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to provide wound treatments as ordered and failed to assess (including wound description, shape, measurements and condition) a wound to the right lower extremity for changes and identify that the wound changed from a superficial wound (minor injury that affects only the outermost layer of skin) to a wound with slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) in the wound bed. Findings include: Review of the facility's policy titled Wound Care, dated October 2010, indicated the following was to be documented in the medical record during wound care treatments: all assessment data including wound bed color, size, drainage obtained when inspecting the wound; if the resident refused the treatment and the reasons why. Review of the facility's policy titled Medication Orders, dated November 2014, indicated when recording treatment orders to specify the treatment, frequency, and duration of the treatment. Resident #27 was admitted to the facility in April 2025 with diagnoses of diabetes, a history of a left transmetatarsal amputation (TMA- a surgical procedure where the forefoot (including the toes and part of the foot bones are removed to preserve the remaining part of the foot and ankle), and history of right foot first, second and third toe amputations. Review of the Minimum Data Set (MDS) assessment, dated 5/13/25, indicated Resident #27 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the medical record indicated Resident #27 was admitted with multiple wounds to the bilateral lower extremities including pressure ulcers to the bilateral heels, vascular wounds to the top of the right foot, and scattered open areas to the lower portions of the lower extremities. Review of the care plans indicated Resident #27 had open areas to the bilateral lower extremities with a goal of healing. The interventions included encouraging good nutrition, identifying and eliminating causes, following facility protocol for skin tears, inform staff of causes to prevent skin tears, to keep skin clean and dry and apply lotion to dry, scaly skin. Review of the original admission hospital paperwork from April 2025 indicated Resident #27 had dry/flaky/scaling skin to the bilateral lower extremities with daily dressing changes on the legs. No further information was provided in the hospital discharge summary. Review of the Weekly Skin Check nursing assessment, dated 4/28/25, indicated Resident #27 had an area to the rear of the right lower leg, no additional information was provided (type of wound, description, size, drainage). Review of the medical record indicated Resident #27 was sent to the hospital in May 2025. Review of the re-admission hospital paperwork, dated 5/7/25, indicated Resident #27 had a wound on the right leg at the pretibial (area towards the front of the lower leg), distal (closer to the ankle), lateral (closer to the outside of the leg, away from the midline) which was present on admission to the hospital. No additional information was provided in the hospital discharge summary regarding this wound. Review of the facility's document, Admission/readmission assessment, dated 5/7/25, failed to indicate there was a wound to the right lower leg, as indicated in the hospital discharge summary. Review of the May 2025 Treatment Administration Record (TAR) included an order, dated 4/27/25, for wound care: right leg and heel superficial wounds, normal saline cleanse and bacitracin (topical ointment to prevent skin infections from minor cuts and scrapes) with Mepore dressing (an adhesive absorbent dressing intended for treating lightly to moderately exuding wounds such as surgical wounds, cuts and abrasions) daily. Although the Resident was in the facility, the TAR did not indicate the treatment was provided on 5/1/25, 5/8/25, 5/11/25, and 5/15/25. Review of the nursing progress notes failed to indicate the wound treatments to the right lower leg were provided on 5/1/25, 5/8/25, 5/11/25 or 5/15/25. During an interview on 5/29/25 at 4:06 P.M., Resident #27 said the staff did not provide the dressing changes to his/her lower legs every day. Review of the nursing progress notes failed to indicate Resident #27 had ever refused wound treatments or any other care. Review of the medical record indicated Resident #27 was sent to the hospital a second time in May 2025. Review of the re-admission hospital paperwork, dated 5/25/25, indicated Resident #27 had bilateral shin wounds with a treatment of a wet to dry dressing (type of wound dressing where moist gauze is applied to a wound and allowed to dry, creating a mechanical debridement (removing dead tissue and debris). The discharge summary indicated the right anterior lower tibial wound bed was red, fragile, pink with a pink peri-wound on 5/25/25. Review of the May 2025 TAR indicated the previous treatment order of wound care: right leg and heel superficial wounds, normal saline cleanse and bacitracin with Mepore dressing was re-instated on 5/26/25. The TAR and nursing progress notes failed to indicate the ordered wound treatment was provided on 5/26/25. Review of the facility's document, nursing Admission/readmission assessment, dated 5/25/25, completed by Nurse #4 indicated Resident #27 had a superficial wound to the right lower leg. The comment section on the assessment indicated the bilateral shins were to be cleansed with normal saline, apply gauze dressing daily. There was no indication the treatment was now a wet to dry dressing, as indicated in the hospital discharge summary. Review of the medical record from admission through 5/29/25 including nursing progress notes, nursing assessments, physician progress notes failed to include descriptions or measurements of the wound on the right lower leg in order to monitor for any changes to the wound. During an interview on 5/30/25 at 9:30 A.M., the Director of Nurses (DON) said the nurses should be documenting wound descriptions including the wound bed and drainage. She said the treatment order should not be clustered together to cover multiple wounds on a leg and each wound should have a separate treatment. She said, as far as she knew, Resident #27 had never refused treatment or care. On 5/30/25 at 10:40 A.M., the DON, the facility Wound Nurse, and the surveyor observed the lower extremity wounds of Resident #27. The bilateral lower portion of the legs were wrapped in gauze from the feet up towards the knees. After removing the gauze, a Mepore dressing was observed on the right lower lateral leg. The DON removed the adhesive bandage and said the wound bed was 100% slough. During an interview on 5/30/25 at 11:45 A.M., Nurse #4 said she had been the nurse providing care to Resident #27 on 5/29/25. She said on 5/29/25 she put bacitracin and the Mepore dressing on the wound to the right lower leg. She said the wound was not superficial and had slough on 5/29/25. She said she could not be sure if the wound had changed. She said she had not documented that the wound had slough on 5/29/25 and had not notified anyone. Review of the Interim Skin Assessment completed 5/30/25 indicated Resident #27 had a vascular wound to the right lower leg with 100% slough measuring 4.7 centimeters (cm) in length by 2.5 cm in width by 0.3 cm in depth. During an interview on 5/30/25 at 1:30 P.M., the DON said the wound bed was covered in slough and she could not be sure, based on the medical record, what the wound had looked like prior to this day.

Based on observation, interview, and record review, the facility failed to schedule a podiatry appointment and failed to ensure good foot health was maintained for one Resident (#27), out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to schedule an appointment with a community podiatrist per physician's order and failed to provide diabetic foot care in accordance with hospital recommendations and professional standards for the Resident who was at risk for decline in his/her foot health related to a history of diabetes and bilateral amputations. Findings include: Review of the facility's policy titled Nursing Care of the Older Adults with Diabetes Mellitus, dated as revised in November 2020, indicated the following for skin and foot care: -skin should be kept as dry and clean as possible, apply lotion to dry skin as needed -use aseptic technique in caring for any lacerations, abrasions or breaks in skin integrity, and report the condition immediately to supervisor -bathe feet in warm (not hot) water as necessary to keep clean -keep feet dry Resident #27 was admitted to the facility in April 2025 with diagnoses of diabetes, a history of a left transmetatarsal amputation (TMA- a surgical procedure where the forefoot (including the toes and part of the foot bones is removed to preserve the remaining part of the foot and ankle), and history of right foot first, second and third toe amputations. Review of the Minimum Data Set (MDS) assessment, dated 5/13/25, indicated Resident #27 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the medical record indicated Resident #27 was admitted with multiple wounds to the bilateral lower extremities including pressure ulcers to the bilateral heels, vascular wounds to the top of the right foot, and scattered open areas to the lower portions of the lower extremities. Review of the medical record indicated Resident #27 was sent to the hospital in May 2025. Review of the hospital Discharge summary, dated [DATE], indicated the following: -diabetics are prone to developing dry skin and fissures/cracking of the skin in the feet due to decreased perspiration associated with diabetic autonomic neuropathy and the skin can start to lose its protective barrier -the nerve damage can decrease the body's ability to control oil and moisture in the foot -this puts people at risk for developing foot ulcers and subsequent infections -it is important to be diligent about moisturizing the feet -after cleansing skin, towel dry feet thoroughly including between toes -cocoa butter products are most comparable with the composition of human skin and are higher in fatty acids, this tends to improve skin elasticity, hydrate, nourish, and provides a protective barrier to hold in moisture -inspect feet before bed each night for any breakdown -consider podiatry consult for possible debridement of eschar (dead tissue) on heels -follow up visits: specialty Podiatry; with name, phone number and office location listed Review of the May 2025 Treatment Administration Record (TAR) included a treatment order to provide diabetic foot care every night at bedtime: observation of feet, toes, ankles, soles and to document any alteration in skin integrity, color, temperature, and cleanliness in progress note. Although the Resident was in the facility, the TAR and nursing progress notes failed to indicate the diabetic foot care was provided on 5/1/25, 5/11/25, 5/15/25, 5/25/25, and 5/26/25. During an interview with observation on 5/30/25 at 10:40 A.M. with the Director of Nurses (DON) and facility Wound Nurse present, Resident #27 said staff had not been washing his/her feet or applying lotion. The feet and lower extremities of Resident #27 were observed with dry, flaky skin and parts of the skin were removed when the DON removed an adhesive dressing from the right lower extremity. During an interview on 5/30/25 at 11:45 A.M., Nurse #4 said she has provided care to Resident #27 on the evening shift, including on 5/29/25. She said the licensed nurses were responsible for diabetic foot care. She said diabetic foot care meant to inspect the feet to make sure there were no new open areas or redness and that even the smallest pinpoint could be an issue for a resident who was diabetic because it could open further and the resident might not be able to feel it. She said, Yes, diabetic foot care was only inspecting the feet and she had not washed the feet or applied lotion for Resident #27. During an interview on 5/30/25 at 1:30 P.M., the DON said that diabetic foot care was more than just looking at the feet and the nurses should be washing the feet and using lotion if needed daily. Review of the medical record for Resident #27 indicated on 5/12/25 the DON had entered a physician order for a podiatry visit to be scheduled with the community Podiatrist who was indicated in the hospital paperwork dated 5/7/25 for foot ulcers. Review of the medical record including the resident Appointment Calendar on 5/30/25 failed to indicate Resident #27 had an appointment scheduled with the podiatrist, 23 days after readmission. During an interview on 5/30/25 at 1:55 P.M., the DON said she checked with the receptionist and the appointment had not been scheduled as of this time, but the receptionist was working on it. During an interview on 5/30/25 at 2:01 P.M., the receptionist said she had not heard prior to this day about scheduling an outside podiatry appointment for Resident #27.

Based on record review and interview, the facility failed to ensure the monthly drug regimen review identified irregularities for one Resident (#34), out of 19 sampled residents. Specifically, the Pharmacist failed to identify and report irregularities (use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) related to the duration of an antibiotic medication (Flagyl) resulting in the Resident receiving an additional 37 doses. Findings include: Review of the facility's policy titled Medication Regimen Review (MRR), dated as revised 5/2019, indicated but was not limited to: -The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication -The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication b. incorrect medications, administration times or dosage forms, c. other medication errors, including those related to documentation -Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity -An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of the adverse consequences Resident #34 was admitted to the facility in April 2022 and had diagnoses which included pyelonephritis (inflammation of the kidneys, typically caused by a bacterial infection), renal and perinephric abscess (result of infection involving the kidney and the surrounding fat and tissues). Review of the Minimum Data Set (MDS) assessment, dated 4/20/25, indicated Resident #34 was receiving antibiotics. Review of Resident #34's Hospital Discharge summary, dated [DATE], indicated he/she should receive Flagyl three times per day for 90 doses. Review of Resident #34's Physician's Orders indicated but was not limited to: -Flagyl oral tablet 500 milligrams (mg) give one tablet by mouth three times a day related to renal and perinephric abscess for 89 days 90 doses, start date 4/15/25 Review of Resident #34's April and May 2025 Medication Administration Record (MAR) indicated he/she had received 127 doses of Flagyl as of 5/29/25. Review of the Monthly MRRs, dated 4/28/25 and 5/26/25, indicated Resident #69's medications had been reviewed and there were no irregularities. During a telephonic interview on 5/29/25 at 12:08 P.M., the Pharmacy Consultant said she conducts monthly MRRs and submits any reports of irregularities to the facility. The Pharmacy Consultant said when reviewing medications she reviewed the residents' orders to ensure the medication dosing was appropriate, stop dates were in place when indicated and the orders were in line with professional standards. During an interview on 5/29/25 at 1:14 P.M., the Pharmacy Consultant said she reviewed Resident #34's medical record and did not catch the conflict in the order of 89 days and 90 doses but she should have. The Consultant Pharmacist said she saw that the order had a stop date and did not report any irregularities to the facility. During an interview on 5/29/25 at 10:57 A.M., the Regional Nurse said the monthly MRRs should identify irregularities and be reported to the facility. During an interview on 5/29/25 at 12:26 P.M., the Director of Nurses (DON) said for Resident #34, the order should have included only the number of days for administration and not both the number of days and doses. The DON said the MRRs conducted by the Consultant Pharmacist should help the facility catch discrepancies and irregularities in orders. Refer to F757

Based on record review and interviews, for one Resident (#69), of 19 sampled residents, the facility failed to provide specialized rehabilitative services, specifically physical and occupational therapy, as ordered. Findings include: Resident #69 was admitted to the facility in February 2025 with diagnoses which included right lower extremity tibia (one of the long bones located in the lower leg) fracture status post-surgical repair. Review of Resident #69's Physician's Orders for Physical Therapy (PT) and Occupational Therapy (OT) indicated but was not limited to: -PT order for 5 times per week for 4 weeks to address therapeutic activities, therapeutic exercise, gait training, neuro re-education, manual therapy, wheelchair management, patient/caregiver education, and discharge planning per plan of care, order date 2/7/25 and end date 3/9/25 -PT updated plan of care as of 3/8/25 for 5 times per week for 4 weeks for continued care and management, order date 3/11/25 and end date 4/30/25 -PT updated plan of care 5 times per week for 4 weeks for therapeutic exercises, therapeutic activities, group therapy, wheelchair management, gait training, and safety education, order date 4/6/25 and end date 5/29/25 -PT updated plan of care 5 times per week for 4 weeks with therapeutic exercise, therapeutic activities, neuro re-education, gait, group therapy, and wheelchair safety, order date 5/5/25 and end date 5/29/25 -PT evaluation and treat for 4 times per week for 4 weeks for therapeutic exercise, therapeutic activity, neuro re-education, gait training, group therapy, manual therapy, and safety education, order date 5/21/25 and end date 5/29/25 -OT 5 times per week for 4 weeks to include therapeutic exercise, therapeutic activities, self-care skills, neuro re-education, group as indicated, and patient/caregiver education as per plan of care, order date 4/3/25 and end date 4/30/25 -OT 5 times per week for 4 more weeks to include therapeutic exercise, therapeutic activities, self-care skills, neuro re-education, group as indicated, and patient/caregiver education as per plan of care, order date 4/28/25 and end date 5/26/25 Review of the PT treatment dates indicated for 8 out of 14 weeks reviewed the facility failed to provide PT 5 times per week: -week of 2/21/25 through 2/27/25: two visits -week of 3/7/25 through 3/13/25: four visits -week of 3/14/25 through 3/20/25: four visits -week of 3/28/25 through 4/3/25: four visits -week of 4/4/25 through 4/10/25: three visits -week of 4/11/25 through 4/17/25: three visits -week of 4/18/25 through 4/24/25: three visits -week of 5/2/25 through 5/8/25: four visits Review of the OT treatment dates indicated for 3 out of 6 weeks reviewed the facility failed to provide OT 5 times per week: -week of 4/3/25 through 4/9/25: one visit -week of 4/10/25 through 4/16/25: zero visits -week of 4/17/25 through 4/23/25: four visits During an interview on 5/27/25 at 3:06 P.M., Resident Representative #1 said up until recently Resident #69 was supposed to receive both PT and OT five times each per week but she did not believe this had occurred. During an interview on 5/29/25 at 9:57 A.M., the Director of Rehab reviewed Resident #69's medical record and said he/she should have received PT 5 times per week from 2/7/25 through 5/21/25 and should have received OT 5 times per week from 4/3/25 through 5/16/25. The Director of Rehab said Resident #69 was not seen by PT 5 times per week for 8 out of 14 weeks reviewed and was not seen by OT for 3 out of 6 weeks reviewed. The Director of Rehab said therapy should have been provided to Resident #69 per physician's orders and an encounter note should have been created. The Director of Rehab said if a resident was not provided with their scheduled therapy visit a missed visit note should have been completed to indicate why he/she was not seen, but there was no additional evidence of therapy visits in Resident #69's medical record.

Based on record review and interview, the facility failed to ensure nursing staff provided the resident and/or representative with a summary of the baseline care plan for one Resident (#126), out of a total sample of 19 residents. Findings include: Resident #126 was admitted to the facility in May 2025 with diagnoses including interstitial pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory with hypercapnia and neurocognitive disorder with Lewy Bodies. Review of the medical record failed to indicate the Resident and/or representative were provided with a written summary of his/her baseline care plan within 48 hours of admission which included initial goals for the resident, current medications and dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility. During an interview on 5/28/25 at 10:42 A.M., Resident #126 said they had not had a care plan meeting yet and he/she'd been at the facility a few weeks. Resident #126 said he/she was their own person, and the facility did not review or provide a summary of a baseline care plan to him/her within 48 hours of admission. During an interview on 5/29/25 at 11:30 A.M., Nurse #2 said the baseline care plan was not developed within 48 hours of admission. During an interview on 5/30/25 at 12:13 P.M., the Administrator said during the morning meeting new admissions are discussed, and it is a team effort to gather the information to complete the baseline care plan within 48 hours. She said the team should have completed the baseline care plan and a summary of it should have been provided to the Resident and/or representative.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of changes to a wound for one Resident (#27), out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to notify the physician of changes to a wound on the right lower extremity from a superficial wound (minor injury that affects only the outermost layer of skin) to a wound with slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) in the wound bed. Findings include: Review of the facility's policy titled Wound Care, dated October 2010, indicated the following was to be documented in the medical record during wound care treatments: all assessment data including wound bed color, size, drainage obtained when inspecting the wound; if the resident refused the treatment and the reasons why. Resident #27 was admitted to the facility in April 2025 with diagnoses of diabetes, a history of a left transmetatarsal amputation (TMA- a surgical procedure where the forefoot (including the toes and part of the foot bones is removed to preserve the remaining part of the foot and ankle), and history of right foot first, second and third toe amputations. Review of the Minimum Data Set (MDS) assessment, dated 5/13/25, indicated Resident #27 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the medical record indicated Resident #27 was admitted with multiple wounds to the bilateral lower extremities including pressure ulcers to the bilateral heels, vascular wounds to the top of the right foot, and scattered open areas to the lower portions of the lower extremities. Review of the re-admission hospital paperwork, dated 5/25/25, indicated Resident #27 had bilateral shin wounds with a treatment of a wet to dry dressing (type of wound dressing where moist gauze is applied to a wound and allowed to dry, creating a mechanical debridement (removing dead tissue and debris). The discharge summary indicated the right anterior lower tibial wound bed was red, fragile, pink with a pink peri-wound on 5/25/25. Review of the May 2025 Treatment Administration Record (TAR) indicated the same treatment order from prior to the hospitalization of wound care: right leg and heel superficial wounds, normal saline cleanse and bacitracin with Mepore dressing was re-instated on 5/26/25. Review of the facility's document, Admission/readmission assessment, dated 5/25/25, indicated Resident #27 had a superficial wound to the right lower leg. The comment section on the assessment indicated the bilateral shins were to be cleansed with normal saline, apply gauze dressing daily. There was no indication the treatment was now a wet to dry dressing as indicated in the hospital discharge summary. On 5/30/25 at 10:40 A.M., the Director of Nurses (DON), the facility Wound Nurse and the surveyor observed the lower extremity wounds of Resident #27. After removing the gauze, a Mepore dressing was observed on the right lower lateral leg. The DON removed the adhesive bandage and said the wound bed was 100% slough. During an interview on 5/30/25 at 11:45 A.M., Nurse #4 said she had been the nurse providing care to Resident #27 on 5/29/25. She said on 5/29/25 she put bacitracin and the Mepore dressing on the wound to the right lower leg. She said the wound was not superficial and had slough on 5/29/25. She said she could not be sure if the wound had changed. She said she had not documented that the wound had slough on 5/29/25 and had not notified anyone. Review of the Interim Skin Assessment completed 5/30/25 indicated Resident #27 had a vascular wound to the right lower leg with 100% slough measuring 4.7 centimeters (cm) in length by 2.5 cm in width by 0.3 cm in depth. During an interview on 5/30/25 at 12:50 P.M., the Physician said she was aware Resident #27 had wounds to the bilateral lower extremities. She said she was not notified of changes to the wound on the right lower leg and was unaware the wound had slough. During an interview on 5/30/25 at 1:30 P.M., the DON said the physician had not been notified of changes until the wound was observed on 5/30/25 with the surveyor. Refer to F684

Based on record review and interview, the facility failed to ensure the drug regimen for one Resident (#34), out of 19 sampled residents, was free of unnecessary drugs. Specifically, the facility failed to ensure an antibiotic medication (Flagyl) was not given in excessive duration resulting in the Resident receiving an additional 37 doses. Findings include: Resident #34 was admitted to the facility in April 2022 and had diagnoses which included pyelonephritis (inflammation of the kidneys, typically caused by a bacterial infection), renal and perinephric abscess (result of infection involving the kidney and the surrounding fat and tissues). Review of the Minimum Data Set (MDS) assessment, dated 4/20/25, indicated Resident #34 was receiving antibiotics. Review of Resident #34's Hospital Discharge summary, dated [DATE], indicated he/she should receive Flagyl three times per day for 90 doses. Review of Resident #34's Physician's Orders indicated but was not limited to: -Flagyl oral tablet 500 milligrams (mg) give one tablet by mouth three times a day related to renal and perinephric abscess for 89 days 90 doses, start date 4/15/25 Review of Resident #34's April and May 2025 Medication Administration Record (MAR) indicated he/she had received 127 doses of Flagyl as of 5/29/25. Review of Resident #34's progress notes failed to indicate a provider had been consulted to extend the duration of the Flagyl. During an interview on 5/29/25 at 9:28 A.M., Physician #1 reviewed Resident #34's physician's orders and said 90 doses would have been roughly 30 days. Physician #1 said she did not recall extending the duration of his/her Flagyl. During an interview on 5/29/25 at 10:57 A.M., the Regional Nurse said the order for Flagyl was transcribed with a stop date that was 89 days out, but additional notes indicated the order was for only 90 doses. During an interview on 5/29/25 at 12:26 P.M., the Director of Nurses (DON) said Resident #34's Flagyl order should have included only the number of days for administration and not both the number of days and doses. The DON said the confusion occurred because the order included both doses and days of duration.

Based on records reviewed and interviews for three of three sampled residents (Resident #1, #2, and #3), the Facility failed to ensure they maintained complete and accurate medical records, related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets, when daily documentation by CNA's were not consistently completed, with ADL Flow Sheets often left completely blank. Findings Include: Review of the Facility's Policy tilted Charting and Documentation, dated as last revised July 2017, indicated all services provided to the resident, progress towards care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The Policy further indicated documentation in the medical record will be complete and accurate. Review of the Facility's documentation for care and services provided by CNA's is recorded on the Facility's document titled Documentation Survey Report v2, going forward in this deficiency the document will be referred as the Resident's ADL Flow Sheet. 1) Resident #1 was admitted to the Facility in June 2023, diagnoses included adult failure to thrive, dysphagia (difficulty swallowing), Alzheimer's, dementia, and contracture of right lower leg (shortening and hardening of muscles and tendons). Review of Resident #1's ADL Flow Sheets, dated 04/01/24 through 04/30/24, indicated that for the following shifts, documentation on the flow sheets was incomplete. -7:00 A.M. to 3:00 P.M.- 26 days (out of 30) all care areas were left blank -3:00 P.M. to 11:00 P.M.- 11 days (out of 30) all care areas were left blank -11:00 P.M. to 7:00 A.M.- 24 days (out of 30) all care areas were left blank Review of Resident #1's ADL Flow Sheets, dated 05/01/24 through 05/31/24, indicated that for the following shifts, documentation on the flow sheets was incomplete. -7:00 A.M. to 3:00 P.M.- 13 days (out of 24) all care areas were left blank -3:00 P.M. to 11:00 P.M.- 3 days (out of 24) all care areas were left blank -11:00 P.M. to 7:00 A.M.- 18 days (out of 24) all care areas were left blank This does not include dates and shifts when Resident #1 was Medical Leave of Absence (MLOA) 05/09/24 through 05/15/24. Review of Resident #1's ADL Flow Sheets, dated 06/01/24 through 06/05/24, indicated for the following shifts, documentation on the flow sheets was incomplete. -7:00 A.M. to 3:00 P.M.- 3 days (out of 5) all care areas were left blank -11:00 P.M. to 7:00 A.M.- 3 days (out of 5) all care areas were left blank 2) Resident #2 was admitted to the Facility in October 2023, diagnoses included polyneuropathy (decreased ability to move or feel sensation), essential tremor (involuntary shaking of body parts), cervical disc disorder at C5-C6 level with myelopathy (injury to spinal cord caused by compression), and hypertensive heart disease without heart failure. Review of Resident #2's ADL Flow Sheets, dated 08/01/24 through 08/12/24, indicated that for the following shifts, documentation on the flow sheets was incomplete. -7:00 A.M. to 3:00 P.M.- 6 to 7 days (out of 12) all care areas were left blank -3:00 P.M. to 11:00 P.M.- 1 day (out of 12) all care areas were left blank -11:00 P.M. to 7:00 A.M.- 7 to 8 days (out of 12) all care areas were left blank 3) Resident #3 was admitted to the Facility in May 2024, diagnoses included muscle wasting and atrophy (thinning of muscle mass), Alzheimer's disease, muscle weakness, and adult failure to thrive. Review of Resident #3's ADL Flow Sheets, dated 08/01/24 through 08/12/24, indicated that for the following shifts, documentation on the flow sheets was incomplete. -7:00 A.M. to 3:00 P.M.- 9 days (out of 12) all care areas were left blank -11:00 P.M. to 7:00 A.M.- 8 to 9 days (out of 12) all care areas were left blank During an interview on 08/13/24 at 1:28 P.M., CNA #1 said they are supposed to do their documentation of care provided to residents every day before the end of their shift. CNA #1 said she was not always able to do her documentation because she is so busy, and just does not have time someday's to document the care she provided to the residents. During an interview on 08/13/24 at 2:03 P.M., CNA #2 said they document resident's care in the Point of Care (POC) system on the computer and that it has to be done by the end of the shift. CNA #2 said she does not have time to do her documentation some days because it is very busy and someday's are harder than others to get her work done. During an interview on 08/19/24 at 1:21 P.M., the Former Director of Nursing (DON) said she was aware that the CNA's were not doing ADL documentation daily, that it was a big issue and always a struggle to get them to do their documentation. The Former DON said that the CNA's should have been documenting daily all care that was provided to residents before the end of their shift. During an interview on 08/13/24 at 4:17 P.M., the Interim Director of Nursing (DON) said she was not aware that the CNA ADL Flow sheets were incomplete and said that the CNAs should be doing their daily documentation by the end of their shift. The Interim DON said she expects the CNAs to complete all documentation on care provided to residents daily and that ADL Flow Sheets should not be left blank.

Based on observation, interview, and policy review, the facility failed to ensure that drugs and biologicals were labeled and stored in accordance with current accepted professional standards. Specifically, the facility failed to ensure medications were properly labeled with a shortened expiration date upon opening and the resident's name was on the medication in two of four medication carts in use by the facility. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised [DATE], indicated but was not limited to the following: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy. Review of the facility's policy titled Administering Medications, dated as revised [DATE], included but was not limited to the following: -The individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time and right method of administration before giving the medication. -The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. On [DATE] at 2:02 P.M., the surveyor reviewed the Unit A low side medication cart with Nurse #2, and made the following observations: - One Advair diskus inhaler (used to control wheezing and shortness of breath), removed from foil pouch, and in use. No open date or shortened expiration date on container or outside packaging. -One Trelegy Ellipta inhaler (used to control wheezing and shortness of breath), removed from foil pouch, and in use. No open date or shortened expiration date on container or outside packaging. -One Flonase nasal spray (used to treat allergies), opened and in use. No open date or shortened expiration date on container or outside packaging. - One Breo Ellipta inhaler (used to control wheezing and shortness of breath), removed from foil pouch, and in use. No open date or shortened expiration date on container or outside packaging. During an interview on [DATE] at 2:08 P.M., Nurse #2 said inhalers and nasal sprays should be dated upon opening and are only good for 30 days after removal from the sealed packaging. On [DATE] at 2:18 P.M., the surveyor reviewed the Unit A low side medication cart with Nurse #3, and made the following observations: - One bottle of Latanoprost (used to treat increased pressure inside the eye) eye drops, seal broken, indicating it was in use. No open date or shortened expiration date on bottle or outside packaging. - One Breo Ellipta inhaler (used to control wheezing and shortness of breath), removed from foil pouch, and in use. No open date, no shortened expiration date, no resident name or identifier on container or outside packaging. -Two Flonase nasal sprays (used to treat allergies), opened and in use. No open date or shortened expiration date on container or outside packaging. - One Spiriva inhaler (used to treat difficulty with breathing), opened and in use. No open date, no shortened expiration date, no resident name or identifier on container, and not on outside packaging. During an interview on [DATE] at 2:26 P.M., Nurse #3 said eye drops and inhalers should have the open date on them once the seal is broken. She said she did not open the medications; she has no idea if the medications are expired. She said without a name on the medications, she does not know what resident they are for. During an interview on [DATE] at 11:43 A.M., the Director of Nursing (DON) was made aware of the surveyor's observations. She said her expectation is for medications with a shortened expiration date to be labeled with the open date upon opening. She said if they were not labeled with the open date, they must be discarded, and new ones ordered. The DON said medications such as inhalers and eye drops may only be used for one resident and must be clearly labeled with a name to ensure it is not administered to the wrong resident. She said any medications that are not labeled with the resident's name, must be discarded, and new ones ordered.

Based on record review, observation, interview, and policy review, the facility failed to follow professional standards for two Residents (#24 and #219), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #24, to reconcile the Resident's medications from the hospital discharge summary to restart Plavix (Clopidogrel- antiplatelet medication that prevents blood clots from forming) on 10/18/23, resulting in the Resident missing 65 doses of Plavix from 10/18/23 to 12/18/23; and 2. For Resident #219, to ensure the Resident's transparent semi-permeable membrane (TSM) dressing to the left upper extremity midline catheter was changed in accordance with the physician's order following readmission, and in accordance with the facility policy. Findings include: 1. Review of the facility's policy titled Reconciliation of Medications on Admission, revised July 2017, indicated but was not limited to the following: -The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescriptions and over the counter medications that includes the drug name dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points of care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. -Using an improved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous medication administration record (if applicable), and the admitting orders (sources). Review of Davis's Drug Guide for Nurses, 18th edition, indicated but was not limited to the following drug information for Clopidogrel (Plavix): -Classification: Antiplatelet agent -Indications: Patients with established peripheral artery disease, recent MI (heart attack), or recent stroke -Discontinue Clopidogrel five to seven days before planned surgical procedures. If Clopidogrel must be temporarily discontinued restart as soon as possible. Resident #24 was admitted to the facility in July 2023 with the following diagnoses: Cerebral vascular accident (stroke) with right-sided involvement, myocardial infarction (MI-heart attack), coronary (heart) artery disease with coronary artery bypass graft (CABG), hyperlipidemia (high cholesterol), hypertension (high blood pressure), and spinal stenosis (narrowing of one or more spaces in the spinal column). Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated that Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 4/9/24 at 10:30 A.M., Resident #24 said he/she had spinal surgery in October 2023, and they stopped the Plavix medication before the surgery and they never restarted it until December 2023 when he/she developed blood clots in the right leg. Review of Physician's Orders from July 2023 through April 2024 indicated the following: -Clopidogrel Bisulfate (Plavix) 75 milligrams (mg), give one tablet by mouth one time a day, date initiated 7/12/23, discontinued 10/3/23. -Stop Plavix (Clopidogrel Bisulfate) on 10/3/23 prior to surgery. -Plavix 75 milligrams, give 75 milligrams by mouth one time a day, start date of 12/19/23. -Aspirin 81 mg in the morning for stroke prevention, date initiated 9/20/23 and discontinued 10/18/23. -Aspirin 81 mg, give one tablet by mouth one time a day for supplement, initiated 10/17/23. -May perform Doppler ultrasound (test to check for blood clots) on Right lower extremity to rule out deep vein thrombosis (blood clot), initiated 12/11/23. Review of the Hospital Discharge Summary following spinal surgery (10/11/23), dated 10/17/23, indicated but was not limited to the following discharge medication instructions: -Held Plavix 75 mg daily. This medication was held. Do not restart Plavix until seven days after surgery. Discharge instructions: -You will be able to restart your Plavix in seven days (10/18). (This was underlined in the discharge summary). Review of the venous Doppler extremity results, dated 12/12/23, indicated the duplex (ultrasound) indicated the imaging of the right lower extremity venous circulation was performed. There is lack of compression with diminished flow in the right common femoral vein, right profunda femoral vein, right femoral vein, right popliteal vein through right popliteal vein trifurcation in the calf. Conclusion: Acute extensive right lower extremity deep vein thrombosis (DVT). Review of the Medication Administration Record (MAR) for October, November, and December 2023 indicated Resident #24 did not receive Plavix from 10/18/23 through 12/18/23, a total of 62 days for the prevention of blood clots, stroke, and MI. During an interview on 4/10/24 at 3:45 P.M., Physician #2 said Resident #24's Plavix was held prior to surgery, and she did not know why the Plavix was not restarted after the surgery. She said she was aware the Plavix was restarted after the Resident #24 developed a DVT in December 2023. Physician #2 said Resident #24 had concerns of increased swelling in the right stroke affected leg previously and had two previous negative ultrasounds for blood clots, the most recent being September 2023. Physician #2 said Plavix is not your normal medication used to prophylactically prevent DVTs and said not being on the Plavix may or may not have had an effect on the development of the DVT. During an interview on 4/12/24 at 8:25 A.M., Resident #24 said he/she missed his/her cardiology appointment prior to surgery due to transportation issues and only saw a cardiologist when he/she was in the hospital. Resident #24 said he/she has been taking Plavix every day for about four years since having two strokes and heart surgery. During an interview on 4/11/24 at 11:05 AM., the Director of Nurses (DON) said Resident #24 only had a cardiology appointment prior to surgery which was canceled due to transportation issues. She said Resident #24 was cleared by cardiology at the hospital for surgery in October and has not seen a cardiologist since the surgery. During an interview on 4/12/24 at 10:06 A.M., Physician #1 said with Resident #24's past medical history of stroke and cardiac history, Resident #24 should have restarted Plavix after surgery unless the cardiologist said not to. The surveyor reviewed with Physician #1 that Resident #24 has not seen a cardiologist since the surgical hospitalization in October 2023. The surveyor also reviewed Resident #24's hospital discharge summary, dated 10/23/23, which indicated the Plavix should be restarted on 10/18/23 (seven days post-surgery). Physician #1 said she agreed the Plavix should have been started on 10/18/23 as recommended in the discharge summary. Physician #1 said sometimes post-surgery, 81 mg of aspirin is enough of an anticoagulant (blood thinner) to prevent blood clots and Resident #24 was on a daily aspirin since returning from the hospital. During an interview on 4/12/24 at 12:45 P.M., the DON said they have a process for admission and readmission and part of the process is a Medication Reconciliation form should be completed with the admission paperwork. The DON said there was no medication reconciliation performed when Resident #24 returned from the hospital in October 2023 and there should have been. The DON said Resident #24 should have re-started on the Plavix as indicated in the discharge summary. 15214 2. Review of the facility's policy titled Peripheral and Midline Dressing Changes, revised 2/2022, included but was not limited to the following: -The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines -Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g. damp, loosened or visibly soiled). -Change the dressing if it becomes damp, loosened or visibly soiled and: -at least every 7 days for TSM dressing; -at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or -immediately if the dressing or site appears compromised. Review of the medical record indicated Resident #219 was readmitted to the facility from a community hospital on 4/2/24 following treatment for bacteremia (bacteria in the bloodstream). The Resident had a left upper extremity midline catheter placed at the hospital on 3/31/24 that remained in place upon readmission to the facility. The midline catheter was used to administer intravenous antibiotics. On 4/9/24 (nine days following insertion of the catheter) at 8:30 A.M., the surveyor observed Resident #219 lying in bed. The Resident's left upper arm midline catheter dressing was clean and intact; however, the surveyor did not observe the TSM catheter dressing to be dated to indicate when it was last changed. On 4/10/24 at 4:06 P.M., the surveyor observed Resident #219 lying in bed. The Resident's left upper arm midline catheter TSM dressing remained clean and intact, but it was not dated. Review of the Treatment Administration Record (TAR) on 4/11/24 at 8:11 A.M., indicated a physician's order to change the PICC/Midline: change transparent dressing, extension set and cap on admission. There was no evidence on the TAR that the dressing had been changed upon readmission to the facility. During an interview on 4/11/24 at 9:59 A.M., the DON said that it is the facility's policy to change midline catheter dressings upon readmission, and every seven days thereafter. She said that the policy was not followed. The DON also said that the physician ordered TSM dressing to the midline catheter be changed upon admission and that order was not followed.

Based on record review and interviews, the facility failed to obtain the recommended eye care services in a timely manner to maintain the highest psychosocial well-being of one Resident (#42), out of a total sample of 20 residents. Specifically, the facility failed to ensure follow-up appointments were scheduled for an eye specialist for cataract surgery (indicated when clouding of the normally clear lens of the eye impairs vision and interferes with usual day-to-day activities), after the initial appointment was canceled due to lack of transportation resulting in a four-month delay. Findings include: Review of the facility's policy titled Sensory Impairments-Clinical Protocol, revised March 2018, indicated but was not limited to the following: -As part of the initial assessment, the staff and physician will help identify individuals with sensory impairments including hearing, taste, vision, smell, and touch. -The physician will order appropriate consultations (for example ophthalmology or Podiatry evaluations) to help define causes and complications of sensory impairments. -The staff and physician will identify approaches to help the resident improve or compensate for sensory deficits. For example, they may refer visually impaired individuals for vision evaluation and/or corrective lenses. -The physician and staff will adjust interventions based on the results of these interventions and on subsequent changes in the resident's condition, prognosis, and function. Resident #42 was admitted to the facility in December 2020 with the following diagnosis: age-related nuclear cataract right eye. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/6/24, indicated that Resident #42 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review indicated Resident #42 had impaired vision: Sees large print, not able to see newspapers/books, and does not use corrective lenses. During an interview on 4/9/24 at 8:55 A.M., Resident #42 said he/she had bilateral cataracts and was seen by the eye doctor approximately eight months ago and was supposed to have the cataracts fixed but the orders disappeared and now he/she must start all over. Review of the facility's consultant eye care group progress note for Resident #42, dated 5/11/23, indicated but was not limited to the following: Assessment: cataract, mixed; moderate; both eyes. -Plan: cataract surgery recommended, referral to ophthalmology for cataract at the Veterans Administration (VA). Review of the facility's consultant eye care group progress note for Resident #42, dated 8/7/23, indicated but was not limited to the following: -Assessment: cataract, mixed; moderate; both eyes -Plan: Wants to proceed with surgery, referral for ophthalmology consult, patient wants and has the right to be taken care of by the VA Health Care system, if transportation continues to be an issue try a local contractor. Follow up on referral given. Review of the facility's Outpatient Referral Form, dated 12/18/23, indicated Resident #42 was seen at the VA's optometry clinic with the following findings: -Visually significant cataracts right greater than left. Plan: Will refer patient for cataract surgery consult. -Peripapillary choroidal neovascularization (new choroidal blood vessels on the nerve head) in the right eye. Plan: will send consults for retina (layer of cells within the eye) evaluation through the VA services. Review of the facility's consultant eye care group progress note for Resident #42, dated 2/23/24, indicated but was not limited to the following: -Assessment: Cataract, mixed; both eyes -patient to continue with ophthalmology. Patient is very happy that he/she was able to receive an appointment with ophthalmology doctor. Review of Resident #42's care plan for vision indicated the following: -Resident has a potential for impaired visual function related to age-related cataracts. -Resident will use appropriate visual devices eyeglasses to promote participation in ADLs and other activities. -Staff to ensure glasses are labeled with name and room number -Ensure eyeglasses are clean and available to support participation in activities. During an interview on 4/11/24 at 10:38 A.M., Assistant Director of Nurses (ADON) said Resident #42 did go out to the VA for the cataract surgery consult and is scheduled to have multiple appointments at the VA, including cataract surgery on both eyes starting later this month. During a follow up interview on 4/11/24 at 9:34 A.M., Resident #42 said he/she has two sets of glasses, but he/she has been unable to read with them for a year. Resident #42 said it is very important for him/her to have the cataract surgery to resume reading the Bible and scriptures again. During a telephonic interview on 4/11/24 at 3:42 P.M., the Consultant Optometrist (OP) #1 said he evaluated Resident #42 in May 2023 and again in August 2023, and both evaluations recommended a referral for cataract surgery. OP #1 said he was aware Resident #42 had an appointment at the VA in July 2023, but it had been canceled due to lack of transportation and it was never rescheduled, and it should have been. OP #1 said Resident #42 never wavered on having cataract surgery because reading the Bible made him/her happy. OP #1 said he was in the facility in December 2023 and was informed Resident #42 still had not been scheduled for cataract surgery and he personally got involved to ensure Resident #42 got an appointment at the VA. During an interview on 4/12/24 at 8:46 A.M., Social Worker (SW) #1 said the OP #1 came to him and asked what was going on with Resident #42's cataract appointments, it should have been taken care of a long time ago. SW #1 said he took it upon himself to call the VA and was able to get an appointment within two weeks. He said Resident #42 was seen on 12/18/23, for the initial consultation and Resident #42 has scheduled appointments for cataract surgeries for both eyes in April and May 2024. During an interview on 4/12/24 at 10:03 A.M., the Director of Nurses (DON) said it did take longer than it should have for Resident #42 to have the cataract surgeries scheduled.

Based on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on two of two open resident units (A and B), on one closed resident unit (C), and the laundry room. Findings include: On 4/11/24 at 5:00 P.M., the Director of Nurses (DON) said they do not have a policy for pest control. Review of Unit A's Pest Sighting/Evidence log indicated the last entry was on 2/13/24. Review of Unit B's Pest Sighting/Evidence log indicated the last entry was on 2/21/24. Review of the facility's Pest Binder indicated the last entry for a pest sighting was on 9/7/23. During a Resident Group Meeting with the surveyor on 4/10/24 at 2:00 P.M., the 21 residents in attendance raised the concern of continued observations of mice running in their rooms and running under closet doors to hide. During an interview with observation on 4/9/24 at 10:30 A.M., Resident #42 said there are problems with mice at nighttime and sees mice every night in the room. The surveyor, with the resident's permission, viewed the room and found mice droppings behind the furniture, in the corners of the room, and in the three closets. During an interview with observation on 4/9/24 at 11:08 A.M., Resident #4 said there are mice in the room running around every day. The surveyor observed the resident's room, with the Resident's permission, and found numerous mice droppings around the border of the room and behind the furniture. Additionally, an enormous number of mice droppings were found in the closet, inside slippers and shoes, and on the shelf directly above where the Resident's clothes were hanging. On the shelf there were foil wrappers from chocolate candy that had been eaten with numerous mice droppings present. On 4/9/24 at 11:17 A.M., the surveyor observed the small dining room on Unit A, on a dining room table there were plastics bags that contained staff personal items. Inside the activity closet in the room, the surveyor observed numerous mice droppings visible between the wood slats of the pallet on the floor. During an interview on 4/9/24 at 11:18 A.M., the surveyor observed CNA #4 accessing her personal belongings from one of the plastic bags stored in the dining room. CNA #4 said there is a little problem with mice in the building. CNA #4 said she keeps her personal items including her pocketbook in a plastic bag while in the facility because of the mice problems. During an interview with observation on 4/9/24 at 11:55 A.M., Resident #11 said there are mice in the room and they go under the wall. The Resident said he/she sees them running around every day. The surveyor, with the Resident's permission, observed mice droppings in the corner of the room and the bathroom. During an interview with observation on 4/9/24 at 12:16 P.M., Resident #44 said there have been mice in the room within the last month. The surveyor, with the Resident's permission, viewed the room and found mice droppings in the closet and a mice hole in the wall. During an interview with observation on 4/9/24 at 1:08 P.M., Resident #27 said the mice situation is getting better, but there are still mice at nighttime in the room. The surveyor, with the Resident's permission, observed the resident's room and found mice droppings in the residents' closet room (closet shared by both residents). On 4/9/24 at 2:03 P.M., on Unit A, the surveyor observed the entrance to the tub room and observed a white bookcase with mice droppings and urine stains on the bottom 3 shelves (ground level). There was evidence of mice droppings in the tub room along the walls, the corners and underneath the radiators. There was also a mice sticky pad (trap) on the ground that was soiled with dirt and mice droppings. During an interview with observation on 4/9/24 at 3:52 P.M., Resident #219 said he/she sees 2-3 mice in the room at night, pointing to the floor over by the closet. The surveyor, with the Resident's permission, viewed the room and found mice droppings behind the furniture and in the Resident's closet. During an interview with observation on 4/10/24 at 9:07 A.M., Resident #17 said the mice come out every night in the room. The only time he/she does not see mice at night is when he/she is asleep. The surveyor, with the Resident's permission, observed mice droppings in the corners, behind the dressers, and in the Resident's closet. On 4/10/24 at 2:20 P.M., the surveyor observed the closed Unit C and made the following observations in the unlocked available rooms: -Rooms #50, #51 and #52, there were many mice droppings and yellow stains along the walls, underneath the radiators, and in the closets. In addition, there was a small amount of trash scattered on the floor throughout the room including bottle caps, hangers, and small pieces of paper. -Tub room, there were large amounts of mice droppings along the walls under the radiators around the tub, and the foot plate of the mechanical lift. Mouse sticky traps that were soiled with dirt and mice droppings. During an interview with observation on 4/10/24 at 3:41 P.M., Resident #7 said there are mice around. The surveyor, with the Resident's permission, viewed the room and observed mice droppings in the closet corners. On 4/10/24 at 2:42 P.M., the surveyor observed the laundry room in the basement and found mice droppings in the back right corner and a few mice droppings on top of a blanket covering the red linen cart. During an interview on 4/10/24 at 2:25 P.M., the Housekeeping Manager said she is aware of the mice issue in the building. She said they clean the rooms daily, sweeping the floors, dry mopping the floors and cleaning the bathrooms. She said everyday a room of the day on each unit is cleaned. She said the room of the day cleaning consists of stripping the beds, cleaning the beds, moving the furniture, and cleaning behind the furniture, cleaning the bathrooms, and washing the floors. She said they do not clean in the closets because of the resident's personal items. In addition, she said when unit C was closed a couple weeks ago, all the resident rooms and storage rooms on the unit were cleaned thoroughly and the floors were buffed. She said because unit C is closed, housekeeping walks through the unit and if they see a room is dirty, they clean it. The surveyor informed the Housekeeping Manager of the mice droppings in the resident rooms on Unit C, specifically in the closets and along the border of the room, and mice droppings observed on the closed unit tub room/storage room and equipment stored in the tub room. Review of the Housekeeping complete room calendar for March and April 2024 indicated the following: March 2024: -Resident #7's room was cleaned on 3/19/24. -Resident #4's aromas cleaned on 3/22/24. -Resident #219's room was cleaned on 3/23/24. -Resident #44's room was cleaned on 3/26/24. -Day rooms cleaned 3/20/24. April 2024: -Resident #27's room was cleaned on 4/2/24. -Resident #42's room was cleaned on 4/8/24. -Resident #27's room was cleaned on 4/9/24. -The Tub rooms were not on the complete room cleaning schedule. During an interview on 4/10/24 at 3:30 P.M., Certified Nursing Assistant (CNA) #2 said when he/she has worked the overnight shift you could see mice running from room to room, but it has gotten better. During an interview on 4/10/24 at 3:35 P.M., Nurse #5 said he/she has seen mice at nighttime. Nurse #5 said when you see mice you just tell the DON, and they will follow up. During an interview on 4/10/24 at 5:00 P.M., the Administrator, with the Director of Maintenance present, said he has been tackling the pest control problem since he arrived. The Administrator said if there is an issue with the room, he goes down there personally and plugs all holes and puts down sticky pads. The Maintenance Director said he rounds with the Pest Control Contractor and inspects resident rooms. The Maintenance Director said, when Unit C was closed approximately two weeks ago, the entire Unit was cleaned. The surveyor reviewed pictures with the Administrator and the Director of Maintenance of the above listed resident rooms on Unit A and B (occupied), resident rooms Unit C (unoccupied), tub rooms on Unit A and Unit C, small dining room Unit A, and the laundry room all with significant evidence of mice droppings. The Administrator and the Director of Maintenance were not sure why the residents' closets had not been cleaned, or why there was the number of mice droppings on Unit C if it was just cleaned. The surveyor reviewed the Pest Control Logbooks from Unit A&B which each logbook containing only one entry dated February 2024, and Pest Control Logbook with the last entry September 2023. The Maintenance Director said they were not good about filling out the logbooks and he finds out about mouse sightings by word of mouth. During a telephonic interview on 4/17/24 at 9:59 A.M., the Contracted Pest Control Manager (PCM) said he has been involved with this building since they obtained the contract services in September 2023. The PCM said during the initial consultation in September, there was evidence of mice in the building including in resident's rooms and the closets. He said the facility staff were educated as part of the pest control program to maintain pest sighting logs and to maintain sanitation in the building. The PCM said when mice droppings were found, the facility staff were told that just sweeping up the mice droppings was not sufficient. When mice droppings are found, the area must be scrubbed clean and sanitized with a chemical based cleaner to remove the urine scent, fecal matter, and to remove the pheromone trail (scent trail which attracts other mice). In addition, he said mice droppings need to be cleaned and set and the area sanitized because of the diseases that are carried in the mice droppings.

Based on record review, interview, and policy review, the facility failed, for five of five sampled Residents (#219, #33, #8, #13, and #53), to ensure residents were offered the pneumonia vaccine, unless the immunization was medically contraindicated or the resident had already been immunized. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised March 2023, included but was not limited to: -Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated/available, are offered the vaccine series within the facility unless medically contraindicated, awaiting shipments of vaccines, or the resident has already been vaccinated. -Assessment of pneumococcal vaccination status is conducted within thirty (30) days of the resident's admission if not conducted prior to admission. -Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Review of the five sampled Residents' (#219, #33, #8, #13, and #53) immunization records indicated that they had not received or had evidence of being offered the pneumonia vaccination within 30 days of admission. The following was determined: -Resident #219 was admitted to the facility in February 2024. The facility had no record of the Resident being offered or receiving the pneumonia vaccine since admission. -Resident #33 was admitted to the facility in June 2023. The facility had no record of the Resident being offered or receiving the pneumonia vaccine since admission. -Resident #8 was admitted to the facility in April 2023. The facility had no record of the Resident being offered or receiving the pneumonia vaccine since admission. -Resident #13 was admitted to the facility in February 2017. The facility had no record of the Resident being offered or receiving the pneumonia vaccine since admission. -Resident #53 was admitted to the facility in November 2023. The facility had no record of the Resident being offered or receiving the pneumonia vaccine since admission. During an interview on 4/12/24 at 9:40 A.M., the Infection Preventionist (IP) said that she did not have a comprehensive roster of residents who had received, refused, or required the pneumonia vaccine. During an interview on 4/12/24 at 12:00 P.M., the Director of Nursing (DON) said that she did not have a current pneumonia vaccination roster for residents who are currently in the facility. She said that the facility policy was for residents to be offered the pneumonia vaccine within 30 days of admission. During an interview on 4/16/24 at 8:00 A.M., the DON said that the policy was to assess the residents for receiving the vaccination upon admission, and if the resident elects to receive it, it should be administered within 30 days of admission. During an interview on 4/16/24 at 12:11 P.M., the IP said that back in November 2023, she recognized that pneumococcal vaccines had not been offered to all the residents in the facility. She said, at that time, she shifted her focus to COVID vaccinations, and only recently did she realize that pneumococcal vaccinations had not been offered to each resident in accordance with the facility policy.

Based on interview and record review, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was obtained prior to the administration of an antipsychotic medication for one Resident (#8), in a total sample of 20 residents. Findings include: In a [NAME] Guardianship Hearing, the court is being asked to authorize extraordinary treatment or care, such as administering anti-psychotic medications, admitting an adult to a nursing home facility, and other medical care. A guardian cannot make decisions about the use of antipsychotics because use of such medications is considered extraordinary treatment, but rather can monitor the implementation of the court-ordered treatment plan. This procedure was established by the Supreme Judicial Court in a decision entitled [NAME] v. Commissioner of the Department of Mental Health, 390 Mass. 489 (1983) - Massachusetts Guardianship Association (massguardianshipassociation.org) Resident #8 was admitted to the facility in April 2023 with diagnoses which included dementia with agitation and paranoid personality disorder. Review of the clinical record indicated Resident #8 was appointed a permanent Guardian by the Commonwealth of Massachusetts Probate and Family Court on 10/24/22. The document further indicated that the legal guardian only had authority to admit Resident #8 to a nursing facility. The document did not include court authorization for a Treatment Plan for the administration of antipsychotic medication. Further review of the clinical record failed to include a Court Ordered [NAME] Treatment Plan. Review of the Physician's Orders, dated active as of 4/12/24, indicated Quetiapine Fumarate (antipsychotic), 50 milligrams (mg) three times daily, start date, 4/21/23. Review of the Informed Consent for Psychotropic Administration Form for administration of the medication Quetiapine, dated 4/21/23, indicated the consent form was signed by the legal guardian. Additional information on the consent form indicated the legal guardian checked off the box which attested to being the guardian with substituted judgement authority and the [NAME] Monitor has been informed and authorized this medication. Review of the Medication Administration Record (MAR) for February, March, and April 2024 indicated the Quetiapine was administered three times daily as ordered by the physician on 4/21/23. During an interview on 4/12/24 at 10:44 A.M., the Director of Social Services said Resident #8 had a previous psychiatric hospitalization on e year ago, and upon readmission to the facility, had an antipsychotic medication in place for administration. The Director of Social Services said the guardian had signed Informed Consent for the administration of the antipsychotic without a [NAME] Treatment Plan in place. The Director of Social Services said guardians could not consent to the administration of an antipsychotic medication without a [NAME] Treatment Plan and said the legal process had been initiated for the implementation of a treatment plan, but currently, there was no [NAME] Treatment Plan in place.

Based on observations, interviews, and record review, the facility failed to conduct COVID-19 testing in accordance to 1. Initiating outbreak testing when a staff member tested positive on [DATE]; 2. Initiating testing for Resident #67 who was exposed to COVID-19 and presented with symptoms; 3. Determining if contact tracing or group level testing should be conducted, including following guidelines from the local health authority; 4. Following community transmission levels for routine testing of staff; and 5. Following infection control practices while testing staff. The facility's COVID-19 outbreak began on [DATE]. As of [DATE], the facility identified 5 staff members and 18 residents had tested positive for COVID-19. Five of the positive residents were sent to the hospital and one unvaccinated resident died at the facility after being exposed to their COVID-19 positive roommate. It was determined the Immediate Jeopardy began on [DATE] and was identified on [DATE]. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy and the Immediate Jeopardy templates to the Facility Administrator on [DATE]. On [DATE], the Department of Public Health determined the Immediate Jeopardy was removed effective [DATE]. In addition to the residents in Immediate Jeopardy, non-compliance at F886 continued at a lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the facility also failed to 6. Conduct BinaxNOW Rapid Point of Care COVID-19 Testing according to manufacturer's instructions and follow infection control practices while testing staff Findings include: 1. Review of the Centers for Medicare & Medicaid Services (CMS) Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, revised [DATE] indicated the following: - A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing. - Residents who have signs or symptoms of COVID-19, regardless of vaccination status, must be tested immediately. - If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. - The facility should test all staff, who are not up to date, at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week. Facilities should monitor their level of community transmission every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the table. Review of the staff COVID-19 positive list indicated a Receptionist tested positive on [DATE] and had chills as a symptom; there was no indication of the date of symptom onset. During an interview on [DATE] at 10:28 A.M., the Infection Preventionist said she had been notified of the Receptionist testing positive for COVID-19 at an appointment, outside of the facility. The Infection Preventionist said she had been in communication with the Administrator on [DATE] and had instructed the Administrator to initiate contact tracing to see which residents and staff had contact with the Receptionist while infectious. During an interview on [DATE] at 10:30 A.M. with the Director of Nurses (DON) and the Infection Preventionist, the DON said she had been on vacation on [DATE]. The Infection Preventionist said she worked off-site and was available to all staff to coordinate infection control. The DON and the Infection Preventionist said the Administrator would have been responsible for implementing and facilitating any response to the outbreak. During the interview, the Infection Preventionist said the facility had conducted contact tracing when Resident #71 tested positive for COVID-19 on [DATE]. The facility determined the close contacts of Resident #71 were the other residents who congregated with Resident #71 in the Solarium, a sitting area off of the reception area. The Infection Preventionist and the DON said they had not taken into consideration that the residents who congregated in the Solarium were close contacts with the Receptionist who had tested positive on [DATE]. During an interview on [DATE] at 2:55 P.M., the Administrator said she had not initiated any testing of staff or residents when the Receptionist tested positive on [DATE]. 2. Resident #67 was admitted to the facility in [DATE] with diagnoses including a pleural effusion, pancreatitis, and congestive heart failure. Review of the list of COVID-19 positive residents indicated the roommate of Resident #67 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #67 indicated the Resident was not vaccinated against COVID-19. Review of a Physician's Progress note, dated [DATE], indicated Resident #67 was exposed to COVID-19, lived with significant comorbidities and would be considered high risk. On [DATE] at 12:02 P.M., the surveyor observed a family member of Resident #67 walk up to the nurses' station and request to Nursing Supervisor #1 that Resident #67 be tested for COVID-19. Review of the paper and electronic medical record indicated the first monitoring for signs or symptoms of COVID-19 was initiated on [DATE] (4 days after the roommate tested positive) with an order to monitor for runny nose, chest congestion, increased shortness of breath, confusion, sore throat, muscle pain, nausea, vomiting, loose stool, headache, loss of taste or smell, or fever. The order was checked off for the night shift on [DATE] as monitored by the nurse, with no indication of whether any of the symptoms were present. Review of the Physician's Progress note, dated [DATE], indicated Resident #67 tested positive for COVID-19 and had cough and congestion for the past few days. Review of the Resident Testing Log indicated Resident #67 was tested for COVID-19 on [DATE] and was negative. There were no further COVID-19 tests conducted until the daughter requested testing on [DATE]. On [DATE] at 12:58 P.M., the surveyor observed four Emergency Medical Technicians (EMT) arrive at the facility and go to the room of Resident #67, where CPR was in progress. At 1:19 P.M. Resident #67 was pronounced dead. 3. During an interview on [DATE] at 9:00 A.M., the Director of Nurses said the outbreak initiated on [DATE] when a resident tested positive for COVID-19 and there were currently 18 positive residents at the facility and three positive staff members. She said 16 COVID-19 positive residents resided on the B Unit and 2 resided on the A unit. She said the facility was currently only conducting outbreak testing for residents on the B unit (group level) and no testing on the A unit (as both residents were roommates and currently positive). The Director of Nurses said the facility had determined the testing strategy based on guidance from the Department of Public Health (DPH) epidemiology. During an interview on [DATE] at 11:36 A.M., the DPH Epidemiologist said she had spoken with the facility Director of Nurses and Administrator on Friday [DATE] and had recommended unit based resident testing on both units (A and B) that had positive cases. The recommendation was to test all residents on these units, every 3 days until the facility was able to go 7 days without a new positive and if no additional positives to test again on day 14. All staff should be tested every 3 days. During an interview on [DATE] at 11:50 A.M., the Director of Nurses said the facility had only tested residents who resided on the B unit and had not tested the residents on the A unit. She said all staff were being tested on Mondays, Wednesdays, and Fridays. She said staff who do not work on these days were responsible for completing and logging their own testing. Review of the resident and staff positive cases and testing indicated the following timeline: [DATE]- Receptionist tested positive for COVID-19. No contact tracing or broad-based testing was initiated at this time. [DATE]- Resident #71 tested positive for COVID-19. The facility initiated contact tracing testing of residents at this time, which did not include testing of the roommate of Resident #71. No staff members were tested . [DATE]- 3 residents (2 from the B unit and 1 from the A unit) who were close contacts with Resident #71 tested positive for COVID-19. [DATE]- the facility initiated unit based testing on the B unit, which identified 7 additional COVID-19 positive residents on the B unit and tested the roommate (Resident #23) of the resident on Unit A, who was negative. No staff members were tested . [DATE]- CNA #2 tested positive at another facility. CNA #2 worked on the B unit on [DATE]. [DATE]- the facility begins testing staff (9 days after the first COVID-19 positive case); Nurse #3 and Nurse #7, who both worked on the B unit, test positive for COVID-19. [DATE]- the facility tested all residents on the B unit- identifying 4 additional COVID-19 positive residents on that unit and tested the roommate from the A unit (Resident #23) who was COVID-19 positive. [DATE]- one additional B unit resident tested positive for COVID-19 [DATE]- CNA #1 tested positive for COVID-19. CNA #1 worked on [DATE] on the A unit. During an interview on [DATE] at 9:17 A.M., Resident #23 said he/she had tested negative for COVID-19, despite his/her roommate being positive and had continued to attend activities. During an interview on [DATE] at 10:15 A.M., the Director of Nurses said Resident #23, who resided on the A Unit had tested positive on [DATE] and had attended activities on the A Unit prior to the positive test result. She said they had not conducted any contact tracing or unit-based testing based on this COVID-19 positive result. During an interview on [DATE] at 8:00 A.M., the Administrator said the Director of Rehabilitation had tested positive for COVID-19 on [DATE]. When asked what the facility response was to the positive result, the Administrator said she had not initiated any additional testing (contact tracing, broad-based) as the staff member had not worked in the previous 48 hours (since [DATE]). When the surveyor inquired about the symptoms of the staff member, the Administrator said the Director of Rehabilitation had congestion which had started either ,d+[DATE] or [DATE], she was not sure. She said she did not know that a person was infectious for 48 hours prior to symptoms and not 48 hours from test date. Review of 5 sampled staff members during outbreak testing from [DATE] through [DATE] indicated the following: -Dietary Assistant was not tested during the outbreak and had worked on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. -Physical Therapy Assistant was not tested during the outbreak until [DATE] and had worked on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], [DATE] and [DATE]. -Activity Assistant #1 was not tested during the outbreak and had worked ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Certified Nursing Assistant (CNA) #3 was not tested during the outbreak and had worked on ,d+[DATE], ,d+[DATE] and [DATE]. Nurse #4 was not tested during the outbreak and had worked on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. During an interview on [DATE] at 10:30 A.M., the Director of Nurses and the Infection Preventionist said all staff were to be tested every three days during the outbreak and they were not checking to ensure staff were being tested and had no log to demonstrate that all staff had been tested . 4. Review of the Routine Testing Intervals by County COVID-19 Level of Community Transmission indicated staff who were not up to date with the COVID-19 vaccine should be tested as follows: High (red) level of COVID-19 Community Transmission- twice per week Substantial (orange) level of COVID-19 Community Transmission - twice per week The Community Transmission Level for [NAME] County from [DATE] through [DATE] was High. The Community Transmission Level for [NAME] County starting [DATE] was Substantial. Activity Assistant #1 was not up to date with the COVID-19 vaccine and was not tested for routine testing during the week of [DATE], the week of [DATE], or the week of [DATE]. Review of the Timecard Report indicated Activity Assistant #1 worked ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Nurse #4 was not up to date with the COVID-19 vaccine and was not tested for routine testing during the week of [DATE], the week of [DATE] or the week of [DATE]. Review of the Timecard report indicated the Nurse had worked on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. During an interview on [DATE] at 10:30 A.M., the Infection Preventionist said the facility had not been tracking the Community Transmission rate for the facility. During the same interview, the Director of Nurses said she had also not tracked the Community Transmission rate for the facility and did not know that routine testing varied based on the Level of Community Transmission. 5. On [DATE] at 7:10 A.M., the surveyor observed staff testing for COVID-19 at the reception desk. There were three staff lined up next to each other on one side of the desk, not wearing masks and swabbing their noses. Each staff member handed their swab to the Medical Records personnel, who was not wearing gloves and did not hand sanitize between touching each swab. The Medical Records personnel then inserted the swabs into the card, which was placed directly on the reception counter. After discarding the cards, the counter was not observed to be disinfected. At 7:30 A.M., the surveyor observed three additional staff members at the reception desk testing for COVID-19. The staff were observed to be standing shoulder to shoulder with their masks down while swabbing their nostrils. Each staff member handed the receptionist their swab. The receptionist was observed to not be wearing gloves and did not perform hand hygiene between taking swabs. The swabs were placed in the testing cards directly on the reception area counter. 42742 6a. Review of the manufacturer's instructions for use (IFU) titled BinaxNOW COVID-19 Ag Card, dated 2020, indicated but was not limited to the following: Test Procedure -Hold extraction Reagent bottle vertically. Hovering ,d+[DATE] inch above the top hole, slowly add 6 drops to the top hole of the swab well - 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 at 15 minutes, and not before. -Note: False negative results can occur if test results are read before 15 minutes. Precautions -Wear appropriate PPE and gloves when running each test and handling patient specimens. Patient samples, controls, and test cards should be handled as though they could transmit disease. -Invalid results can occur when an insufficient volume of extraction reagent is added to the test card. On [DATE] at 9:45 A.M., the surveyor observed Consulting Staff #3 in a room behind the front reception desk self-performing a BinaxNOW COVID-19 nasal swab. Consulting Staff #3 placed the COVID-19 Ag Card onto the windowsill surface with the sample swab inserted. She did not place a liner underneath the collection sample and did not disinfect the windowsill when finished. Receptionist #1 told Consulting Staff #3 that she would set a timer for 15 minutes. Receptionist #1 picked up her cellular device then set it down. The surveyor did not observe Receptionist #1 set the timer. During an interview on [DATE] at 9:52 A.M., seven minutes later, Receptionist #1 told Consulting Staff #3 that 15 minutes had passed. Consulting Staff #3 left the reception area and walked down the hallway without documenting her name, the date, or the test results on the Binax Testing Form. When the surveyor pointed out to Receptionist #1 that only seven minutes had passed, not the required 15 minutes, Receptionist #1 was unable to show the surveyor a timer had been set. During an interview on [DATE] at 9:55 A.M., Consulting Staff #3 said her results were negative and she should have documented the results on the Binax Testing Form immediately after but did not. During an interview on [DATE] at 11:10 A.M., the Director of Nurses (DON) said the results should have been promptly read at 15 minutes, not before, and the results should have been documented immediately after. The DON said Consulting Staff #3 did not maintain infection control practices while performing the BinaxNOW COVID-19 testing. 6b. On [DATE] at 11:01 A.M. and 11:06 A.M., the surveyor observed Consulting Staff #1 supervise and assist with BinaxNOW rapid COVID-19 testing for Certified Nursing Assistant (CNA) #11 and Nurse #14 in the basement conference room. Consulting Staff #1 held the extraction reagent bottle above the top hole of the swab well on the testing cards and squeezed the bottle three times for each card. Consulting Staff #1 did not wear gloves at any time while handling the specimens. Both test results were negative, and CNA #11 and Nurse #14 returned to their assigned units. During an interview on [DATE] at 11:44 A.M., Consulting Staff #1 said she added three drops of the reagent, not the required six drops per the manufacturer's IFU, and should have worn gloves to handle the specimens but did not. The DON said because an insufficient amount of the extraction reagent was added to the test cards, she could not validate the results of the two staff members and would have to retest them.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to 1. Identify and respond to an outbreak of COVID-19 on [DATE]; 2. Ensure staff implemented infection prevention and control practices including: a. Cohorting residents during an outbreak, including those who were not up to date with the COVID-19 vaccine, and b. Utilizing the appropriate personal protective equipment (PPE) between the care of COVID-19 positive residents and COVID-19 negative residents, including those residents who were not up to date with the COVID-19 vaccine; and 3. Implement and utilize a system of surveillance for residents and staff positive for COVID-19. The facility COVID-19 outbreak began on [DATE]. As of [DATE], the facility identified 5 staff and 18 residents positive for COVID-19. Five residents were sent to the hospital and one unvaccinated resident died at the facility after being exposed to their COVID-19 positive roommate. It was determined the Immediate Jeopardy began on [DATE] and was identified on [DATE]. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy and the Immediate Jeopardy templates to the Facility Administrator on [DATE]. On [DATE], the Department of Public Health determined the Immediate Jeopardy was removed effective [DATE]. In addition to the residents in Immediate Jeopardy, non-compliance at F880 continued at a lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility also failed to 4. Ensure staff and residents wore appropriate PPE and implemented enhanced PPE precautions for residents not up to date with their COVID-19 vaccine during a current COVID-19 outbreak on all three units; 5. Ensure staff maintained proper hand hygiene and PPE use during the medication pass; 6. For Residents #76, #78 and #92, ensure staff maintained proper infection control during a dressing change; and 7. Ensure proper signage was posted at the front entrance notifying staff and visitors of PPE needed to be worn, and ensure dialysis transportation personnel entering the building performed proper hand hygiene and wore appropriate PPE prior to attending to a Resident. Findings include: 1. Review of the Centers for Medicare & Medicaid Services (CMS) Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, revised [DATE] indicated the following: -A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. -Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing. Review of the staff COVID-19 positive list indicated a Receptionist tested positive on [DATE] and had chills as a symptom, there was no indication of the date of symptom onset. Review of the Timecard Report for the Receptionist indicated she had worked on [DATE] and [DATE]. Therefore, the Receptionist was infectious 48 hours prior to testing positive or symptom onset (whichever was first). During an interview on [DATE] at 10:28 A.M., the Infection Preventionist said she had been notified of the Receptionist testing positive for COVID-19 at an appointment, outside of the facility. She said she had been in communication with the Administrator on [DATE] and had instructed the Administrator to initiate contact tracing to see which residents and staff had contact with the receptionist while infectious. During an interview on [DATE] at 10:30 A.M. with the Director of Nurses and the Infection Preventionist, the Director of Nurses said she had been on vacation on [DATE]. The Infection Preventionist said she worked off-site and was available to all staff to coordinate infection control. The DON and the Infection Preventionist said the Administrator would have been responsible for implementing and facilitating any response to the outbreak. During the interview, the Infection Preventionist said the facility had conducted contact tracing when Resident #71 tested positive for COVID-19 on [DATE]. The facility determined the close contacts of Resident #71 were the other residents who congregated with Resident #71 in the Solarium, a sitting area off of the reception area. The Infection Preventionist and the Director of Nurses said they had not taken into consideration that the residents who congregated in the Solarium were close contacts with the receptionist who had tested positive on [DATE]. During an interview on [DATE] at 2:55 P.M., the Administrator said she had not initiated any response (contact tracing, testing, additional monitoring of residents) when the Receptionist tested positive on [DATE]. During an interview on [DATE] at 10:29 A.M., the Director of Nurses (DON) said a COVID-19 outbreak had initiated when a resident tested positive on [DATE]. 2. Review of the Centers for Disease Control and Prevention Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, indicated: -Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Review of the facility's policy titled Isolation- Room Placement, dated as revised [DATE], indicated the facility would care for residents in accordance with guidelines as defined by the Centers for Disease Control and Prevention (CDC) and Federal and State Health Care Regulations. In addition, the policy indicated: -Exposed residents who are not recovered and/or are not up to date should be quarantined for 10 days and placed in a private room. If a private room is not available, they can cohort with another exposed resident with no active symptoms if exposure is within 3 days of each other. During an interview on [DATE] at 3:30 P.M., the Administrator said the facility followed guidance from the Massachusetts Department of Public Health but had been unable to update specifics to their facility's policies due to a change in ownership and provided the surveyor with the guidance from [DATE]. Review of the Massachusetts Department of Public Health memorandum Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated [DATE] indicated: -Residents who are a close contact of a case of COVID-19 and are not recovered from COVID-19 in the last 90 days or up to date with COVID-19 vaccine, should be placed in quarantine in a private room or, if unavailable, in a room with another resident who is recovered from COVID-19 in the last 90 days or up to date with COVID-19 vaccine. -Residents who are symptomatic should be placed in isolation in a private room or, if unavailable, in a room with another resident who is recovered from COVID-19 in the last 90 days or up to date with COVID-19 vaccine. The long-term care facility should follow up with the resident's provider for next steps. A1. Resident #67 was admitted to the facility in [DATE] with diagnoses including a pleural effusion, pancreatitis, and congestive heart failure. Review of the list of COVID-19 positive residents indicated the roommate of Resident #67 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #67 indicated the Resident was not vaccinated against COVID-19. Review of a Physician's Progress note, dated [DATE], indicated Resident #67 was exposed to COVID-19, lived with significant comorbidities, and would be considered high risk. On [DATE] at 12:02 P.M., the surveyor observed a family member of Resident #67 walk up to the nurses' station and request to Nursing Supervisor #1 that Resident #67 be tested for COVID-19. Review of the Physician's Progress note, dated [DATE], indicated Resident #67 tested positive for COVID-19 and had cough and congestion for the past few days. Review of the paper and electronic medical record indicated the first monitoring for signs or symptoms of COVID-19 was initiated on [DATE] (4 days after their roommate tested positive for COVID-19) with an order to monitor for runny nose, chest congestion, increased shortness of breath, confusion, sore throat, muscle pain, nausea, vomiting, loose stool, headache, loss of taste or smell, or fever. The order is checked off for the night shift on [DATE] as monitored by the nurse, with no indication of whether any of the symptoms were present. On [DATE] at 12:58 P.M., the surveyor observed four Emergency Medical Technicians (EMT) arrive at the facility and go to the room of Resident #67, where CPR was in progress. At 1:19 P.M. Resident #67 was pronounced dead. A2. Resident #302 was admitted to the facility in [DATE]. Review of the list of COVID-19 positive residents indicated the roommate of Resident #302 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #302 indicated the Resident was not vaccinated against COVID-19. Review of the paper and electronic medical record indicated the first monitoring for signs or symptoms of COVID-19 was initiated on [DATE] (9 days after the roommate tested positive) with an order to monitor for runny nose, chest congestion, increased shortness of breath, confusion, sore throat, muscle pain, nausea, vomiting, loose stool, headache, loss of taste or smell, or fever. Resident #302 tested positive for COVID-19 on [DATE]. A3. Resident #95 was admitted to the facility in [DATE]. Review of the list of COVID-19 positive residents indicated the roommate of Resident #95 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #95 indicated the Resident was not up to date with the COVID-19 vaccine, as they had not received any booster shots. Review of the paper and electronic medical record indicated the first monitoring for signs or symptoms of COVID-19 was initiated on [DATE] (3 days after the roommate tested positive) with an order to monitor for runny nose, chest congestion, increased shortness of breath, confusion, sore throat, muscle pain, nausea, vomiting, loose stool, headache, loss of taste or smell, or fever. Resident #95 tested positive for COVID-19 on [DATE]. A4. Resident #102 was admitted to the facility in [DATE]. Review of the list of COVID-19 positive residents indicated the roommate of Resident #102 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #102 indicated the Resident was not up to date with the COVID-19 vaccine, as he/she had not received the second recommended booster for their age group. Resident #102 tested positive for COVID-19 on [DATE]. During an interview on [DATE] at 2:55 P.M., the Administrator said she had made the decision to not move roommates who were residing with residents who had tested positive for COVID-19 because there were only nine open beds in the facility. She said the vaccination status of the exposed residents did not play a role in her decision and had not been considered. She said she had checked with the Infection Preventionist on [DATE] and at the start of the outbreak the facility did not have any residents who were recovered from COVID-19 within the last 90 days. Review of the medical records for 22 sampled residents indicated 1 out of 22 sampled residents was recovered from COVID-19 in the previous 90 days. The medical record for Resident #60 indicated Resident #60 had tested positive for COVID-19 during a hospital stay on [DATE] (77 days before the outbreak). B. Review of the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised on February 2, 2022, indicated: -HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the facility policy titled: PPE-COVID, updated [DATE], indicated for confirmed, suspected, or exposed residents: - eliminate the practice of re-use of N95 respirators. N95 respirators should be discarded after doffing, such as when leaving a patient room - if reusable goggles or face shields are used ensure the appropriate cleaning and disinfection between uses Review of the facility policy titled: COVID-19 Outbreak Management, updated [DATE], indicated to avoid floating staff between units, to cohort residents with COVID-19 with dedicated Health Care Personnel (HCP) and other direct care providers. Review of the Isolation/droplet precautions sign indicated all staff entering these rooms were to don an N95 respirator, eye protection, gown, and gloves. During an interview on [DATE] at 11:00 A.M., the Director of Nurses said that as of [DATE] the CNA assignments on Unit B were changed. She said CNAs would not have a mix of COVID-19 negative and COVID-19 positive residents on their assignments to provide dedicated staff to care for the residents with known COVID-19 and the staff were no longer floating between units. On [DATE] at 11:54 A.M., the surveyor observed CNA #9 and CNA #4 boosting Resident #302 (who was exposed to COVID-19 and on transmission-based precautions) and adjusting his/her bed linens. CNA #9 was not wearing a gown or eye protection and was wearing a surgical mask, not an N95 face mask. CNA #4 was not wearing a gown or eye protection. An isolation sign was posted outside the room indicating full PPE was required prior to entering the room consisting of eye protection (goggles or face shield), N95 mask, gown, and gloves. During an interview on [DATE] at 11:57 A.M., CNA #9 said she should have worn a gown and eye protection prior to entering the room. She said she wore a surgical mask instead of an N95 face mask because the N95s did not fit her. CNA #4 said he should have worn a gown and eye protection prior to entering the room. On [DATE] at 12:31 P.M., the surveyor observed CNA #1 enter the room and approach Resident #47, who tested positive for COVID-19 on [DATE]. The CNA was observed to only be wearing an N95 mask and eye protection. When exiting the room, the CNA was asked if she knew Resident #47 was COVID-19 positive, she said she did, but thought she did not have to put on a gown or gloves unless she was providing care to the Resident. CNA #1 said she was assigned to care for Resident #47 as well as other residents on the unit who were COVID-19 negative. A later review of staff COVID-19 positive cases indicated CNA #1 tested positive for COVID-19 on [DATE]. On [DATE] at 4:32 P.M., the surveyor observed Nurse #3 in the room with Resident #29, who tested positive for COVID-19 on [DATE]. There was a droplet precaution sign observed on the doorway to this room. Nurse #3 was observed to be wearing an N95 mask and eye protection but was not wearing a gown or gloves. Nurse #3 was observed to exit the room, without performing hand hygiene or doffing the N95 or eye protection, walk down the hallway and take the vital machine caddy to the room of Resident #76, who was negative for COVID-19. Nurse #3 was observed to put on gloves, still had not performed hand hygiene, and use the vital machine to take the blood pressure and oxygen level of Resident #76, while wearing the same eye protection and mask from the encounter with a COVID-19 positive resident (#29). During an interview on [DATE] at 4:45 P.M., Resident #29 said Nurse #3 had been administering medications to him/her during the previous observation. The Resident said he/she was still testing positive for COVID-19 and that was why they were still on isolation precautions. On [DATE] at 4:49 P.M., the surveyor observed Certified Nursing Assistant (CNA)# 3 and CNA #6 exiting the room of Resident #302. Resident #302 tested positive for COVID-19 on [DATE] and a droplet precaution sign was observed on the door of the room. CNA #3 was observed to remove a gown and gloves, did not perform hand hygiene, walk down the hall, push the linen cart towards the room, and then perform hand hygiene. During an interview on [DATE] at 4:50 P.M. CNA #3 said she and CNA #6 had been providing care to Resident #302. Then, upon exiting the room of Resident #302, the surveyor observed CNA #3 and CNA #6 not doff (remove) their N95 mask or eye protection and go to the next resident to provide care. CNA #3 and CNA #6 were then observed to assist Resident #30, who was COVID-19 negative, to the bathroom. On [DATE] at 7:45 A.M., the surveyor observed CNA #6 in the room with Resident #40, who tested positive for COVID-19 on [DATE]. An isolation sign was posted outside the room indicating full PPE was required prior to entering the room consisting of eye protection (goggles or face shield), N95 mask, gown, and gloves. CNA #6 was observed to be wearing an N95 mask, a gown, and gloves and was not wearing eye protection. During an interview on [DATE] at 7:46 A.M. CNA #6 said he had been washing the resident and was not aware it was an isolation room because he had been on vacation. CNA #6 said he had not gotten report yet that day of what residents were positive for COVID-19 on the unit and did not see the isolation sign indicating the required PPE. He said he should have worn eye protection but did not. On [DATE] at 6:55 A.M., the surveyor observed CNA #8 and CNA #7 with Resident #402, who was exposed to COVID-19 and was on transmission-based precautions. CNA #8 was wearing personal eyeglasses without a face shield or goggles. CNA #7 doffed his PPE when exiting the room without performing hand hygiene afterwards. CNA #7 then walked down the hall, put on gloves without performing hand hygiene and entered the room of Resident #37, who tested positive for COVID-19 on [DATE], without donning (putting on) a gown. During an interview with CNA #7 and CNA #8 on [DATE] at 7:10 A.M., CNA #8 said she should have been wearing eye protection, but did not, and personal eyeglasses were not a form of PPE. CNA #7 said he should have worn full PPE to enter an isolation room including a gown but did not wear one because he needed to help CNA #8 boost a resident. He said he should have performed hand hygiene after doffing his PPE and prior to entering another resident's room. On [DATE] at 3:20 P.M., the surveyor observed Nurse #5 enter the room of Resident #94 and Resident #302, which had a droplet precaution sign, indicating to wear a gown, gloves, eye protection and N95, on the door. Nurse #5 was observed to be wearing an N95 mask and eye protection. She did not don a gown or gloves prior to entering the room. When she was exiting the room, she said both residents were positive for COVID-19 and because she did not provide care to them, she did not put on a gown or gloves. She said her nursing assignment for the evening shift consisted of COVID-19 positive and COVID-19 negative residents. During an interview on [DATE] at 10:58 A.M., the Infection Preventionist said staff entering the room of a COVID-19 positive or an exposed resident were to wear an N95, eye protection, gown and gloves. Upon exiting the room, the staff should discard everything, except the eye protection which can be disinfected and put on a new N95 to wear with the disinfected eye protection on the unit. She said the facility was not in crisis capacity and was not re-using N95 masks after an encounter with a COVID-19 positive or exposed resident. Review of the facility's policy titled: COVID-19 Outbreak Management, updated [DATE], indicated to avoid floating staff between units, to cohort residents with COVID-19 with dedicated Health Care Personnel (HCP) and other direct care providers. Review of the facility schedule indicated CNA#4 worked on Unit B, which as of [DATE] had 16 COVID-19 positive residents on [DATE] and [DATE]. During an observation with interview on [DATE] at 11:00 A.M., the surveyor observed CNA #4 working on Unit C, which had no COVID-19 positive cases at that time. CNA#4 said he had started working/ orienting at the facility the previous week and had been assigned to work on the C unit on [DATE]. During an interview on [DATE] at 3:30 P.M., the scheduler said CNA #4 was new and did not have an assigned unit, so had not thought about which units he had or had not worked on or considered if he had worked with COVID-19 positive residents. 3. Review of the facility policy titled: COVID-19 Outbreak Management, revised [DATE], indicated pertinent information regarding each resident and employee case should be entered into the surveillance log and updated daily. Once an outbreak has been identified, cases should be placed on a line list. Review of the facility policy titled: COVID-19 Resident Testing, revised [DATE], indicated documentation of testing included the date and times of identification of signs or symptoms. During the entrance conference on [DATE] at 9:30 A.M., the surveyors requested a list of resident cases of confirmed COVID-19 over the last four weeks to include if the resident was hospitalized or died . The line list was provided on [DATE] at 9:00 A.M. A. Review of the COVID-19 positive Resident Line Listing failed to include Resident #71 (tested positive [DATE]) and failed to include Resident #67, who tested positive for COVID-19 on [DATE], experienced respiratory failure, and expired on [DATE]. The line list did not indicate hospitalization s or deaths. The line list category for symptoms only indicated symptoms or no symptoms and did not indicate what the symptoms were or when they started. During an interview on [DATE] at 12:15 P.M., the Director of Nurses said she did not know Resident #67 had tested positive for COVID-19 and she was not sure why Resident #71 was not on the line listing. An updated line listing was provided to the surveyor on [DATE] at 2:10 P.M. and included 18 COVID-19 positive residents. A review of the line listing indicated the following: -Resident #71 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record for Resident #71 and the hospital discharge summary indicated Resident #71 was sent to the hospital with shortness of breath and oxygen saturation at 80%. -Resident #94 tested positive for COVID-19 on [DATE] and had symptoms. Review of the medical record indicated an order for symptom monitoring was not initiated until [DATE], 9 days after the COVID-19 positive test result. -Resident #29 tested positive for COVID-19 on [DATE] (review of the medical record indicated this date was incorrect and the resident tested positive on [DATE]) and had no symptoms. Review of the medical record indicated Resident #29 went to the hospital on [DATE] with hypoxia (low oxygen levels) and change in condition. Resident #29 was treated at the hospital with an antiviral treatment for COVID-19. -Resident #101 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record indicated Resident #101 went to the hospital on [DATE] following a fall related to weakness. Review of the hospital discharge summary indicated the family was with Resident on [DATE] and the Resident had a cough. Review of a Nursing Progress note, dated [DATE], indicated the resident continued with a moist, non-productive cough. -Resident #92 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record indicated Resident #92 had a cough on [DATE] and was experiencing symptoms on [DATE]. -Resident #87 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record indicated Resident #87 had an occasional cough on ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. An order was initiated on [DATE] for cough medicine and for an antiviral therapy for five days. -Resident #5 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record indicated Resident #5 had a cough on [DATE] and a change in mental status on [DATE]. -Resident #32 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record indicated Resident #32 had a cough on [DATE]. An order for symptom monitoring was not initiated until [DATE], 8 days after the COVID-19 positive test result. -Resident #7 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record indicated Resident #7 had a cough on [DATE] and [DATE]. An order for symptom monitoring was not initiated until [DATE], 8 days after the COVID-19 positive test result. -Resident #37 tested positive for COVID-19 on [DATE] and had no symptoms. Review of the medical record indicated Resident #37 was tested on [DATE] related to a sore throat. During an interview on [DATE] at 9:19 A.M., the Infection Preventionist said she works off-site and is at the facility about once per month. She said in order to update the resident line listing she reads the nursing progress notes to determine if a resident has symptoms. She said she does not monitor symptom start date or type of symptoms on the line list. B. Review of the CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated [DATE], indicated: -Determining the time period when the patient, visitor, or HCP with confirmed SARS-CoV-2 infection could have been infectious: For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions. For individuals with confirmed SARS-CoV-2 infection who never developed symptoms, determining the infectious period can be challenging. In these situations, collecting information about when the asymptomatic individual with SARS-CoV-2 infection may have been exposed could help inform the period when they were infectious. On [DATE] at 10:15 A.M. the surveyor received a list of three staff (two nurses and one CNA) who had tested positive for COVID-19 with no symptoms listed. At this time, the surveyor requested the Staff COVID-19 Line Listing for the past four weeks to include positive test dates, positions, and symptoms. On [DATE] at 10:15 A.M., the Director of Nurses provided the surveyor with a list of five staff who had tested positive for COVID-19. The line listing indicated the following: -Receptionist tested positive for COVID-19 on [DATE] with symptoms of chills. No indication of when symptoms started. -CNA #2 tested positive for COVID-19 on [DATE], no symptoms listed. -Nurse #3 tested positive for COVID-19 on [DATE] with a cough. No indication of when symptoms started. -Nurse #7 tested positive for COVID-19 on [DATE] with a cough. No indication of when symptoms started. -CNA #1 tested positive for COVID-19 on [DATE], no symptoms listed. During an interview on [DATE] at 10:15 A.M., the Director of Nurses said she had been on vacation when the Receptionist, CNA #2, and Nurse #3 tested positive so she could not be sure when the symptoms started. At this time, the Infection Preventionist said she was only told when the staff members tested positive and was responsible for determining when they could test again but had not been keeping a list of staff symptom monitoring. On [DATE], the Department of Public Health determined the Immediate Jeopardy was removed effective [DATE]. Refer to F886 27189 4a. Observations on Unit B- On [DATE] at 8:20 A.M., the surveyor observed Nurse #12 without eye protection (goggles or face shield). Upon further observation it was noted that Nurse #12 had goggles that had the appearance of eyeglasses. The sides provided the correct protection, however there was a large gap at the top of the goggles which does not provide full coverage/complete protection. During an interview on [DATE] at 8:22 A.M., Nurse #12 said that she works at another facility and these types of goggles were provided. When the surveyor indicated the concern of the goggles not providing full eye coverage/protection, she agreed with the surveyor and said that she would obtain a face shield. Observations on Unit C- On [DATE] at 8:28 A.M., the surveyor observed CNA #12 with the N95 mask around her neck. She observed the surveyor, went into the bathroom in a resident's room and then exited the room. The surveyor approached CNA #12 who indicated that she was observed with the mask around her neck. The CNA said that she was in the process of changing the mask and that is why it was positioned around her neck, and she indicated that the mask that she had donned is a new/clean mask. The surveyor observed that although the mask was clean according to the CNA, while in the Resident's room, the mask should remain in place at all times. The current mask that CNA #12 had donned, also was not donned correctly. It was not providing a proper seal around her nose and mouth and was slipping down. The metal bar inside the mask at the top of the mask had not been pinched to provide a better seal. The mask kept sliding down. Review of the Employee Education Attendance Record, dated [DATE], which addressed proper donning and doffing of Personal Protective Equipment indicated that CNA #12 did not attend the required inservice. On [DATE] at 7:49 A.M., review of documentation for residents in the facility not Up To Date (UTD) with COVID-19 vaccination/boosters indicated the following: Unit A: Resident #352 (not UTD) Unit B: Resident #1A (not UTD) Resident #72 (not UTD) Resident #401 (not UTD) On [DATE] at 8:38 A.M. the following observations were made: Unit A For Resident #352, outside of their room there was no enhanced precautions sign posted and no covid immunizations were documented in the Electronic Medical Record (EMR). Unit B For Resident #1A, Resident #72 and Resident #401, outside of their room there was no enhanced precautions sign posted and no covid immunizations were documented in the Electronic Medical Record (EMR). During an interview on [DATE] at 9:16 A.M., the DON said none of these residents are UTD on recommended vaccines and that the facility follows Department of Public Health, Center for Disease Control and the Center for Medicare and Medicaid Services guidance and tries to stay up to date on changes. The DON said that the enhanced precautions should remain in place on the affected units for the 14 days with no new cases, and that there should have been signs posted to indicate the Residents are on enhanced precautions. 34145 4b. Unit C observations: On [DATE] at 7:13 A.M., the surveyor observed Resident #81, who was unmasked, seated in a chair across from the nursing station on Unit C (COVID positive cases on the unit) with six other residents seated in the hallway close to Resident #81. Three of the six residents in the hallway were wearing masks. On [DATE] at 7:14 A.M., the surveyor observed Laundry Aide #1 pushing a laundry [TRUNCATED]

Based on observation, interview, and record review, the Administration failed to 1. Initiate an appropriate response to an outbreak of COVID-19 when a staff member tested positive for COVID-19 on [DATE]; and 2. Implement the facility's infection prevention and control program, including testing of staff and residents, and cohorting and quarantine measures to protect vulnerable residents during a COVID-19 outbreak. The facility's COVID-19 outbreak began on [DATE]. As of [DATE], the facility identified 5 staff members and 18 residents had tested positive for COVID-19. Five of the positive residents were sent to the hospital and one unvaccinated resident died at the facility after being exposed to their COVID-19 positive roommate. It was determined the Immediate Jeopardy began on [DATE] and was identified on [DATE]. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy and the Immediate Jeopardy templates to the Facility Administrator on [DATE]. On [DATE], the Department of Public Health determined the Immediate Jeopardy was removed effective [DATE]. Findings include: 1. Review of the staff COVID-19 positive list indicated a Receptionist tested positive on [DATE] and had chills as a symptom; there was no indication of the date of symptom onset. During an interview on [DATE] at 10:28 A.M., the Infection Preventionist said she had been notified of the Receptionist testing positive for COVID-19 at an appointment, outside of the facility. The Infection Preventionist said she had been in communication with the Administrator on [DATE] and had instructed the Administrator to initiate contact tracing to see which residents and staff had contact with the Receptionist while infectious. During an interview on [DATE] at 2:55 P.M., the Administrator said she had not initiated any response (contact tracing, testing, additional monitoring of residents) when the Receptionist tested positive on [DATE]. Review of the staff testing log indicated staff testing was not initiated until [DATE], nine days after the outbreak began. 2A. Review of the facility's COVID-19 Testing Logs and Line Listings indicated the facility did not respond to the outbreak through broad-based or close contact testing. A review of the positive residents indicated 4 residents tested positive on [DATE] (3 on the B Unit and 1 on the A Unit). The facility initiated unit based testing of the B Unit and contact tracing for the roommate (#23) of the resident on the A Unit. The facility administration did not initiate staff outbreak testing until [DATE], which identified two nurses who worked on the B Unit, tested positive for COVID-19. During an interview on [DATE] at 9:17 A.M., Resident #23 said he/she had tested negative for COVID-19, despite his/her roommate being positive and had continued to attend activities. Resident #23 tested positive for COVID-19 the evening of [DATE]. During an interview on [DATE] at 10:15 A.M., the Director of Nurses said Resident #23, who resided on the A Unit had tested positive on [DATE] and had attended activities on the A Unit prior to the positive test result. She said they had not conducted any contact tracing or unit-based testing based on this COVID-19 positive result on the A Unit. During an interview on [DATE] at 8:00 A.M., the Administrator said the Director of Rehabilitation had tested positive for COVID-19 on [DATE]. When asked what the facility response was to the positive result, the Administrator said she had not initiated any additional testing (contact tracing, broad-based) as the staff member had not worked in the previous 48 hours (since [DATE]). When the surveyor inquired about the symptoms of the staff member the Administrator said the Director of Rehabilitation had congestion which had started either [DATE] or [DATE], she was not sure. She said she did not know that a person was infectious for 48 hours prior to symptoms and not 48 hours from test date. 2B. Review of 5 sampled staff members during outbreak testing from [DATE] through [DATE] indicated the following: -Dietary Assistant was not tested during the outbreak and had worked on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. -Physical Therapy Assistant was not tested during the outbreak until [DATE] and had worked on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], [DATE] and [DATE]. -Activity Assistant #1 was not tested during the outbreak and had worked ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Certified Nursing Assistant (CNA) #3 was not tested during the outbreak and had worked on ,d+[DATE], ,d+[DATE] and [DATE]. Nurse #4 was not tested during the outbreak and had worked on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. During an interview on [DATE] at 10:30 A.M., the Director of Nurses and the Infection Preventionist said all staff were to be tested every three days during the outbreak and they were not checking to ensure staff were being tested and had no log to demonstrate that all staff had been tested . 2C. Review of exposed residents who were unvaccinated or not up to date with the COVID-19 vaccine indicated four out of four were not isolated from their COVID-19 positive roommate following a COVID-19 negative test result on [DATE]. Review of the list of COVID-19 positive residents indicated the roommate of Resident #67 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #67 indicated the Resident was not vaccinated against COVID-19. Review of a Physician's Progress note, dated [DATE], indicated Resident #67 was exposed to COVID-19, lived with significant comorbidities, and would be considered high risk. On [DATE] at 12:02 P.M. a family member of Resident #67 was observed to walk up to the nurses' station and request to Nursing Supervisor #1 that Resident #67 be tested for COVID-19. Review of the Physician's Progress note, dated [DATE], indicated Resident #67 tested positive for COVID-19 and had cough and congestion for the past few days. On [DATE] at 12:58 P.M., the surveyor observed four Emergency Medical Technicians (EMT) arrive at the facility and go to the room of Resident #67, where CPR was in progress. At 1:19 P.M. Resident #67 was pronounced dead. Review of the list of COVID-19 positive residents indicated the roommate of Resident #302 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #302 indicated the Resident was not vaccinated against COVID-19. Resident #302 tested positive for COVID-19 on [DATE]. Review of the list of COVID-19 positive residents indicated the roommate of Resident #95 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #95 indicated the Resident was not up to date with the COVID-19 vaccine, as they did not have any booster shots. Resident #95 tested positive for COVID-19 on [DATE]. Review of the list of COVID-19 positive residents indicated the roommate of Resident #102 tested positive for COVID-19 on [DATE]. Review of the medical record for Resident #102 indicated the Resident was not up to date with the COVID-19 vaccine, as they had not received the second recommended booster for their age group. Resident #102 tested positive for COVID-19 on [DATE]. During an interview on [DATE] at 2:55 P.M., the Administrator said she had made the decision to not move roommates who were residing with residents who had tested positive for COVID-19 because there were only 9 open beds in the facility. She said the vaccination status of the exposed residents did not play a role in her decision and had not been considered. She said she had checked with the Infection Preventionist on [DATE] and at the start of the outbreak the facility did not have any residents who were recovered from COVID-19 within the last 90 days. Review of the medical records for 22 sampled residents indicated 1 out of 22 sampled residents was recovered from COVID-19 in the previous 90 days. The medical record for Resident #60 indicated Resident #60 had tested positive for COVID-19 during a hospital stay on [DATE] (77 days before the outbreak). Refer to F880 and F886

Based on record review, interview, and observation, the facility failed for one Resident (#78), out of a total of 22 sampled residents, to a. Initiate treatment to the Resident's mid coccyx to promote wound healing, and b. Ensure the Resident was evaluated by the wound practitioner for multiple pressure ulcers (stage 2 and 3). Findings include: Review of the facility's policy titled Skin Assessment and Risk, dated November 2019, indicated assess existing pressure ulcers, obtain history of pressure ulcers, perform the risk assessment on admission along with the Braden or Norton Scale, obtain risk score, and evaluate its meaning based on resident's unique characteristics. The skin condition is recognized, evaluated, and reported to the practitioner, and addressed. Resident #78 was admitted to the facility in July 2022 with diagnoses including adult failure to thrive and type 2 diabetes. Review of the Wound Evaluation and Progress Note from the Hospital Emergency Department (ED), dated 7/2022, indicated Resident #78 had multiple wounds: a.) a wound to the left anterior ankle as active. The wound progress note indicated the stage 2 pressure area to the left ankle measuring 2.5 centimeters (cm) (length) by 3.1 cm (width) by 0.5 cm (depth), a surface area of 3.88 cm squared; with small seropurulent drainage. The treatment recommendations included cleanse the wound, apply Santyl; then Adaptic; and cover with Dry dressing. b.) a wound to the left buttocks as active. The wound progress note indicated the stage 3 pressure area to the left buttock area measuring 1.3 centimeters (cm) (length) by 4.7 cm (width) by 0 cm (depth), a surface area of 0.3 cm squared; with scant seropurulent drainage. The treatment recommendations included to cleanse the wound, apply Therahoney sheet, cover with Foam. c.) a wound to the mid coccyx as active. The wound progress note indicated the stage 2 pressure area to the to the coccyx mid area measuring 1 centimeter (cm) (length) by 1 cm (width) by 0 cm (depth), a surface area of 0.3 cm squared; with scant serous drainage. The treatment recommendations included cleanse the wound, apply Therahoney sheet, cover with Foam. Review of the medical record indicated would treatment was initiated for: - left coccyx (buttocks) wound treatment begun as ordered on 7/11/22 - left lateral (anterior) ankle wound treatment begun as ordered on 7/10/22 Further review of the medical record failed to indicate wound treatment was initiated for the mid-coccyx wound identified in the July 2022 ED summary. Review of the Resident Weekly Skin Assessment, dated 8/27/22, indicated the Resident had no skin issues; skin on his/her heels and coccyx were intact. During an interview with Nurse #2 and Resident #78 on 8/31/22 at 9:49 A.M., Nurse #2 said she had already applied protective cream to the Resident's coccyx area. Nurse #2 confirmed that the Resident had an open area to the mid coccyx. The Resident said the pressure area on the mid coccyx hurts so bad. The surveyor requested to see the area, but Resident #78 refused and said he/she was in pain. Review of the paper and electronic clinical record failed to include any documentation of the stage 2 pressure area to the to the mid coccyx and failed to include the treatment recommended by the hospital wound practitioner. Review of the Treatment Administration Record (TAR) failed to include any treatments to the mid coccyx. Further review of the clinical record indicated Resident #78 had not been evaluated by the Wound Care practitioner since admission to the facility. During an interview on 8/31/22 at 8:15 A.M., the Unit Manager said he was aware the Resident had pressure areas but not their location or staging. During an interview on 8/31/22 at 11:15 A.M., the Director of Nurses (DON) said the Wound Physician Consultant said they did not see the Resident or evaluate the wounds. The Attending Physician told her there was no recommendation for him to evaluate the Resident's wounds or skin from admission until this morning (8/31/22). During an interview on 8/31/22 at 11:25 A.M., the DON said she was not aware the Resident had pressure areas on the coccyx that required treatment. The DON said she reviewed the documentation for Resident #78, and she could not locate any treatments or documentation for the mid coccyx. She said the facility failed to follow their policy for skin assessments and risk.

Based on observation, record review, and interviews, the facility failed to: 1) provide adequate supervision for 10 Residents (#3, #6, #2, #41, #28, #18, #29, #48, #54 and #5) who have been assessed as being at risk for elopement. Specifically the facility failed: -To provide adequate supervision for residents who have been assessed as being at risk for elopement as its electronic system for monitoring residents with wandering behavior to prevent their elopement from a secure unit was not working, and the Facility had not initiated repairs or alternative methods of monitoring for elopement at the time of survey to ensure the resident's safety. -To initiate any interventions, provide education to staff or make changes to the plan of care to compensate for the lack of a functioning electronic monitoring system to ensure the safety of residents who are assessed to be at risk for elopement; and 2. ensure that supervision was provided to residents to prevent accidents, such as falls, and interventions were revised and implemented to prevent further falls with injury from occurring for one Resident (#44), out of a total sample of 33 residents. Findings include: 1. Review of the facility's elopement prevention polices, dated as revised February 2020, indicated the following: *The policy titled Elopement Prevention and Management indicated the facility strives to prevent resident elopement. *Elopement is defined as the ability of a resident who leaves the physical structure of the facility unattended and without the staff knowledge, and may enter into harm's way. *Wandering refers to cognitively impaired resident's ability to move about inside the facility aimlessly and without an appreciation of personal safety needs and who may enter into a dangerous situation. *The purpose of the policy is to identify residents at risk for elopement and develop individualized prevention and management intervention based on exit seeking elopement evaluations, and make frequent monitoring of the resident's whereabouts to assure he or she remains in the facility. *The evaluations are to complete prior to admission, on admission, re-admission, significant change and quarterly. *The facility staff are to develop an individualized plan with interventions which may include electronic monitoring/alarm system, environmental modifications, protected list of names and photographs of those at risk for elopement, psychological interventions, regular rounds, staff and family interventions and structured group activities. *The facility will assess both internal and external potential environmental risk factors including: elevators, exit doors, screens, stairwells and windows, maintain door alarms, wander control systems, highways and bodies of water, to ensure proper working order. *The facility will maintain a current list of names and photographs of residents identified at risk for elopement using the resident's demographic, and the facility will monitor their whereabouts. This will be validated through observation that the resident is wearing an electronic device and the interdisciplinary team will re-evaluate cognitively impaired residents who have attempted, unsuccessful or successfully to leave the facility without staff knowledge and determine the cause and re-evaluate interventions. *Staff will be educated on the elopement policy which included the assessment, monitoring and proper function of a wander bracelet. The facility conducts and tracks elopement drills at least quarterly which identify staff knowledge of the policy and the need for further education. Unit C was identified by the facility as the secured unit for those residents who are at risk for elopement when left unattended. The unit is equipped with door alarm codes to access and exit the unit and a Wanderguard System. The residents that are assessed to be at risk for elopement have a Wanderguard bracelet placed on their ankle or wrist. During multiple observations on 6/9/21, 6/10/21, 6/11/21, 6/14/21, 6/15/21, and 6/16/21, residents were observed wandering the unit. Resident #2, #29, #31 and #48 were observed wandering throughout the unit and attempting to open exit doors. The staff did not engage the residents, nor did they provide redirection away from the exit doors, elevator doors, unsafe areas, to maintain the wandering residents' safety. During an interview on 6/16/21 at 3:04 P.M., Maintenance Staff #1 said the Unit C electronic system for monitoring residents with Wanderguard bracelets was not working properly Maintenance Staff #1 said the facility had been aware that it had not been functioning for a long time. Maintenance Staff #1 could not provide the quarterly documentation that the Wanderguard System had been checked, per the facility policy to ensure proper functioning. Maintenance Staff #1 also said that he did not know what the facility staff had implemented for the residents with Wanderguards for their safety and to prevent them from exiting the building through the elevator. During an interview on 6/16/21 at 3:06 P.M., Unit Manager #1 (UM #1) said she did not have a list of residents who were at risk for elopement and could not identify which residents were at risk for elopement. After review of the resident's Physician Orders, UM#1 created a list of residents identified to be at risk for elopement. Review of the list indicated there were 10 residents who had been identified as at risk for elopement. UM #1 did not know the facility's procedure for elopement. During an interview on 6/16/21 at 3:24 P.M., Surveyor #2 informed the Administrator that the Wanderguard System was not working properly and Maintenance Staff #1 said it had not been working since July of 2020. The Administrator said to take what the maintenance staff said with a grain of salt. During an interview on 6/16/21 at 5:32 P.M., the Administer said he had no alternate plan in place for resident safety related to elopement risk and safety. On 6/17/21 at 7:30 A.M., the Director of Nurses said she did not know anything about the Wanderguard System not functioning correctly. During an interview on 6/17/21 at 9:00 A.M., the Staff Development Coordinator said she had no education for staff and could not provide the documentation for emergency preparedness which included elopement. Emergency preparedness or disaster plan includes a plan for locating a missing resident and the facility did not have one. She said the employee folders were empty files. On 6/17/21 at 11:25 A.M., Surveyor #3 entered the elevator without entering an access code. The surveyor was carrying a functional Wanderguard. The elevator door remained open for six seconds and an alarm was sounding but the door shut and the elevator descended to the basement. The surveyors did not observe staff respond to the alarm and check for elopement. The surveyor observed three exit doors to the outside. None of the doors were locked and none of the doors were alarmed. The three exit doors had access to the facility parking area which had direct access to a busy state divided highway. During an interview on 6/17/21 at 1:00 P.M., the surveyor asked the Administrator about the facility's safety plan for the Wanderguard System. The Administrator had no alternate plan in place for resident safety related to elopement risk. 2. Review of the facility's policy titled Falls Management and Prevention, revised 1/2021, indicated the following: - A fall is the unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g , onto a bed, chair, or bedside mat) - The staff will implement goals and interventions with the resident/patient/family for inclusion in the interdisciplinary care plan based on the resident's individual needs - Communicate interventions to the care givers and resident/family - Review and revise IDT care plan when a change is identified, after an event - The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events etc. - If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention as resolved - If the individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. - Post Fall: the nurse will complete an incident report - Monitoring and Follow up: Residents who continue to fall with interventions in place will be assessed for changes in or additions to interventions. Resident #44 was admitted to the facility in May 2017 with diagnoses that included tremors, adult failure to thrive, and gait instability resulting in frequents fall and recent left distal fibula fracture (broken ankle). Review of the most recent Minimum Data Set (MDS) assessment, dated 5/11/21, indicated that Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15 which indicated that he/she was cognitively intact. The Resident had a Health Care Proxy in place that had not been activated. During an interview on 6/14/21 at 10:02 A.M., Resident #44 said he/she recently had a fall trying to use the vending machine in the solarium. The Resident said before my last fall I could walk around the building using my walker but now I have to use the wheelchair so I can't move around as much. Review of Resident 44's progress notes from April 2020 through June 2021 indicated he/she had a total of fourteen falls in the facility. The falls were as follows: - 4/22/20 2:00 A.M.: Unwitnessed fall out of bed reaching for remote control - no injury - 4/24/20 4:45 A.M.: Unwitnessed fall ambulating to bathroom - no injury - 5/12/20 5:30 A.M.: Unwitnessed fall ambulating to bathroom, nurse notified by roommate of fall - no injury - 7/25/20 11:25 P.M.: Unwitnessed fall ambulating to bathroom, nurse notified by roommate of fall - 1 cm (centimeter) by 1.5 cm induration on back of head and 3 cm by 2 cm bruise to left shoulder - 8/25/20 7:05 A.M.: Unwitnessed fall in bathroom - Back pain - 11/15/20 11:15 A.M.: Fall in front foyer of building - Friction burn from rug to left elbow - 12/1/20: Fall in solarium - no injury - 1/2/21 10:05 P.M.: Fall self-transferring in room, nurse notified by roommate - Sent to ER for back pain - 1/26/21: Unwitnessed fall in bathroom, nurse notified by roommate - no injury - 2/23/21: Found leaning against vending machine in solarium due to loss of balance. Lowered to chair by staff. - No injury - 5/6/21 9:30 P.M.: Unwitnessed fall in solarium attempting to use vending machine - no injury - 5/11/21 7:49 A.M.: Unwitnessed fall in room - No injury - 5/11/21 11:15 P.M.: Unwitnessed fall in solarium attempting to use vending machine - Sent to ER for left distal fibula fracture. Review of the medical record (MDS and nurse's notes) indicated that prior to 5/11/21, Resident #44 was able to ambulate with a rolling walker and supervision. Review of the Physician's progress note for Resident #44, dated 5/12/21 indicated that following the fall on 5/11/21 the Resident had sustained a left distal fibula fracture, required a splint and was non-weight bearing on the left lower extremity. Resident # 44 was to follow up with orthopedics within 3 days. Review of the Resident's care plan for falls (initiated 11/20/20), indicated that the Resident was at risk for falls related to weakness, tremors and the use of [CONDITION(S)] medications. The goal was for no injuries related to falls. Previously resolved care plans for falls were unavailable for surveyor review. Interventions to prevent falls/injury included: - 2 quarter side rails to assist with bed mobility and transfers (4/17/21) - Continuous education on importance of using call light and keep reminding the Resident to ask for assistance when getting out of bed and walking and wait for assistance all the time (5/11/21) - Educate and remind the Resident to ask for assistance when getting out of bed and walking (11/20/20) - Electrical bed to assist with safe transfers (11/20/20) - Ensure items are within reach of resident (11/20/20) - Ensure proper foot wear on when ambulating: Nonskid socks or shoes (1/26/21) - Keep room well-lit and clutter free (11/20/20) - Monitor for changes in cognitive status, evidence of infection (11/20/20) - Monitor pain as ordered (11/20/20) - Monitor side effects of [CONDITION(S)] medications (11/20/20) - Remind Resident if she wants a soda to ask for assistance (5/6/21) - Notify MD and NP as needed (11/20/20) - Orient to call light; keep within reach and encourage use (11/20/20) - Overnight checks for toileting (11/20/20) - Place TV remote within reach (11/20/20) - PT/OT as ordered (11/20/20) - Reeducation on importance of using call light and asking for help with all ADL's care and transfers when needed, and wait for staff to help (5/11/21) - Rehab referral regarding safe ambulation and walker (11/18/20) - Remind resident to ask for assistance with getting things from low areas (shelves, floor etc.) (5/6/21) - Ask Resident if they would like you to get something from the vending machine on 7-3 and 3-11 shifts (5/12/21, after injury occurred) Review of the Physician's progress note for Resident #44 dated 5/11/21, indicated that last night the Resident slid to the floor. He/She is noncompliant with nursing instructions and frequently attempts to transfer to the bathroom. Gait is unsteady and she/he is on fall precautions due to high risk of falls. During an interview on 6/14/21 at 11:58 A.M., Unit Manager #2 said Resident #44 is impulsive and would ambulate without asking for assistance. We have tried to educate the Resident and make sure she has her call light but she keeps falling. She said the Resident likes to go to the vending machine to buy sodas. We have encouraged her to use her call light and keep her things within reach. On 6/14/21 at 12:40 P.M., the surveyor observed Resident #44 in his/her room. The Resident was sitting in his/her wheelchair between his/her bed and the window. There was no call light available within reach of the Resident. The surveyor asked the Resident how he/she would call for help if needed. The Resident said he/she would probably scream for someone or just do things myself. On 6/14/21 at 12:44 P.M., the Infection Control Nurse (who was assigned to work this current shift as a staff nurse) and was caring for Resident #44) said she was unaware of the specific fall interventions in place for the Resident but would expect his/her call light to be within reach at all times. The surveyor and the Infection Control Nurse reentered the room and observed the call light out of reach to the Resident. During an interview on 6/14/21 at 2:02 P.M., the Director of Nurses (DON) and the surveyor attempted to review all incident reports (a total of 14) for Resident #44's falls between April 2020 and June 2021, as referenced in the nurse's notes. The Director of Nurses said she had only been in the building since April 2021 and could not find all incident reports because a lot of documentation had gone missing. She was able to locate seven falls investigation reports out of 14 reports for review. At 2:28 P.M. the DON also said, fall prevention interventions were reviewed for Resident #44 including call light use and the education provided to the Resident. The Director of Nurses said that education with the Resident was ineffective since she is so impulsive, but her expectation is that the call light is within the Residents reach.

Based on observations, interviews, and record review, the facility failed to ensure pain management consistent with professional standards and the resident's goals and preferences was provided to one Resident (#59), out of a total sample of 33 residents. Specifically, for Resident #59, the facility failed to: 1) administer medications timely and per facility policy; and 2) accommodate transportation to a scheduled pain clinic appointment. Findings include: 1. Resident #59 was admitted to the facility in November 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that he/she was cognitively intact. Review of the facility's policy titled Medication Administration, updated December 2019, indicated the following: - Medications shall be administered in a safe and timely manner, and as prescribed. - Medications should be administered in accordance with the physician orders, including any required time frame. - Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During an interview on 6/16/21 at 8:40 A.M., the Staff Development Coordinator (SDC), who had just accepted responsibility for the medication cart on Unit B, said there was a scheduling conflict and she will be administering medications until the scheduled nurse arrives. On 6/16/21 at 9:19 A.M., the surveyor observed Resident #59 telling the SDC that he/she had a pain level of 8 out of 10 in his left hip (indicating the Resident had severe pain). On 6/16/21 at 9:33 A.M., the surveyor observed Resident #59 lying in bed and was grimacing. The Resident said he/she was all done eating breakfast but still had not received his/her insulin, had his/her blood sugar checked, or received pain medication for the pain reported in his/her left hip. Resident #59 said, the pain is constant. During an interview on 6/16/21 at 9:40 A.M., the SDC said she had not given out any medications and was late on everything. She said she would check Resident #59's blood sugar and planned to call the doctor. On 6/16/21 at 9:45 A.M. (26 minutes after requesting pain medication from the SDC for his left hip pain), the surveyor observed Resident #59 yelling out from the bed saying, Come on now will you, hurry up! The surveyor asked the Resident what was wrong and he/she said, I'm in pain and need something to help it! Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 10 mg (Steroid used for pain) daily at 9:00 A.M. - [MEDICATION(S)] ER 15 mg (pain) give seven tablets (105 mg) two times per day at 9:00 A.M. and 9:00 P.M. - Acetaminophen 500 mg (pain) give two tablets (1000 mg) three times per day at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Further review of the Resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 30 mg-Give two tablets by mouth every six hours as needed for pain. -Acetaminophen Tablet 325 mg-Give two tablets by mouth every six hours as needed for pain -Apply hot pack to right thigh for pain/discomfort, every six hours as needed for pain -Biofreeze Gel 4% ([MEDICATION(S)] topical [MEDICATION(S)])-apply right thigh topically every 12 hours as needed for pain -[MEDICATION(S)] Cream 0.025% apply to body topically every eight hours as needed for arthritis -[MEDICATION(S)] patch 4%-Apply to right hip topically every 12 hours as needed for pain -[MEDICATION(S)] Tablet 2 mg-Give two mg by mouth every eight hours as needed for muscle cramps. On 6/16/21 at 10:00 A.M., the surveyor observed the SDC preparing and administering the following pain medications to Resident #59 (41 minutes after the Resident requested pain medication for hip pain): - Acetaminophen 1000 mg (approximately 1 hour late) - [MEDICATION(S)] 10 mg (approximately 1 hour late) - [MEDICATION(S)] ER 105 mg (approximately 1 hour late) The surveyor observed no additional pain management medications or treatments provided to Resident #59. During an interview on 6/16/21 at 10:13 A.M., the SDC said she spoke with the physician who said to hold the 7:30 A.M. sliding scale Novolog insulin, but could administer the remaining medications. There was no discussion related to Resident #59's pain management. The surveyor was present at the nurse's station at the time of the telephone conversation between the SDC and the physician. On 06/16/21 at 10:25 A.M., the surveyor observed Resident #59 grimacing and yelling out in pain saying, I need pillows under my legs, it hurts, my god! The Resident said to the surveyor, When I don't get my pain medications on time, I get sharp shooting pains that don't go away. The medication helps take the edge off so it doesn't hurt so bad. 2. Review of Resident #59's physician's note, dated 5/3/21, indicated the following: Chronic pain disorder- Patient has a history of chronic pain and is on [MEDICATION(S)] sustained released 105 mg twice a day and [MEDICATION(S)] immediate release 60 mg every 6 hours as needed. -Resident also received [MEDICATION(S)] 200 mg three times a day for chronic peripheral [CONDITION(S)]. -Resident is reported to have knowledge of when his/her next dose of as needed medication is able to be given. -Behaviors concerning with substance abuse and tolerance. -I recommend that he be referred to pain clinic and that his/her medications be considered for change including consideration of [MEDICATION(S)] for pain management. Review of Unit B schedule book indicated the following: -Resident #59 had a scheduled appointment 5/19/21 at Pain management Clinic for chronic pain, severe bilateral [CONDITION(S)] and [CONDITION(S)] at 1:00 P.M. During an interview on 06/11/21 at 10:28 A.M., Resident #59 said the last two nights the pain has been really bad. Resident #59 said he had a scheduled appointment with the pain clinic in May, but the facility canceled the appointment because they could not provide transportation to the appointment. During an interview on 06/16/21 at 08:35 A.M., Resident #59 said he/she is still experiencing a lot of pain. Resident #59 said when he gets the pain, it is a sharp pain, and if it was a 10, it's now a 15 (scale 0-10). Resident #59 said he needs a hip replacement, but is unable to have the surgery due to his breathing difficulty. Resident #59 said physical therapy gave him a wheelchair with the best cushion, but because of the hip pain he/she can only sit up for one hour before he/she starts getting sharp hip pain. Resident #59 said he wanted to be seen in the pain clinic because they have helped him in past with pain relief by changing his/her medication doses or by receiving injections. During an interview on 06/16/21 at 08:40 A.M., the Director of Nurses (DON) said, at the time of the scheduled appointment on 5/19/21, the facility did not have a transportation contract for non-emergency appointments requiring medical supervision. During an interview on 06/16/21 01:35 P.M., with the DON and the Administrator, the DON said we could not provide Resident #59 with transportation to the pain clinic appointment. The Administrator confirmed they had no transportation contract to bring any residents to appointments in May 2021.

Based on observation, record review and interviews, the facility failed to ensure nutritional status was maintained for three Residents (#8, #1, and #35), out of a total sample of 33 residents. Specifically, the facility failed to: 1. Monitor the fluid restriction and provide adequate nutrition prior to attending hemodialysis for one Resident (#8); and 2. Maintain acceptable parameters of nutritional status which resulted in weight loss for two Residents (#1 and #35). Findings include: 1. Review of the [CONDITION(S)] contract indicated: Preparation of [CONDITION(S)] Residents: The nursing home shall ensure that [CONDITION(S)] Residents are prepared to spend an extended length of time at the [CONDITION(S)] [CONDITION(S)] Unit and have received proper nourishment and any medications prescribed as appropriate, before coming to the [CONDITION(S)] [CONDITION(S)] Unit. Resident #8 was admitted to the facility in March of 2016 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 3/9/21, indicated the Resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact. The MDS also indicated that the Resident was 68 inches tall, weighed 273 pounds and received [CONDITION(S)]. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's care plans indicated: 1.) The Resident has renal failure and receives [CONDITION(S)] four times a week (initiated and revised 3/20/21). The interventions include: -[CONDITION(S)] scheduled at center -Fluid restriction as ordered, educate as needs, non-compliant at times, [CONDITION(S)] MD aware -monitor renal failure and dietary restrictions -nursing not to leave fluids at bedside, resident is non-compliant, educate frequently -non-compliant with meal choices continue with education and offer better choices 2.) Altered nutrient utilization-carbohydrate metabolism related to diabetes and [CONDITION(S)], overweight/obesity, altered labs related to [CONDITION(S)] [CONDITION(S)] (elevated potassium) and [CONDITION(S)] (initiated 3/14/19). The interventions include: -diet: CCD, NAS large protein portions at meals, 1.5 l fluid restriction (240 ml at each meal for dietary (beverage of choice) (revised 3/10/20 -observe/document as indicated: meal consumption, amount of assistance needed at meals and tolerance to diet/fluids (initiated 3/14/19) During an interview on 6/14/21 at 9:15 A.M., Resident #8 said that he/she goes to [CONDITION(S)] four times a week, and today was leaving at 11:00 am to go to the [CONDITION(S)] center. The Resident said he/she does not eat lunch on those days, nor receive any snacks or lunch from the facility to take to [CONDITION(S)]. Review of the annual nutrition assessment, dated 3/15/21, indicated that Resident #8 was 68 inches tall, weighed 275 pounds and required 2093 calories, 84-105 grams protein and 2093 ml of fluid per 24 hours to meet his/her nutritional needs. The Dietitian also documented that the resident was prescribed a no added salt, consistent carbohydrate diet, and had a 10 pound weight loss in six months (not significant), however there was no documentation that the resident was on a fluid restriction. There was no indication of an alternative plan in place to ensure that the Resident received 100% of his/her nutritional needs since he/she was out of the facility to attend [CONDITION(S)] during the noon meal four times each week. On 6/14/21 at 9:15 A.M., the surveyor observed Resident #8 finishing breakfast. The Resident consumed eight ounces of coffee and eight ounces of milk. Review of the meal ticket indicated that Resident #8 was on a No added salt, consistent carbohydrate diet, 1500 fluid restriction, allergy: tomato, banana, orange, mandarin orange, and tomato sauce. The meal ticket also indicated coffee (no amount) and 4 ounces of milk, with large portions of meat at all meals and no lunch Monday, Wednesday and Friday. The surveyor also observed a 16 ounce bottle of soda and a 16 ounce insulated cup, on the Resident's tray table, which the Resident said he/she drinks during the day On 6/15/21 at 12:25 P. M., the surveyor observed Resident #8 during mealtime and the Resident consumed eight ounces of coffee and four ounces of milk. On 6/16/21 at 8:30 A.M., the surveyor observed Resident #8 and he/she consumed 16 ounces of coffee from [NAME] Donuts. On 6/16/21 at 9:00 A.M., the surveyor observed Resident #8 had consumed an additional eight ounces of coffee. On the Resident's bureau was a 16 ounce insulted mug with liquid inside. Review of the Treatment Administration Record (TAR) for June 2021 indicated 1500 cc fluid restriction indicating the three shifts were marked with a check only. No identified quantity of fluid consumed was documented to monitor that the Resident's fluid consumption did not exceed the 1500 cc fluid restriction order. During an interview on 6/16/21 at 9:55 A.M., Nurse #3 said she was aware that Resident #8 was on a fluid restriction, but could not speak to the quantity of fluid consumed daily by the Resident. During an interview on 6/21/21 at 11:00 A.M. (via telephone), the facility Dietitian said she was aware that the Resident was prescribed a fluid restriction but was not aware that the dietary staff were providing the incorrect amount on fluids on the Resident's tray. She also said that she was not aware that there was no plan in place for the 3-4 meals a week the Resident misses when he/she is at [CONDITION(S)] receiving treatment. 2. Resident #35 was admitted to the facility in October 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment, dated 1/26/21, indicated Resident #35 had impaired short and long term memory and required supervision cueing and encouragement to complete each meal. The resident weighed 167 pounds and was 64 inches (5'4 tall). Review of the Comprehensive Nutrition Assessment, dated 1/31/21, indicated Resident #35 weighed 161 pounds and required assistance when he/she ate and drank. The assessment indicated both the resident's physical and mental conditions affected his/her nutritional status. At the time of the assessment, the dietitian indicated Resident #35's intake was variable, tolerating 25 - 75% of his/her meals, and weight changes were not clinically significant. No change was made to the plan of care. Review of the most recent MDS, dated [DATE], indicated a weight of 155 pounds, a loss of 12 pounds (7.1%). Review of the Resident's monthly weights for May and June 2021 were as follows: - On 5/10/21 - the Resident's weight was 152.3 lbs., an additional 2.2 pound weight loss since 4/27/21, with overall weight loss of 23.7 lbs. since 1/26/21 - On 6/3/21 - the Resident's weight was 143 lbs., an additional 12 pound weight loss in less than a month and an overall weight loss of 24 pounds since 1/27/21. Review of the medical record indicated there was no intervention or change in the nutrition plan of care to address the weight loss. On 6/10/21, seven days after the facility staff obtained Resident #35's weight of 143 lbs., the nurse's note, indicated the Resident was referred to nutrition for consult due to weight loss. The note indicated Resident #35 had lost 10 pounds in one month and 20 pounds in six months. A nutritional assessment was completed on 6/10/21. The dietitian added Mighty shakes and Med pass, 120 ml, twice daily between meals for added calories. On 6/9/21 at 12:00 P.M., the surveyor observed Resident #35 during mealtime in the dining room. Resident #35 was provided a meal on tray, which was placed on the table. The staff did not cue or encourage him/her during the meal. The Resident looked disinterested in the meal. At the end of the meal, the staff asked if the Resident was done and took the meal away, the plate of food was barely touched. On 6/11/21 at 12:20 P.M., the surveyor observed Resident #35's during mealtime in the dining room. The Resident was observed occasionally picking at meal. At no time did staff assist, cue, or encourage Resident #35 to eat. During an interview on 6/11/21 at 2:00 P.M., Unit Manager #1 said the facility does not have nutrition risk meetings. She said that had notified the dietitian about Resident #35's weight loss once she had become aware on 6/10/21. During an interview on 6/15/21 at 1:45 P.M., the Dietitian said that she had just started working at the facility and was not aware of the weight loss until the unit manager had identified the loss on 6/10/21. The Dietitian said she has remote access to the medical record and could have identified the problem, but had not. She said Resident #35 weight loss was not planned and interventions for undesirable weight changes had not been put in place until she had been notified by the staff on 6/10/21. 3. Resident #1 was admitted to the facility in February 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition Assessment, dated 2/25/21, indicated the resident required supervision with meals, weighed 136 pounds, had a pressure injury and was at risk for unintentional weight loss. The Dietician recommended Ensure for extra protein for wound healing. Review of the MDS assessment, dated 3/3/21, indicated the Resident scored 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment and he/she was able to eat independently. Review of the medical record did not include a care plan for nutrition. Review of the June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the monthly weights is as follows: -2/24/21: 136 lbs. -3/3/21: 134.4 lbs. -6/10/21: 125. 4 lbs. (loss of 10.6 lbs. or 7.7% in 4 months) There were no weights for April or May 2021 available for review. During an interview on 6/10/21 at 7:30 A.M., Resident #1 said that breakfast was not very good and had only eaten the oatmeal. The Resident said that no one has come and asked what he/she likes to eat. During an interview on 6/15/21 at 12:30 P.M., Resident #1 said he/she did not like the meal and was eating a peanut butter and jelly sandwich instead. During an interview on 6/15/21 at 1:45 P.M., the Dietitian said she knew nothing about Resident #1's weight loss or missing weights.

Based on record review and interview, the facility failed to provide medically-necessary transportation for one Resident (#59), out of a total sample of 33 residents. Specifically, Resident #59 was not transported to a scheduled pain clinic appointment causing the Resident undue physical distress. Findings include: Resident #59 was admitted to the facility in November of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 3/16/21, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the Resident was cognitively intact. Review of Resident #59's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident also received [MEDICATION(S)] 200 mg three times a day for chronic peripheral [CONDITION(S)]. Resident is reported to have knowledge of when his/her next dose of PRN (as needed) medication is able to be given. Behaviors concerning with substance abuse and tolerance. I recommend that he/she be referred to pain clinic and that his/her medications be considered for change including consideration of [MEDICATION(S)] for pain management. Review of Unit B schedule appointment book indicated that Resident #59 had a scheduled appointment on 5/19/21 at 1:00 P.M. at the Pain Management Clinic for chronic pain, severe bilateral [CONDITION(S)], and [CONDITION(S)]. Review of the nursing progress notes, dated 5/18/21, indicated that the Unit Manager asked Resident #59 if he/she wanted to go out to the hospital and informed the Resident, the facility cannot give him/her more opioid than is scheduled and said Resident #59 has an order not to give PRN [MEDICATION(S)] within two hours of scheduled medication because of his/her respiratory status. Resident #59 agreed to go out to the hospital. When emergency medical services (911) arrived, the Resident refused to go and was eating, stating that he/she was not in pain but requested PRN [MEDICATION(S)]. During an interview on 06/11/21 at 10:28 A.M., Resident #59 said the last two nights the pain has been really bad. Resident #59 said she/he had a scheduled appointment with the pain clinic on 5/19/21, but the facility canceled the appointment because they could not provide transportation to the appointment. Review of the Brewster Ambulance letter sent to the facility Administrator, dated 3/1/21, indicated the following: We regret to inform you that as of April 1, 2021, the facility contracted Ambulance Service will no longer be servicing the Charlwell House Health and Rehabilitation Center. Review of the local EMS report, for service on 5/18/21, indicated: Resident #59 was found seated in his/her wheelchair eating with no signs of pain or distress. Staff explained that the patient was in excruciating pain and they can't manage it at the facility. Emergency Medical Service (EMS) spoke with the patient and was told that the pain is chronic and no worse than usual and that he/she was supposed to have an appointment with a pain specialist tomorrow. Patient stated the staff canceled his/her appointment tomorrow because they cannot find him/her a ride from any private EMS company. Patient asked if he/she would like to go to the hospital to which he/she stated, I don't need to go to the hospital; I need to get to my appointment. Patient also told EMS that nursing staff asked patient so your pain is excruciating right? making quotations with her fingers as to make the degree of pain warrant a 911 emergency response. Staff brought to the room again and asked if this was an emergency and they stated yes, but offered no rationale. EMS asked about a non-emergency transport and they replied we have called them all and none will come to this area. Staff stated again that Resident #59 did not want to go and this is not an emergency. NA3 (EMS) cleared no emergency and obtained a patient refusal signature after patient refused assessment. During an interview on 06/16/21 at 08:35 A.M., Resident #59 said he/she is still experiencing a lot of pain. Resident #59 said when she/he gets the pain, it is a sharp pain and if it was a 10, it's now a 15 (scale 0-10). Resident #59 said she/he needs a hip replacement, but is unable to have the surgery due to her/his breathing difficulty. Resident #59 said physical therapy gave him a wheelchair with the best cushion, but because of the hip pain he/she can only sit up for one hour before he/she starts getting sharp hip pain. Resident #59 said he/she wanted to be seen in the pain clinic on 5/19/21 because they have helped him/her in past with pain relief by changing his/her medication doses or by receiving injections. During an interview on 06/16/21 at 08:40 A.M., The Director of Nurses (DON) said, at the time of the scheduled appointment on 5/19/21, the facility did not have a transportation contract for non-emergency appointments requiring medical supervision. The DON said the facility called 911, because Resident #59 said he/she was in excruciating pain. The DON said, when 911 arrived, Resident #59 refused to go to the hospital because he/she was eating. The DON said the pain clinic appointment was rescheduled to July 2021.

Based on records reviewed and interviews for two of three sampled residents (Resident #3 and Resident #2), the Facility failed to ensure nursing staff were competent to recognize and respond appropriately to residents experiencing a change in condition. -On [DATE], Resident #3, who experienced an acute change in condition, which included nausea, vomiting, decreased oxygen saturation levels with the need to increase his/her oxygen liter flow from 2 liters to 4 liters, and increased lethargy, and despite being instructed by the Physician to have Resident #3 transported emergently to the Hospital Emergency Department (ED) for evaluation, Nurse #2 called for a non-medical chair van service to transport Resident #3 to the ED, and while being transported, Resident #3 vomited, became unresponsive, and died in the chair van. -On [DATE], Resident #2, who was found by nursing with blood on his/her forehead, was noted to have a skin tear that required steri-strips to close, nursing staff failed to complete a neurological assessment on Resident #2, after he/she was found with a head injury of unknown origin. Findings include: 1. The Facility Policy titled, Change in Condition Notification, dated [DATE], indicated that except in a medical emergency, the Facility must consult with the resident immediately (as soon as possible) if the resident is competent, and notify (and document the person notified and any fall/injury sustained) the resident's physician and designated representative when there was: -A significant decline in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); -A need to alter treatment significantly; and -A decision to transfer or discharge the resident from the Facility. Resident #3 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Report submitted by the Facility via the Health Care Facility Reporting (HCFRS), dated [DATE], indicated that Resident #3 expired during transport to the Hospital Emergency Department via a Chair Van Transportation Company. During an interview on [DATE] at 11:11 A.M., Certified Nurse Aide (CNA) #4 said on [DATE] at 8:00 A.M. Resident #3 was in bed and while assisting him/her with morning care, said she noticed Resident #3's bed sheets soiled with something black, said she thought it was either feces or vomit with blood and said she reported it to Resident #3's nurse right away. CNA #4 said around 11:00 A.M., Nurse #2 said she wanted Resident #3 out of bed, however Resident #3 was sleepy, unable to keep his/her eyes open and was unable to hold him/herself up in a sitting position. CNA #4 said she reported this to Nurse #2. During an interview on [DATE] at 3:00 P.M., the Director of Rehabilitation said on [DATE], during Resident #3's afternoon therapy session, Resident #3 told her that he/she did not feel well. The Director said Resident #3 looked pale and had vomited (vomitus was reddish-brown color and watery), and said she reported this to a nurse. During an interview on [DATE] at 2:25 P.M., Nurse #2 said on the morning of [DATE], Resident #3 was tired, wanted to sleep and said Resident #3 said he/she didn't feel like getting out of bed. Nurse #2 said around 2:00 P.M., Nurse #6 and the Director of Rehabilitation were in Resident #3's room checking his/her vital signs. Nurse #2 said Resident #3's oxygen saturation level was a little low, so she increased Resident #3's oxygen liter flow from 2 liters to 3 liters. Nurse #2 said Resident #3 had vomited around ,d+[DATE] milliliters (ml) of a light greenish color liquid consistency vomitus. Nurse #2 said she contacted Resident #3's Physician, and reported to her Resident #3 vomited, had nausea, his/her oxygen saturation was slightly lower than normal and that they had increased Resident #3's oxygen liter flow level. During an interview on [DATE] at 9:32 A.M., the Physician said on [DATE], she was notified by Nurse #2 via phone that Resident #3 had an acute change in condition, with nausea and vomiting, and that Resident #3 oxygen saturation levels had dropped into the 60's. The Physician said Resident #3 was at high risk to quickly develop respiratory complications, was experiencing an acute change of condition and said Resident #3 needed to be sent to the hospital emergent with Emergency Medical Services (EMS). Review of the Physician's Written Statement, dated [DATE], indicated she instructed Nurse #2 to send Resident #3 to the hospital for an urgent evaluation for acute respiratory failure. Review of Nurse #2's Progress Note, dated [DATE], indicated Resident #3 had nausea, vomiting, pallor and decreased oxygen saturation. The Note indicated Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Note indicated Resident #3's oxygen saturation levels dipped below 70%, with audible slight crackles and diminished lung sounds. Nurse #2 said when she assessed Resident #3 again, he/she was fine, was responsive, had no signs or symptoms of respiratory or cardiac distress, that his/her lung sounds were diminished with slight crackles which was not far off from his/her baseline, and said his/her vital signs were stable. Nurse #2 said Resident #3 didn't present to be in critical condition and said she didn't even think Resident #3 needed to go to the hospital to begin with. Nurse #2 said she did not feel that Resident #3 required emergent transfer to the Hospital and said she did not call 911. Nurse #2 said instead she called their transportation company, and was told a non-medical chair van could be at the Facility in less than 30 minutes. Nurse #2 said she thought that would be alright, so she booked the Chair Van to transport Resident #3 to the Hospital Emergency Department. However, Nurse #2's statements conflicted with her Progress Note, dated [DATE], describing Resident #3's decline in condition and with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2's statement also conflicted with the Physician interview and written statement that indicated she ordered Nurse #2 to send Resident #3 to the hospital for an urgent evaluation of acute respiratory failure. Nurse #2 said around 2:00 P.M., she rechecked Resident #3's oxygen saturation levels, said they were in the mid 80's, and said she increased Resident #3's oxygen liter flow from 3 liters to 3.5 liters, to be on the safe side. Nurse #2 said around 3:00 P.M. the Chair Van arrived, said she checked Resident #3's oxygen saturation levels again prior to Resident #3 leaving the Facility and said she increased Resident #3's oxygen flow to 4.0 liters. During an interview on [DATE] at 12:20 P.M., The Chair Van Driver said when he arrived at Facility, staff asked if he was an ambulance, said he told Facility staff no, that he was driving a Chair Van for the transportation company. The Driver said he only transported patients to and from appointments. The Driver said he waited about ten to fifteen minutes before Resident #3 was brought out of his/her room to be transported. The Driver said the Nurse ( later identifed as Nurse #2) then told him, Resident #3 would be traveling with an oxygen tank. The Driver said, at that point, prior to agreeing to transport Resident #3, he called his company's dispatch to check and make sure it was alright to travel with an oxygen tank. The Driver said Resident #3 looked very sick, that Resident #3 looked like he/she was struggling to breathe, and his/her facial color was pale. The Driver said he asked nursing staff if Resident #3 would be alright to travel with him to the emergency room . The Driver said he was told by staff that Resident #3 would be alright. The Driver said he let the Facility staff know he had no medical training and would not be able to provide medical assistance if needed. The Driver said the ride from the Nursing Home to the Hospital should have taken about 17 minutes. The Driver said after driving for about five minutes, Resident #3 was responding less and less to his questions, so he pulled over, and called his company's dispatch. The Driver said he reported to dispatch, that Resident #3 did not look good, and that dispatch asked him how far away were they from the hospital, and that he told dispatch it about 13 minutes away. The Driver said, he started driving again to the Hospital and after one to two minutes, Resident #3 stopped responding to him, Resident #3's head went down (forward) and then Resident #3 vomited. The Driver called the company's dispatch and reported what happened and called 911. The Driver said Emergency Medical Services (EMS) arrived in about two minutes and they performed Cardiopulmonary Resuscitation (CPR) on Resident #3. The Driver said EMS declared Resident #3 dead on the scene. The Driver said an EMS member accompanied him in the Chair Van with Resident #3 and he was escorted to the Police Station, because someone needed to identify the body. During an interview on [DATE] at 12:44 P.M., Administrator #1 said he received a call from the Facility's Social Worker on [DATE] at 4:45 P.M., who said the Police Station called the Facility, and asked her to go the police station to identify a deceased resident. Administrator #1 said that he went to the Police Station and identified Resident #3 as the deceased resident. 2. The Facility Policy titled, Neurological Assessments, dated [DATE], indicated that neurological assessments are preformed to evaluate the resident's nervous system, including brain function. The Policy indicated that early detection of an injury or underlying condition provides the best chance of decreasing long-term complications; residents with conditions resulting in changes or potential changes, in their neurological status will be assessed for transfer to the acute setting. The Policy indicated that a licensed nurse would: -Assess level of consciousness for traumatic or potentially traumatic injury to the head, after any loss of consciousness or change in condition that may have resulted from stroke or adverse event; -Complete neurological assessments to assess the central nervous system of a resident and would be completed as follows: -Every 15-minutes for one hour -Every 30 minutes for two hours -Every hour for two hours -Every shift for 72 hours Resident #2 was admitted in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #2, who appeared chronically ill, was admitted for short-term rehab after a hospitalization related to a recent fall and fractures. The Note indicated Resident #2 could make his/her own healthcare decisions. Review of Nurse #7's Progress Note, dated [DATE] at 4:57 A.M., indicated Resident #2 rang the call light and requested pain medication. The Note indicated when she (Nurse #7) responded, she saw blood on his/her left forearm and right side of his/her forehead. The Note indicated Resident #2 was unaware of having skin tears, and was noted to have long and jagged finger nails. The Note indicated the skin tears were cleaned, steri-strips were applied to his/her forehead and forearm, and his/her forearm was covered with a non-adherent bandage. Review of the Occupational Therapy (OT) Treatment Encounter Note, dated [DATE], indicated that Resident #2 was lying in bed with blood on his/her clothes and he/she had a forehead laceration with steri-strips in place. The Note indicated Resident #2 had decreased cognition and increased fatigue. The Note indicated Resident #2's Nurse was notified. During an interview on [DATE] at 10:15 A.M., Minimum Data Set Nurse (MDS) Coordinator said she worked the day shift on ,d+[DATE]//21, and Resident #2 was on her care assignment. The MDS Coordinator said she asked Resident #2 about what happened to his/her forehead, and Resident #2 said he/she put his/her head down and hit his/her head on the bedside table. The MDS Coordinator said that she did not document this conversation. During an interview on [DATE] at 10:24 A.M., the Physician said that neurological assessments would need to be completed by staff because there may be an internal head bleed or neurological changes that may occur after such an incident. Review of Resident #2's medical record indicated there was no documentation to support, that after Nurse #7 found Resident #2 with an obvious head injury of unknown origin that a neurological assessment was completed or that an investigation into how he/she sustained the injuries was initiated. There was no documentation in Resident #2's medical record to support after he/she reported to nursing staff that his/her forehead injury was a result of him/her hitting it on the bed side table, that nursing completed neurological assessments, or updated the physician as to how the injury occurred.

Based on records reviewed and interviews for two of three sampled residents (Resident #3 and Resident #2), the Facility failed to ensure nursing staff provided care and services that met professional standards of practice. -On [DATE], Resident #3, who experienced an acute change in condition, which included nausea, vomiting, decreased oxygen saturation levels with the need to increase his/her oxygen liter flow from 2 liters to 4 liters, and had increased lethargy, that despite being instructed by the Physician to have Resident #3 transported emergently to the Hospital Emergency Department (ED) for evaluation, Nurse #2 called for a non-medical chair van service to transport Resident #3 to the ED, and while being transported, Resident #3 vomited, became unresponsive, and died in the chair van. -On [DATE], Resident #2, who was found with a skin tear to his/her forehead that required steri-strips (bandages used to help close shallow cuts or wounds) to close, staff failed to assess and monitor him/her for acute changes in mental and physical status including conducting neurological assessments, per Facility policy. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1. Resident #3 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Report submitted by the Facility via the Health Care Facility Reporting (HCFRS), dated [DATE], indicated that Resident #3 expired during transport to the Hospital Emergency Department via a Chair Van Transportation Company. Review of Nurse #2's Progress Note, dated [DATE] and written by Nurse #2, indicated that Resident #3 had nausea, vomiting, pallor and decreased oxygen saturation. The Note indicated Resident #3 was on continuous oxygen to maintain levels of ,d+[DATE]% oxygen saturation. The Note indicated Resident #3's oxygen level dipped below 70%, with audible slight crackles and diminished lung sounds. During an interview on [DATE] at 2:25 P.M., Nurse #2 said on [DATE], Resident #3 was on her assignment. Nurse #2 said around 2:00 P.M. Nurse #6 and the Director of Rehabilitation were in Resident #3's room checking his/her vital signs. Nurse #2 said Resident #3's oxygen level was a little low, so she increased Resident #3's oxygen liter flow from 2 liters to 3 liters. During an interview on [DATE] at 3:00 P.M., the Director of Rehabilitation said on [DATE], during Resident #3's afternoon therapy session, Resident #3 told her that he/she did not feel well. The Director said Resident #3 looked pale and had vomited (vomitus was reddish-brown in color and watery), and said she reported this to a nurse. Nurse #2 said Resident #3 had vomited about ,d+[DATE] milliliters of liquid consistency vomitus, which she described as being light greenish in color. Nurse #2 said she notified the Physician of Resident #3's condition. During an interview on [DATE] at 9:32 A.M., the Physician said on [DATE], she was notified by Nurse #2 via phone that Resident #3 had an acute change in condition, with nausea and vomiting, and that Resident #3 oxygen saturation levels had dropped into the 60's. The Physician said Resident #3 was at high risk to quickly develop respiratory complications, was experiencing an acute change of condition and said Resident #3 needed to be sent to the hospital with Emergency Medical Services (EMS). Review of the Physician's Written Statement, dated [DATE], indicated that she instructed Nurse #2 to send Resident #3 to the hospital for an urgent evaluation for acute respiratory failure. Nurse #2 said when she assessed Resident #3 again, he/she was fine, was responsive, had no signs or symptoms of respiratory or cardiac distress, that his/her lung sounds were diminished with slight crackles which was not far off from his/her baseline and said his/her vital signs were stable. Nurse #2 said Resident #3 didn't present to be in critical condition and said she didn't even think Resident #3 needed to go to the hospital to begin with. Nurse #2 said she did not feel that Resident #3 required emergent transfer to the Hospital and did not call 911. Nurse #2 said instead she called their transportation company, and was told a non-medical chair van could be at the Facility in less than 30 minutes. Nurse #2 said she thought that would be alright, so she booked the Chair Van to transport Resident #3 to the Hospital Emergency Department. However, Nurse #2's statements conflicted with her Progress Note, dated [DATE], describing Resident #3's decline in condition and with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Nurse #2 said around 3:00 P.M. the Chair Van service arrived, said she checked Resident #3's oxygen levels again prior to Resident #3 leaving the Facility and said she increased Resident #3's oxygen liter flow to 4 liters. Review of the Chair Van Transportation Company's Event Report, dated [DATE] at 2:12 P.M., indicated a Nurse (later identified as Nurse #2) booked a Chair Van ride reservation for Resident #3 to be transported to the Hospital Emergency Department (ED), and was told the pick-up time would be around 30 minutes. The Report indicated the Chair Van Driver arrived at the Facility 2:46 P.M. and staff asked him to assist Resident #3 with getting ready and with transferring him/her into a wheelchair. The Report indicated that the Driver said it was not company policy nor was he trained to perform physical transfers of patients. The Report indicated the Chair Van Driver told staff that Resident #3 looked pale and staff said he/she was tired. The Report indicated the Chair Van Driver and Resident #3 departed from the Facility at 3:36 P.M. The Report indicated the Chair Van Driver became concerned when Resident #3 was no longer speaking and he saw his/her head bobbing back and forth. The Report indicated the Driver pulled over and contacted the Transportation Company's Dispatch who contacted the Facility and spoke with a nurse (later identified as Nurse #2) about Resident #3 physical changes. The Report indicated a Nurse (later identified as Nurse #2) told Dispatch that Resident #3 was tired, had been falling asleep in the Facility and told Dispatch that the Driver should proceed to the Emergency Department. The Report indicated that a short time later, the Driver saw Resident #3 exhibiting a chewing motion with his/her mouth, with foaming and groaning, with his/her head slumped forward. The Report indicated the Driver pulled over and again called Dispatch who instructed him to call 911. The Report indicated an ambulance responded within three minutes and in the meantime, Resident #3 had vomited, was no longer responsive, then EMS arrived to the scene and attempted to revive Resident #3. Review of the Police Report, dated [DATE], indicated that at 3:41 P.M., police responded to a 911 call from a pulled over Chair Van Service that was transporting a resident (later identified as Resident #3) to the Hospital due to low oxygen saturation levels, nausea, and vomiting. The Police Report indicated that upon arrival to the scene, the Officer saw Resident #3 was unresponsive and sitting in a wheelchair in the van. The Report indicated that the Fire Department also arrived at the scene and performed Cardiopulmonary Resuscitation (CPR) on Resident #3. The Report indicated Resident #3 was declared dead on the scene by EMS. The Report indicated the police escorted that Chair Van with Resident #3's deceased body, to the police station, for identification. During an interview on [DATE] at 2:25 P.M., Nurse #2 said she was unaware that Chair Van Drivers were not medically trained and had she known, then she would have called 911. However, this conflicted with the Chair Van Driver interview, who said he made it clear to Facility staff he was not medically trained. During an interview on [DATE] at 12:20 P.M., The Chair Van Driver said when he arrived at Facility, he was asked if he was an ambulance, and said he told the Facility staff no, that he was driving a chair van for the transportation company. The Driver said he only transported patients to and from appointments. The Driver said the Nurse (later identified as Nurse #2) then told him, Resident #3 would be traveling with an oxygen tank. The Driver said, at that point, prior to agreeing to transport Resident #3, he called his company's dispatch to check and make sure it was alright to travel with an oxygen tank. The Driver said Resident #3 looked very sick, that Resident #3 looked like he/she was struggling to breathe, and his/her facial color was pale. The Driver said he asked nursing staff if Resident #3 would be alright to travel with him to the Emergency Department. The Driver said he was told by staff that Resident #3 would be alright. The Driver said he let the Facility staff know, he had no medical training and would not be able to provide medical assistance if needed. 2. The Facility Policy titled, Neurological Assessments, dated [DATE], indicated that neurological assessments are preformed to evaluate the resident's nervous system, including brain function. The Policy indicated that early detection of an injury or underlying condition provides the best chance of decreasing long-term complications; residents with conditions resulting in changes or potential changes, in their neurological status will be assessed for transfer to the acute setting. The Policy indicated that a licensed nurse would: -Assess level of consciousness for traumatic or potentially traumatic injury to the head, after any loss of consciousness or change in condition that may have resulted from stroke or adverse event; -Complete neurological assessments to assess the central nervous system of a resident and would be completed as follows: Every 15-minutes for one hour Every 30 minutes for two hours Every hour for two hours Every shift for 72 hours Then as primary healthcare provider orders Resident #2 was admitted in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Progress Note, dated [DATE], indicated Resident #2, who appeared chronically ill, was admitted for short-term rehab after a hospitalization related to a recent fall and fractures. The Note indicated Resident #2 could make his/her own healthcare decisions. Review of Nurse #7's Progress Note, dated [DATE] at 4:57 A.M., indicated Resident #2 rang the call light and requested pain medication. The Note indicated when she (Nurse #7) responded, she saw blood on his/her left forearm and right side of his/her forehead. The Note indicated Resident #2 was unaware of having skin tears, and was noted to have long and jagged finger nails. The Note indicated the skin tears were cleaned, steri-strips were applied to his/her forehead and forearm, and his/her forearm was covered with a non-adherent bandage. During an interview on [DATE] at 10:15 A.M., the Minimum Data Set (MDS) Coordinator said she worked the day shift on [DATE], and Resident #2 was on her care assignment. The MDS Coordinator said she asked Resident #2 about what happened to his/her forehead, and Resident #2 said he/she put her head down and hit his/her head on the bedside table. The MDS Coordinator said that she did not document her conversation with Resident #2. During an interview on [DATE] at 10:24 A.M., the Physician said she would expect neurological assessments to be completed by staff because there may be an internal head bleed or neurological changes that may occur after such an incident. Review of Resident #2's medical record indicated there was no documentation to support, that after Nurse #7 found Resident #2 with an obvious head injury of unknown origin that a neurological assessment was completed or an investigation was started into how he/she sustained the injuries.

Based on records reviewed and interviews, for one of three sampled residents (Resident 2), who was assessed at being high risk for falls, the Facility failed to ensure he/she was provided with adequate supervision and the necessary level of assistance to maintain his/her safety. When on 2/10/20, Resident #2 was transferred with a mechanical lift with only one staff member present, during the transfer Resident #2 fell , hit his/her left hand on a bureau, sustained a deep laceration to the palm of his/her left hand, and was transferred to the Hospital Emergency Department (ED) where he/she received nine sutures to close the wound. Findings include: A Fall Risk Plan of Care, dated as last revised on 6/5/19, indicated Resident #2 was at risk for falls secondary to dementia, weakness and poor standing balance, and he/she required the assistance of two persons with transfers. The Fall Risk Assessment, dated 11/10/19, indicated Resident #2 was assessed as being a high risk for falls. The Quarterly Minimum Data Set (MDS) Assessment, dated 11/12/19, indicated Resident #2 was non-ambulatory and was totally dependent on the assistance of two persons with transfers. The Nurse Tech Information Kardex, undated, utilized by the Certified Nurse Aide (CNA) indicated Resident #2 required the assistance of two persons with transfers. A Facility Incident Report, dated 2/10/20, indicated Resident #2 was found lying on the floor in his/her room and upon assessment, he/she was noted to have a laceration on the palm of his/her left hand, just below the thumb. The Report indicated Resident #2's was transferred to the ED for evaluation and received nine sutures to close the wound. During an interview on 2/24/20 at 2:05 P.M., CNA #1 said she was aware Resident #2 required two staff persons to assist with all transfers. CNA #1 said on the afternoon of 2/10/20 when she was getting Resident #2 ready to return to bed, she could not find another staff person to help her. CNA #1 said she brought the Sara Lift (mechanical lift) into Resident #2's room and attempted to transfer Resident #2 back to bed by herself, using the Sara Lift. CNA #1 said she stood Resident #2 upright from the wheelchair in the Sara Lift with the use of the supporting sling and placed Resident #2's arms around the arms of the Sara Lift and positioned Resident #2's feet firmly on the lift platform. CNA #1 said she then positioned the Sara Lift at the side of Resident #2's bed and prepared to lower Resident #2 into bed. CNA #1 said when she attempted to lower Resident #2 into the bed, Resident #2 lifted his/her feet off the platform of the Sara Lift, and Resident #2 then let go of the arms of the Sara Lift. CNA #1 said Resident #2 started to swing around in the sling, and said the sling which was supporting Resident #2's weight, became detached from the lift frame. CNA #1 said Resident #2 fell to the floor hitting his/her left hand on a nearby bureau. During interviews on 2/24/20, Unit Manager #2, Nurse Supervisor #1 and Nurse #1 all said, Resident #2 was a two person physical assist with transfer and did not require the use of a Sara lift. Unit Manager #1, Nurse Supervisor #1 and Nurse #1 said they responded to Resident #2's cry for help and saw Resident #2 on the floor, with CNA #1 positioned beside him/her and the Sara Lift was present in the room.

Based on record review, observation and staff interview, the facility failed for 1 resident (# 10) of a total sample of 24 residents, to ensure that each resident have proper supervision to prevent accidents.The findings included:The facility failed to ensure the resident's safety devices were in place and functioning as planned.Resident #10 had [DIAGNOSES REDACTED]. The resident's most recent significant change Minimum Data Set Assessment (MDS) with a reference date of 8/1/11 indicated that the resident was cognitively impaired and needed extensive assistance from facility staff to complete the activities of daily living. The resident was assessed as high risk for falls. A care plan for the prevention of falls, created 12/30/09, included that the resident would have non-skid footwear, clutter free areas, a call bell within reach, "reminders" for the resident to use the call light and wait for assistance with transfers and to slow down and wait for staff before walking, and that the resident have an alarmed bed and chair sensor at all times.The resident's physician orders [REDACTED].The resident was unable to transfer without assistance of staff. On 8/1/11 the resident was found in the bedroom on the floor at 3 AM. A nurses' note, dated 8/1/11 at 3 AM, reported that a nurse aide found the resident on the floor while "walking by" the room. The nurse described that the resident was "bleeding profusely." The resident was admitted to the hospital with [REDACTED].A statement written by the nurse aide that found the resident reported that the nurse aide was walking by the room and heard the resident "talking." The aide reported entering the room and found the resident on the floor. Based on the nurses' note, staff statements and facility investigation of the incident, there was no indication that the resident's safety alarm sounded.Per review of the facility investigation and interview with the facility Director of Nurses and the "A" unit manager on 8/25/11 at 1:23 PM, the facility failed to attempt to determine why the alarm didn't sound. No interventions were put in place to insure that the safety alarms were functional.The resident was observed during survey. The resident appeared frail, utilizing a wheelchair for mobility. The resident had bruises under both eyes.