Every finding on record at Courville at Nashua

Based on record review and interview, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days for 1 of 5 residents reviewed for Unnecessary medications in a final sample of 16 residents. (Resident identifier is #5.)Findings include:Review on 7/1/26 of Resident #5's Medication Administration Record (MAR) revealed a current order for Lorazepam Oral Tablet 0.5 MG (milligram) give 1 tablet by mouth every 4 hours as needed for agitation, with a start date of 6/12/26. Interview on 7/2/26 at approximately 8:24 a.m. with Staff C (Director of Nursing) confirmed that the Lorazepam order for Resident #5 was greater than 14 days. Interview on 7/2/26 at approximately 10:47 a.m. with Staff G (Physician's Assistant) revealed that they did not document a rationale for the Lorazepam. Review on 7/2/26 of the facility's policy The [NAME] at Nashua Psychotropic Medication Use, with no review date, revealed, 2. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days.

Based on observation, interview, and record review, the facility failed to implement their policies for hand hygiene and enhanced barrier precautions (EBP) for 1 of 4 residents observed for medication administration and for 1 of 3 residents reviewed for EBP. (Resident identifiers are #34 and #42.) Findings include: Resident #34 Review on 6/30/26 of Resident #34's physician's orders revealed an order for IV Cefazolin (antibiotic) 2 grams every 8 hours for left knee infection and orders to maintain a PICC line. Observation on 06/30/2026 at approximately 1:56 p.m. with Staff B (Licensed Practical Nurse) during Resident #34's medication administration revealed Staff B entered the room wearing a gown and no gloves, Staff B was holding a pair of clean gloves, an IV antibiotic bag, saline flushes, alcohol wipes, and a pack of IV tubing. Staff B placed these items on a dresser, the saline flush fell onto the floor. Staff B picked it up with an ungloved hand and placed it on top of the dresser, Staff B moved Resident #34's belongings from the bedside table onto the dresser. Staff B donned clean gloves without performing hand hygiene and began cleaning and disinfecting the bedside table with bleach wipes. Afterward, Staff B doffed the gloves, discarded them, and donned a new pair of gloves without performing hand hygiene. After flushing Resident #34's Peripherally Inserted Central Catheter (PICC) line, attaching the IV antibiotic to the IV tubing, priming the IV tubing, and threading the IV tubing to the IV pump to start the IV antibiotic infusion, Staff B doffed gloves and donned a new pair of gloves without performing hand hygiene then labeled the IV tubing with a date. Interview on 6/30/26 at approximately 2:12 p.m. with Staff B confirmed that they did not perform hand hygiene after changing gloves as mentioned during the above observation. Review on 7/1/26 of the facility's policy titled, Handwashing/Hand Hygiene, revision date of October 2023, revealed, .Hand hygiene is indicated: .after touching the resident's environment .immediately after glove removal . Review on 7/1/26 of the facility's policy titled, Personal Protective Equipment - Using Gloves, revision date of September 2010, revealed, .wash hands after removing gloves. (Note: Gloves do not replace handwashing.) Review on 7/2/26 of the Centers for Disease Control and Prevention (CDC) website titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, retrieved from: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, revealed, .Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves . Resident #42 Observation on 7/2/26 at approximately 8:55 a.m. outside Resident #42's room revealed a posted sign for EBP. Observation further revealed that the sign was specific to Bed A, belonging to Resident #42. The EBP signage at Resident #42's door revealed, Providers and staff must also: Wear gloves and gown for the following high-contact resident care activities Transferring .changing linens . Observation on 7/2/26 at approximately 8:56 a.m. revealed Resident #42 transfering from their bed to wheelchair by Staff E (Licensed Nursing Assistant (LNA)) wearing gloves and no gown. Further observation revealed that Staff E then removed the linens from Resident #42's bed wearing gloves and no gown. Interview on 7/2/26 at approximately 9:07 a.m. with Staff E confirmed the above findings. Review on 7/2/26 of Resident #42's care plan revealed an intervention for Right and Left Stage 3 pressure ulcers of Enhanced barrier Precautions. Review on 7/2/26 of Resident #42's physician orders revealed and order dated 11/3/25 for Enhanced barrier precautions r/t (related to) wounds. Review on 7/2/26 of the facility's Infection Prevention Control Program reviewed on 1/7/26 revealed, Enhanced Barrier Precautions: Used for care of . chronic wounds . Precautions Enhanced Barrier Precautions . Applies to Any Resident with any of the following . wounds.PPE use for these situations .during high contact care activities .transferring .changing linens . Interview on 7/2/26 at approximately 9:34 a.m. with Staff F (Infection Preventionist) confirmed that staff should wear gowns and gloves for residents on EBP during high contact activities such as transferring a resident and changing linens.

Based on interview and record review, the facility failed to provide residents with written bed-hold notice at the time of transfer for 2 of 2 residents reviewed for hospitalizations. (Resident identifiers are #4 and #23.) Findings include: Resident #4 Review on 7/2/26 of Resident #4's progress notes from March 2026 to June 2026 revealed that Resident #4 was admitted to the facility on [DATE] for skilled services. Further review revealed that Resident #4 was transferred to the hospital on 3/9/26, 4/28/26, and 6/25/26. There was no documentation indicating that a written bed hold notice was provided to Resident #4 at the time of transfer to the hospital. Interview on 7/2/26 at approximately 11:13 a.m. with Resident #4 confirmed that they did not receive a written bed hold notice in regards to the above mentioned hospital transfers. Resident #23 Review on 7/2/26 of Resident # 23's provider note, dated 6/9/26, revealed that Resident #23 was sent to the hospital for evaluation. There was no documentation indicating that a written bed-hold notice was provided to Resident #23 at the time of the hospital transfer. Interview on 7/2/26 at approximately 11:00 a.m. with Staff A confirmed that Resident #23 was not provided a written bed-hold notice at the time of the 6/9/26 hospital transfer. Interview on 7/2/26 at approximately 11:20 a.m. with Staff A (admission Coordinator) confirmed that Resident #4 and Resident #23 were not provided a written bed-hold notice at the time of the above mentioned hospital transfers. Staff A revealed that they do not provide written bed-hold notice for residents who are transferred to the hospital.

Based on interview and record review, it was determined that the facility failed to implement and review, at least annually, the facility's water management program, which had the potential to effect the facility census of 69 residents who resided at the facility.Findings include:Review on 7/24/25 of the facility's Water Management Program revealed that the facility had identified multiple at-risk areas in the facility, including water heaters, expansion tanks in the maintenance office; pipes, valves and fittings in the bathrooms, shower rooms and kitchen; faucets, aerators, faucet flow restrictors in the bathrooms/kitchen; shower heads and hoses in the first/second floor shower rooms; air washer and humidifiers in the second floor resident rooms; eyewash stations in the laundry, shower, chemical rooms, housekeeping closets and shower rooms; ice machines in the kitchen and 1st and 2nd floors; CPAP machines, bubblers for oxygen, nebulizers in the resident rooms; hydrotherapy equipment, heater-cooler units in the therapy office; water filters in the employee lounge and the [brand name omitted] coffee maker. Further review revealed the program did not describe what control measures would be applied and monitored to the at risk areas. Interview on 7/24/25 at 12:05 p.m. with Staff D (Maintenance Director) revealed that the facility identified the above areas where Legionella could grow and spread. Staff D was unable to provide additional documentation for control measures for the identified at-risk areas in the facility. Staff D did not know what nationally-recognized standard was used to developed their facility's water management program. Interview on 7/24/2025 at 12:18 p.m. with Staff F (Infection Preventionist) revealed that Staff D managed the Water Management Program. Staff F confirmed that they did not have documentation that Water Management Plan was discussed at a committee meeting and did not know which nationally-recognized standards the facility used to develop the facility's water management program. Review on 7/24/25 of the facility's policy titled Legionella Policy revealed it was last reviewed/updated on 11/20/2018. Interview on 7/24/2025 at 1:32 p.m. Staff E (Administrator) confirmed that there was no additional documentation to identify how control measures were applied and monitored and confirmed there was no documentation to show the policy had been reviewed since 2018.

Based on observation and interview, it was determined that the facility failed to ensure that equipment was clean and sanitary for 1 of 1 kitchen observed and handling of food for 1 of 2 kitchenettes observed. Findings include: Observation on 7/22/2025 at approximately 8:30 a.m. of the ice machine in the main kitchen with Staff B (Food Service Director) revealed a greenish brown film located in the interior of the ice machine below the ice cube metal grid.Interview on 7/22/25 at approximately 8:30 a.m with Staff B confirmed the above observation.Review on 7/24/25 of the manufacturer's instructions of the facility's ice machine revealed, .General : Clean and sanitize the ice machine every 6 months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test water quality and recommend water treatment .Observation on 7/22/25 at approximately 8:40 a.m. of the first floor satellite kitchenette refrigerator with Staff B revealed 5 supplemental shakes with a hand written date of 7/20/25.Interview on 7/22/25 at approximately 8:40 a.m. with Staff B confirmed the above finding. Staff B stated that the handwritten date on the above supplemental shakes was the use by date which was the 14th day from the thaw date. Review on 7/23/25 of the supplemental shake container revealed the following instructions: .Use thawed product within 14 days. Keep Refrigerated .

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary care to ensure that a resident's ability to communicate was maintained with a communication device for 1 of 1 resident reviewed for communication in a final sample of 19 residents (Resident Identifier is #40). Findings include: Interview on 5/13/24 at approximately 12:10 p.m. with Resident #40's Durable Power of Attorney (DPOA) revealed that Resident #40 has difficulty with communication due to his/her advanced Parkinson's Disease and was admitted in March 2024 with a communication board that he/she used to allow for easier communication. Resident #40's DPOA stated that he/she has not seen the communication board since shortly after admission. Interview on 5/14/24 at approximately 8:30 a.m. with Staff M (Registered Nurse) revealed that he/she did recall Resident #40 being admitted with a communication device that he/she used at home. Staff M confirmed that it could not be located at the time of the interview. Interview on 5/14/24 at approximately 8:35 a.m. with Staff K (Licensed Nursing Assistant (LNA)) and Staff F (LNA) revealed they were unaware of Resident #40 using a communication board. Staff K stated that Resident #40 can answer simple yes or no questions when asked if you give him/her enough time to respond. Interview on 5/14/24 at approximately 8:45 a.m. with Staff M revealed that the communication board was located in a drawer in Resident #40's room. Interview on 5/14/24 at approximately 11:50 a.m. with Resident #40 revealed that communication with the staff has been difficult without his/her communication board.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents receive appropriate treatment to maintain mobility for 1 resident reviewed for limited range of motion in a final sample of 19 (Resident Identifier is #28). Findings include: Review on 5/14/24 of Resident #28's care plan revealed: Interventions for Preventing Pressure Injury, dated 3/19/24, Place face cloth rolled into R [right] hand, change with care and re-apply should resident remove. Observation on 5/13/24 at approximately 10:00 a.m. revealed Resident #28 was asleep in bed with his/her right hand clenched. There was no rolled face cloth in his/her right hand. Observation on 5/13/24 at approximately 12:15 p.m. revealed Resident #28 was up in his/her chair in the dining room. His/Her right hand was clenched. There was no rolled face cloth in his/her right hand. Observation on 5/14/24 at approximately 11:00 a.m. revealed Resident #28 was up in his/her chair in the hallway. His/her right hand was tightly clenched with no rolled face cloth in his/her right hand. Interview on 5/14/24 at approximately 11:30 a.m. with Staff I (Licensed Nursing Assistant) revealed that Staff I did not know that Resident #28 should have a rolled face cloth to hold in his/her right hand. Review on 5/14/2024 or Resident #28's Physical Therapy Discharge Summary, dated 2/20/23, revealed: discharge goal met if Pt [patient] tolerates folded/rolled wash cloth in right hand between palm and thumb >/= [less than or equal to] 8 hours without evidence of skin integrity issues or new/worsening pain.

Based on interview and record review, it was determined that the facility failed to ensure that an ongoing collaboration and communication process was established between the nursing home and the hospice company for 1 out of 1 hospice residents reviewed in a final sample of 19 residents (Resident Identifier is #6). Findings include: Review on 5/13/24 of Resident #6's Medical Record revealed they had been admitted to hospice services as of 4/26/24. Review on 5/14/24 of Resident #6's Hospice Team Care Plan as of 5/3/24 revealed the visit frequency for aide to be 3 x [times] week x [for] 9 weeks. Review on 5/14/24 of Resident #6's Hospice Aide Weekly Visit Record revealed the following: Week of 4/29/24-5/3/24 had one aide visit that was documented on 5/2/24; Week of 5/6/24-5/10/24 had one aide visit that was documented on 5/9/24. Interview on 5/14/24 at approximately 10:00 a.m. with Staff N (Unit Manager) confirmed the above finding. Staff N stated that there was no actual schedule for the facility staff to know when the Hospice Aide is coming in to see Resident #6. Interview on 5/14/24 at approximately 11:30 a.m. with Staff O (Hospice Aide) confirmed that he/she had only documented one visit for each of the above two weeks for Resident #6. Staff O stated he/she came only once the week of 4/29/24-5/3/24, as he/she was new to their case load and that was normal. Staff O stated that they did come three times the week of 5/6/24-5/10/24, but had only documented one visit. Staff O confirmed that there is no schedule for the days or times that they come to see Resident #6.

Based on observation, interview and record review, it was determined that the facility failed to follow facility policy on contact precautions to reduce transmission of communicable diseases in 1 of 1 residents reviewed for Transmission Based Precautions in a final sample of 19 residents. Findings include: Standards: Per Centers for Disease Control (CDC) Follow specific recommendations when treating a patient with confirmed or suspected C. Difficile infection .When entering the room of a patient with C. difficile, the priority should be to ensure glove use (in addition to a gown) and proper technique when removing gloves to minimize the risk of self-contamination. (Accessed at https://www.cdc.gov/clean-hands/hcp/clinical-safety/ on 5/16/24). Observation on 5/13/24 at approximately 8:30 a.m. of Staff H (Licensed Practical Nurse (LPN)) revealed them entering a Transmission Based Precaution (TBP) room [ROOM NUMBER]-1 without donning a gown and/or gloves. Further observation revealed that Staff H was administering resident's medications without a gown and gloves. Interview on 5/13/24 at approximately 8:30 a.m. with Staff H revealed that the resident was on contact precautions for Clostridium Difficile (CDiff). Staff H stated when he/she is not providing direct care he/she does not put on PPE. Interview on 5/13/24 at approximately 2:10 p.m. with Staff G (Unit Manager/Infection Preventionist) revealed it is the facility's policy for the staff to wear a gown and gloves before entering a room with transmission based precautions for CDiff. Review on 5/13/24 of Facility Infection Prevention and Control Program, on page 5 revealed: .C-Difficile gastroenteritis, contact precautions .

Based on interview and record review, it was determined that the facility failed to notify the resident and/or residents representative of care plan meetings for 2 residents reviewed for care plans in a sample of 19 residents (Resident Identifiers #16 and #40). Findings include: Resident #16 Interview on 5/13/24 at approximately 11:50 a.m. with Resident #16's activated Durable Power of Attorney (DPOA) revealed he/she has not been invited to any care plan meetings for over 6 months. The DPOA would like to be in attendance to share thoughts about the care of Resident #16. Review on 5/14/24 of Resident #16's Medical Record revealed no documentation of care plan meeting notifications to Resident #16's DPOA. Interview on 5/14/24 at approximately 9:20 a.m. with Staff J (Social Worker) confirmed that their was no documentation that could be provided showing Resident #16 and/or their DPOA were invited to or attended a care plan meeting for the time period of December 2023 through May 2024. Resident #40 Interview on 5/13/24 at approximately 12:00 p.m. with Resident #40's activated DPOA revealed he/she did not get invited to care plan meetings. The DPOA revealed that he/she did not know what a care plan meeting was or when they had been scheduled. The DPOA would be able to attend as he/she is at the facility almost every day visiting Resident #40. The DPOA would like to be in attendance to share thoughts about the care of Resident #40. Review on 5/14/24 of Resident #40's Medical Record revealed no documentation of care plan meeting notifications to Resident #40's DPOA. Interview on 5/14/24 at approximately 9:21 a.m. with Staff J confirmed that their was no documentation that could be provided showing Resident #40 and/or their DPOA were invited to or attended a care plan meeting. Review on 5/14/24 of the facility policy titled Care Planning- Interdisciplinary Team, revised on March 2022, revealed: .4. The resident, and the family and/or the residents's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. 6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record .

Based on observation, interview, and record review, it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 of 1 residents reviewed for choices in a final survey of sample of 19 residents (Resident identifier #60). Findings include: Observation on 3/30/23 at 11:00 a.m. of Resident #60's overbed table revealed a medicine cup containing 7 medications. Resident #60 was not present in the room. Interview at 11:05 a.m. with Staff B (Registered Nurse) confirmed that the Resident #60 had not been assessed to self-administer medications and that the medications should not have been left at the bedside. Interview at 11:10 a.m. with Staff C (Licensed Practical Nurse) revealed that he/she did leave the medications on the bedside table for Resident #60 to take when he/she gets out of the bathroom. Staff C confirmed that the medications in the cup were Resident #60's a.m. medications. Medications in the medication cup were: Losartan 50 milligrams (mg) Oxybutin Chloride ER (extended release) Vitamin D3 25 micrograms (mcg) Tylenol 325 mg 2 tablets Tramadol 50 mg Lasix 40 mg Valium 2 mg Review on 3/30/23 at 11:20 a.m. of Resident #60's medical record revealed that Resident #60 had no documented evidence of an assessment to self-administer medications. Interview on 3/30/23 at 11:30 a.m. with Staff A (Director of Nursing) confirmed that Resident #60 was not assessed to self-administer medications.

Based on observation and interview, it was determined that the facility failed to be administered in a manner permitting all residents to maintain or attain their highest practicable well being. Findings include: Interview on 3/15/22 at approximately 3:00 p.m. with Staff L (Interim Administrator) and Staff G (Director of Nursing) revealed that Staff Z (Administrator) had been working remotely for several months before taking leave 3 weeks ago. Staff L stated that he/she works at the assisted living next door and comes to this facility and checks in on the building since January 2022. Interview and record review between 3/13/22 to 3/15/22 revealed the administrator failed to ensure that a resident was free of physical restraint imposed for purpose of convenience and document ongoing re-evaluation of the need for restraint for 1 resident out of 1 resident reviewed for physical restraints in a final sample of 25 residents. Refer to F604: Free from Abuse and Neglect Interview, record review, and observation between 3/13/22 to 3/15/22 revealed the administrator failed ensure that medication were properly transcribed and administered for 1 out of 4 new admissions, for 1 out of 7 residents reviewed for unnecessary medications in a final sample of 25 residents, for 1 out of 32 medication administrations observed, for 2 out of 2 residents reviewed for pain management, for 1 out of 2 resident reviewed for pressure injuries, and for 1 out of 6 residents reviewed for nutrition. Refer to F635: Admission Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview, observation and record review between 3/15/22 and 3/15/22 revealed the administrator failed to ensure that facility-sponsored group and individualized activities were provided to support residents based on the resident's preferences, interests, and all needs for each resident for 4 weekend days in February 2022 and 3 days in March 2022. Refer to F679: Activities Meet Interest/Needs of Each Resident. Interview, observation, and record review between 3/13/22 and 3/15/22 revealed the administrator failed to ensure that licensed nurses and licensed nurse aides had demonstrated competencies and skills necessary to care for resident's needs as identified in the facility assessment for 5 out of 5 staff and received abuse training for 4 out of 5 staff. Refer to F726: Competent Nursing Staff and F943 Abuse, Neglect, and Exploitation Training. Interview, observation, and record review between 3/13/22 and 3/15/22 revealed the administrator failed to ensure that individuals working in the facility as a feeding assistant receive required training. Refer to F811: Feeding Assistant/Training/Supervision/Resident. Interview and record review between 3/13/22 and 3/15/22 revealed the administrator failed to ensure that the required members were present for the quarterly Quality Assurance and Performance Improvement meetings. Refer to F868: QAA Committee. Interview, observation, and record review between 3/13/22 and 3/15/22 revealed the administrator failed to ensure adherence to infection control practices for universal masking and contact precautions, and that staff were screened and evaluated prior to entering the facility as recommended by the Centers for Disease Control and Prevention (CDC). Refer to F880: Infection Prevention and Control. Interview and record review between 3/13/22 and 3/15/22 revealed the administrator failed to implement their policy to track and securely document COVID-19 vaccination status of all staff and any staff who have obtained any booster doses as recommended by the CDC for staff COVID-19 vaccination matrix reviewed. Refer to F888: COVID-19 Vaccination of Facility Staff.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that facility-sponsored group and individualized activities were provided to support residents based on the resident's preferences, interests, and all needs for each resident for 4 weekend days in February 2022 and 3 days in March 2022. (Resident identifiers are #19, #34, #47, and #62.) Findings include: Interview on 3/13/22 at approximately 9:22 a.m. with Resident #34 revealed they were unaware of any activities that they could do. Resident #34 stated other than doing therapy they just sit in their room. Interview on 3/13/22 at approximately 09:47 a.m. with Resident #47 revealed that other than group therapy sessions and my daughters visits, there is nothing more to do here. Resident #47 stated that no one has said anything to them about activities going on at the facility. Interview on 3/13/22 at approximately 11:30 a.m. with Resident #62 revealed they do not know of anything going on for activities in the facility. Resident #62 stated I wish there was stuff to do. Review on 3/13/22 at approximately 2:00 p.m. of the March 2022 facility Activities calendar revealed that on 3/13/22 the schedule reads All Day Leisure Cart. Review on 3/14/22 at approximately 9:00 a.m. of the March 2022 facility Activities calendar revealed an event at 9:30 a.m. titled Coffee Cart & [NAME] Daily. Observation on 3/14/22 at approximately 9:45 a.m. of the first floor nursing units revealed no coffee cart on the unit and no group activity in process. Further observation revealed Resident #19 and Resident #44 sitting at a table together. Interview on 3/14/22 at approximately 12:15 p.m. with Staff J (Activities Director) stated that there are no activities on going for the first floor due to staffing but if they can come to the second floor to participate in group activities. Staff J stated that a daily word puzzle is passed to the first floor residents. Review on 3/15/22 at approximately 9:00 a.m. of the March 2022 activities scheduled revealed that on 3/15/22 the following activities were scheduled: 9:30 a.m. is Coffee Cart & [NAME] Daily; 10:30 a.m. Chair Yoga; 1:00 p.m. Rosary; 2:00 p.m. Refreshment cart 2:30 p.m. Word Mining 3:30 p.m. Bowling Observation on 3/15/22 at approximately 10:50 a.m. of the second floor activities room revealed several residents in the room with drinks. Further observation revealed no Chair Yoga being provided as indicated on the activities calendar. Observation on 3/15/22 at approximately 10:55 a.m. of Resident #19 and Resident #44 revealed them both sitting in the dining room area in front of nurses station with no music or TV on. Further observation of Resident #19 and Resident #44 revealed they had empty cups in front of them. Interview on 3/15/22 at approximately 10:50 a.m. with Staff K (activities assistant) revealed that when they were done with coffee they will do exercises with those that want to. Observation on 3/15/22 at approximately 1:00 p.m. of the second floor activities room revealed residents were still being assisted with lunch. Observation on 3/15/22 at approximately 1:35 p.m. of second floor activities room revealed residents were still being assisted with lunch. Interview on 3/15/22 at approximately 1:45 p.m. with Staff K revealed that when the lunch meal is done they will bring those people that want to do rosary into activities room and have Rosary. Review on 3/15/22 at approximately 1:55 p.m. of daily participation documentation for residents who attend/ participate in activities was blank for February 2022 and thus far for March 2022. Interview on 3/15/22 at approximately 1:55 p.m. with Staff K confirmed that the daily participation documentation for residents who attend/ participate in activities has not been done for several months. Staff K stated that the All Day Leisure Cart listed on the activities calendar refers to a cart of self directed activities that is left in the dining room on each floor for the residents to use if they want to. Observation on 3/15/22 at approximately 2:15 p.m. of the second floor revealed in the activities room was one resident in the room doing a puzzle. Further observation of the second floor revealed eight residents in the dining area in front of nurses station sitting in chairs with no music or TV on. Further observation revealed no rosary being offered. Observation on 3/15/22 at approximately 2:15 p.m. of Resident #44 revealed they were sitting in their Broda chair reclinded on the side of the hallway with legs hanging off footrest. Further observation of Resident #44 revealed they were fidgeting and attempting to scoot forward in their Broda chair. Several staff walked by and placed Resident #44's feet back on the footrest. Review on 3/15/22 at approximately 2:45 p.m. of the activities February 2022 and March 2022 staffing schedule revealed the following: Sunday, February 6th; no staff scheduled Sunday, February 13th; no staff scheduled Sunday, February 20th; no staff scheduled Sunday, February 27th; no staff scheduled Sunday, March 13th; staff only scheduled 3 p.m.-7 p.m. Review on 3/15/22 at approximately 2:45 p.m. of the February 2022 facility activities schedule revealed the following: 2/6/22 All Day Leisure Cart and 1:30 p.m. Movie; 2/13/22 All Day Leisure Cart and 1:30 p.m. Movie; 2/20/22 All Day Leisure Cart and 1:30 p.m. Movie; 2/27/22 All Day Leisure Cart and 1:30 p.m. Movie. Review on 3/15/22 at approximately 2:45 p.m. of the March 2022 facility activities schedule revealed the following: 3/13/22 All Day Leisure Cart Interview on 3/15/22 at approximately 2:50 p.m. with Staff L (Administrator) confirmed the above listed activities staffing and scheduled activities for 2/6/22, 2/13/22, 2/20/22, 2/27/22 and 3/13/22. Staff L stated there are days there are no activities staff scheduled and no activities scheduled other than All Day Leisure cart. Review on 3/15/22 of facility policy titled Activity Programs revised 6/18, revealed .6. Activities are scheduled 7 (seven) days a week . Review of facility policy titled Activities Attendance revised 6/18, revealed .The Activities Department records activities attendance and participation of all residents .Attendance and participation is recorded for every resident in the group and individual citifies on a daily basis . Review on 3/15/22 of facility policy titled Activity Program Staffing revised 6/18, revealed ;;;5. Sufficient activity personnel are on duty to meet the needs of the residents and the functions of the activity programs . Observation on 3/13/22 at approximately 10:00 a.m. of the 1st floor unit revealed that all residents on the unit were in their rooms. There were no activities being offered on the unit. Observation on 3/13/22 at approximately 11:30 a.m. of the 1st floor unit revealed that all residents on the unit were in their rooms. There were no activities being offered on the unit. Observation on 3/13/22 at approximately 1:30 p.m. of the 1st floor unit revealed that all residents on the unit were in their rooms. There were no activities being offered on the unit. Observation on 3/14/22 at approximately 10:00 a.m. of the 1st floor unit revealed that there were no activities being offered on the unit. The majority of residents were in their rooms. Observation on 3/14/22 at approximately 2:00 p.m. of the 1st floor unit revealed that there were no activities being offered on the unit. The majority of residents were in their rooms.

1. Based on interview and record review it was determined that the facility failed to ensure that licensed nurses have competencies in skills necessary to care for resident's needs for 1 of 1 resident reviewed for choices in a final sample of 25. (Resident identifier is #173.) Findings include: Review on 3/15/22 of Resident #173's nursing progress notes dated 3/10/22 revealed that Resident #173's primary care physician ordered IV fluids and that the IV infiltrated and Resident #173 refused to have another attempt. Interview on 03/13/22 09:49 AM with Resident #173 revealed that he/she had an implanted venous access port available and Staff X (Agency Nurse) attempted to access it but failed because they did not know how to use it so Staff Y (Agency Staff) attempted IV (intravenous) insertion 8 times in arm until Resident #173 stated stop because it hurt. Interview on 03/15/22 at 1:00 p.m. with Staff G (Director of Nursing) confirmed that the expectation would be to contact the pharmacy and request their IV team. Staff G confirmed that the pharmacy IV team is used often at the facility. 2. Based on interview and record review, it was determined that the facility failed to ensure that licensed nurses and licensed nurse aides had demonstrated competencies and skills necessary to care for resident's needs as identified in the facility assessment for 5 out of 5 staff reviewed for nursing competencies. (Staff identifiers are Staff P, Staff Q, Staff R, Staff S and Staff T.) Findings include: Review on 3/13/22 of the facility's facility assessment, updated date of 1/31/22, revealed .Employees are required to complete training and competencies for their respective areas. Licensed nursing assistants are required to complete 12 hours of continuing education per year. All employees are required to complete mandatory education in the following areas: Abuse, neglect and exploitation Resident's rights and facility responsibilities Dementia Person-centered care Activities of daily living Disaster planning and [sic] Infection Control Medication Care for person's with Alzheimer's or other dementia . Staff P Review on 3/13/22 of Staff P's (Registered Nurse) training and competency records revealed that Staff P a signed acknowledgment form of the facility's policy on abuse and elder justice act upon hire on 2002. Staff P had no documentation of training nor demonstration of competencies for abuse, dementia, activities of daily living, medications and care for person's with Alzheimer's or other dementia for 2021. Staff Q Review on 3/13/22 of Staff Q's (Agency Licensed Nursing Assistant (LNA)) training and competency records revealed that there were no documentation of demonstrated competencies as mentioned in the facility assessment. Staff R Review on 3/13/22 of Staff R's (LNA) training and competency records revealed a signed acknowledgement form of the facility's abuse policy dated 3/27/19 (upon hire). Staff R had no documentation of training nor demonstration of competencies as mentioned in the facility assessment. Staff S Review on 3/13/22 of Staff S's (LNA) training and competency records revealed a signed acknowledgement form of the facility's abuse policy upon hire. Staff R had no documentation of training nor demonstration of competencies as mentioned in the facility assessment. Staff T Review on 3/13/22 of Staff T's (Licensed Practical Nurse) training and competency records revealed a signed acknowledgement form of the facility's abuse policy dated 3/27/19 upon hire. Staff R had no documentation of training nor demonstration of competencies as mentioned in the facility assessment. Interview on 3/14/22 at approximately 1:00 p.m. with Staff T revealed that he/she does not remember any annual training nor competencies provided for 2021. Interview on 3/14/22 at approximately 10:00 a.m. with Staff G (Director of Nursing) revealed that nursing staff were required annual training and competencies based on the care that staff provide to the residents. Staff G was unable to provide any documentation on above mentioned staff for the 2021 demonstration of competencies and training as mentioned in the facility assessment. Staff G stated that they don't have any records of training and competencies for Staff Q as he/she started 3/13/22 and that he/she was agency.

1. Based on observation, interview, and policy review, it was determined that the facility failed to adhere to infection control practices for universal masking and contact precautions recommended by the Centers for Disease Control and Prevention (CDC) during 2 observations of the first floor nursing unit. (Resident identifiers are #34 and #47.) Findings include: Resident #47 Observation on 3/13/22 at approximately 8:45 a.m. of first floor nursing unit revealed Resident #47 to be on contact precautions. Further observation revealed Staff O (agency Licensed Nursing Assistance LNA) enter Resident #47's room without donning a gown or gloves and proceed to assist them to the bathroom with their upper torso exposed. Interview on 3/13/22 at approximately 8:55 a.m. with Staff O LNA confirmed they did not don gloves or a gown when entering or assisting Resident #47. Staff O stated that he/she had already had shingles so they did not have to worry about the precautions. Interview on 3/13/22 at approximately 9:00 a.m. Staff P (Registered Nurse) revealed that Resident #47 is on contact precautions for shingles on his left side. Staff P stated that everyone going into the room should be donning gloves and gown. Review on 3/14/22 at approximately 11:30 a.m. of Staff Q's COVID-19 vaccination record revealed that they were up to date with all recommended COVID-19 vaccinations. Resident #34 Observation on 3/13/22 at approximately 11:48 a.m. of first floor nursing unit revealed Staff Q agency LNA walking down nursing hall with mask under chin eating potatoe chips and drinking from a Styrofoam cup. Staff Q then turned and entered Resident #34's room. Further observation of Resident #34's room revealed the resident was not in the room. Interview on 3/13/22 at approximately 11:48 a.m. with Staff Q confirmed that his/her mask was down and that they were eating and drinking on the nursing unit and in resident rooms. Staff Q stated it was ok to have their mask down as they were eating and drinking. Review on 3/15/22 of facility policy titled Isolation-Categories of Transmission Based Precautions revised on 10/18, revealed .contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment . Review on 3/15/22 of CDC (Centers for Disease Control and Prevention) website titled, Transmission-Based -Precautions, updated January 7, 2016, retrieved from https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html revealed the following: .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . Review on 3/15/22 of facility policy titled Facemasks as Source control revised on 9/21, revealed .5. Staff are required to wear face coverings upon entering the facility and prior to leaving the building .Staff must wear a facemask at all times when in the facility when not utilizing PPE (Personal Protective Equipment), including breakrooms or other places where they may encounter other employees . Review on 3/15/22 of the CDC (Center for Disease Control and Prevention) website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 2,2022, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed the following: .Source control refers to use of well-fitting cloth mask, face mask, or respirators to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .HCP [healthcare personnel] who are up to date with all recommended COVID-19 vaccine doses: Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors). 2. Based on observation, interview, and policy review, it was determined that the facility failed to maintain infection control practices related to glove use during medication administration for 1 out of 32 medication administration observed . (Resident identifier is #62) Findings Include: Observation on 3/13/22 at approximately 9:30 a.m. of Staff E (Registered Nurse) during administration of medications revealed [MEDICATION(S)] Suspension nasal spray , and [MEDICATION(S)] Emulsion 0.05% (percent) eye drops given to Resident #62 without gloves being changed between medications. Review of Resident #62's EMAR (Electronic Medication Administration Record) revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 3/13/22 at approximately 9:35 a.m. Staff E confirmed gloves should have been changed between medications. Interview on 3/13/22 at approximately 11:00 a.m. with Staff G (Director of Nursing ) confirmed the expectation would be to change gloves after giving nasal spray prior to administration of eye drops. Professional reference: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th edition St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 34 Infection Prevention and Control. Page 667 .Change gloves between tasks and procedures on the same client . Chapter 35 Medication Administration. Page 725. Administering ophthalmic medications .apply clean gloves . 3. Based on interview and record review, it was determined that the facility failed to ensure that staff were screened and evaluated appropriately prior to entering the facility per CDC guidelines for 2 staff out of 4 staff COVID-19 screenings reviewed. (Staff identifiers are Staff V and Staff W.) Findings include: Review on 3/14/22 of CDC's website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated date of 2/2/22, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic . .Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: -1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2, -2) symptoms of COVID-19, or -3) close contact with someone with [CONDITION(S)]-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2 . Review on 3/14/22 of CDC's website titled, Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2, updated date of 1/21/22, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assessment-hcp.html, revealed .Evaluating Healthcare Personnel with Symptoms of [CONDITION(S)]-CoV-2 Infection HCP with even mild symptoms of COVID-19 should be prioritized for [CONDITION(S)] testing with nucleic acid or antigen detection assays; ensure that [CONDITION(S)]-CoV-2 testing is performed with a test that is capable of detecting external icon? [CONDITION(S)]-CoV-2 even with currently circulating variants in the United States . Review on 3/14/22 of CDC's website titled, Symptoms of COVID-19, updated date of 2/22/21, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html, revealed Watch for Symptoms People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19: · Fever or chills · Cough · Shortness of breath or difficulty breathing · Fatigue · Muscle or body aches · Headache · New loss of taste or smell · Sore throat · Congestion or runny nose · Nausea or vomiting · Diarrhea . Review on 3/14/22 of facility's staff COVID-19 screening logs from 3/1/22 to 3/14/22 revealed the following: -On 3/4/22, Staff W (Licensed Nursing Assistant (LNA)) answered Yes to having symptoms of nasal congestion or runny nose, cough, and shortness of breath. -On 3/10/22, Staff W answered Yes to having symptoms of nasal congestion or runny nose, cough, shortness of breath and headache. -On 3/11/22, Staff V (Hospice LNA) answered Yes to having symptoms of nasal congestion or runny nose, sore throat, and cough. -On 3/11/22, Staff W answered Yes to having symptoms of nasal congestion or runny nose, cough, shortness of breath and headache. Further review of the staff COVID-19 screening logs revealed no documentation of further evaluation for Staff V and Staff W. Interview on 3/15/22 at approximately 11:00 a.m. with Staff G (Director of Nursing) was unable to provide any documentation and explanation of any further evaluation of Staff V and Staff W symptoms on the above mentioned dates in the staff COVID-19 screening logs. Staff G was also unable to provide any documentation that Staff V and Staff W were not allowed to enter the facility with signs and symptoms of COVID-19 on the above dates of 3/4/22, 3/10/22, and 3/11/22. Review on 3/15/22 of facility's antigen testing logs revealed that Staff W was last tested for COVID-19 on 3/3/22, which was negative. Review on 3/15/22 of Staff V's COVID-19 rapid antigen test report dated 3/14/22 revealed a result of negative. No documentation were provided for COVID-19 testing for Staff V for 3/11/22. Review on 3/15/22 of Staff V's COVID-19 vaccination record revealed that Staff V completed initial series of COVID-19 vaccines. Review on 3/15/22 of Staff W's COVID-19 vaccination record revealed that Staff W completed initial series of COVID-19 vaccines. Review on 3/15/22 of the facility's COVID-19 line list for staff and residents revealed that the last resident who was COVID-19 positive was on 1/31/22 and last staff who was COVID-19 positive was on 2/16/22. Review on 3/15/22 of the facility's policy titled, Coronavirus Disease (COVID-19)- Occupational Health, revised date of 9/2021, revealed .6. Healthcare workers and other facility staff are required to self-monitor and report fever (temperature [greater than or equal to] 100 [degrees] Fahrenheit or subjective fever) or symptoms consistent with COVID-19. Staff are screened before each shift for sign and symptoms of COVID-19 infection . Review on 3/15/22 of the facility's policy titled, Coronavirus Disease (COVID-19) - Work Restrictions and Return to Work Criteria for Staff, revised date of 9/2021, revealed .Staff with symptoms of COVID-19 or confirmed [CONDITION(S)]-CoV-2 infection are restricted from work according to the policy entitled, Coronavirus Disease (COVID-19) - Testing Staff . Review on 3/15/22 of the facility's policy titled, Coronavirus Disease (COVID-19) - Testing Staff, revised date of 9/2021, revealed .Testing Staff with Symptoms of COVID-19 .2. Symptomatic staff are restricted from work pending the results of testing. a. Staff who do not test positive for COVID-19 but have symptoms will follow the symptom-based strategy for returning to work .

Based on interview and record review, it was determined that the facility failed to implement their policy to track and securely document COVID-19 vaccination status of all staff and any staff who have obtained any booster doses as recommended by the CDC for staff COVID-19 vaccination matrix reviewed. Findings include: Review on 3/13/22 of the NHSN data, dated 2/27/22, revealed that the facility reported 100% of their staff were fully vaccinated. Further review of the NHSN data also revealed that the facility reported 100% of their fully vaccinated staff received a booster dose. Review on 3/14/22 of the facility's COVID-19 Staff Vaccination Status for Providers matrix revealed that there were 65 total direct hired staff, 18 contracted staff, and 13 other staff. Review also revealed that 1 contracted physician had a pending non-medical exemption. Further review also revealed that they were only 8 direct hire staff that received the COVID-19 booster dose. Review on 3/14/22 of the 1 contracted physician pending non-medical exemption record, revealed a pending religious exemption dated 3/14/22 and was still in review. Interview on 3/15/22 at approximately 2:20 p.m. with Staff G (Director of Nursing) confirmed the above findings. Staff G stated that the 1 contracted physician with the pending non-medical exemption last visited the facility couple weeks ago. Staff G was unable to provide their complete staff COVID-19 vaccination line list and their complete tracking and secured document of their staff COVID-19 vaccination status (initial series and booster doses). Review on 3/15/22 of the facility's policy titled, Coronavirus Disease (COVID-19) - Vaccination of Staff, dated 11/2021, revealed .Documenting and Reporting 1. The infection preventionist maintain a tracking worksheet of staff members and their vaccination status. 2. The tracking worksheet provides the most current vaccination status of all staff who provide any care, treatment or other services for the facility and/or its residents. The worksheet includes: a. staff name; b. initial start of employment or service; c. termination of employment or service (if applicable); d. unique ID; and e. vaccination status (vaccine manufacturer, date of dose(s) and date of completion; or exemption status) 3. The facility maintains documentation related to staff COVID-19 vaccination that includes at minimum, the following (as applicable): a. Staff were provided education regarding the benefits and potential risk associated with COVID-19 vaccine; b. Staff were offered the COVID-19 vaccine information on obtaining COVID-19 vaccine; c. A copy of the informed consent; and d. Verification of vaccination (or documentation of exemption). .6. The following information is reported electronically in a standardized format to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) at least weekly .

Based on interview and record review, it was determined that the facility failed to ensure that staff received abuse training for 4 out of 5 staff reviewed for abuse training. (Staff identifiers are Staff Q, Staff R, Staff S, and Staff T.) Findings include: Staff Q Review on 3/13/22 of Staff Q's (Agency Licensed Nursing Assistant (LNA)) training and competency records revealed no abuse training. Staff R Review on 3/13/22 of Staff R's (LNA) training and competency records revealed a signed acknowledgement form of the facility's abuse policy dated 3/27/19 (upon hire). Staff R had no other documentation of abuse training. Staff S Review on 3/13/22 of Staff S's (LNA) training and competency records revealed a signed acknowledgement form of the facility's abuse policy upon hire. Staff R had no other documentation of abuse training. Staff T Review on 3/13/22 of Staff T's (Licensed Practical Nurse) training and competency records revealed a signed acknowledgement form of the facility's abuse policy upon hire. Staff R had no other documentation of abuse training. Interview on 3/14/22 at approximately 1:00 p.m. with Staff T revealed that he/she does not remember any abuse training done. Interview on 3/14/22 at approximately 10:00 a.m. with Staff G (Director of Nursing) confirmed the above findings. Staff G stated that they don't have any records of abuse training for Staff Q as he/she started 3/13/22 and that he/she was agency.

Based on interview, record review and policy review it was determined that the facility failed to notify the physician of one medication being refused for 1 resident of 2 residents reviewed for pressure in a final sample of 25 residents. (Resident identifier is #8.) Findings include: Review on 3/14/22 of Resident #8's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] January 2022 5 refused doses of Liquacell 30cc PO (by mouth) for wound healing scheduled at 9:00 a.m. daily. 21 refused doses of Liquacell 30cc PO for wound healing scheduled at 9:00 p.m. daily. February 2022 3 refused doses of Liquacell 30cc PO BID for wound healing scheduled at 9:00 a.m. daily. 20 refused doses of Liquacell 30cc PO BID for wound healing scheduled at 9:00 p.m. daily. March 2022 1 refused doses of Liquacell 30cc PO BID for wound healing scheduled at 9:00 a.m. daily. 10 refused doses of Liquacell 30cc PO BID for wound healing scheduled at 9:00 p.m. daily. Review on 3/14/22 of Resident #8's nursing and provider progress notes revealed that the physician had not been notified of the missed doses. Interview on 3/14/22 at approximately 2:00 p.m. with Staff N (Unit Manager) revealed that the physician should be notified after medication is refused 3 times and that Resident #8's physician had not been notified regarding the refusal of medication. Interview on 3/14/22 with Staff D (Licensed Practical Nurse) confirmed when medication is refused, the physician should be notified. Review on 3/15/22 of the facility policy titled, Change In A Resident's Condition Or Status dated 7/1/08 revealed: .Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .f. Refusal of treatment or medications (i.e., two (2) or more consecutive times); .

Based on observation and interview the facility neglected the needs of the residents by not answering resident's call lights for 1 of 2 units observed during survey. (Resident identifiers are #61, #67, #173 and #175.) Findings include: Observation on 3/13/22 at approximately 11:27 a.m. of the first floor nursing unit revealed the following: At 11:27 a.m. room [ROOM NUMBER] call light was activated. Staff Q (Licensed Nursing Assistant) continued to walk up the hall passed room [ROOM NUMBER] but did not enter. At 11:28 a.m. room [ROOM NUMBER] (Resident #67) call light was activated. Staff Q was observed walking up and down the hall and exited the hallway. At 11:42 a.m. Staff Q walked back on to the hallway walking pass room [ROOM NUMBER] and room [ROOM NUMBER] and entered room [ROOM NUMBER]. At 11:50 a.m. Trays arrived on unit and Staff Q went to pass trays. At 11:54 a.m. Staff Q entered room [ROOM NUMBER] to deliver lunch tray and exited room with call light still activated. Resident #67 Interview on 3/13/22 at approximately 11:55 a.m. with Resident #67's visitor revealed that Staff Q had not asked if Resident #67 needed assistance or why they had activated their call light. Resident #67's visitor stated It's fine I helped [her/him] to the bathroom already. I asked them if the call light was broken but they didn't even answer me and walked out. Resident #173 Interview on 3/13/22 at approximately 9:45 a.m. with Resident #173 (has a private room) revealed that call light responses from staff take a long time to be answered. Resident #173 states that he/she has had episodes of incontinence due to the time waiting for staff to answer his/her call light. Resident #61 and Resident #175 Interview on 3/13/22 at approximately 11:00 a.m. with Resident #61 and Resident #175 (the 2 residents share a room) revealed that call light responses from staff take a long time to be answered. Resident #61 stated, Something could be seriously wrong with us and they would never know until it is too late.

Based on interview and record review, it was determined that the facility failed to ensure that a resident was free of physical restraint imposed for purpose of convenience and document ongoing re-evaluation of the need for restraint for 1 resident out of 1 resident reviewed for physical restraints in a final sample of 25 residents. (Resident identifier is #18.) Findings include: Review on 3/14/22 of Resident #18's nurse's note dated 2/21/22 written by Staff N (Unit Manager) revealed that Resident #18 was observed to have mitts on bilateral hands at the beginning of shift (7:00 a.m. to 3:00 p.m. shift), mitts were removed and swelling was noted on Resident #1's bilateral hands. Review on 3/14/22 of Resident #18's nurse's note dated 2/22/22 written by Staff N revealed that Resident #1 had an intact blister to left wrist. Further review of the nurse's note dated 2/22/22 revealed that Resident #1's blister to left wrist opened and wound treatment was applied (normal saline wash, [MEDICATION(S)] and dry protective dressing). Interview on 3/14/22 at 3:15 p.m. with Staff N confirmed above findings. Staff N stated that the mitts he/she observed on 2/21/22 encased Resident #18's hands and were secured around Resident #18's wrists, which Resident #18 had sustained friction marks on his/her wrists when Staff N removed the mitts. Staff N also stated that the mitts he/she observed were the type used for physical restraints and should not have been on Resident #18. Interview with Staff N also revealed that Resident #18 went to the emergency roiagnom on [DATE] because Resident #18 pulled their G-tube (gastrostomy) out. Staff N also stated that a physician order was required for the use of the hand mitts and renewed every 24 hours with continued use. Review on 3/15/22 of Resident #18's electronic and paper medical record revealed no assessment for the mitts used, no physician orders for the mitts used and no ongoing evaluation for the need of the mitts used. Further review of Resident #18's electronic medical record revealed health status notes on 2/19/22 indicated that Resident #18 went to the hospital twice for pulling out the G-tube initially, came back to the facility with a temporary tube, went out again to the hospital for pulling out the temporary tube then Resident #18 came back to the facility on [DATE] at approximately 10:00 p.m. Interview on 3/15/22 at approximately 1:00 p.m. with Staff G (Director of Nursing) confirmed that the mitts that were found on Resident #18 on 2/21/22 were the type used for physical restraints. Staff G stated that he/she interviewed Staff U (agency nurse) and he/she obtained a written statement from Staff U. Staff G also stated that the nurses on the weekend should have called him/her about the mitts as they were considered to be physical restraints and should have been removed from Resident #18. Review on 3/15/22 of Staff U written statement via e-mail (electronic) revealed that Staff U worked on 2/20/22 and that he/she got report from the outgoing nurse that Resident #18 went out to the hospital on 2/19/22 due to G-tube pull off and that Resident #18 came back with the splint [it is the mitts that were mentioned above] on his/her hands. Interview on 3/15/22 at approximately 4:00 p.m. with Staff G confirmed the above findings on Resident #18's record review and Staff U's statement. Review on 3/15/22 of the facility's policy titled, Restraints, effective date 2/1/05, revealed .Physical Restraints are defines as any manual method or physical or mechanical devices, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body. Physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests . .As a guide to assist residents in their decisions, the alternatives, benefits and risks of a restraint will be explained and they will be offered an alternative to a restraint. In case of a resident who is incapable of making decision, the resident's healthcare surrogate or legal representative may exercise this right. However, the surrogate or representative cannot give permission to use restraints for the sake of discipline or staff convenience, or when the restraint is not necessary to treat the resident's medical symptoms. After a clear explanation, informed consent will be obtained for the most appropriate and least restrictive restraint device . .Restraints will be limited, for example, used to protect a resident from a fall while up in a chair/ wheelchair [sic]. Restraints will be checked frequently, and removed every two hours o allow the resident change of position and exercise. All residents with restraint will be reviewed for restraint reduction