Every finding on record at Elizabeth Seton

Based on observations, interviews, and record review, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for two Residents (#63 and #34), out of a total sample of 18 residents. Specifically: 1.) For Resident #63, the facility failed to ensure nursing implemented a care plan intervention for bilateral floor mats for fall prevention. 2.) For Resident #34, the facility failed to ensure nursing developed and implemented a care plan intervention for bilateral floor mats for fall prevention. Findings include: Review of the facility policy titled 'Falls', undated, indicated, but was not limited to the following: - The licensed nurse, in conjunction with the interdisciplinary team will identify interventions to try to prevent subsequent falls. - Interventions that will be considered include but are not limited to: equipment-related interventions, surrounding environment modifications. - Care plans will be updated to reflect final interventions as necessary. 1.) Resident #63 was admitted to the facility in September 2023 with diagnoses including a history of a stroke and right sided hemiparesis (weakness on one side of the body). Review of the most recent Minimum Data Set (MDS) assessment, dated 6/23/24, indicated Resident #63 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. Review of Resident #63's active physician's order, initiated 7/21/24, indicated: - Bed in low position with fall mats on both sides of the bed while Resident is in bed. Check fall mats placement every shift. Review of Resident #63's active care plan related to falls, dated as reviewed 8/3/24, indicated: - Bed in low position with fall mats on both sides of the bed while Resident is in bed. Check fall mats placement every shift. Further review of Resident #63's care plan failed to indicate any history of refusal of fall mats. On 9/3/24 at 1:50 P.M., 9/4/24 at 6:48 A.M., 9/4/24 at 7:55 A.M., 9/4/24 at 8:30 A.M., 9/4/24 at 9:28 A.M., and 9/4/24 at 10:10 A.M., the surveyor observed Resident #63 in bed. There was a fall mat in place only on the left side of his/her bed, and there was no fall mat in place on the right side of his/her bed. There was another fall mat stored leaning upright against the wall near the bathroom in the Resident's room. During an interview on 9/4/24 at 10:17 A.M., Certified Nurse Assistant (CNA) #1 said she consistently cares for Resident #63. CNA #1 said Resident #63 should have fall mats on both sides of his/her bed. CNA #1 and the surveyor visualized a fall mat in place on the left side of Resident #63's bed and another fall mat leaning upright against the wall near the bathroom in the Resident's room. CNA #1 said they must have forgotten to put the right fall mat into place, but it should have been in place in addition to the left fall mat. Review of Resident #63's Certified Nurse Assistant (CNA) Documentation Survey Report, dated August 2024, indicated CNA #1 provided care to Resident #63 during nine shifts in August 2024. During an interview on 9/4/24 at 10:25 A.M., Nurse #1 said Resident #63 should have fall mats in place on both sides of the bed, not just on the left side, because he/she has a physician's order and care plan intervention for fall mats on both sides of the bed while the Resident is in bed. During an interview on 9/4/24 at 10:40 A.M., Unit Manager #1 said Resident #63 should have fall mats in place on both sides of the bed, not just on the left side, because he/she has a physician's order and care plan intervention for fall mats on both sides of the bed while the Resident is in bed. Unit Manager #1 said it should have been documented in either the TAR or progress notes if there was any refusal or rationale for only one fall mat being in place instead of two. Unit Manager #1 said Resident #63 should have both fall mats in place whenever he/she is in bed, not just at night. Review of the medical record, including the TAR and progress notes, failed to indicate any refusal or rationale for the right fall mat not being in place on 9/3/24 or 9/4/24. During an interview on 9/4/24 at 11:19 A.M., the Director of Nursing (DON) said Resident #63 should have fall mats in place on both sides of the bed, not just on the left side, because he/she has a physician's order and care plan intervention for fall mats on both sides of the bed while the Resident is in bed. The DON said Resident #63 should have both fall mats in place whenever he/she is in bed, not just at night. 2.) Resident #34 was admitted to the facility in May 2024 with diagnoses including altered mental status and recent history of fall. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/9/24, indicated Resident #34 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. This MDS also indicated Resident #34 had two falls since he/she was admitted to the facility in May 2024, one fall with injury (except major) and one fall with major injury. Review of Resident #34's active physician's order, initiated 5/9/24, indicated: - Bed in low position with fall mats on both sides of the bed while resident in bed, every shift. Review of Resident #34's fall investigation report, dated 8/3/24, indicated Resident #34 was found on the floor after being last seen in bed. This investigation indicated fall interventions utilized for Resident #34 included floor mats. Review of Resident #34's active care plan failed to indicate an intervention for fall mats on both sides of the bed while the Resident is in bed. On 9/3/24 at 8:45 A.M., 9/3/24 at 11:19 A.M., 9/3/24 at 1:55 P.M., and 9/4/24 at 6:53 A.M., the surveyor observed Resident #34 in bed. There was a fall mat in place only on the right side of his/her bed, and there was no fall mat in place on the left side of his/her bed. During an interview on 9/3/24 at 8:45 A.M., the surveyor observed Resident #34 in bed with a large purple bruise-like area on his/her forehead. Resident #34 said he/she sustained the bruise during a fall in his/her room. During an interview on 9/4/24 at 10:17 A.M., Certified Nurse Assistant (CNA) #1 said she consistently cares for Resident #34. CNA #1 said Resident #34 only has one fall mat that should be in place whenever he/she is in bed. CNA #1 and the surveyor visualized only one fall mat in Resident #34's room. Review of Resident #34's Certified Nurse Assistant (CNA) Documentation Survey Report, dated August 2024, indicated CNA #1 provided care to Resident #34 during nine shifts in August 2024. During an interview on 9/4/24 at 10:25 A.M., Nurse #1 said Resident #34 should have fall mats in place on both sides of the bed, not just on the right side, because he/she has a physician's order for fall mats on both sides of the bed while the Resident is in bed. During an interview on 9/4/24 at 10:40 A.M., Unit Manager #1 said Resident #34 should have fall mats in place on both sides of the bed, not just on the right side, because he/she has a physician's order for fall mats on both sides of the bed while the Resident is in bed. Unit Manager said if only one fall mat was available, the nurses should have clarified the order for fall mats to both sides of the bed or obtained another fall mat instead of signing it off as complete. During an interview on 9/4/24 at 11:19 A.M., the Director of Nursing (DON) said she wrote the interventions for floor mats in Resident #34's fall investigation report, dated 8/3/24, and that the plural meant that two fall mats should be in place. The DON said the intervention for Resident #34 to have fall mats on both sides of the bed, not just the right side, while in bed should have been part of the Resident's plan of care and should have been implemented, but was not. The DON further said that since the physician's order stated fall mats on both sides of the bed, the nurses should have clarified the order or obtained another fall mat if only one fall mat was available instead of signing it off as complete since the physician's order was not implemented as ordered.

Based on observations, interviews, and record review, the facility failed to provide respiratory care services in accordance with professional standards of care and the plan of care for one Resident (#31) out of a total sample of 18 residents. Specifically, the facility failed to ensure nursing implemented a physician's order to change Resident #31's oxygen tubing. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #31 was admitted to the facility in October 2018 with a diagnosis including respiratory failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/5/24, indicated Resident #31 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Review of Resident #31's physician's order, initiated 12/26/21, indicated: - Change oxygen tubing every week on Sunday 11-7 (date and initial). Review of Resident #31's Treatment Administration Record (TAR) indicated the following order was documented as implemented on 9/1/24: - Change oxygen tubing every week on Sunday 11-7 (date and initial). On 9/3/24 at 8:39 A.M., 9/3/24 at 1:51 P.M., 9/4/24 at 6:52 A.M., and 9/4/24 at 10:26 A.M., the surveyor observed Resident #31 in bed receiving oxygen through a nasal cannula with tubing dated 8/26. During an interview on 9/3/24 at 8:3:9 A.M., Resident #31 said he/she always wears oxygen. During an interview on 9/4/24 at 10:28 A.M., Nurse #1 said oxygen tubing should be changed every seven days. Nurse #1 visualized the label on Resident #31's oxygen tubing dated 8/26 and said that the oxygen tubing change was overdue, and it should have been changed three days ago. Nurse #1 said the order to change oxygen tubing should not have been documented as implemented in the TAR because it was not done. During an interview on 9/4/24 at 10:35 A.M., Unit Manager #1 said oxygen tubing should be changed every seven days. Unit Manager #1 said nurses are supposed to check the oxygen tubing every shift, and if it was overdue, it should be changed immediately. Unit Manager #1 said the order to change oxygen tubing should not have been documented as implemented in the TAR because it was not done. Unit Manager #1 said if there was reason the oxygen tubing was not changed it should have been documented in the TAR or progress notes. Review of Resident #31's medical record, including the TAR and progress notes, failed to indicate any rationale for oxygen tubing not being changed as ordered by the physician on 9/1/24. During an interview on 9/4/24 at 11:17 A.M., the Director of Nursing (DON) said oxygen tubing should be changed every seven days and/or as ordered by the physician if it is being used. The DON said nurses are supposed to check the oxygen tubing every shift, and if it was overdue, it should be changed immediately. The DON said the order to change oxygen tubing should not have been documented as implemented in the TAR because it was not done.

Based on observation, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for two Residents (#63 and #80) out of 18 total sampled residents. Specifically: 1.) For Resident #63, the presence external urinary catheter (a hollow, partially flexible tube that externally collects urine from the bladder and leads to a drainage bag) and ostomy (a surgically created opening from an area inside the body to the outside of the body) was inaccurately coded in the MDS. 2.) For Resident #80, the facility inaccurately coded the MDS to indicate the Resident had come off of skilled services. Findings include: 1.) Resident #63 was admitted to the facility in September 2023 with diagnoses including urinary retention and a history of a stroke. Review of the most recent MDS assessment, dated 6/23/24, indicated Resident #63 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. This MDS also indicated the presence of bowel/bladder appliances including an indwelling urinary catheter, an external urinary catheter, and an ostomy. On 9/3/24 at 8:34 A.M., the surveyor observed Resident #63 in bed. Resident #63 showed the surveyor a clear tube that was protruding from his/her lower abdomen, which was connected to a urinary drainage bag, attached to his/her bed frame, containing clear yellow urine. Resident #63 was unable to answer additional questions related to this suprapubic urinary catheter (a tube that is surgically inserted into the lower abdomen and bladder, which drains urine directly from the bladder.) Review of Resident #63's physician's order, initiated 2/22/24, indicated: - Cleanse SPT (suprapubic catheter tube) site with n/s (normal saline) then apply DPD (dry protective dressing) daily. Review of Resident #63's medical record for June 2024 failed to indicate the presence of an external urinary catheter or an ostomy. During an interview on 9/4/24 at 10:43 A.M., Unit Manager #1 said she was the Unit Manager in June 2024, and that Resident #63 only had a suprapubic urinary catheter. Unit Manager #1 said Resident #63 never used an external urinary catheter or had an ostomy since she had known him/her. During an interview on 9/4/24 at 10:50 A.M., the MDS Nurse said Resident #63 only had a suprapubic urinary catheter, which was coded as an indwelling urinary catheter on the MDS. The MDS Nurse said Resident #63 did not use an external urinary catheter or have an ostomy, so those two bowel/bladder appliances had been coded in error. During an interview on 9/4/24 at 11:22 A.M., the Director of Nursing (DON) said the MDS should be coded according to the Resident Assessment Instrument (RAI) guidelines and that the presence of an external urinary catheter and ostomy had been coded in error. 36797 2.) Resident #80 was admitted to the facility in April 2024 with diagnoses including hip fracture, kidney disease and high blood pressure. Review of the MDS assessment dated [DATE] indicated that the assessment was coded as a discharge return not anticipated and also coded as discharged off of skilled services. (When a resident comes off of their medicare benefit, the facility is required to complete an MDS assessment to notify the Centers for Medicare and Medicaid (CMS) that the facility will no longer be billing CMS for the residents stay at the facility). Review of the medical record indicated that Resident #80 was discharged off of skilled services on 5/14/24 not 6/14/24, as the MDS, dated [DATE], inaccurately coded. During an interview on 9/04/24 at 10:55 A.M., the MDS coordinator said that the MDS dated [DATE] was coded incorrectly as Resident #80 came off of skilled services on 5/14/24 and not 6/14/24.

Based on observation, record review and interview the facility failed to implement a comprehensive care plan for 4 Residents (#1, #17, #18, and #21) from a total sample of 23 residents. Finding Included: Review of the facility policy titled, Care Plans-Comprehensive, undated, indicated the following: Policy Interpretation and Implementation *2. Residents will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. *10. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. 1. For Resident #21 the facility failed to implement the medical plan of care for Resident #21's daily use of hearing aids for communication in accordance with the physician's orders. Resident #21 was admitted to the facility in August 2020 with diagnoses that include cerebral infarction unspecified, chronic systolic heart failure and unspecified hearing loss, bilateral. Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating he/she is cognitively intact. Further review of the MDS indicated Resident #21 requires extensive assistance of one person for daily activities and has moderate difficulty hearing when using his/her hearing aids. During an interview on 8/29/23, at 9:25 A.M., Resident #21 had difficulty answering questions due to being hard of hearing. Resident #21 said he/she wears hearing aids and was currently not wearing them. Resident #21 said the hearing aids are kept in the medication cart and the nursing staff normally assist him/her putting them on in the morning. During an interview on 8/29/23, at 10:30 A.M., Resident #21 was asked if he/she received his/her hearing aids. Resident #21 said no. Review of Resident #21's physician orders dated 10/22/21, indicated the following: Give resident both hearing aids in the a.m. and remove at bedtime (place them in resident's box in med cart), two times a day. Further review of Resident #21's medical record indicated the following audiology recommendations on 7/28/22: Daily use of hearing aids is recommended; Staff should assist with insertion and care of hearing aid(s). On 8/30/23, at 8:33 A.M.,10:28 A.M., and 11:05 A.M., Resident #21 was observed sitting up in bed. Resident #21 did not have his/her hearing aids on. During an interview on 8/31/23, at 8:15 A.M., Nurse #1 was asked if Resident #21 uses a hearing device. Nurse #1 said yes, he/she wears hearing aids. Nurse #1 was asked if she had given them to Resident #21 this morning, she said no but I can give them to him/her now. During an interview on 8/31/23, at 10:33 A.M., the Director of Nursing said the expectation would be that the physician's orders should be followed as written for the on and off schedule for Resident #21's hearing aids, and the nursing staff is responsible for putting on and removing the Resident's hearing aids. 36797 2. Resident #1 was admitted to the facility in August 2017 with diagnoses including dysphagia (difficulty swallowing), dementia and gastro-esophogeal reflux disease. Review of the care plan indicated a focus for risk for aspiration with the intervention for: supervise resident for all meals. On 8/29/23, at 12:45 P.M. the surveyor observed Resident #1 in her/his room eating without staff present. The surveyor observed a nurse set up Resident #1's meal and then leave the room. On 8/30/23, at 12:53 P.M., the surveyor observed Resident #1 in her/his room eating without staff present. The surveyor observed a nurse set up Resident #1's meal and then leave the room. 3. Resident #17 was admitted to the facility in April 2019 with diagnoses including dysphagia, stroke and hemiplegia. Review of the care plan indicated a focus for ADL (activities of daily living) with an intervention for eating with continual supervision after set up during the day. Further review indicated that Resident #17 is dependent on staff for eating on the 3-11 shift ( 3:00 P.M.-11:00 P.M.) Further review indicated a focus for nutrition related to dysphagia with an intervention to supervise with feeding. On 8/29/23, at 12:47 P.M., the surveyor observed Resident #17 eating alone in her/his room. On 8/30/23, at 12:46 P.M., the surveyor observed Resident #17 eating alone in her/his room. 4. Resident #18 was admitted to the facility in December 2020 with diagnoses including gastroesophogeal reflux disease, anxiety and depression. Review of the care plan with a focus for ADL (activities of daily living) assist dated 10/22/21, and an intervention for assist/supervise resident during meals. On 8/29/23,, at 12:47 P.M., the surveyor observed Resident #18 in her/his room eating without supervision. On 8/30/23, at 8:41 A.M., and 12:41 P.M., the surveyor observed Resident #18 in her/his room eating without supervision. On 8/31/23, at 8:32 A.M., the surveyor observed Resident #18 in her/his room eating without supervision. During an interview on 8/31/23, at 8:38 A.M., Nurse #2 said that continual supervision and supervision, with eating, means that somebody has to watch the resident while they are eating and can not leave them alone. During an interview on 8/31/23, at 8:49 A.M., Certified Nurse's Aide (CNA) # 1 said that the nurse's tell the CNAs what level of dependence a resident has for eating, if they require supervision with eating.

Based on record review and interview, the facility failed to revise the physician's orders for one Resident (#43) out of a sample of 23 residents. Specifically, the facility failed to update the physician's orders after Resident #43 was determined to not be at risk for elopement. Findings include: A review of the facility policy titled 'Care Plans-Comprehensive' with no revision date indicated the following: *10. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Resident #43 was admitted to the facility in June 2022 with diagnoses including Parkinson's disease. Review of the most recent Minimum Data Set (MDS) completed 5/25/23, indicated a Brief Interview Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Review of Resident #43's August 2023 physician's orders indicated the following: *Resident has a wander guard alarm attached to his/her wheelchair, check for proper functioning of device Q shift, (every shift)for risk of elopement. A review of an elopement assessment completed on 8/22/23, indicated the following: *History of elopement episodes in the last 6 months-no history, not a risk for elopement. Further review of an elopement assessment completed on 8/31/23, indicated the following: *Resident is no longer a risk for elopement. During an interview on 8/31/23, at 8:43 A.M., Unit Manager #1 said the Resident is not an elopement risk anymore based on the last two recent elopement assessments, she said the Resident's physician's orders should have been revised to reflect that. During an interview on 8/31/23, at 11:02 A.M., the Director of Nurses said the Resident's physician's orders should have been revised to indicate that the Resident is not an elopement risk.

Based on observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. medications were refrigerated per manufacturer's directions, 3. once opened were dated as required and 4. topical and treatment items were not stored with oral medications. Findings include: On 8/30/23, at 9:54 A.M., the surveyor observed the following in the 2A medication cart: 1. a Breztri inhaler (used to treat Chronic Obstructive Pulmonary Disease (COPD)) open and without a date. Review of the manufacturer's directions indicated that the inhaler expires three months after removal from foil pouch. 2. 2 Fluticasone propionate inhalers (used to treat COPD) open and without a date. The inhalers were not in the manufacturer's packaging. Review of the manufacturer's directions indicated that the inhaler expires according to the manufacturer's expiration date on the packaging. 3. a Levabuterol inhaler (used to treat asthma and COPD) open and without a date. The inhaler was not in the manufacturer's packaging. Review of the manufacturer's directions indicated that the inhaler expires according to the manufacturer's expiration date on the packaging. During an interview on 8/30/23, at 9:54 A.M., Nurse #3 said that she did not know when the inhalers were opened, but they are supposed to be dated. 1. On 8/30/23, at 11:02 A.M., the surveyor observed the following in the 1 D/E medication cart: A. a medicine cup containing 7 pills and labeled E6. During an interview on 8/30/23, at 11:02 A.M., Nurse #1 said that the resident had gone to mass so she saved them in the medication cart for later. 2. On 8/30/23, at 11:08 A.M., the surveyor observed the following in the 1 A/BC medication cart: 1 bottle of Latanoprost (used to treat glaucoma) open without a date. 1 bottle of Latanoprost unopened and not refrigerated. Review of the manufacturer's directions indicated to refrigerate until opened. 1 tub of Aquaphor cream. 1 Foley catheter insertion tray During an interview on 8/30/23 11:13 AM Nurse #4 said that the Aquaphor cream and the Foley catheter insertion tray belong in the treatment cart.

Based on observations, record review and interviews, the facility failed to maintain accurate medical records for one Resident (#43) out of a sample of 23 residents. Specifically, the facility documented that Resident #43's wander guard alarm was administered, when it wasn't. Findings include: Resident #43 was admitted to the facility in June 2022 with diagnoses including Parkinson's disease. A review of the most recent Minimum Data Set (MDS) completed 5/25/23 indicated a Brief Interview Mental Status (BIMS) score of 4 out of a possible 15 indicating severe impairment. A review of Resident #43's August 2023 physician's orders indicated the following: *Resident has a wander guard alarm attached to his/her wheelchair, check for proper functioning of device Q shift, every shift for risk of elopement. On 8/29/23, at 9:14 A.M., the surveyor observed Resident #43 sitting at the dining table, his/her wheelchair did not have a wander guard alarm on. On 8/30/23, at 8:43 A.M., and 12:24 P.M., the surveyor observed Resident #43 sitting at the dining table, his/her wheelchair did not have a wander guard alarm on. A review of Resident #43's August 2023 Treatment Administration Record (TAR) indicated that on 8/29/23 and 8/30/23 day shift, staff had documented that the wander guard alarm was administered. During an interview with the Unit Manager #1 on 8/31/23, at 8:43 A.M. she said nurses are expected to maintain accurate documentation. During an interview with the Director of Nurses on 8/31/23, at 11:02 A.M., she said medical records should be documented to reflect what is going on with a Resident, she said the nurses are expected to document accurately.

Based on observation, record review, policy review and interview the facility failed to implement the medical plan of care for 4 Residents (#69, #44, #13 and #11 ) out of total sample of 17 residents. Findings include: 1. For Resident #69, the facility failed to ensure the air mattress setting was implemented in accordance with the medical plan of care. Resident #69 was admitted to the facility in 11/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #69 scored a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating Resident #69 is cognitively intact. In addition, Resident #69 is totally dependent on staff for activities of daily living. Review of Resident #69's physician's orders indicated a current order for Check setting on air mattress, please match up with stickers on mattress pump. In addition, the record indicated Resident #69 currently weighed 185 pounds. On 8/16/22 at 11:05 A.M., an air mattress was observed on Resident #69's bed. There was a dial on the air mattress pump set at 250 pounds. A sticker with an arrow pointing to 160 pounds was also observed on the mattress pump. On 8/17/22 at 8:50 A.M., Resident #69's air mattress dial was observed again to be set at 250 pounds and the sticker pointing to 160 pounds was still in place. During an interview with Unit Manager #3 on 8/17/22 at 1:00 P.M., she stated nursing is responsible for ensuring the air mattress is at the correct setting. Unit Manager #3 also stated the air mattresses should be at a setting that reflects the resident's weight. 2. For Resident #44, the facility failed to ensure the air mattress setting was implemented in accordance with the medical plan of care. Resident #44 was admitted to the facility in 1/2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An Admission Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #44 scored a 3 out of a possible 15 on the Brief Interview for Mental Status, indicating Resident #44 has severe cognitive impairment. In addition, Resident #44 is dependent on staff for activities of daily living. Review of Resident #44's physician's orders indicated a current order for Check setting on air mattress, please match up with stickers on mattress pump. In addition, the record indicated Resident #44 currently weighed 205 pounds. On 8/16/22 at 11:14 A.M., an air mattress was observed on Resident #44's bed. The air mattress was set to 350 pounds. There was no sticker present to indicate what the mattress should be set at, per the physician's order. On 8/17/22 at 9:05 A.M., Resident #44's air mattress was observed to be set at 330 pounds. There was no sticker present to indicate what the air mattress should be set on, per the physician's order. During an interview with Unit Manager #3 on 8/17/22 at 1:00 P.M., she stated nursing is responsible for ensuring the air mattress is at the correct setting. Unit Manager #3 also stated the air mattresses should be at a setting that reflects the resident's weight. 3. For Resident #13 the facility failed to ensure the air mattress setting was implemented in accordance with the medical plan of care. Resident #13 was admitted to the facility in September of 2021 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 6/2/22 indicated Resident #13 had a score of 5 out of 15 on the brief interview for mental status, which indicated severe cognitive impairment and required extensive assistance from staff for daily care activities. The MDS further indicated that Resident #13 was at risk for developing pressure ulcers. On 8/16/22 Resident #13's bed was observed to be equipped with an air mattress. The dial on the air mattress was set to over 240 pounds. Resident #13 was observed in the dining area eating breakfast and was observed to be average stature and was not observed to be a person who weighs over 240 pounds. Review of the physician's orders dated for 8/2022 indicated the following: *Check setting on air mattress, please match up with stickers on the mattress pump. every shift, active 2/21/22. Further review of the medical record indicated Resident #13 weighed 107.2 pounds on 8/1/22. On 8/16/22 at 2:07 P.M., Resident #13 was observed resting in bed, the air mattress dial was set above 240. There was no sticker on the pump to match up the air mattress setting, therefore nursing staff would not know how to implement the physician's order. On 8/17/22 at 7:38 A.M., Resident #13 was observed in bed with the air mattress dial set to over 240 pounds. There was no sticker observed on the mattress pump to indicate the air mattress setting. Resident #13 had his/her legs over the side of bed on his/her left side. The mattress was firm/hard to the surveyor's touch. During an interview on 8/17/22 at 1:05 P.M., Unit Manager #3 said air mattresses are set to a resident's weight and staff should ensure it (the air mattress) is not too inflated or not inflated enough and is used for pressure ulcer prevention. Unit Manager #3 said that Resident #13 had a skin issue on his/her back at one time and the air mattress was implemented. Unit Manager #3 said Resident #13 weighs 107 pounds and the air mattress should be set to his/her weight and that the sticker on the pump would be set at the resident's weight. During an interview on 8/17/22 at 2:11 P.M., Nurse #1 said air mattresses are set to a resident's weight and that is where the sticker is placed. At this time, Unit Manager went into Resident #13's room observed the air mattress and said it was too hard for Resident #13 and she changed the setting to correspond to Resident #13's weight. 4. For Resident #11 the facility failed to follow facility policy regarding reweighing residents with a discrepancy of 3 or more pounds gained or lost with each weight taken. Findings include: Review of the facility policy titled, Weight Assessment and Intervention undated, included: -All weights (daily/weekly/monthly) must be taken by 11 am. Weekly weights will be done every Monday and all re-weights will be taken on Tuesday. -Residents need to be re-weighed if they are up or down 3 pounds from previous weight. ---Document BOTH weights in the computer. Mark the first weight (Monday's weight) as invalid. This will show a re-weight was completed. Resident #11 was admitted to the facility in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's Minimum Data Set assessment (MDS), dated [DATE], indicated the Resident scored an 8 out of 15 on the Brief Interview for Mental Status exam, which indicated the Resident's cognition was moderately impaired. On 08/16/22 at 11:15 A.M., review of Resident #11's Medical Record included the following: - A physician order dated 2/28/22, indicated weigh weekly, Monday 7-3. - Weight Summary: -7/18/22: 138.2 pounds (lbs). (Wheelchair) -7/25/22: 106.8 lbs. (Standing) (No re-weigh was documented) -8/1/22: 106.8 lbs. (Standing) -8/8/22: 145.5 lbs. (Standing) (No re-weigh was documented) -8/15/22: 148.2 lbs. (Standing) (No re-weigh was documented) During an interview on 8/17/22 at 8:38 A.M., Unit Manager #1 said nurses were responsible for documenting weights in the computer and the expectation is for any weight discrepancy of +/- 3 lbs. to prompt a re-weigh. She said a re-weigh should be done within 24-48 hours, the physician should be notified, and a nursing note completed. Unit Manager #1 said there was no re-weigh completed for Resident #11. During an interview on 8/17/22 at 1:23 P.M., the Dietician said she looks at weights weekly and identifies any weight changes of 2-3 lbs. The Dietician said she identified Resident #11's weight changes for the first time on 8/17/22.

Based on observation, record review and interview the facility 1) failed to properly store and label food in the facility kitchen, ensure food ready for resident consumption was stored properly and not expired on three out of five nourishment kitchens and the country kitchen on the first floor modules, 2) failed to maintain clean, sanitary food storage in the kitchen, and 3) failed to perform hand hygiene in accordance with professional standards of practice for food safety and sanitation to prevent potential foodborne illness to residents who are at high risk. Findings include: Review of the facility's policy, entitled Food Receiving and Storage, dated as revised [DATE] indicated the following: -Food shall be received and stored in a manner that complies with safe food handling practices. -Food Services, or other designated staff will maintain clean food storage areas at all times, all food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). -Food and snacks kept on the nursing units must be maintained as indicated: all food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located in the module and labeled with a use by date. -All food belonging to residents must be labeled with the resident's name and the use by date. -Food will be discarded after 3 days if no manufacturer expiration date. 1. On [DATE] at 7:21 A.M., the surveyor made the following observations in the facility kitchen: Walk-in refrigerator: * A tray with three covered salads not dated; *Three Seafood salad sandwiches wrapped not dated; *Three opened packages of sliced cheese wrapped in plastic not labeled or dated; * A two-tiered cart, parked in the refrigerator with cooked meat in pans on each level, loosely wrapped in foil not labeled or dated. Cook #1 said the pans contained turkey for today's lunch and said they should be securely covered, labeled and dated. Cook #1 said all items in the refrigerator are to be labeled and dated. During observation of the first-floor modules on [DATE] at 2:21 P.M., the surveyor observed the following: -The D module freezer had a small foiled wrapped food item, labeled with a name, not dated. -The Country Kitchen had an opened bottle of salad dressing with a use by date of ,d+[DATE]. On [DATE] during observation of the first-floor module nourishment kitchen at 7:42 A.M., the surveyor made the following observations: -B Module, an opened loaf of whole wheat bread with a best by date of [DATE]. An open bag of country white bread with a best if used by date of [DATE], two loaves of opened raisin bread with a fresh thru date of ,d+[DATE]. -C module, a loaf of country white bread with a best if used by date of [DATE], an open loaf of whole wheat bread with a best used by date of Jun 5, 2022, and an open loaf of raisin bread with a fresh thru date of ,d+[DATE]. During an interview on [DATE] at 8:05 A.M., Unit Manager #3 said the food in the module kitchens are available for residents and the staff make toast for breakfast and snacks. Unit Manager #1 and the surveyor observed the bread in Module B and C and Unit Manager #3 acknowledged the loaves of bread were pass the best by/use by date. Unit Manager #3 said both unit staff and kitchen staff are responsible to make sure items are used before the use by dates, and food is dated and labeled. During an interview on [DATE] at 8:47 A.M., the Registered Dietician said food items in the unit refrigerators should be checked for use by/best by dates. 2. The facility failed to maintain clean and sanitary conditions in food storage areas in the kitchen. On [DATE] the surveyor made the following observations in the facility kitchen: -The walk-in freezer had debris on the floor including pieces of ice around and under the storage racks, food wrappers, and an empty beverage storage bin was on the floor under the storage racks. -Upon opening the milk storage refrigerator, a strong foul odor of sour milk could be detected, and standing water was on the bottom of the cooler. The Executive Chef who was present said it was supposed to be cleaned the previous day. On [DATE] at 11:15 A.M., during a revisit to the kitchen the surveyor made the following observation with the Assistant Food Service Director. The walk-in freezer floor had three ice cream container cups on the floor under the storage racks, various debris including paper, ices pieces, and three beverage bins were on the floor under the storage racks. The Assistant Food Service Director acknowledged the walk-in freezer floor needed to be cleaned and said he is working on a cleaning schedule. 3. The facility staff failed to adhere to hand hygiene practices during meal preparation in the kitchen. Review of the current facility policy titled Handwashing/Hand Hygiene indicated the facility considers hand hygiene the primary means to prevent the spread of infections. Under implementation the policy indicated employees must wash their hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after handling food, after removing gloves or aprons. The policy indicates the use of gloves does not replace handwashing/hand hygiene. On [DATE] between 7:21 A.M. through 8:15 A.M., the surveyor made the following observations: -Cook #1 was at a food preparation station wearing gloves on both hands wrapping food items in metal pans. He then removed his gloves from both hands and tossed them in a trash container and did not perform hand washing. Cook #1's thermometer dropped out of his pocket onto the floor and he proceeded to pick up the thermometer, placed it in his pocket, then without performing hand hygiene picked up the small metal pans and placed them in the food steamer. -Cook #2 was observed at food preparation counter wearing gloves on both hands. She doffed the gloves, threw them away and without hand hygiene, picked up a large box of cake mix and walked to the dry storage area and placed the box on the shelf. On [DATE] at 11:14 A.M., the surveyor made the following observations: -The Assistant Food Service Director was at the food preparation station making sandwiches wearing gloves on his hands. He touched the bread directly when spreading the mixture on the bread, then directly placed the sandwiches into plastic food storage containers. Wearing the same gloves, he left the food preparation area and placed the sandwiches in a serving area. He then removed his gloves, tossed them in the trash container, removed the serving spoon from the prep area, went to the three-bay sink, rinsed off the spoon, placed it on the side, then walked across the kitchen to a bin of clean utensils and grabbed a scoop and returned to the food preparation area. He then put on new gloves without performing hand hygiene and started preparing sandwiches. The Assistant Food Service Director moved between clean and dirty areas of the kitchen after contact with food, after removing his gloves and did not perform hand washing. -The Assistance Food Service Director was observed with gloved hands touching bread directly to make another set of sandwiches, he moved between the food preparation area, entered and exited the walk-in refrigerator without removing his gloves and performing hand washing. He then moved from making sandwiches with the same gloves to the steam table. Wearing the same gloves, he opened a binder to assist in recording the food temperatures. During an interview on [DATE] at approximately 11:30 A.M., the surveyor shared the observations with the Registered Dietician. The Registered Dietician said the Assistant Food Service Director should have removed his gloves and washed his hands between tasks and areas and washed his hands before putting on new gloves.

Based on observation, interview and record review, the facility failed to assess the use of a seatbelt utilized in a wheelchair as a possible restraint for 1 Resident (#69) in a total sample of 17 residents. Findings include: Resident #69 was admitted to the facility in 11/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #69 scored a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating Resident #69 was cognitively intact. In addition, Resident #69 was totally dependent on staff for activities of daily living and did not utilize a restraint. On 8/16/22 at 11:04 A.M., Resident #69 was observed sitting in a wheelchair in his/her room. Resident #69 had a clip seat belt attached around his/her waist. Resident #69 said he/she has had the seatbelt for a long time. Resident #69 stated he/she was not sure if he/she could unfasten the seatbelt. On 8/17/22 at 9:06 A.M., Resident #69 was observed in his/her room sitting in a wheelchair. A clip seatbelt was attached around his/her waist. Certified Nursing Assistant (CNA) #1 was present at that time. CNA #1 said Resident #69 has had the seatbelt for a long time and needs it because he/she leans forward in the wheelchair. On 8/17/22 at 11:29 A.M., Resident #69 was observed in his/her room sitting in a wheelchair with the seatbelt unattached. Resident #69 stated he/she did not unclip the seatbelt. CNA #1 stated Resident #69 unclips the seatbelt sometimes. CNA #1 reattached the seatbelt around Resident #69's waist. Review of Resident #69's record indicated there was no assessment conducted to determine if the seatbelt was a restraint. During an interview with Unit Manager #3 on 8/17/22 at 1:00 P.M., she stated the wheelchair belongs to Resident #69. When Resident #69 was admitted , the wheelchair had the seatbelt attached to it and Resident #69's spouse did not want the seatbelt removed. Unit Manager #3 stated the seatbelt should never be utilized and staff will be educated to ensure it is not.

Based on record review and interview, the facility failed to ensure that PRN (as needed) orders for [CONDITION(S)] medications were limited to 14 days and were not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication for 1 Resident (#44) in a sample of 17 residents. Findings include: Resident #44 was admitted to the facility in January, 2019 with a diagnosis of Alzheimer's Disease. An Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #44 scored a 3 out of a possible 15 on the Brief Interview for Mental Status, indicating Resident #44 has severe cognitive impairment. Review of the physician's orders for Resident #44 indicated an order, dated 7/1/22, for [MEDICATION(S)] (a medication used for anxiety) 0.25 milligrams every 6 hours PRN for increased agitation without a stop date. Review of Resident #44's physician's orders and Medication Administration Record on 8/17/22, indicated the order for [MEDICATION(S)] was still in effect, 48 days after the initial order. Review of Resident #44's record indicated the Pharmacy Consultant had made recommendations on 7/18/22 and 8/11/22 to evaluate the PRN [MEDICATION(S)]. Review of a Nurse Practitioner note dated 8/2/22 failed to indicate an evaluation for the appropriateness of continuing the PRN [MEDICATION(S)]. During an interview with Unit Manager #3 on 08/17/22 01:08 P.M., she stated Resident #44's doctor does not come in that often and hasn't been in for a while. Unit Manager #3 stated she understands there should be a stop date for the [MEDICATION(S)] and will get in touch with the doctor.

Based on observation, record review and interview the facility failed to maintain a complete and accurate medical record for 3 Residents (#69, #44 and #13) out of a total sample of 17 residents. Findings include: 1. For Resident #69, the facility failed to accurately document treatment sheets related to the use of an air mattress. Resident #69 was admitted to the facility in 11/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/22 at 11:05 A.M., an air mattress was observed on Resident #69's bed. There was a dial on the air mattress pump set at 250 pounds. A sticker with an arrow pointing to 160 pounds was also observed on the mattress pump. On 8/17/22 at 8:50 A.M., Resident #69's air mattress dial was observed again to be set at 250 pounds and the sticker pointing to 160 pounds was still in place. Review of the Treatment Administration Record (TAR) dated 8/16/22 and 8/17/22 indicated the licensed nursing staff signed off that the setting on the air mattress matched up with stickers on the mattress pump. During an interview with Unit Manager #3 on 8/17/22 at 1:00 P.M., she stated nursing is responsible for ensuring the air mattress is at the correct setting and should not be signing the TAR inaccurately. 2. For Resident #44, the facility failed to accurately document treatment sheets related to the use of an air mattress. Resident #44 was admitted to the facility in 1/2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #44's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/22 at 11:14 A.M., an air mattress was observed on Resident #44's bed. The air mattress was set to 350 pounds. There was no sticker present to indicate what the mattress should be set at, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/17/22 at 9:05 A.M., Resident #44's air mattress was observed to be set at 330 pounds. There was no sticker present to indicate what the air mattress should be set on, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Treatment Administration Record (TAR) dated 8/16/22 and 8/17/22 indicated the licensed nursing staff signed off that the setting on the air mattress matched up with stickers on the mattress pump. During an interview with Unit Manager #3 on 8/17/22 at 1:00 P.M., she stated nursing is responsible for ensuring the air mattress is at the correct setting and should not be signing the TAR inaccurately. 3. For Resident #13 the facility failed to ensure an accurate medical record related to the use of an air mattress. Resident #13 was admitted to the facility in September of 2021 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/22 Resident #13's bed was observed to be equipped with an air mattress. The dial on the air mattress was set to over 240 pounds. Resident #13 was observed in the dining area eating breakfast and was observed to be average stature and was not observed to be a person who weighs over 240 pounds. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Check setting on air mattress, please match up with stickers on the mattress pump. every shift, active 2/21/22. On 8/16/22 at 2:07 P.M., Resident #13 was observed resting in bed, the air mattress dial was set above 240. There was no sticker on the pump to match up the air mattress setting, therefore nursing staff would not know how to implement the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/17/22 at 7:38 A.M., Resident #13 was observed in bed with the air mattress dial set to over 240 pounds. There was no sticker observed on the mattress pump to indicate the air mattress setting. Review of the Treatment Administration Record (TAR) dated 8/16/22 indicated the licensed nursing staff signed off that the setting on the air mattress match up with stickers on the mattress pump. There was no observed sticker to match the setting observed on the air mattress pump. During an interview on 8/17/22 at 2:11 P.M., Nurse #1 said air mattresses are set to a resident's weight and that is where the sticker is placed and nursing check the setting and document on the TAR.

Based on observations, interviews and facility policy review, the facility failed to prevent the possible spread of COVID-19 on Pods A, B, C and E as evidenced by (1.) A laundry staff member failing to wear proper Personal Protective Equipment (PPE) and failing to perform hand hygiene after contact with the environment of a resident quarantined for potential COVID-19, (2.) A Certified Nursing Assistant failing to remove her gloves and performing hand hygiene prior to exiting a resident room, and (3.) The failure of multiple CNA's to perform hand hygiene appropriately and to remove their johnny's (a short collarless gown that ties in the back) that they were wearing under an isolation gown, prior to exiting resident rooms. In all instances the staff members potentially contaminated the environment with pathogens. Findings include: The facility policy titled Hand Hygiene, dated 3/2020, indicated: * Hand hygiene is a simple and effective way to prevent the spread of pathogens which cause infections and is considered the single most important procedure to prevent the spread of microorganisms. * Pathogens can contaminate the hands of staff during contact with residents, contaminated equipment and environmental surfaces. * Failure to adequately clean contaminated hands can result in the spread of pathogens. * All staff is required to wash hands after direct or indirect resident contact. The facility policy titled Droplet Precautions, undated, indicated: *Droplet precautions are used in addition to standard precautions for residents with infections that are spread by droplets. Droplets may be generated by coughing, sneezing, talking or during the performance of procedures such as suctioning. * Appropriate Personal Protective Equipment (PPE) is provided for all staff and must be used when exposure to the infection is planned or anticipated. The facility's policy titled Infection Prevention and Control Program, dated 1/2020, indicated 1.) Hand hygiene is required: * Before and after resident contact. * After contact with inanimate objects in the immediate vicinity of the resident. 2.) Airborne precautions are used in addition to standard precautions for residents with infections that are spread by the air and: * Appropriate PPE is provided for staff and must be used when exposure to an infection is planned or anticipated. On 8/4/20 at 7:18 A.M., the surveyor arrived at the facility's 2nd floor pod (Pod B) that housed all of the rooms for residents on quarantine for potential COVID-19. Nurse (#1) informed the surveyor that all persons entering the pod's must wear a mask and goggles at all times. On 8/4/20 at 7:20 A.M., the surveyor observed Laundry Aide #1 (LA) open the door of Pod B, she entered Pod B wearing a glove on each hand. LA#1 was pushing a cart of clean linen, and the surveyor observed that LA (#1) did not have on googles or a face shield during this time. LA #1 then opened room B2 with her gloved hand, potentially contaminating the door handle, and entered the room without wearing goggles or a face shield. Moments later LA #1 exited the room wearing the same gloves on each hand, and without performing hand hygiene, she opened Pod B's main door, potentially contaminating the door handle. LA (#1)then exited the Pod with her linen cart. At 7:23 A.M., the surveyor observed LA (#1) stop her cart outside a room identified by a sign as the Shower Room, she opened the door with her gloved hand and potentially contaminated the door handle. LA (#1) then reached onto a shelf, moved some towels around with her gloved hand, potentially contaminating the towels, and removed a towel from the shelf. LA (#1) then opened the towel with her gloved hands and laid it atop the clean linen cart, potentially contaminating all the linen in the cart. LA (#1) then observed the surveyor and removed the gloves and placed them in her pocket without performing hand hygiene, and continued to push the linen cart down the corridor. At 7:25 A.M., the surveyor observed LA (#1) walk to the elevator, and without performing hand hygiene she pushed the elevator button, potentially contaminating the button, and left the unit. On 8/4/20 at 7:35 A.M., the surveyor arrived at the facility's 2nd floor Pod E which housed a mix of COVID-19 recovered and negative residents. The surveyor observed a Certified Nursing Assistant CNA (#1) exit room #E1 without performing hand hygiene, wearing a glove on each hand and carrying trash. CNA #1 crossed the pod and placed the items in the trash and then turned around to return to room E1. CNA (#1) saw the surveyor, turned back around again, removed the gloves and performed hand hygiene before returning to room #E1. On 8/4/20 at 8:42 A.M., the surveyor arrived the the facility's 1st floor Pod E. The surveyor observed CNA (#2)opening the door of room #E4 that housed a resident negative for COVID-19. There was a sign outside the door indicating that the staff should wear full PPE in the room and remove full PPE prior to exiting the room. CNA (#2) removed her gown with the gloved hands, potentially contaminating a the johnny that she wore underneath. CNA (#2) then removed her gloves and eye wear, and after performing hand hygiene, exited the room still wearing the johnny. On 8/4/20 at 8:45 A.M., the surveyor observed CNA (#2) enter room #E6, wearing the same johnny and 2 face masks, and without performing hand hygiene enter the room that housed a resident negative for COVID-19, and potentially contaminated the resident and room. During an interview with CNA (#2) on 8/4/20 at 8:50 A.M., she said that she wears a johnny over her scrubs at all times to protect herself and that she didn't realize that she had touched the johnny with her gloved hands. On 8/4/20 at 8:55 A.M., the surveyor observed a CNA (#3) exit the first floor Pod A wearing a johnny and cross over into another hallway, potentially contaminating others with her contaminated johnny. On 8/4/20 at 9:00 A.M., the surveyor entered first floor Pod C and observed a CNA (#4) standing in the common area of the Pod wearing a johnny. Pod C had two rooms that housed COVID-19 recovered residents and 2 rooms that housed COVID-19 negative residents. CNA (#4) then entered one of the negative resident rooms, wearing the johnny and without performing hand hygiene. A short while later CNA (#4) exited the room and the Pod without removing the johnny and without performing hand hygiene, potentially contaminating the environment. On 8/4/20 at 9:06 A.M., the surveyor observed CNA (#4) return to Pod C wearing the johnny. The surveyor interviewed CNA (#4) who said that she always wore the johnny to protect her clothes and self from exposure to germs. CNA (#4) further said that she did not change the johnny between rooms but did wear a second gown over the johnny when providing care. The surveyor met with the Director of Nursing (DON) on 8/4/20 at 9:45 A.M., to review the morning observations. The DON said: 1.) The housekeeper entering the Pod wearing gloves is a huge concern due to the risk of potential contamination to all residents in the Pod who were on quarantine for potential COVID-19. Further she said, it is absolutely not okay for any staff to exit resident rooms wearing gloves, or enter a quarantined resident room without goggles due to the risk of contamination and spread of COVID-19 and other pathogens. 2.) That she has discouraged the staff from wearing a johnny under a gown but they don't get it and feel better protected. She acknowledged that when touching the johnny with gloved hands they are potentially contaminating the johnny that they wear from room to room and potentially risk infecting COVID-19 negative residents with COVID-19.

Based on observations and staff interviews, the facility failed to monitor and screen visitors and staff before entering the building and failed to designate a staff member to monitor the entrance that staff enter the facility. Findings Include: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic: -Limit and monitor points of entry to the facility. -Consider establishing screening stations outside the facility to screen individuals before they enter -Screen everyone (patients, healthcare providers (HCP), visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection and ensure they are [MEDICATION NAME] source control. -Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature =100.0°F or subjective fever. -Ask them if they have been advised to self-quarantine because of exposure to someone with [DIAGNOSES REDACTED]-CoV-2 infection. On June 26, at 8:00 A.M., the surveyor entered the front door and rang the bell. The door was remotely unlocked and the surveyor entered the reception area. There was no staff member or station set up for screening. The surveyor walked down the hallway to the right, returned to the reception area and then walked to left into a resident unit. The surveyor asked a staff member if they could direct the surveyor to the Administrator or the Director of Nursing (DON). The staff member said the DON's office is on the second floor. The Surveyor took the elevator to the second floor and found the DON's office. The surveyor met with the DON in a conference room and informed the DON the surveyor still has not been screened for COVID-19 symptoms or had their temperature taken. On June 26 at 8:30 A.M., the DON was interviewed and said they used to have a screening station set up at the side entrance where the regular staff enter, but it was discontinued. The DON said now all staff come in on the first floor side entrance and come up to the second floor office and are screened for COVID-19 symptoms and have their temperature taken before they start their shift. On June 26, 2020 at 10:30 A.M., Hospice worker #1 was interviewed and said she always enters the facility at the front door. Hospice Worker #1 said she rings the bell and the door is unlocked and she then takes the elevator to the second floor to get screened. On June 26, 2020 at 10:30 A.M., Rehab Staff # 1 said she enters the facility from the side entrance and goes into the rehab room and takes her own temperature and records it in the book. On June 26, 2020 at 12:15 the Rehabilitation Director (Rehab Director) was interviewed and said all the rehab staff take their temperature and log it into the book here in the rehab room. The Rehab Director said they are only asked symptom based questions if they have a fever. On June 26, 2020 at 12:30 P.M. the front desk Receptionist was interviewed and said she is not here when staff enter the building in the morning. She said her primary responsibility is to screen medical personal who come through the front door like the nurse practitioner, doctor or transport personnel. The Receptionist said the staff members go to the second floor to get screened and they usually come in the door down the hallway, pointing to a set of double doors.

Based on observation, record review and interview, the facility staff failed to implement interventions regarding falls for 1 sampled resident (#18) out of a total of 18 sampled residents. Findings include: Resident #18 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set, dated dated [DATE], indicated he/she requires assistance with transfers and toileting. Resident #18 scored 3 out of a possible 15 on the Brief Interview for Mental Status Assessment indicating he/she has severe cognitive impairment. On 10/1/19 at 9:24 [NAME]M. and 10/3/19 at 11:32 [NAME]M. the surveyor observed Resident #18 in bed. During both observations the bed was in a low position and there was a motion sensor alarm mounted on the wall. The sensor was pointing toward the floor and a portion of the sensor was covered by a photo frame. On 10/3/19 at 11:43 [NAME]M., the surveyor asked CNA #3 if she could set off the alarm. CNA #3 slid the power switch up and down and was unable to make the alarm sound. Review of Resident #18's clinical record indicated he/she was assessed for fall risk on 5/16/19. Resident #18 scored a total of 23 on the [NAME][NAME]Fall Risk Assessment (an assessment form in which a score higher than 10 indicates being at high risk for falls). Review of Resident #18's care plans indicated the following: Problem: Resident is at risk for falls due to decreased mobility, decreased safety awareness, initiated 6/4/18. Approaches: Wall mounted motion detector to use when in recliner and/or bed, initiated 4/17/19. Review of the facility's Fall Management Guideline, dated (YEAR), indicated the following: *When an alarm is utilized the following will be considered: A provider's order will be obtained. The nurse/CNA assigned to the resident will document placement and function of the alarm at least once a shift. Alarm use should be entered on the resident's care plan and the care card/plan of care. Review of an Incident/Accident report dated 6/19/19, indicated that Resident #18 had fallen out of bed at 6:10 [NAME]M. The witness statements completed by CNA #1, CNA #3 and Nurse #1 failed to indicate if Resident #18's motion sensor alarm was sounding. The form indicated that Resident #18 sustained a [MEDICAL CONDITION] olecranon (elbow). Review of the facility's Use of Motion Sensor Alarms, undated, indicated the following: *Motion sensor alarms, as the name implies, senses motion wherever it's placed and then sends a signal to a local or remote receiver unit. When positioned along the bedside, the fall prevention motion sensor will alarm as the resident attempts to vacate the bed. *Proper functioning should be assessed at least once a shift. Review of the Manufacturer Guide/Instructions for the AliMed PIR Alarm used in Resident #18's room, undated, indicated the following: *When set in alarm or chime mode, alarm will sound for 30 seconds unless re-set by by caregiver. *Alarm emits an invisible fan-shaped beam that will cover an area approximately 60 degrees horizontal and 6 degrees vertical. *Use to alert caregivers to patients or residents who have or are about to rise from bed or exit room. During an interview with Nurse #1 on 10/4/19 at 6:58 [NAME]M., she said that on the day of the fall she could not say for certain if Resident #18's alarm was sounding. Review of Resident #18's Treatment Administration Record for 6/2019 indicated that his/her alarm had been checked for functioning on the 11:00 P.M. - 7:00 [NAME]M. shift, but did not indicate what time it was checked. During an interview with CNA #1 on 10/4/19 at 7:11 AM., she said that on the day of the fall, she had heard Resident #18 yelling for help. CNA #1 said she found Resident #18 on the floor and immediately got help from Nurse #1 and CNA #3. CNA #1 said the alarm was not sounding. CNA #3 was unavailable for interview. During an interview with the Maintenance Director on 10/4/19 at 8:32 [NAME]M., he said that the Maintenance department checks the motion sensor alarms monthly when they check the batteries. He said that the nursing staff is responsible for alerting the maintenance department if there are issues or concerns with the motion alarms functioning. The Maintenance Director, the Maintenance Supervisor and the surveyor then went to Resident #18's room and observed Resident #18 laying in bed. The motion sensor alarm was turned off. The sensor portion was facing the floor and the Maintenance Director said that it would not pick up on the movement of Resident #18 in that position. The Maintenance Director and the Maintenance Supervisor said that the alarm would also not sound if a portion of the sensor was covered by Resident #18's photo frame as observed on 10/1/19 and 10/3/19. CNA #2 then entered the room and said that the alarm would sound every few minutes if it was positioned facing the resident while he/she was in bed. CNA #3 said she did not know that the alarm was off. During an interview with the Director of Nursing and the Assistant Director of Nursing on 10/4/19 at 9:16 [NAME]M., the above observations were discussed.

Based on observation, record review and interview, the Facility staff failed to report two allegations of abuse for 1 resident (#32) out of a total of 27 sampled residents. Findings include: Resident #32 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set, (MDS), dated [DATE], indicated that he/she is severely cognitively impaired and requires assistance with bathing, dressing and toileting. A. During interview with Resident #32 on 12/5/18 at 8:30 A.M., she told the surveyor that on 12/4/18, a staff person threw him/her in his/her wheelchair. The Surveyor immediately informed facility staff of the allegation. Review of the Facility's Prevention of Abuse Policy, dated 11/28/16, indicated the following: The Facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made. During interview with the Director of Nursing (DON) and the Administrator on 12/6/18 at 12:27 P.M., (4 hours after the allegation was reported) the DON said she did not report the allegation to the state agency because she did not know that all allegations of abuse is required to be reported within 2 hours. B. Review of the facility Grievance Log indicated that in 5/2018, Resident #32 alleged that his/her leg was slapped by a CNA. During interview with the Social Worker on 12/6/18 at 1:00 P.M., the Social Worker said that the facility did not report the allegation to the state agency.

Based on observation, record review and staff interview, the facility staff failed to ensure that services provided met professional standards of quality by failing to ensure that a medication was administered as ordered by the physician, for 1 Resident (#21) from total sample of 27 residents. Findings include: On 12/6/18 at 9:45 A.M., during Surveyor observation of a medication pass in Module D unit, the surveyor observed Nurse #2 preparing and administering [MEDICATION NAME] (a medication that lowers blood pressure) 5 mg (milligram) tablet for Resident #21. The surveyor observed the nurse assessed the resident's blood pressure prior to the medication administration; the resident's blood pressure was observed to be 118/68. The [MEDICATION NAME] was administered to Resident #21 with his/her other medications. Review of the 12/2018 physician's orders [REDACTED]. Review of the medication administration policy and guidelines for the facility indicated the following. -Medications are checked against the prescription or order before they are administered. -Nurse compares the Medication Administration Record [REDACTED]. -The nurse takes and records any necessary vital signs as indicated for the order on the Medication Administration Record [REDACTED]. On 12/6/18 at 10:30 A.M., Nurse #2 was interviewed; she told the surveyor that the medication should have been held. She told the surveyor that she would notify the Nurse Practitioner.

Based on observation, record review and interview, the facility staff failed to provide the necessary treatment and services to prevent the development of a pressure ulcer for 1 resident, (#50), out of a total of 27 sampled residents. Findings include: Resident #50 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] indicated that Resident #50 was cognitively intact, with a Brief Interview of Mental Status scrore of 15 out of 15. Resident #50 required extensive assistance of 2 people for bed mobility and extensive assistance of 1 person for transfers. The MDS also indicated that at the time of the assessment the Resident had no ulcers, wounds, or skin problems. The MDS indicated that Resident #50 had a pressure reducing device in his/her chair, bed, had a turning and repositioning program and had ointments/medications in place. Review of the Physician's orders dated 10/18/18, indicated house moisturizing lotion to heels, elbows, hips and buttocks every shift and Skin Assessment Weekly on Thursdays. A care plan titled Skin Care with start date of 10/18/18 and last review revision date of 11/2/18 indicated that Resident #50 was identified as being at risk of skin breakdown/pressure injury due to decreased mobility. The goal of the care plan indicated that Resident #50 skin would remain intact. The identified approaches that were put into place on 10/18/18 indicated resident will be assisted by 2 for bed mobility, assisted to reposition every two hours when in wheelchair. Apply house moisture lotion to hips, heels, elbows, and buttocks every shift, and to offer fluids between meals to maintain hydration. During interview with Nurse #2 on 12/6/18, at 9:27 A.M., she said that applying the house moisturizing lotion (barrier cream) is a Certified Nursing Assistant (CNA) task. During an interview with CNA #1 on 12/06/18, at 11:00 A.M., she said that there are 3 types of skin prep/barrier cream. Yellow for non-open area, Purple for open area, and that nursing does a medicated one. She said that she is able to see what tasks or interventions she has to do for each resident during her shift by checking Point of Care (P[NAME]). She said that she can not see if the tasks or interventions are ordered for other shifts, only what is due during her shift. She said that Resident #50 is accepting of care and does not refuse treatments. Review of the Point of Care History Report (a log of completed CNA tasks) dated 10/18/18 through 12/6/18 indicated that the task of applying the House Moisturizing Lotion (Barrier Cream) was completed on only 1 of 3 shifts on 10/19/18 , 10/20/18, 10/21/18, 10/22/18, 10/23/18, 10/25/18, 10/30/18, 10/31/18, 11/1/18, 11/2/18 and 11/14/18. The task was completed on 2 of the 3 shifts on 10/24/18, 11/15/18, 11/17/18 and 11/18/18. The task was not completed on any shift on 10/26/18, 10/27/18, 10/28/18, 11/3/18, 11/9/18, 11/10/18, 11/11/18 or 11/13/18. Review of the facility policy entitled Skin Assessments (Dated 2/17/16) indicated the policy of the facility is that weekly skin (check) assessment will be done on all residents and documented on the treatment sheet. Attention to bony prominences, abdominal folds, axilla. Identify and report findings. Obtain treatment orders, if pressure ulcer, sizing and staging on identification. Report to nurse manager/nursing supervisor. The policy also indicates that weekly skin assessments will be monitored by the Nurse Manager and Nursing Supervisors. Monitoring will be reported to the Director of Nursing and the Skin Committee. Skin Committee will review all skin issues, assess for effectiveness of prevention treatments and make recommendations. Review of the medical record indicated no skin assessment was completed on 11/29/18. A nursing progress note dated 11/24/18, indicated that the Resident complained of heel discomfort, a red area was identified on the left outer heel measuring 1 cm (centimeter) x 1 cm. The note indicated that skin prep was applied and the heels were elevated with 2 pillows. A nursing progress note dated 11/25/18, indicated that the Resident's heels were offloaded during the night and both heels were treated with skin prep. The note indicated that the right heel was found to have a fluid filled blister which was intact as well as a pink area on the left heel which was identified as a stage 1 pressure ulcer. A nursing note dated 11/26/18, indicated that the right heel had a flat blister measuring 2 cm x 2 cm, the note described the area as whitish yellow with dark pinpoint in the middle of blister. The note also indicated that skin prep was applied and that no shoes were to be put on the resident until the areas on heels had resolved. A nursing note dated 12/5/18, indicated that the right heel was slightly improved with reddish/brownish scab intact. The physician's orders dated 11/25/18, indicated offload heels when in bed every shift, apply skin prep every shift to bilateral heels outer aspects every shift until areas resolved, and no shoes until right heel skin blister resolves. During the interview on 12/6/18 at 11:00 A.M., CNA #1 further indicated that the open area on the resident's heels just started the other day when she returned from being off for a couple days. She said that the heel opened overnight. She said that the right heel is open and that they are not putting shoes on Resident #50 until the area heals. She also said that they have been putting pillows under the resident's feet to help with healing. She said that when there is a change in a resident's status, nursing gives a report each shift. She said that this is how she knows not to put shoes on and to offload heels. She was able to demonstrate how to look up tasks and how to check the care plan for interventions. During an interview with the ADON on 12/6/18, at 12:11 P.M., she said that the area on Resident # 50's heel was due to the Resident's shoes being too tight. She said that the resident is being followed during wound rounds. She reviewed the physician orders and acknowledged that the order for house moisturizing lotion (barrier cream) was for every shift. She reviewed the Point of Care History- task log and acknowledged that the task was not completed every shift as ordered. She said that there is an expectation that the tasks be completed as ordered by the physician. During an observation on 12/6/18, at 1:30 P.M. the Surveyor observed Resident #50 in his/her room. Resident # 50 was sitting in his/her wheelchair and had a shoe on his/her left foot The right shoe was on the floor in front of him/her and his/her right foot was observed to have a compression stocking on which had a cut out in the heel area of the sock to leave the scabbed area open to air. The right outer aspect of the right heel had a red scabbed area present. Resident #50 said that he/she had to remove the right shoe because it was causing him/her pain and discomfort. He/She said that the therapist had put the shoes on him/her prior to going to therapy before lunch around 12:00 P.M. Resident #50 said he/she managed to take the right shoe off by himself/herself but was unable to remove the left shoe and was about to put the call light on to ask for assistance from the CNA to take off the left shoe and assist him/her in getting socks on. During an interview with the ADON on 12/6/18, at 1:51 P.M., she said that the physician's order is for no shoes on until wound is healed. She said that there had been no change to the physician's orders and that although the area was healing it had not been resolved. When informed of the observation of Resident #50 having shoes on and that the Resident had stated rehab staff had put the shoes on, she said that nursing is responsible for updating therapy about changes in treatments and plan of care. She said that nursing should be ensuring rehab is aware of the orders by giving a verbal report but that rehab has access to the Electronic Medical Record (EMR) and can see recommendations and orders. During an interview with the ADON on 12/6/18, at 3:03 P.M., she said that after review, she confirmed that the heels were intact upon admission and that the heel area developed and was identified by nursing staff on 11/24/18. She said that interventions had been put into place upon admission and they were looking into why those interventions were not completed as ordered. She said that new orders were put into place at the time the skin area was identified and that the interventions were being monitoring and documented in the nursing notes. She said that nursing was to complete a skin assessment weekly and she confirmed that no assessment was completed on 11/29/18 in accordance with the physician's order. She also said that the rehab director and herself are looking into why the rehab staff member put shoes on the resident today; she said that the order remained that no shoes were to be used until the wound healed and although it was noted that the area was scabbed over, there had been no MD order to discontinue the current plan of care.

Based on interview and record review, the facility staff failed to ensure fall prevention interventions were implemented as planned and/or revised for one Resident (#34), in a total sample of 27 residents. Findings include: 1. For Resident #34, the Facility Staff failed to implement and update appropriate interventions to prevent falls. Resident #34 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set (MDS), dated [DATE], indicated that he/she is cognitively intact with a Brief Interview of Mental Status score of 13 out of 15. Review of Resident #34's clinical record indicated that he/she had falls on 10/29/18, 11/2/18 and 11/22/18. Review of the resident's fall care plan, initiated 7/24/2015 indicated the following: interventions to prevent falls: keep call bell in reach at all times when in bed. At night, assist him/her with oxygen tubing. Keep room clear of clutter, but also in a way that is easy for him/her to get what he/she uses often. Encourage to call for help at night. Review of the Facility's Fall's and Falls Risk Management policy, undated, indicated that when a resident falls, staff are to document appropriate interventions taken to prevent future falls. Review of Resident #34's Incident Report dated 7/26/18 indicated that the resident fell in his/her room at 7:35 P.M., after losing his/her balance and sustained a major injury. The report indicated that the new intervention put in place to prevent recurrence was to have Resident #34 work with rehab and ortho services. Review of Resident #34's Incident Report dated 10/29/18 indicated that the resident fell in his/her room at 7:25 P.M. while trying to put his/her clothing away. The report indicated that the new intervention put in place to prevent recurrence was to remind Resident #34 that staff is always available and to call for help: an intervention that had been in place since (YEAR) per his/her care plan. Review of Resident #34's Incident Report dated 11/2/18 indicated that the resident fell in his/her room at 7:30 P.M. while trying to transfer himself/herself. The report indicated that the new intervention put in place to prevent recurrence was for Resident #34 to be screened by rehab services. Interviews with both the Director of Rehabilitation Services and Unit Manager #1 on 12/6/18 and record review indicated that Resident #34 was never screened by rehab after this fall. On 12/7/18 at 9:50 A.M., the Director of Rehabilitation Services said that she spoke with the Restorative Aide working with Resident #34 regarding his/her status, but did not have documentation or a completed rehab assessment. During interview with the Assistant Director of Nursing, (ADON), on 12/7/18 she said that she was not sure if the facility had a policy on rehab screens. She said that a Restorative Aide would not be able to perform a rehab screen. Review of Resident #34's Incident Report dated 11/22/18 indicated that the resident fell after sliding out of his/her wheelchair. The report indicated that the new intervention put in place to prevent recurrence was for Resident #34 to be screened by Speech and Language Pathology, (SLP), to assess Resident #34's cognitive status and insight. Resident #34 began working with SLP on on 11/29/18. During interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 12/7/18 at 8:20 A.M., the Surveyor reviewed Resident #34's fall history and subsequent interventions put in place after his/her falls on 10/29/18 and 11/2/18. The DON said she understood that encouraging Resident #34 to call for assistance was not a new intervention and the DON and ADON said they did not know why Resident #34 was never screened by rehab services after his/her fall on 11/2/18.

Based on observation and interview, the facility staff failed to store and secure medications in a manner consistent with federal regulations and professional standards of practice for medication storage. Findings include: 1. On 12/5/18 at 9:03 A.M., during the initial tour of the facility, the following medication/treatments were observed on Unit 1 (Module C and Module E) unattended in the Resident's room: - One bottle of Prevagen (a health supplement that is clinically shown to help with mild memory problems) on the top of the drawer in Room E8. - 2 tubes of [MEDICATION NAME] Santyl Ointment (used in [MEDICATION NAME] chronic dermal ulcers) on the top of the drawer in Room E3. - 2 bottles of [MEDICATION NAME] Powder (used to treat fungal skin infections) on the top of the drawer in Room C3 On 12/5/18 at 9:40 A.M., Nurse #3 told the surveyor that a family member of the Resident would be coming to pick up the medication Prevagen. On 12/5/18 at 11:50 A.M., the bottle of Prevagen continued to remain on the top of the drawer in Room E8. 2. On 12/6/18 at 10:10 A.M., the surveyor observed 2 tubes of Santyl Ointment and 2 bottles of [MEDICATION NAME] Powder continuing to remain on top of the dresser in Rooms E3 and C3. On 12/6/18 at 11:36 A.M., Unit Manager (UM) #2 was notified; she told the surveyor that any medications/treatments should be secured in the medication cart and treatment cart. She told the surveyor that she will speak with the nurses about it. 3. On 12/7/18 at 8:38 A.M., the surveyor observed both the Santyl and [MEDICATION NAME] left unattended in the Resident's room despite notifying UM #2 about it on the previous day (12/6/18).