Every finding on record at Knollwood Nursing Center

Based on observations, interviews, and record review, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to facility residents on the steam table service area and on two (Bayberry Lane and [NAME] Lane) out of two facility kitchenettes. Specifically, the facility failed to ensure that:1. [NAME] Supervisor #1 changed gloves and performed appropriate hand hygiene while working on the resident food service line in the kitchenette located between the Bayberry Lane and [NAME] Lane units and handling food, clean dishes and touching equipment and surfaces in the steam table service area. 2. food items were appropriately stored in the Bayberry Lane and [NAME] Lane kitchenettes. Findings include:Review of the facility policy titled, Handwashing/Hand Hygiene, dated 2001, indicated: -all personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -the use of gloves does not replace hand washing/hand hygiene. -perform hand hygiene before applying non-sterile gloves.-when removing gloves pinch glove at the wrist and peel away from the hand.perform hand hygiene. Review of the facility policy titled, Personal Protective Equipment - Gloves, dated 2001, indicated to wash your hands after removing gloves. Review of the facility policy for Use and Storage of Food and Beverage Brought in for Residents, undated, indicated:-it is the policy .to provide safe and sanitary storage, handling, and consumption of all foods including those brought into residents by family and other visitors.-the staff will help you ensure that all food is labeled with the following information:>Resident's name and room number.>the date the food was brought into the center.-all food brought in must be stored in a disposable microwaveable container with a tight-fitting lid. -all perishable food brought in will be discarded 3 days from the date on the label. 1. On 10/2/25 at 7:54 A.M., the surveyor observed the following during the breakfast meal service in the steam table service area:-Cook Supervisor #1 stepped away from serving food to open and reach inside a cabinet drawer to retrieve a knife and cut some sausage links. [NAME] Supervisor #1 did not change her gloves or perform hand hygiene and continued serving food and touching clean plates and utensils. -At 8:06 A.M., [NAME] Supervisor #1 removed her gloves, did not perform hand hygiene and started stacking clean plates into various cabinets in the steam table service area. -At 8:44 A.M., [NAME] Supervisor #1 was wearing gloves, removed her gloves, did not perform hand hygiene and proceeded to touch clean plates, cabinets and the food thermometer. During an interview on 10/2/25 at 8:50 A.M., [NAME] Supervisor #1 said that she should have washed her hands after removing her gloves and was unaware that she did not perform hand hygiene. During an interview on 10/2/25 at 8:55 A.M., the Food Service Director (FSD) said that [NAME] Supervisor #1 should have washed her hands after removing her gloves. 2. On 12/9/25 8:23 A.M., the surveyor observed the following in the facility kitchenettes:a) Bayberry Lane Unit: >Storage Cabinet:-three small 0.813-ounce boxes of Special K cereal, with best by date 11/12/25-one opened package of wheat bread, sealed fresh through 11/8/25>Freezer:-one opened, 16-ounce soda bottle frozen, undated>Refrigerator: -two plastic storage bags containing three, 7-ounce containers of pre-sliced cheddar cheese, undated-one large, opened coffee creamer, dated 11/7/25-one opened and resealed pumpkin pie, best if used by date 11/22/25-one plastic container of pasta with meat sauce, unlabeled and undated-four 5.3 - ounce containers of vanilla yogurt, expiration date 11/30/25-one 5.3 - ounce container of two percent Greek yogurt, expiration date 12/8/25-one covered container of apple sauce, unlabeled and undated-one partially open to air pecan pie, dated 11/30/25 b) [NAME] Lane Kitchenette:>Refrigerator:-one sealed muffin, unlabeled and undated -one small plastic container of noodle soup, dated 11/7/25-two small, covered containers of apple sauce, dated 11/14/25-two take-out containers of turkey, mashed potatoes, stuffing, carrots, one undated, and the other dated 11/27/25-one plastic container of assorted pastries, unlabeled and undated-one Styrofoam container of grilled cheese, unlabeled and undated-one 9 - ounce microwaveable pasta bowl with vegetables with a label which read perishable, keep frozen that was stored in the refrigerator, and undated-one large plastic container of turkey soup, dated 11/30/25 During an interview on 12/11/25 at 11:28 A.M., the Administrator said that the kitchenettes are supposed to be checked for expired food every morning. During an interview on 12/11/25 at 11:48 A.M., the FSD said that the Dietary Aides should clean out the refrigerators every morning. The FSD said that the food brought in by family members and ordered by Residents should be labeled and thrown away after three days, all expired food and foods past their best buy date should be thrown away by those dates. The FSD also said these items had not been thrown away and they should have been.

Based on observations, interviews, and records reviewed, the facility failed to conduct an inspection of the mattress and bed rail to identify areas of possible entrapment for one Resident (#3) of two applicable residents, out of a total sample of 18 residents. Specifically, the facility failed to inspect Resident #3's mattress and bed rail for entrapment risk when the facility changed the Resident's mattress from a standard pressure reducing mattress to an air mattress and the Resident used a quarter length upper bed rail in the upward position when in bed with a gap observed between the air mattress and bed rails. Findings include:Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guide to Reduce Entrapment, dated 3/10/06, indicated the following:- .air mattress replacements, and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose an additional risk of entrapment when used with conventional hospital bed systems.-When these types of mattresses compress, the space between the mattress and the bed rail may increase and pose an additional risk of entrapment.-While entrapments have occurred with the use of . air mattress replacements, these products are excluded from the dimensional limit recommendations, except for those spaces within the perimeter of the rail.-This partial exemption is due to the highly compressible nature of these mattresses, which poses technical difficulties with measuring certain dimensional gaps in these types of products.-Additional caution should be taken when using these products to ensure a tight fit of the mattress to the bed system. If a powered air mattress is replacing a mattress on a bed system that meets the recommendations in the guidance with the original mattress, the resulting bed system with the new air mattress may still pose a risk of entrapment. Review of the facility's policy titled Bed Rail Safety, dated 8/10/10, indicated the following:-It was the facility's policy to take all reasonable steps to ensure the safety and independence of its residents .-Environmental Services shall be responsible for measuring bed rails to assure compliance with FDA guidelines for zones 1-4 indicated in the publication Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.-Pressure reducing mattress replacement systems are mandated to comply with guidelines. Resident #3 was admitted to the facility in May 2025 with diagnoses including Glaucoma, Frailty, and Impaired Mobility and Activities of Daily Living (ADLs). Review of the Side Rail Rationale Screen, dated 5/5/25, indicated Resident #3:-had a history of falls.-was on medication which required increased safety precautions.-expressed desire to have side rails raised while in bed.-side rails are indicated and serve as an enabler to promote independence. Review of Resident #3's ADL and Mobility Care Plan, initiated 5/5/25, indicated the Resident used quarter length bed rails to increase bed mobility and transfers. Review of Resident #3's Physician orders, dated 5/12/25, indicated: Air mattress, check setting and function. Review of the Minimum Data Set (MDS) Assessment, dated 11/7/25, indicated Resident #3: -was moderately cognitively impaired as evidenced by a brief interview for mental status (BIMS) score of eight out of 15 total possible points. -required partial/moderate assistance to roll left and right in bed. Review of Resident #3's Medication Administration Records (MAR) for May 2025 through December 2025 indicated the Resident had an air mattress in place every day the Resident was in the facility between 5/12/25 through 12/11/25. On 10/1/25 at 8:10 A.M., the surveyor observed the following in Resident #3's room:-The Resident was in bed.-The mattress on the bed was an air mattress.-The left quarter length bed rail (on the Resident's right side) was in the raised position.-A small gap (approximately one inch) between the left side of the air mattress and the raised left side quarter length bed rail.-The right side of the Resident's bed (on the Resident's left side) was positioned against the wall. On 12/12/25 at 12:30 P.M., the surveyor observed the following in Resident #3's room:-The Resident was sitting up in bed eating lunch.-The right side of the bed was positioned directly against the wall. -The left quarter length bed rail was in the raised position.-A small gap (approximately one inch) between the left side of the air mattress and the raised left quarter length bed rail. Review of the facility's Bedframe Checklist, undated, failed to indicate any evidence that the Resident's bed equipment had been assessed relative to entrapment risk on/or after the Resident's air mattress was placed on 5/12/25. During an interview on 12/11/25 at 4:11 P.M., the Director of Nursing (DON) said that Resident #3's mattress was changed from a standard pressure redistribution mattress to an air mattress on 5/12/25. The DON said that the Nursing staff were not responsible to change the mattresses on the beds and that mattress changes were only completed by the Maintenance Director. During an interview on 12/11/25 at 4:40 P.M., the Maintenance Director said that he was responsible to assess residents bed equipment for entrapment risk. The Maintenance Director said when an air mattress was required for a resident, a Nurse would alert him of the need for the mattress to be changed. The Maintenance Director said he was responsible to remove the standard pressure redistribution mattress from the bed and replace it with an air mattress. The Maintenance Director said that when he placed the air mattress on the bed, he was responsible to assess the fit of the mattress with the bed rails for potential entrapment. The Maintenance Director said that once the assessment was completed, he was required to log the assessment and results on the facility's Bedframe Checklist. The Maintenance Director said he could not recall when the air mattress was placed on Resident #3's bed, and he could not say that he remembered assessing for entrapment risk when the air mattress was placed. The Maintenance Director said there was no evidence logged on the facility's Bedframe Checklist that Resident #3's bed was assessed for entrapment risk any time after the air mattress was placed on the Resident's bed.

Based on observation, interview, record review, and Facility Assessment Tool review, the facility failed to implement the Facility Assessment Tool's staff training/education and competencies plan, and update the Facility Assessment Tool to accurately reflect the resident population and care needs for day-to-day operations and medical emergencies for one Resident (#5) out of one applicable resident with a tunneled hemodialysis catheter (a type of central venous catheter that is inserted under the skin and tunneled into a large vein). Specifically, the facility failed to identify and ensure the need for Licensed Nurse education/training and competencies related to day-to-day care and emergency care for residents on dialysis when Resident #5 was admitted to the facility, and his/her dialysis care needs were not identified on the Facility Assessment Tool. Findings include:Review of the facility policy titled End Stage Renal Disease (ESRD), Care of a Resident with, last revised September 2010, indicated:-Residents with ESRD will be cared for according to currently recognized standards of care. -Staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents. -Education and training of staff includes, specifically:>the nature and clinical management of ESRD (including infection prevention and nutritional needs).>the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis.>signs and symptoms of worsening condition and/or complications of ESRD.>how to recognize and intervene in medical emergencies such as hemorrhages and septic infections. >how to recognize and manage equipment failure or complications (according to the type of equipment used in the facility). -the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the Facility Assessment Tool, updated 6/30/25, included the following: -The facility accepted residents with renal insufficiency, Renal Failure and End Stage Renal Disease (ESRD). -The facility employs a clinical screener.who reviews the clinical information on every referral to ensure that the nursing center is competent to provide care to the patients. -The Director of Nursing will then ensure that the nursing staff receives the appropriate education and supervision to care for the patients. -The nursing center subscribes to a company that provides information, guidance, policies, procedures, and competencies for resident care. -Policies will be reviewed as needed for new regulations, clinical care, etc.-If a new clinical procedure is needed within the nursing center, policies, procedures/competences will be reviewed and educated. -Outside assistance/education from other professionals may be sought out to ensure the nursing staff's ability to be competent. Further review of the Facility Assessment Tool failed to indicate any evidence that the facility identified residents who received dialysis care of any kind as part of the resident population they served and did not have evidence of a competency/education plan in place to address the dialysis population's needs. Resident #5 was admitted to the facility in May 2025 with diagnoses including Acute Kidney Failure and fluid overload. Review of Resident #5's Care Plan titled Renal Disease, last reviewed 8/20/25 indicated:-the Resident has chronic renal failure-Interventions for:>outpatient dialysis care >provide education regarding dialysis treatments>monitoring labs, vital signs, and weight Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #5:-was unable to complete the Brief Interview for Mental Status (BIMS) examination as evidenced by a score of 0 out of a total of 15 possible points-has end stage renal disease-received dialysis Review of Resident #5's December 2025 Physician's orders indicated:-[Dialysis Facility Name] Monday, Wednesday, Friday at 10:30 A.M. to 12:00 P.M., original order date 9/19/25-Left chest wall: monitor port site for signs and symptoms of infection, monitor that dressing is clean, dry and intact, notify Physician if any signs and symptoms of infection, original order date 5/15/25-monitor vital signs three times a week on dialysis days, every Monday, Wednesday, and Friday on 7:00 A.M. - 3:00 P.M., [sic] original order date 8/5/25 On 12/10/25 at 9:50 A.M., the surveyor observed Resident #5 in sitting in a wheelchair in his/her bedroom. During an interview at the time, the Resident said that he/she has a dialysis port located on his/her left chest. The surveyor did not observe any type of clamp or emergency equipment in the room or in any of the drawers to address any potential dialysis access cite complications. During an interview on 12/11/25 at 3:44 P.M., Nurse #2 said that no emergency equipment is required to be kept at Resident #5's bedside should an urgent situation with the Resident's dialysis port arise. Nurse #2 also said that there was no emergency equipment located in Resident #5's bedroom. During an interview on 12/11/25 at 4:49 P.M., the Director of Nursing (DON) said that the facility did not require Nurses to have competency or training in the care or monitoring of Resident #5's dialysis port because the facility did not access the port or change the dressing. The DON also said that Resident #5 would not require emergency supplies at the bedside like dressings or a clamp. During an interview on 12/15/25 at 9:55 A.M., the Administrator said that the purpose of the Facility Assessment Tool is to assess the clinical, physical, educational, and environmental needs of the building for its residents and staff. The Administrator also said that dialysis should have been included in the Facility Assessment, and it had not been included. During an interview on 12/15/25 at 10:53 A.M., Administrator said that there was no evidence that the facility nursing staff had received education or demonstrated competency to care for residents with ESRD or was on dialysis.

Based on record review, and interview, the facility failed to ensure that one Resident (#59) out of a total sample of 18 residents received treatment and care in accordance with professional standards of practice related to wound care. Specifically, the facility failed to ensure that a verbal Provider order for a treatment change on wound care was transcribed and implemented when the Resident's wound was found to have increased in size and drainage, resulting in a delay of care and placing the Resident at risk for further wound deterioration and/or infection. Findings include: Review of the facility policy titled Medication and Treatment Orders, dated 2001, included but was not limited to the following: -Orders for medications and treatments will be consistent with principles of safe and effective order writing.-Verbal orders must be recorded immediately in the resident's chart by the person receiving the order .and include the time of the order. Resident #59 was admitted to the facility in July 2018 with diagnoses including Adult Failure to Thrive and Pressure Ulcer. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59: -had a stage two pressure ulcer (a partial-thickness skin loss, appearing as a shallow open sore with red/pink wound bed, or a blister intact or broken) that had not been present on admission or re-entry to the facility. -had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of nine out of a total possible score of 15. Review of Resident #59's Medical Record indicated that the Resident's Left Lateral Knee Wound had healed and reopened multiple times. Further review of Resident #59's medical record failed to indicate evidence of a treatment plan change ordered on 12/12/25, when the Left Lateral Knee Wound was observed to be longer and deeper, and with increased wound drainage. Review of the Person-Centered Skin Integrity Care Plan indicated Resident #59: -was at risk for skin integrity alteration due to Adult Failure to Thrive and had a Left Outer (lateral) Knee Wound, effective 7/12/18. -Interventions included but were not limited to: >Treatment as ordered, effective 7/15/25. Review of Resident #59's December 2025 Physician's orders included but were not limited to: -Wound to the left lateral knee: cleanse with soap and water, pat dry, apply Skin Prep (a liquid barrier applied to the skin to create a protective film, improving dressing adherence, reducing friction and protecting skin from irritation) to the area and apply Optifoam (medical foam wound dressing designed to absorb excess fluid, protect wounds and create optimal healing environment) dressing every five days, effective 11/7/25. Review of Resident #59's Wound and Skin Record, dated 12/12/25 included: Left Lateral Knee Wound-Left Lateral Knee Wound had deteriorated as of 12/12/25. -Wound measurements had increased in size to 1.7 centimeters (cm) long by (x) 2 cm wide x 0.3 cm deep, compared to the previous wound measurements documented on 12/5/25 of 1 cm long x 2 cm wide x 0.1 cm deep. -Comment: follow up with Nurse Practitioner (NP) for new treatment change and possible wound consult. -The Resident's treatment plan had changed. During an interview on 12/15/25 at 11:28 A.M., Nurse #3 said Resident #59's left knee wound was chronic and frequently opened, healed over and would re-open again. Nurse #3 said she was the Nurse who provided Resident #59 with wound care to the left knee on 12/12/25 and had contacted the Resident's Provider the same day because the Resident's left knee wound had deteriorated. Nurse #3 said she received a new treatment order via electronic text from the Resident's Provider on 12/12/25 but forgot to transcribe the order to the Resident's medical record that same day. Nurse #3 said the new order to clean left lateral knee with Normal Saline, apply collagen followed by Calcium Alginate and an Optifoam dressing daily for wound care should have been entered on 12/12/25. Nurse #3 said she had not entered the Resident's new treatment order that she received on 12/12/25, until three days later on 12/15/25. The surveyor and Nurse #3 reviewed Resident #59's December 2025 Treatment Administration Record (TAR) and Nurse #3 said that Resident #59 was not provided with daily wound care as ordered for the dates of 12/13/25 and 12/14/25. Nurse #3 said not transcribing the Resident's new wound care order that she received on 12/12/25, would be considered a delay in treatment that could result in Resident #59's left knee wound becoming infected or cause delay to the left knee wound's healing. During an interview on 12/15/25 at 1:03 P.M., the Director of Nursing (DON) said she had reviewed the texted wound care order from 12/12/25 with Nurse #3 relative to Resident #59's left knee and that the order should have been transcribed immediately on 12/12/25, not on 12/15/25. The DON said that verbal orders should be transcribed immediately to a Resident's record by the Nurse that received the verbal order. The DON said that electronic receipt of orders such as a text message or e-mail were considered types of verbal orders.

Based on observations, interviews, and record review, the facility failed to maintain professional standards of practice relative to the care and treatment of a urinary catheter (a small, soft, flexible tube in the bladder that drains urine from the body) device for one Resident (#7) out of a total sample size of 18 residents. Specifically, the facility failed to ensure that Resident #7's urinary catheter drainage bag was not placed directly on the floor placing the Resident at risk for contamination and urinary infections. Findings include: Review of facility policy titled Catheter Maintenance of Urethral/Suprapubic, dated 7/1/11, included but was not limited to: >Purpose: To reduce the occurrence of catheter associated infections. >Procedure: Do not rest the (drainage) bag on the floor. Resident #7 was admitted to the facility in May 2024 with diagnoses including Dementia and Urine Retention. Review the most recent Minimum Data Set (MDS) assessment, dated 9/5/25, indicated Resident #7: -has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of a total possible score of 15. -has an indwelling urinary catheter. -was receiving hospice services. -was dependent for toileting and personal hygiene. Review of Resident #7's December 2025 Physician's orders included but was not limited to: -Urinary Catheter size: 16 French (Fr)/ 10 milliliter (ml) balloon to drainage bag every day, start date 8/6/25. -Catheter Care every shift, for catheter, initiated 12/18/24. Review of Resident #7's person-centered Indwelling Urinary Catheter Care Plan, effective 5/9/25, included but was not limited to: >Goal: Resident will not exhibit signs of urinary tract infection. >Interventions: Do not allow tubing or any part of the drainage system to touch the floor. On 10/1/25 at 7:31 A.M., the surveyor observed Resident #7 in his/her bedroom lying in his/her bed with eyes closed. The surveyor observed Resident #7's urinary catheter drainage tubing hanging freely over the edge of the bed and the drainage system bag laying flat against the floor. On 12/11/25 at 8:01 A.M., the surveyor observed Resident #7 lying in his/her bed and his/her urinary catheter drainage tubing hanging freely over the edge of the bed and the drainage system bag laying on the floor. On 12/11/25 at 9:04 A.M., the surveyor and Certified Nurses Aide (CNA) #1 observed Resident #7's drainage system bag laying on the floor. During an interview at the time, CNA #1 said he was the CNA assigned to Resident #7. CNA #1 said that Resident #7 was dependent for all care and did not touch the drainage system tubing or bag him/herself. CNA #1 said a basin was supposed to be used under the drainage system bag to prevent germs from getting on the bag and causing an infection. CNA #1 said he had not provided care to Resident #7 as yet, but the basin should have already been in place from the overnight (11:00 P.M. - 7:00 A.M.) shift. During an interview on 12/11/25 at 9:09 A.M., Nurse #3 said she was the Nurse assigned to Resident #7. Nurse #3 said that a basin should be placed under Resident #7's drainage system bag to avoid contact with the floor. Nurse #3 said when Resident #7's drainage system bag was on the floor without the basin in place, the system was at risk for contamination with germs and could make the Resident sick with an infection or sepsis. During an interview on 12/11/25 at 10:30 A.M., the Infection Preventionist (IP) said the facility staff had implemented the use of basins under the drainage system bags for residents last year. The IP said that Unit Managers, Nurses and CNA's were all responsible to ensure that a basin was in place for Resident #7. The IP said that placing a protective basin under the drainage system bag was important to prevent germs or organisms from entering Resident #7's drainage system bag and bladder which could cause an infection.

Based on observation, interview, policy review, and test tray results, the facility failed to serve palatable food at an appetizing temperature for the residents on two units (Bayberry and Willow) out of two units. Findings include: During a Resident Council meeting held on 8/22/24 at 1:29 P.M., several residents said that there have been concerns that hot foods are arriving to the units at cool/cold temperatures. Test trays were ordered and test trays tasting were conducted by Surveyor #1 and #2 on 8/23/24. On 8/23/24, between 8:17 A.M. and 8:28 A.M., Surveyor #1 observed the following on the Bayberry Unit: -The Meal Tray caddy doors were left open between tray removal. -The last resident tray was served at 8:28 A.M. On 8/23/24 at 8:29 A.M., Surveyor #1 observed the Staff Development Coordinator (SDC) take temperatures of the Bayberry Unit test tray and beverages and the surveyor taste tested the food and beverage items on the tray with the following results: -Eggs: 95.3 degrees Fahrenheit (F), cold to taste -Sausage: 91 degrees F, cool to taste -Toast: 87 degrees F, cool to touch and taste, soggy On 8/23/24, between 8:16 A.M. and 8:34 A.M., Surveyor #2 observed the following on the [NAME] Unit: -Meal Tray caddy doors were intermittently left open between tray removal. -The last resident tray was served at 8:34 A.M. On 8/23/24 at 8:29 A.M., Surveyor #2 observed Unit Manager (UM) #2 take temperatures of the [NAME] Unit test tray and beverages and the surveyor taste tested the food and beverage items on the tray with the following results: -Hard Boiled Egg: 94.6 degrees F, lukewarm to taste -Pureed Egg: 90.8 degrees F, cold to taste -Ground Sausage: 88.7 degrees F, cold to taste -Milk: 61.8 degrees F, lukewarm to taste The test tray tasting results validated the complaints of cool/cold food voiced by the residents during Resident Council. During an interview on 8/27/24 at 11:30 A.M. the surveyor and the Food Service Director (FSD) reviewed the test tray results. The FSD said he was aware of the concern for food and beverage temperatures on meal trays. The FSD said it was important that for palatability, hot foods are served hot and cold foods are served cold.

Based on observation, interview and policy review, the facility failed to follow sanitation and food handling practices in accordance with professional standards for food service safety in the facility's main kitchen to prevent the risk of foodborne illnesses. Specifically, the facility failed to: 1. Ensure that Dietary Staff #3 performed hand hygiene (washing or sanitizing of hands) as indicated after touching her mask while handling resident food trays. 2. Ensure that Dietary Staff #1 changed gloves between food handling and used separate utensils for different types of food to prevent the potential for cross contamination. Findings include: 1. Review of the facility policy titled Handwashing/Hand Hygiene, revised August 2019, indicated but was not limited to the following: -Use an alcohol-based hand rub containing at least 62% alcohol; or alternative soap (antimicrobial or non-antimicrobial) and water for the following situations: >after handling . contaminated equipment, etc. During an observation of the kitchen tray line on 8/23/24 at 7:45 A.M., the surveyor observed Dietary Staff #3 touch her mask with bare hands while calling out resident diets to the dietary staff member serving food. The surveyor observed Dietary Staff #3 then take a food plate from the dietary staff member without first performing hand hygiene after touching her mask with bare hands. During an interview on 8/23/24 at 7:48 A.M., Dietary Staff #3 said she should have performed hand hygiene after touching her mask as this was a concern for unsanitary practice. During an interview on 8/23/24 at 9:50 A.M., the Food Service Director (FSD) said that staff not performing hand hygiene after touching their mask and then touching items on the resident food trays was not sanitary. 2. Review of the facility policy titled Nutrition Services Food Storage and Handling Policies and Procedures, dated May 2019, indicated but was not limited to the following: -Food [service] employees shall ensure contamination from food surfaces, equipment and utensils is prevented. All food-contact surfaces .must be clean and sanitized before and between preparation of each food item to prevent contamination and cross-contamination. -All foods shall be served in a method that protects against potential contamination and unacceptable microbial growth. During an observation of the kitchen tray line on 8/23/24 at 7:45 A.M., the surveyor observed Dietary Staff #1 using a gloved hand to serve sausage links and toast. The surveyor further observed that Dietary Staff #1 did not change gloves between touching sausage links and toast food items. During an interview on 8/23/24 at 8:15 A.M., Dietary Staff #1 said he did not use a set of tongs for the toast and a different set of tongs for the sausage because he thought it would save time. Dietary Staff #2 said that he should not have used the same gloved hand to handle the sausage links and the toast because of the risk of cross-contamination. During an interview on 8/23/24 at 9:50 A.M., the Food Service Director (FSD) said that the use of a gloved hand without changing (gloves) between sausage and toast creates a risk for cross-contamination. The FSD further said that this cross-contamination could become an issue for a resident who has a pork allergy or is on a religious diet that does not allow pork.

Based on interview, policy and record review, the facility failed to ensure that two Residents (#57 and #8) out of a total sample of 18 residents were free from significant medication errors. Specifically, the facility staff failed to: 1. For Resident #57, adhere to the Physician's order to administer a one-time dose of Trulicity (medication used to improve blood sugar control and reduce the risk of major adverse cardiovascular events in patients with multiple risks for, or existing cardiovascular disease) when staff administered two doses of Trulicity to the Resident over two consecutive days, which increased the Resident's risk for low blood sugar (hypoglycemia). 2. For Resident #8, adhere to the Physician's order relative to sliding scale Insulin (progressive increase in the pre-meal . insulin dose, based on pre-defined blood sugar ranges) administration when Humalog (type of Insulin medication) was administered to the Resident outside of the ordered parameters for Insulin administration, which increased the Resident's risk for hypoglycemia. Findings include: Review of the facility's policy titled Adverse Consequences and Medication Errors, dated 2001, and revised April 2014, indicated: -A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with Physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 1. Review of the Consumer Medication Information Summary for Trulicity, dated May 2024, indicated the following relative to Trulicity use: -Follow all directions given to you by your Doctor . -Follow the instructions provided . -Trulicity should be used once weekly, at any time of the day, with or without meals. -You should take your Trulicity on the same day each week if you can. -Trulicity should be used regularly on the same day each week. If you miss your dose on the usual day, and if there are at least 3 days before your next dose is due, then take your Trulicity dose as soon as possible. -Do not take a double dose . -Too much Trulicity can make you feel sick or be sick. Resident #57 was admitted to the facility in June 2024, with diagnoses including Type Two Diabetes Mellitus (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels), Hypertension (HTN: high blood pressure. When the blood pressure measures consistently above 130/80 millimeters of mercury [mm Hg]), and Chronic Combined Systolic and Diastolic Heart Failure (a mixed cardiomyopathy [chronic disease of the heart muscle which makes it difficult to deliver blood to the body and can lead to heart failure] that occurs when there is a combination of both systolic and diastolic heart failure). Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points. -The Resident had diagnoses including Heart Failure, Hypertension, and Diabetes Mellitus. Review of Resident #57's Physician's orders, dated 6/28/24 and renewed 7/30/24, indicated: -Trulicity 0.75 milligrams (mg)/0.5 milliliters (ml) subcutaneous (under the skin) pen injector. -Inject 0.75 mg by subcutaneous route every week on Sunday. Review of Resident #57's clinical record indicated the following: -Trulicity was not administered to the Resident, as ordered, on 8/18/24 (Sunday). -The Nurse Practitioner (NP) gave a new order to give Trulicity now as a one-time dose and then continue weekly on Tuesdays. -The dose of Trulicity was administered to the Resident on 8/20/24 (Tuesday), as ordered. -Staff administered another dose of Trulicity 0.75 mg to the Resident on 8/21/24 (Wednesday). -Facility staff notified the Physician of the second dose of Trulicity administered on 8/21/24. -The Physician ordered a Basic Metabolic Panel (BMP: group of blood tests that provide information about your body's chemical balance and metabolism, including glucose [sugar]) for the following morning and for staff to monitor the Resident's blood sugars twice daily for seven days. During an interview on 8/21/24 at 10:30 A.M., Resident #57 said he/she has Diabetes and he/she required medication to be injected into his/her body to help manage his/her Diabetes. During an interview on 8/22/24 at 2:17 P.M., Nurse #2 said Resident #57 missed his/her dose of Trulicity on Sunday, 8/18/24. Nurse #2 said the NP gave an order for a one-time dose of Trulicity to be administered to Resident #57 on Tuesday, 8/20/24. Nurse #2 said she administered the dose of Trulicity to the Resident that same day (8/20/24), but did not record the administration of the Trulicity on the Resident's Medication Administration Record (MAR) before she left the facility for the day, so the Nurse who worked the following shift did not know that the one-time dose of Trulicity had already been administered. Nurse #2 said since the one-time dose of Trulicity was not recorded on the MAR as being administered, the Physician gave an order for the one-time dose to be re-scheduled for the following day (8/21/24). Nurse #2 said a different Nurse worked at the facility on 8/21/24, and administered Trulicity to the Resident, so the Resident received two doses of Trulicity medication on two consecutive dates. During an interview on 8/23/24 at 11:04 A.M., the NP said that Trulicity was a medication that was to be administered to Resident #57 once weekly. The NP said that facility staff had administered Trulicity to the Resident two times over two consecutive days, on 8/20/24 and 8/21/24, which was a medication error. The NP said administering too much Trulicity could increase the Resident's risk for low blood sugars over a period of time and that was why additional monitoring for the Resident had been ordered. 2. Resident #8 was admitted to the facility in March 2023, with diagnoses including Type Two Diabetes Mellitus and Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language). Review of Resident #8's Diabetes Mellitus Care Plan, dated 2/15/24, indicated: -Administer medications as ordered. Review of Resident #8's Physician's orders, dated 11/8/23 and renewed on 8/9/24, indicated: -Humalog KwikPen (U-100) Insulin 100 unit/milliliter (mL) subcutaneous -Inject by subcutaneous route three times per day before meal. Further review of the Physician's orders indicated the following sliding scale: -Inject two units of Humalog for blood sugar of 200 - 250 (mg/dL - milligrams per deciliter). -Inject four units of Humalog for blood sugar of 251- 300 (mg/dL). -Inject six units of Humalog for blood sugar greater than 301 (mg/dL). Review of Resident #8's August 2024 MAR indicated the following for 8/4/24: -The Resident's blood sugar reading was 177 mg/dL at 7:30 A.M. -Nurse #4 administered Humalog subcutaneously into the Resident's right abdomen. -The amount/dosage of Humalog that was administered was not recorded. During an interview on 8/21/24 at 7:00 A.M., the Staff Development Coordinator (SDC) said she had been covering at the facility for the Director of Nursing (DON) as the DON had been out and was in the process of returning to work. During an interview on 8/23/24 at 11:25 A.M., the surveyor and the SDC Nurse reviewed Resident #8's Physician's orders and MAR relative to Humalog medication administration on 8/4/24. The SDC said Nurses were required to administer Humalog to the Resident prior to meals, based on the Resident's blood sugar reading. The SDC said the Resident would require administration of the Humalog prior to meals if his/her blood sugar reading was 200 or higher. The SDC said that the Resident should not have received Humalog on 8/4/24 for a blood sugar reading of 177, and that this was a medication error. The SDC also said administering Humalog when it was not required increased the Resident's risk for low blood sugar. During an interview on 8/22/24 at 4:17 P.M., the NP said Resident #8 required sliding scale Insulin (Humalog) prior to meals based on the Resident's blood sugar readings. The NP said Nurses were required to administer Humalog to the Resident in accordance with the sliding scale that was ordered. The NP said if the Resident's blood sugar reading indicated the Humalog was not required, Nurses were not to administer the Humalog to the Resident. During an interview on 8/23/24 at 11:59 P.M., Nurse #4 (the Nurse working on 8/4/24) said she worked infrequently at the facility and could not recall how much Humalog she administered to Resident #8 on 8/4/24.

Based on observation, interview, record and policy review, the facility failed to maintain an environment that was free of accident and hazards for one Resident (#61), out of a total sample of 18 residents. Specifically, the facility staff failed to ensure the safe temperature of a hot beverage prior to serving Resident #61, placing resident at risk of being burned by the hot beverage. Findings include: Review of the facility's policy titled Nutrition Services -Food Temperature Recording Policy, revised 1/2014, indicated: -Beverages must be reheated at 15 second intervals and check temperature before serving to a resident. -No guidance for beverage temperature reheating was included in the facility policy. Review of Harvard Medical School research topics on scalding (to burn the skin with liquid), July 2023, at www.harvardhealth.edu indicated: -scalding of the skin from hot liquids could occur at temperatures as low as 120 Fahrenheit (F). Resident #61 was admitted to the facility in May 2024, with diagnoses including memory loss, Hypertension (HTN: high blood pressure. When the blood pressure measures consistently above 130/80 millimeters of mercury [mm Hg]) and Falls. Review of the most current Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #61: -had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of 15. -required set up assistance with eating (the ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on the table). Review of the Resident's medical record indicated that Resident #61 had a Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themselves) in place since 5/15/24, due to memory loss. On 8/21/24 at 8:00 A.M., the surveyor observed that the Bayberry Unit kitchenette had a digital thermometer chained to a shelf on the right side of the microwave. The surveyor also observed signage taped to the microwave, undated, that indicated: >For Resident Safety: -Reheat hot beverages 15 seconds at a time per resident preference. -Thermometer is located to the right of the microwave. On 8/22/24 at 9:18 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 heat a mug of hot cocoa for Resident #61 using the microwave in the Bayberry Unit kitchenette. CNA #1 was observed to program the microwave to heat the hot cocoa for one minute continuously. The surveyor observed CNA #1 remove the hot cocoa mug from the microwave, stir the hot cocoa with a plastic spoon and then place the hot cocoa back in the microwave and heat the mug with hot cocoa for an additional 20 seconds continuously. The surveyor observed CNA #1 remove the mug from the microwave and serve the hot cocoa to Resident #61 without checking the temperature of the hot cocoa. During an interview on 8/22/24 at 9:30 A.M., CNA #1 said the facility policy is to heat the drinks for only 30 seconds at a time. CNA #1 said that he had heated the hot cocoa for one minute and then for an additional 20 seconds for Resident #61. CNA #1 said he did not use the thermometer to test the hot cocoa before giving it to Resident #61 but should have to ensure the drink was not too hot, because hot drinks could burn the Resident. On 8/26/24 at 8:30 A.M., the surveyor observed CNA #5 reheating a mug of hot cocoa in the microwave for Resident #61. CNA #5 was observed to remove the mug from the microwave, stir the mug with a plastic spoon, and deliver to the Resident without checking the temperature of the hot beverage. During an interview on 8/26/24 at 9:15 A.M., CNA #5 said Resident #61 always asks for the hot cocoa to be reheated. CNA #5 said she heats the mug for 30 seconds at a time until the drink is hot. CNA #5 then said she was unable to tell what temperature the hot cocoa was at the time Resident #61 received it because she did not use the thermometer to test the beverage. CNA #5 said the digital thermometer next to the microwave was only used to check the temperature of the refrigerator. CNA #5 further said staff do not check temperature for food or drink on the unit, that is something that the kitchen does. During an interview on 8/26/24 at 9:28 A.M., Unit Manager (UM) #1 said the thermometer is next to the microwave on the Bayberry Unit. UM #1 also said the facility policy for reheating with the microwave is posted directly on the microwave door. UM #1 said beverages get heated for 15 seconds at a time. UM #1 further said all staff should test all beverages with the thermometer before serving to a resident, to make sure the beverage is not too hot because beverages that are too hot could burn a resident.

Based on record review, and interview, the facility failed to coordinate vision care services for one Resident (#49) out of a total sample of 18 residents. Specifically, for Resident #49, the facility failed to ensure that the Resident with a diagnosis of Glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve [which sends visual information from the eye to the brain]) received proper treatment to maintain vision abilities, after receiving consent from the Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) for vision care services. Findings include: Resident #49 was admitted to the facility in December 2022, with diagnoses including Glaucoma and Type 2 Diabetes (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar [glucose] levels). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a BIMS (Brief Interview for Mental Status) score of 5 out of 15. Review of the Eye Care Services Consent Form signed by the Resident's HCP on 1/4/23, indicated the HCP consented for Resident #49 to receive eye care (vision care) services. Review of Resident #49's clinical record indicated no evidence that vision care services had been provided to the Resident since his/her admission to the facility. During an observation and interview on 8/21/24 at 9:33 A.M., Resident #49 said that he/she was concerned that he/she had vision loss over the last few months. During an interview on 8/22/24 at 11:12 A.M., Nurse #2 said that residents were routinely seen for their eye care approximately every six months to a year by the in-house Provider. Nurse #2 further said that if there was a need between visits the nursing staff would notify Medical Records Staff #1 and she would schedule the appointment. During an interview on 8/22/24 at 12:00 P.M., the surveyor and Medical Records Staff #1 reviewed the Eye Care Services Consent Form. Medical Records Staff #1 said that typically once the consent form is filled out it should have been sent over to the Eye Center (that provide vision care services to the facility) and the Resident would be added to the list to be seen. Medical Records Staff #1 further said that residents are not always seen unless there was a specific need. During a follow-up interview on 8/22/24 at 12:08 P.M., Nurse #2 said that Resident #49 has a diagnosis of Glaucoma and should have been seen/followed by the Eye Doctor (Optometrist). During a follow-up interview on 8/22/24 at 12:15 P.M., Medical Records Staff #1 said she reviewed her Eye Care Center visit records and found no indication that Resident #49 had been seen or was offered to be seen and refused the (vision care) visit. During an interview on 8/22/24 at 1:52 P.M., CNA #2 said she worked regularly with Resident #49. CNA #2 said that over the last month or two she had noticed the Resident using his/her reading glasses more. CNA #2 said the Resident always requested to keep the reading glasses on when reading the paper.

Based on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards for one Resident (#275) out of a total sample of 18 residents. Specifically, the facility staff failed to apply medical devices as ordered by the Physician to assist in managing Resident #275's Orthostatic Hypotension (a sudden drop in blood pressure that occurs with position changes from a seated or lying position to standing). Findings include: Review of the Facility Policy titled Nursing Clinical Procedures, Subject: Elastic Stockings, dated 3/1/07, indicated, the following: -Purpose: to facilitate venous blood return (the flow of blood from the body back to the heart) in patients/residents with impaired circulation. -Special Considerations >apply the stockings in the morning, if possible . Resident #275 was admitted to the facility in August 2024, with diagnoses including Orthostatic Hypotension, and Tachycardia (an increased heart rate over 100 beats per minute [bpm] that can be caused by irregular heart rhythms [arrhythmias], exercise or stress). Review of Resident #275's clinical record indicated the following Physician's orders: -Abdominal (ABD) Binder (a device that applies compression around the abdomen to help prevent blood pooling which causes a drop in blood pressure upon standing) to be worn at all times, order date of 8/6/24. -Apply TEDs (Thrombo-Embolus Deterrent stockings: compression stockings that reduce blood clots and promote improved blood flow and circulation in the legs) to bilateral lower extremities in A.M. (in the morning), off at HS (hour of sleep: at bedtime), order date of 8/6/24. Review of Resident #275's Nurse Practitioner (NP) Encounter Note, dated 8/6/24, indicated that the hospital made a recommendation to use compression stockings and an abdominal binder for treatment of the Resident's Orthostatic Hypotension. Review of Resident #275's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -A Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating mild cognitive impairment. -The Resident required partial/moderate assistance with upper and lower body dressing. Review of Resident #275's August 2024 Medication Administration Record (MAR) indicated that the ABD binder was administered as ordered from 8/6/24 through 8/22/24. Review of Resident #275's August 2024 Treatment Administration (TAR) indicated the TED stockings were applied as ordered from 8/8/24 through 8/22/24. On 8/21/24 at 8:12 A.M., the surveyor observed Resident #275 sitting up in his/her wheelchair wearing TED stockings but not wearing an abdominal binder. The Resident said he/she should have an abdominal binder on but staff had not put the ABD binder on him/her. On 8/21/24 at 3:53 P.M., the surveyor observed Resident #275 lying in his/her bed wearing his/her abdominal binder. Resident #275 said that he/she wore it because of his/her hypotension and had asked the staff to put the binder on him/her. On 8/22/24 at 10:15 A.M., the surveyor and Unit Manager (UM) #1 observed Resident #275 sitting in his/her wheelchair and was not wearing his/her ABD binder and TED stockings. During an interview at the time, the Resident said that he/she did not have the ABD binder on all night because staff took it off when he/she went to bed and no-one put the ABD binder on him/her this morning. The Resident further said that he/she did not refuse the ABD binder or TED stockings this morning and that he/she did not mind wearing either one of the devices. During an interview immediately following the observation, UM #1 reviewed Resident #275's orders and said that the abdominal binder should be on at all times and the TED stockings should be applied in the morning. UM #1 further said that she reviewed the nursing documentation and the documentation indicated the Nurse had signed off (signature or initials confirmation) that the abdominal binder was applied for the current (7:00 A.M. to 3:00 P.M.) shift and the TED stockings were signed off on 8/22/24 at 6:00 A.M. During an interview on 8/26/24 at 10:53 A.M., the Director of Nursing (DON) said that staff should not document the application of abdominal binders and TED stockings unless the items were applied. The DON further said that in some cases the Resident might refuse but that would be documented as refused. The DON reviewed the MAR and TAR, the DON said it indicated the abdominal binder and TED stockings were applied with no refusal indicated.

Based on observation, record and policy review, and interview, the facility failed to maintain infection control measures to prevent the development and transmission of communicable diseases and infections for two Residents (#25 and #225) out of a total sample of 18 residents. Specifically, the facility staff failed to: 1. For Resident #25, appropriately store the Resident's oxygen tubing and nasal cannula (a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) when not in use, and change the Resident's oxygen tubing weekly as ordered by the Physician placing the Resident at risk for equipment contamination and infection. 2. For Resident #225, failed to position the urinary catheter drainage bag (a bag used to collect urine) off the floor to prevent the risk of contamination and infection. Findings include: 1. Review of the facility policy for Departmental (Respiratory Therapy) - Prevention of Infection last revised November 2011, indicated: -change the oxygen cannula and tubing every seven days or as needed (PRN). -keep the oxygen cannula and tubing in a plastic bag when not in use. Resident #25 was admitted to the facility in April 2021, with diagnoses including Acute Respiratory Failure (ARF - inadequate gas exchange by the respiratory system, meaning that oxygen, carbon dioxide, or both in the blood cannot be kept at normal levels) with hypoxia (difficulty attaining normal blood oxygen levels), Chronic Obstructive Pulmonary Disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and Cerebral Palsy (a group of conditions that affect movement and posture caused by brain damage to the developing brain before birth). Review of Resident #25's Minimum Data Set (MDS) Assessment, dated 7/8/24, indicated: -the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 total possible points. Review of the Resident #25's care plans, last revised 7/9/24 indicated: -the Resident received oxygen therapy. -an intervention to provide oxygen as ordered by the Physician. -the Resident required assistance with Activities of Daily Living (ADLS - basic skills you need to perform daily activities such as bathing, eating or dressing) due to weakness and loss of fine motor control secondary to Cerebral Palsy. Review of Resident #25's August 2024 Physician's orders indicated: -the Resident was prescribed oxygen at hour of sleep (HS) and as needed (PRN) to maintain oxygen saturation (SpO2 - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) greater than 90 percent. -Change and date oxygen tubing and storage bag weekly on Sunday, during the 11 P.M. to 7 A.M. shift (night shift). -Check oxygen tubing every shift for date. On 8/21/24 at 9:33 A.M., the surveyor observed Resident #25 in their room. During an interview at the time Resident #25 said that he/she uses oxygen at night and had last used the oxygen the previous night. The surveyor observed that Resident #25's oxygen tubing with a label that indicated the tubing had last been changed on 8/12/24. The surveyor further observed that the oxygen tubing and nasal cannula was not stored in a bag and was hanging in a space between the wall and a dresser. Review of Resident #25's August 2024 Treatment Administration Record (TAR) indicated: -that the oxygen tubing and storage bag had been changed on 8/4/24, 8/11/24, and 8/18/24 -that the oxygen tubing had been checked every shift from 8/19/24 through 8/21/24 On 8/21/24 at 9:45 A.M., the surveyor and Nurse #3 observed that Resident #25's oxygen tubing in his/her room was unbagged and hanging off the dresser. During an interview at the time, Nurse #3 said that Resident #25's oxygen tubing should not look like this, that it should be changed every week, and it had not been changed. During an interview on 8/26/24 at 10:50 A.M., the Director of Nursing (DON) said that Resident #25's oxygen tubing should have been changed weekly and that the oxygen tubing and nasal cannula should have been stored in a plastic bag when not in use. 50138 2. Review of the facility's policy, titled Catheter Care, Urinary, Level III, dated 2001 with revision date 8/2022, indicated the following: -The purpose of this procedure is to prevent catheter-associated urinary tract infections (UTI - bacterial infection of the urinary tract). Infection Control: -Be sure the catheter tubing and drainage bag are kept off the floor. Resident #225 was admitted to the facility in August 2024, with diagnoses including Urine Retention (the inability to completely or partially empty urine from the bladder), and Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances in and on the walls of the arteries). Review of Resident #225's August 2024 Physician's orders indicated the following: -Urinary catheter 14 French (size: 4.7-millimeter diameter) with 10 ml (milliliter) balloon, to drainage bag every shift, effective 8/13/24. -Macrobid (antibiotic to treat infection) 100 mg (milligram) by mouth twice a day with food for 13 doses to treat urinary tract infection, effective 8/26/24. Review of Resident #225's comprehensive resident centered care plans indicated the following: >Focus: Indwelling Urinary Catheter effective 8/13/24 Interventions included: -Use 14 French catheter with 10 ml balloon, effective 8/13/24 -Do not allow tubing or any part of the drainage system to touch the floor, effective 8/13/24 >Focus: Urinary Tract infection effective 8/26/24 Interventions included: -Administer medications as ordered, effective 8/26/24 -Maintain Enhanced Barrier Precautions (EBP - use protective barrier gowns and gloves during high contact resident care) due to urinary catheter as ordered to prevent spread of infection, effective 8/26/24 Further review of the comprehensive care plans did not indicate that Resident #225 had behaviors of placing his/her urinary drainage bag on the floor. On 8/21/24 at 7:30 A.M., the surveyor observed Resident #225 seated in the dining room with the urinary drainage bag hanging under his/her wheelchair seat and in direct contact with the floor of the dining room. On 8/27/24 at 9:48 A.M., the surveyor observed Resident #225 lying in bed, with eyes closed. The surveyor further observed that the urinary drainage bag was laying flat on the floor under the Resident's bed. During an observation and interview on 8/27/24 at 9:55 A.M., Nurse #1 said that the urinary catheter bag for Resident #225 was not secured to the frame of the bed like it should be and was laying flat on the floor. Nurse #1 said urinary catheter drainage bags should never make contact with the floor. Nurse #1 also said when urinary catheter drainage bags contact the floor, it could cause the spread of infection onto the urinary catheter.

Based on observation, record review, and interview, the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded to reflect the Residents' status for two Residents (#25 and #73) out of a total sample of 18 residents. Specifically, the facility failed to ensure that the MDS assessment: 1. For Resident #25, was accurately coded relative to the use of Oxygen (a drug that is a vital and essential medication, usually prescribed to treat cardiac and respiratory conditions). 2. For Resident #73, was accurately coded relative to being discharged to home. Findings include: 1. Resident #25 was admitted to the facility in April 2021, with diagnoses including acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, with difficulty attaining normal blood oxygen levels). Review of the Resident #25's care plans, last revised 7/9/24, indicated: -The Resident was diagnosed with Chronic Obstructive Pulmonary Disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs and difficulty breathing) and Emphysema (a chronic lung condition where air is abnormally present in the lungs causing shortness of breath). -The Resident received oxygen therapy. Review of Resident #25's August 2024 Physician's orders indicated that the Resident was prescribed Oxygen at hour of sleep (HS- nighttime/while asleep) and as needed (PRN) to maintain oxygen saturation (SpO2 - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) greater than 90 percent. Review of Resident #25's August 2024 Treatment Administration Record (TAR) indicated that the Resident receiving Oxygen continuously at 1 liter per minute (LPM- the rate of supplemental Oxygen delivered through an oxygen delivery device) at hour of sleep, and as needed (PRN) with a start date of 8/5/24. Review of Resident #25's most recent Minimum Data Set (MDS) assessment dated [DATE], did not indicate that the Resident received oxygen therapy during the MDS observation period. During an interview on 8/27/24 at 9:35 A.M., the Director of Nursing (DON) said that the Resident did receive oxygen therapy during the MDS observation period. The DON said the MDS Assessment had been inaccurately coded and should have indicated the Resident as receiving oxygen therapy, but it did not. 50320 2. Resident #73 was admitted to the facility in May 2024, with diagnosis of Respiratory Syncytial Virus (RSV - a common that infects the lungs, nose, and throat and causes cold like symptoms in most people but can cause more severe infections in older adults. It is spread through respiratory droplets from coughing and sneezing and can survive on hard surfaces for hours virus that usually causes mild cold like symptoms in most people but can cause more severe infections in older adults). Review of Resident #73 Physician's orders dated 5/29/24, indicated the Resident may discharged home with medications and services. Review of the Resident's Nursing Progress Note dated 5/31/24, indicated Resident #73 was discharged to home with family via personal vehicle. Discharge paperwork had been signed. Review of the Social Work Progress Note for Resident #73 dated 6/7/24, indicated the Resident was discharged on [DATE], and returned to the community without incident. Review of the Resident's record indicated in the Minimum Data Set (MDS) discharge assessment completed on 6/10/24, that the Resident's discharge destination was a short-term stay general hospital. During an interview on 8/23/24 at 2:23 P.M., the MDS Nurse said the Resident was discharged home and should not have been coded as discharge to a short-term stay general hospital. The MDS Nurse also said that the discharge should have been coded as home/community.

Based on record review and staff interview, the facility failed to ensure its staff maintained complete clinical records related to an adverse interaction between two sampled Residents (#18 and #23), out of a total sample of 19 residents. Specifically, the facility staff failed to document: 1) the negative interaction for Resident #23, and 2) corresponding follow-up for both Resident #18 and Resident #23 after the adverse interaction occurred. Findings include: Resident #18 was admitted to the facility in June 2022 with diagnoses including Alzheimer's Dementia with Behavioral Disturbances, Mood Disorder, and Delusional Disorder, and had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 out of 15 as indicated in a review of the Minimum Data Set (MDS) assessment dated [DATE]. Resident #23 was admitted to the facility in March 2021 with a diagnosis of Dementia with Mood Disorder and had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15 as indicated in the MDS assessment dated [DATE]. Review of Resident #18's medical record included a Nurse's Progress Note, dated 3/22/23, that indicated a Certified Nurse Assistant (CNA) notified the Nurse that when Resident #18 was in the Main Dining Room during lunch, he/she started to yell at his/her roommate (Resident #23), took food from his/her plate, took a personal item and told him/her that their family was going to be contacted to pick him/her up at the facility. The Nurse's note indicated that Resident #23 was removed from the Main Dining Room, Resident #18 followed him/her and continued to make accusations which caused Resident #23 to be visibly upset (cry). Further review of Resident #18's medical record indicated no documented evidence of who the roommate was nor additional information about the interaction and response by facility staff to address the situation. Review of Resident #23's clinical record indicated no documented evidence that there was an adverse interaction between him/her and Resident #18 on 3/22/23 nor response by the facility staff on any follow-up after the event. During an interview on 5/9/23 at 9:15 A.M., Unit Manager (UM) #1 identified Resident #23 as Resident #18's roommate at the time of the incident and said that she worked on the day that the interaction occurred. UM #1 said Resident #23 was moved to another room as soon as one became available and no further negative interactions occurred between the two Residents after the incident. During an interview on 5/9/23 at 3:46 P.M., Social Worker (SW) #1 said that if any resident-to-resident altercation occurred, the Director of Nurses (DON) and nursing staff would initiate an incident report and investigate the altercation. SW#1 said she was aware of the event that occurred on 3/22/23, that Resident #23 was well known to her, and that she and the other facility staff monitored him/her for signs and symptoms of distress such as trouble sleeping or weepiness. SW#1 further said that facility staff were monitoring Resident #23 and Resident #18 closely after the interaction on 3/22/23. After review of Resident #18 and Resident #23's clinical records, SW #1 said there was no documentation of what was done for either Resident following the interaction on 3/22/23 and there should have been. During an interview on 5/9/23 at 4:11 P.M., the DON said that she was aware of Resident #18's behaviors, particularly in the Main Dining Room. The DON said any resident-to-resident altercation should be investigated, and an incident report completed which included obtaining witness statements. The Surveyor reviewed the nurse's notes from 3/22/23 for both Resident #18 and Resident #23 with the DON. The DON said that facility staff assessed Resident #23 for signs of distress such as decline in appetite, tearfulness, trouble sleeping, or withdrawal from activities after the interaction on 3/22/23, and that there should have been follow-up documentation included in the medical records for both Residents following the incident.

Based on record review and interview, the facility failed to maintain sanitation procedures related to monitoring and recording food temperatures, to ensure food safety. Findings include: Review of the facility Food Temperature Recording policy, revised November 2013, included but was not limited to the following: Controlling the temperature of food is extremely important in ensuring that food is safe to eat, and you must ensure food is always cooked, cooled, chilled or reheated properly to minimize the risk of harmful levels of bacteria in the food that you serve. Food service employees will record and date the temperature of the corresponding food item prior to the service line. ( .) During an interview on 12/21/21 at 8:10 A.M., the surveyor asked to see the food temperature logs, while observing the breakfast service. The surveyor reviewed the temperature logs with the Food Service Director (FSD) and observed there were no temperatures recorded for 3 out of 3 meals on 12/18/21 and 12/19/21. Further review of the logs indicated the evening meal temperatures were not recorded from 12/12/21 through 12/15/21 and on 12/17/21. The Food Service Director said the food temperatures should be monitored and recorded in the food temperature log book at each meal, before the food is served. The FSD further said sometimes the cook recorded the temperatures on a napkin and later transferred them to the book but he could not provide evidence that the temperatures had been monitored or recorded for the above mentioned dates/meals.

Based on observation, line list (used to track infections/contagious illness) review, and interview, the facility failed to complete an investigation related to an outbreak of a gastrointestinal (GI) virus, failed to notify family and visitors of an outbreak of a GI virus, and failed to report the outbreak to the Department of Public Health (DPH). Findings include: On 12/16/21, during the resident screening process on the Bayberry Unit, several residents reported they had recently experienced GI symptoms (nausea, vomiting, diarrhea). There were no signs on the entry to the building or to the unit, of a GI virus outbreak. During an interview on 12/16/21 at 9:13 A.M., Unit Manager (UM-of the Bayberry Unit) #1 said they had a recent GI virus. She said she was unaware that residents were still showing symptoms that morning and she thought that as of yesterday it seemed like it was [NAME] down. She said she was sorry no one had alerted the survey team. During an interview on 12/16/21 at 10:35 A.M., the Infection Preventionist (IP) said the GI virus started around December 10th with residents experiencing vomiting and diarrhea. She said all of them were tested but was unsure of what exactly had been tested . She said she thought at least one stool sample was sent to test for [CONDITION(S)] (C-diff: inflammation of the intestine caused by a bacteria) but she needed to check. She said there were no staff cases. The IP said she was unsure if it was reported to the DPH because the Director of Nurses (DON) did the reporting. Review of the line list, given to the surveyor on 12/16/21 at 10:35 A.M., indicated that from 12/10/21 through 12/13/21 four residents had vomiting/diarrhea, two residents had vomiting, and one resident had a fever and diarrhea. One stool sample was sent to the laboratory and was negative for C-diff. All of the residents documented on the line list resided on the Bayberry Unit. During an interview with the IP and DON on 12/16/21 at 1:14 P.M., the DON said GI outbreak was not reported to the DPH. She said she thought the criteria for reporting to the DPH was based on a percentage of cases, but she wasn't sure and would have to check. The surveyor requested that the DON provide a copy of the guidance she was referring to (copy was not provided for the duration of the survey). The DON said she didn't think the outbreak was that bad but now that she heard that residents had vomited multiple times, she would need to further investigate. The DON said the IP's line list probably wasn't up to date because the IP was off yesterday. When the surveyor asked if anyone else took over the line list yesterday since they were in the middle of an outbreak, the DON had no response. The DON said that she would have to look at their infection control policies to see what they should be implementing at this time. The DON said she can't fix what happened but she can fix it going forward. Both the IP and DON confirmed that no other specimens had been sent to the lab since the first case, when they sent a stool specimen for C-diff. On 12/16/21 at 3:06 P.M., UM #1 approached the surveyor and said they added another resident to the line list as of yesterday because the agency nurse who had worked that day hadn't written a progress note when the resident displayed symptoms of the GI virus so it had not been added to the line list. During an interview on 12/16/21 at 4:24 P.M., the IP said the surveyor would have to ask the administrator if any notification was sent to the residents' families. During an interview on 12/16/21 at 4:54 P.M., with the IP, administrator and DON, the administrator said she sent a notice out that day to alert the residents' families about the GI virus (six days after the initial onset of GI symptoms). The DON said they should have posted a notice to visitors at the onset of the illness and that there had been a miscommunication about how that was handled. The DON said they should have been doing a deeper dive to investigate the illness. Review of the line list on 12/21/21 indicated that from 12/15/21 through 12/19/21 the following was added: two residents had vomiting, two residents had nausea/diarrhea (one of them had vomiting on 12/13/21 which had been previously added to the line list), and six residents had diarrhea; resulting in 10 new resident cases. Review of the line list for staff, given to the surveyor on 12/21/21, indicated the following: -12/16/21- one staff member with fever, vomiting, diarrhea -12/16/21- one staff member with diarrhea -12/17/21- three staff with diarrhea (one staff member did not report it until 12/21/21) -12/20/21- one staff with loose stools During an interview on 12/21/21 at 10:15 A.M., the DON said that once they started asking around, the staff reported the symptoms as indicated above in the staff line list. She said they were all direct care staff. During an interview on 12/21/21 at 11:30 A.M., the DON repeated that she couldn't fix what hadn't been done initially and could only move forward.

Based on observation, record review and interview the facility failed to provide assistance with grooming for one Resident (#37) in a total sample of 18 residents. Findings include: Resident #37 was admitted to the facility in February 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment, dated 11/4/21, indicated Resident #37 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated the Resident required extensive assistance with personal hygiene. On 12/16/21 at 8:30 A.M., the surveyor observed that Resident #37 had long facial hair on his/her upper lip and chin. On 12/21/21 at 9:44 A.M., the surveyor observed Resident #37 was fully dressed and still had long hair on his/her upper lip and chin. During an interview on 12/21/21 at 9:44 A.M., Nurse #1 observed Resident #37's long facial hair and said the aides should have provided assistance with grooming daily. She said the facial hair should have been taken care of by the Certified Nurse Aides (CNA) during daily care. Review of the December 2021 CNA flowsheets indicated personal hygiene had not been signed off on 11 out of 20 days. During an interview on 12/21/21 at 11:15 A.M., Unit Manager (UM) #1 reviewed the December 2021 CNA flowsheets and said she was not aware that personal hygiene was not recorded for multiple days in December. The UM further said the CNAs were responsible for providing Resident #37 with assistance for grooming because the Resident was not able to perform that himself/herself.

Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments were submitted timely for three residents (#1, #2, and #3) out of three applicable sampled residents. Findings include: 1. Resident #1 was admitted to the facility in July 2021. Review of the clinical record indicated an MDS assessment with Assessment Reference Date (ARD) of 10/7/21 was completed but not successfully transmitted, as required. 2. Resident #2 was admitted to the facility in July 2021. Review of the clinical record indicated an MDS assessment with ARD of 10/7/21 was completed but not successfully transmitted, as required. 3. Resident #3 was admitted to the facility in February 2020. Review of the clinical record indicated an MDS assessment with ARD of 10/7/21 was completed but not successfully transmitted, as required. During an interview on 12/21/21 at 2:03 P.M., the MDS Coordinator said that the three assessments had not been transmitted as required. She said they had a problem with their software at the time of these assessments. She said that she didn't notice on her end that the three assessments had not been transmitted, and it was her oversight.

Based on document review, record review and interview, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control (IPC) as required, related to COVID-19. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance, considered a national standard by the Centers for Medicare and Medicaid Services (CMS), indicated the following on their website: Preparing for COVID-19 in Nursing Homes, updated 11/20/20, indicated the following: -Assign one or more individuals with training in Infection Control to provide on-site management of the IPC Program. -CDC has created an online training course that can be used to orient individuals to this role in nursing homes. Review of the facility IPC binder indicated no evidence of completed training (i.e. certificate) for the IP. During an interview on 2/11/21 at 1:13 P.M., the IP said she had been in the role for about one year. She said she didn't have any training for infection control. She said she shared the role with the Director of Nurses (DON). During an interview on 2/11/21 at 2:40 P.M., the DON said she had started the training but had not yet completed it.

Based on interviews, policy review and observations, the facility failed to ensure staff (1.) Placed signage outside of resident rooms to indicate precautions and required Personal Protective Equipment (PPE), (2.) Adhered to infection control practices for the use of PPE, and (3.) Wore appropriate PPE for high contact resident care activities related to COVID-19, on two out of two units. Findings include: During an interview on 2/11/21 at 8:30 A.M., the Director of Nurses (DON) said the last Covid-19 positive resident was on 2/8/21. She said staff were wearing full PPE (mask, eye protection, and gown/gloves for high contact care) for all of the residents. The DON said they had plenty of PPE and were not experiencing a shortage. 1. The facility staff failed to place signage outside of resident rooms to indicate transmission based precautions and required PPE. Review of the facility bed board (used to indicate resident Covid-19 status) indicated there were five residents that were on quarantine due to exposure to Covid-19 on the Willow Lane Unit. Observation of the Willow Lane Unit on 2/11/21 indicated there were no signs outside of the quarantine resident rooms to indicate the transmission based precautions and the required PPE. Review of the facility's policy for Covid-19 Pandemic, dated 1/9/21, indicated the following: -Policy-The Center's Covid-19 plan, intended to supplement the facility's Disaster Plan and Infection Control Policies already in place. Please note: Department of Public Health (DPH) and Centers for Disease Control and Prevention (CDC) guidelines for PPE, testing, and infection practices more current than this policy will prevail until policy is updated. Further review of the facilities policy indicated: -Covid-19 Supplies and Resources: Signage is posted outside of all precaution rooms to identify PPE needed. -For Quarantine residents use Droplet/Contact Precaution signs which indicated to wear a mask, eye protection, gown, and gloves . Review of the DPH Memorandum, Update to Caring for Long Term Care Residents during COVID-19 Emergency, dated 12/7/20, indicated: -Post a Quarantine sign outside of the resident rooms for new admissions or residents who have been exposed to a confirmed case of COVID-19. During an interview on 2/11/21 at 2:45 P.M., the DON said there should have been signs outside of the resident rooms to indicate they were on quarantine precautions, as required per policy. 2. The facility failed to ensure staff adhered to proper infection control for the use of re-useable gowns. A. On 2/11/21 at 9:30 A.M. on the Willow Lane Unit, the surveyor observed three double occupancy resident rooms with two wall hooks at the entry way of the rooms. Two of the rooms had four gowns over two hooks. The other room had three gowns over two hooks. The gowns hung on top of each other and were touching each other, with the outer (contaminated) surfaces resting against the inner (clean) surfaces. Two of the rooms the hooks were labeled A and B; the other room had no labels over the hooks. During an observation and interview on 2/11/21 at 10:55 A.M., Unit Manager #1 observed the rooms with the surveyor. She said there should have only been one gown per hook because the hooks were for the Certified Nurse's Aides (CNAs); one gown per CNA for each resident. She said she didn't know who the gowns belonged to and they should not have put a used gown over another used gown. Further review of the facility's policy for COVID-19 Pandemic, dated 1/9/21, indicated: -Use patient specific cloth gown for close contact care, may hang in room for duration of shift then discard B. During an observation on 2/11/21 at 10:06 A.M., on the Willow Lane Unit, the surveyor observed the Restorative Aid don (put on) a washable lab coat and gloves, and then go into a resident room. Review of the facility bed board indicated the resident was Covid-19 negative (never had Covid-19). Review of the DPH Memorandum, Update to Caring for Long Term Care Residents during COVID-19 Emergency, dated 12/7/20, indicated: -For Covid-19 negative residents when there are resident or staff cases identified within the last 14 days in the facility, full PPE (mask, eye protection, gown, and gloves)- gowns can be prioritized for high contact resident care activities .CDC provides these examples of high contact resident care activities .assisting with toileting .showering . During an observation on 2/11/21 at 10:08 A.M., the surveyor observed the Restorative Aid provide direct assistance while the resident ambulated in the room. The Restorative Aid then helped toilet the resident. During an observation on 2/11/21 at 10:15 A.M., the surveyor observed the Restorative Aid remove her gloves and dirty laboratory coat. She then hung the laboratory coat across the handles of the closet in the resident's room. She performed hand hygiene and exited the room. During an observation on 2/11/21 at 10:45 A.M., the surveyor observed the lab jacket still hung across the closet handles. During an interview on 2/11/21 at 10:52 A.M., the Restorative Aid said she put the dirty laboratory coat across the closet handles because there was nowhere else to hang it, and she may need to use it again later in her shift. When asked how another staff member or the resident, could access the closet without touching the contaminated coat, the Restorative Aid said that was a good point and she probably should not have put it there. C. During an observation on 2/11/21 at 1:26 P.M., on the quarantine area of the Bayberry Lane Unit, the surveyor observed CNA #3 doff (remove) a re-useable gown and hang it on Hook A in the resident room entry way. During an observation on 2/11/21 at 1:37 P.M., the surveyor observed Nurse #1 enter the same resident room and don the gown from Hook A (the same one CNA #3). During an interview at 1:42 P.M., Nurse #1 said that Hook A was for the nurse and Hook B for the CAN. Nurse #1 said the CNA must have put her gown on Hook A by mistake. She said they should not share the same gown. 3. The facility failed to ensure staff wore gowns that are considered to be PPE when showering (high contact resident care activity) two COVID-19 negative residents. Review of the CDC website, Strategies for Optimizing the Supply of Isolation Gowns, dated 10/9/20, indicated the following: -In situations of severely limited or no available isolation gowns, the following pieces of clothing can be considered as a last resort . However, none of these options can be considered PPE, since their capability to protect Health Care Personnel (HCP) is unknown . -Disposable laboratory coats -Reusable (washable) patient gowns -Reusable (washable) laboratory coats . During an observation on 2/11/21 at 10:27 A.M., the surveyor observed Certified Nurses Aid (CNA) #1, and the CNA student she was training, enter a shower room to shower a resident. Both of the CNAs had patient gowns (not considered PPE) over their scrubs. Review of the facility bed board indicated the resident was COVID-19 negative (required full PPE including a gown for high contact care). During an interview on 2/11/21 at 11:00 A.M., CNA #1 said that they always wore patient gowns over their scrubs when they gave the residents showers. She said she was told they were a little low on (isolation) gowns, so they should wear the patient gowns instead. During an observation on 2/11/21 at 10:40 A.M., the surveyor observed CNA #2, and the CNA she was training, enter a different shower room to shower a resident. Both of the CNAs had patient gowns on over their scrubs. Review of the facility bed board indicated the resident was COVID-19 negative. During an interview on 2/11/21 at 11:20 A.M., CNA #2 said they had always used patient gowns over their scrubs when they showered a resident.