Every finding on record at Liberty Commons

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 11 of 11 residents attending the resident group meeting during the survey, the facility failed to ensure their grievance policy included the right to file grievances anonymously and failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).Findings include:Review of the facility's policy titled Grievances & Resolution of Other Issues, undated, failed to indicate residents and/or their representatives had the right to file grievances anonymously.On 1/7/26 at 9:58 A.M., the surveyor toured all three units in the facility. A document titled Grievances was posted on a bulletin board on each unit. The document indicated, but was not limited to:-You have a right to file a grievance in writing or orally and may do so anonymously.The posting failed to indicate availability and location of grievance forms as well as instructions on where or how to submit the forms to file anonymously.On 1/7/26 at 1:00 P.M., the surveyor held a resident group meeting with 11 residents in attendance. Eleven of 11 residents said that they were not aware of their right to file a grievance anonymously. They said if they have an issue, they must tell a staff member about it. The residents said they have not seen any grievance forms anywhere, and even if they had them, there is nowhere to file them to remain anonymous.During an interview on 1/7/26 at 2:21 P.M., the Administrator identified himself as the Grievance Officer. He reviewed the grievance policy and said it does not include the residents or their representatives right to file grievances anonymously. He said the process to file grievances is that a resident or their representative can tell a staff member their concern and if it can't be addressed right away, the staff person obtains a grievance form from the social worker and completes it on the resident's behalf. He said they do not have a process in which a resident or their representative has access to grievance forms to complete on their own and submit them anonymously. He said they need to speak to staff and they will complete the form.

Based on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include:Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following:-The purpose of the Resident Council is to provide a forum for: a. Residents to have input in the operation of the facility; b. Discussion of concerns; c. Consensus building and communication between residents and facility staff; and d. Staff to disseminate information and gather feedback from interested residents.Review of the facility's Grievance & Resolution of Other Issues policy, undated, included but was not limited to:-It is the policy of the organization to afford all persons served with known mechanisms by which requests for review and resolution of issues can be raised without discrimination or reprisal, including but not limited to those about treatment which has been furnished; those about treatment that has not been furnished; and those about behavior of other residents/patients.-We seek resolution expediently, and keep the applicable parties informed within established and appropriate timeframes. Those timeframes generally include prompt investigation which begins within two business days of receipt of the complaint, with all participants in the investigatory process reported to the administrator or designee withing the following three business days and in response to the aggrieved within a week.-Persons-served have reasonable expectation of care and services, and that the facility addresses those expectations in a timely, reasonable, and consistent manner.-Communication back to the party with the concern is coordinated by one of the senior staff members.Review of Resident Council Minutes, dated 8/28/25, indicated residents voiced concerns about the Certified Nursing Assistants (CNA) rushing and would like them to slow down.Review of the Grievance book failed to indicate the residents' grievance voiced during the 8/28/25 meeting was addressed, acted upon or any follow-up was conducted.Review of Resident Council Minutes, dated 9/30/25 and 10/30/25, failed to indicate the residents' care concern brought forward during the 8/28/25 Resident Council meeting was addressed or had any follow-up.Review of Resident Council Minutes, dated 11/20/25, indicated residents voiced concerns about the CNAs using ear buds while providing care and staff talking in the middle of the night outside of their rooms and waking them up.Review of the Grievance book failed to indicate that any of the residents' grievances voiced during the 11/20/25 Resident Council meeting was addressed or acted upon or any follow-up was conducted.Review of Resident Council Minutes, dated 12/30/25, failed to indicate the residents' care concerns brought forward during the 11/20/25 Resident Council meeting were addressed or had any follow-up.On 1/7/26 at 1:00 P.M., the surveyor held a group meeting with 11 residents in attendance. The residents said there has been no follow-up to any of their concerns voiced during the 8/28/25 and 11/20/25 Resident Council meetings. They said their concern about CNA staff rushing while providing care continues to be a problem, staff continue to speak loudly outside of their room at night and early in the morning and it wakes them up. They said although staff wearing ear buds while providing care has improved, it continues to be a problem.During an interview on 1/7/26 at 2:21 P.M., the Administrator and surveyor reviewed the concerns brought forward by residents during the Resident Council meetings held on 8/28/25 and 11/20/25. He said the concerns were not brought forward through the grievance process and he was not aware the concerns were still a problem. He said they need to make sure concerns brought up during Resident Council are documented and brought through the grievance process to ensure they are addressed, and the problem is resolved.

Based on interviews and record review, the facility failed to monitor the nutritional status of one Resident (#1) with an unplanned significant weight loss, out of a total sample of 26 residents. Specifically, the facility failed to identify and address a 5.27% significant weight loss in one month for Resident #1. Findings include:Review of the facility's policy titled Weight and Measuring the Resident, undated, indicated but was not limited to the following:- Report significant weight loss/weight gain to the nurse supervisor. Ensure physician and health care proxy notified.- 1 month - 5% weight loss is significant: greater than 5% is severe.- When recommended by the nurse or dietitian, weight monitoring can be done more frequently & recorded in the electronic record. The dietitian will review the results, making recommendations as necessary.- The dietitian will also review the unit Weight Record (weekly and/or monthly) to follow individual weight trends over time. Negative trends will be assessed and addressed by the dietitian whether the definition of Significant Weight Change is met.- If the weight change is desirable, this will be documented and no change in the care plan will be necessary.- If a weight loss meets the definition of Significant, the dietitian should discuss with the interdisciplinary team if a Significant Change MDS (Minimum Data Set) is necessary. Resident #1 was admitted to the facility in January 2023 with diagnoses including cerebral infarction, moderate protein-calorie malnutrition, and abnormal weight loss. Review of Resident #1's most recent Minimum Data Set (MDS) assessment indicated he/she was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Furthermore, the MDS assessment indicated he/she had a mechanically altered (change in food texture or liquids) diet as well as needing supervision from staff while eating. Review of Resident #1's Physician's Orders indicated but was not limited to the following:- 1/6/26: House Diet - moist ground texture, thin consistency- 11/25/25: Mighty Shake with meals for dietary supplement; document with % intake on MAR/TAR (Medication/Treatment Administration Record) appropriately- 11/25/25: Ensure Oral Liquid (Nutritional Supplements) - give 240 mL (milliliters) by mouth two times a day for supplement- 11/25/25: Weight weekly on Monday; every day shift every Monday Review of Resident #1's November 2025 Medication Administration Record (MAR) indicated but was not limited to the following:- 50% or less intake of Mighty Shake Dietary Supplement: 16 out of 16 administrations Review of Resident #1's December 2025 MAR indicated but was not limited to the following:- Ensure Oral Liquid Nutritional Supplement: refused three times (12/19/25, 12/22/25 and 12/29/25)- 50% or less intake of Mighty Shake Dietary Supplement: 84 of 93 administrations Review of Resident #1's January 2026 MAR indicated but was not limited to the following:- 50% or less intake of Mighty Shake Dietary Supplement: 14 of 22 administrations Review of Resident #1's weights in the medical record indicated but were not limited to the following:- 11/28/25: 239.0 pounds (lbs.)- 12/5/25: 237.8 lbs.- 12/8/25: 235.8 lbs.- 12/15/25: 234.0 lbs.- 12/22/25: 226.4 lbs.- 12/29/25: 226.0 lbs.- 1/5/26: 221.6 lbs. Review of Resident #1's weights indicated he/she had a 5.27% weight loss in one month (11/28/25 to 12/22/25). Furthermore, review of Resident #1's weights indicated he/she continued to lose weight following the significant weight loss that was triggered on 12/22/25. Review of Resident #1's Nutrition Assessment, dated 12/1/25, indicated he/she was re-admitted to the facility following a hospitalization. The assessment indicated Resident #1's weight had risen in comparison to prior to the hospitalization but was within the usual fluctuation of his/her weight history. Furthermore, the assessment indicated Resident #1 was at a high risk for weight loss and there was a concern related to poor intake of meals and supplements. Further review of Resident #1's medical record failed to indicate any additional Nutrition Assessments were completed after 12/1/25. Review of Resident #1's Dietitian progress note, dated 11/26/25, indicated he/she was re-admitted to the facility following a hospitalization. The progress note indicated Mighty Shakes and Ensure nutritional supplements were offered daily, and they were required to prevent weight loss. The progress note further indicated Resident #1's weight had been relatively stable in the previous 90-days but does fluctuate due to fluid status and intake at meals. Further review of Resident #1's medical record failed to indicate any additional dietitian progress notes were completed after 11/26/25. Additionally, review of the medical record failed to indicate dietitian documentation identifying the significant weight loss of 5.27% in one month from 11/28/25 to 12/22/25 or identify the continued weight loss after 12/22/25. Review of Resident #1's nursing progress notes failed to indicate documentation related to Resident #1's significant weight loss. Review of Resident #1's physician (MD) and nurse practitioner (NP) progress notes failed to indicate documentation related to his/her significant weight loss. During an interview on 1/8/26 at 10:57 A.M., Nurse #3 said when a resident's weight is placed in the medical record it triggers if a weight loss is identified. Nurse #3 said staff would likely re-weigh the resident and alert the unit manager to the weight loss. Nurse #3 said the dietitian and or the unit manager would follow up with any documentation regarding the weight loss. During an interview on 1/8/26 at 11:28 A.M., the Dietitian said she reviews weights weekly on Tuesdays for the facility as most weekly weights are obtained on Monday. The Dietitian said she also receives messages from the unit managers at the facility when a weight loss is identified. The Dietitian said the interdisciplinary team meets weekly to discuss any residents with weight loss and document in progress notes the goals for each resident. The Dietitian and the surveyor reviewed the weights of Resident #1 from 11/28/25 to current. The Dietitian said she was unaware of a significant weight loss for Resident #1 on 12/22/25 and it did not trigger for her. The Dietitian said she was notified of a significant weight loss for Resident #1 on 1/5/26 and was waiting on a re-weight to confirm. The Dietitian said Resident #1's weight does fluctuate after hospitalizations due to an increase in fluid. The Dietitian said she had not completed any documentation since the Resident's re-admission. During an interview on 1/8/26 at 11:44 A.M., the Director of Nursing (DON) said weights are reviewed weekly by the dietitian and are discussed in weekly interdisciplinary team meetings. The DON said the Resident typically has an increase in fluid when they return from the hospital. The DON said the medical record should reflect documentation of the Resident's weight loss.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to:1. Ensure medication carts were locked when not in direct supervision of the licensed nurse; and2. Ensure topical treatments were securely stored and not left at the bedside on one of three units in the facility.Findings include: Review of the facility's policy titled Storage of Medications, last revised 2024, indicated but was not limited to:-Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.-Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1. On 1/8/26 at 8:30 A.M., the surveyor observed an unlocked, unattended medication cart positioned outside the main dining room on the Oyster Pond unit (memory impaired residents on this unit). Nurse #1 was supervising residents in the dining room, and the unlocked medication cart was not in her line of sight. No other staff were in the vicinity of the medication cart. From 8:30 A.M. to 8:45 A.M., a visitor, maintenance staff, housekeeping staff, and activity staff were noted to walk by the unlocked medication cart. During an interview on 1/8/26 at 8:45 A.M., Nurse #1 said that she was responsible for the medication cart and forgot to lock it before she went into the dining room and left the cart unattended.During an interview on 1/9/26 at 10:30 A.M., the Director of Nursing said that medication carts should always be locked when unattended.2. On 1/6/26 at 9:00 A.M., the surveyor observed multiple topical treatments at the bedside in 9 of 16 resident rooms on the Oyster Pond North unit (memory impaired residents). On 1/8/26 at 11:42 A.M., Unit Manager #3 and the surveyor toured the Oyster Pond North unit. The following items were observed in multiple resident rooms, unsecured, and easily accessible to any residents on the unit:-room [ROOM NUMBER]: one tube Desitin cream (topical zinc oxide), two tubes of PeriShield with zinc oxide-room [ROOM NUMBER]: two cans of shaving cream, two tubes of PeriShield with zinc oxide-room [ROOM NUMBER]: two tubes of PeriShield with zinc oxide-room [ROOM NUMBER]: one tube of Desitin, one tube of PeriShield-room [ROOM NUMBER]: one tube of PeriShield with zinc oxide-room [ROOM NUMBER]: two tubes of PeriShield with zinc oxide, one can of shaving cream-room [ROOM NUMBER]: three tubes of PeriShield, one tube of Biofreeze (topical analgesic)-room [ROOM NUMBER]: one tube of PeriShield with zinc oxide-room [ROOM NUMBER]: one tube of PeriShield with zinc oxideDuring an interview on 1/8/26 at 12:00 P.M., Unit Manager #3 said the topical treatments found in the residents' rooms should be secured and not left at the bedside.

Based on record review and interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure for one Resident (#84), out of a total sample of 26 residents, that as needed (PRN) use of Ativan (treats anxiety) was limited to 14 days and the prescriber documented an evaluation of the Resident's current condition and the appropriateness for continued use prior to extending its duration.Findings include:Review of the facility's policy titled Psychotropic Medication Use, dated 2001, indicated the following:-Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.-PRN orders for psychotropic medications are limited to 14 days.-For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.Review of the facility's policy titled 14-day PRN Psychotropic/Anti-Psychotic Medication Review Procedure, undated, indicated but was not limited to:-The purpose of this procedure is to ensure consistency in the communication process to assure compliance with Centers for Medicare and Medicaid Services (CMS) guidelines regarding PRN orders for psychotropics and anti-psychotics which states as follows: -PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's record and indicate the duration for the PRN order.Resident #84 was admitted to the facility in June 2023 and had diagnoses including anxiety disorder.Review of the Minimum Data Set (MDS) assessment, dated 1/6/26, indicated Resident #84 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, and was administered psychotropic medication.Review of Resident #84's medical record indicated but was not limited to:-Ativan (Lorazepam) 0.5 milligrams (mg) every 6 hours as needed for anxiety for 14 days (4/19/25, discontinued 4/29/25)-Ativan 0.5 mg every 6 hours as needed for anxiety for 30 days (4/29/25)Review of the medical record failed to indicate the Physician or Physician extender documented a clinical rationale for the extension of the PRN Ativan order as required.-Ativan 0.5 mg every 6 hours as needed for anxiety/agitation for 30 days (8/29/25)Review of a Physician's progress note, dated 8/29/25, indicated to extend the PRN Ativan order for another 30 days for anxiety/agitation. However, there was no current PRN Ativan order in place. The last PRN Ativan order was initiated on 4/29/25 for 30 days.-Ativan 0.5 mg every 6 hours as needed for anxiety/agitation for 180 days (start date 10/2/25, d/c 11/26/25)Review of the medical record failed to indicate the Physician or Physician extender documented a clinical rationale for the extension of the PRN Ativan order as required.During an interview on 1/8/26 at 11:24 A.M., Unit Manager #3 reviewed Resident #84's medical record and said there was no documentation from the Physician or Physician extender to indicate an evaluation was conducted and a documented clinical rationale for continued use and extension of PRN Ativan.During an interview on 1/9/26 at 10:30 A.M., the Director of Nursing (DON) reviewed Resident #84's medical record and said neither the Physician nor Physician extender documented a clinical rationale for the continued use of PRN Ativan prior to extending the order.

Based on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents for four Residents (#20, #24, #84, and #72), out of a total sample of 26 residents. Specifically, the facility failed:1. For Resident #20, to implement the Resident's seat/chair alarm as indicated in the Resident's care plan;2. For Resident #24, to implement the Resident's personal alarm as indicated in the Resident's care plan; 3. For Resident #84, to develop and consistently implement effective interventions to prevent four unwitnessed falls; and 4. For Resident #72, to implement the Resident's bed/chair alarm and fall mats as indicated in the Resident's care plan.Findings include:Review of the facility's policy titled Falls and Fall Risk, undated, indicated, but was not limited to, the following:-It is the policy of the organization to ensure the risk of harm to residents caused by falls is minimized.-Residents who do fall will be appropriately managed.-The Safety Care Plan will be updated accordingly.-Examples of interventions may include but are not limited toa. Addressing medical issues with the physician such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medicationsb. Use of low bed with matsc. Alarms to alert staff of attempts to self-transferd. Enabling devices i.e. Velcro alarmed seat belt, wedge cushionse. Perimeter mattressf. Non-skid strips-If interventions have been successful in preventing additional falls, the staff will continue with the current approach or reconsider whether these measures are still needed if the problem that required the intervention has resolved.-All care plans are reviewed and updated quarterly or with a significant change in condition when the MDS (Minimum Data Set) is completed. Review of the facility's policy titled Care Plans – Comprehensive, undated, indicated, but was not limited to, the following:-Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.-Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. -Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 1. Resident #20 was admitted to the facility in December 2025 with diagnoses including altered mental status and mild cognitive impairment. Review of the Minimum Data Set (MDS) assessment, dated 12/13/25, indicated Resident #20 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of Resident #20's medical record indicated Resident #20 had fallen on 12/23/25 and 1/3/26. Review of Resident #26's Care Plans indicated, but was not limited to, the following:Focus: SAFETY PLAN: Patient has a potential for injury related to: weakness, admit fall score of 13Interventions:-seat/chair alarm when OOB (out of bed) in w/c (wheelchair) without direct supervision (12/24/25) Review of Resident #20's Kardex (Certified Nursing Assistant (CNA) Care Card) indicated, but was not limited to, the following:-Safety: seat/chair alarm when OOB in w/c without direct supervision Review of Resident #20's fall incident reports/investigations indicated, but was not limited to, the following:-On 12/23/25 at 1:30 P.M., the CNA observed the Resident stand up from his/her wheelchair and begin to walk. The CNA asked the Resident if he/she was supposed to be walking and held on to the Resident's waist. Before the CNA had a chance to put the gait belt on, the Resident fell to the floor. At the time of the fall, no alarms were in place. -On 1/3/26 at approximately 8:10 P.M., the CNA assigned to the Resident's care informed the nurse he had heard the Resident calling out and observed him/her on the floor in his/her room. The Resident stated he/she was trying to lose the blinds and fell on his/her buttocks. The Resident's chair alarm was not in place at the time of the fall. Review of Resident #20's Progress Notes indicated that on 1/3/26, the Resident had an unwitnessed fall, his/her seat alarm was not on, and the CNA was educated on ensuring the Resident's safety alarm was on at night. During an interview on 1/7/26 at 1:37 P.M., Nurse #6 said after Resident #20's first fall on 12/23/25, the Resident had asked to use a chair alarm so he/she could remember to sit down when it went off and Nurse #6 implemented the alarm. During an interview on 1/8/26 at 2:42 P.M., Nurse #5 said she was working when Resident #20 fell on 1/3/26. Nurse #5 said she was not in the room at the time of the fall, but she did not hear a chair alarm sounding when the Resident fell and she would have heard it if it had been in place. During an interview on 1/8/26 at 3:09 P.M., the Director of Nursing (DON) said Resident #20 had been cleared by therapy to transfer independently in his/her room during the day when he/she fell on 1/3/26, but the Resident's chair alarm had not been removed from his/her care plan and should have been in place at the time of the fall. 2. Resident #24 was admitted to the facility in October 2025 with diagnoses including Alzheimer's disease and history of falling. Review of Resident #24's MDS assessment, dated 12/22/25, indicated Resident #24 was severely cognitively impaired, as evidenced by a BIMS score of 3 out of 15. Further review of the MDS assessment indicated the Resident had had one fall with no injury since the last MDS assessment 10/20/25. Review of Resident #24's medical record indicated Resident #24 had fallen on 11/29/25 and 1/2/26. Review of Resident #24's Care Plans indicated, but were not limited to, the following:Focus: SAFETY PLAN: Patient has a potential for injury related to: cognitive impairment, history of fall, cognitive impairment [sic]Interventions:-Personal Alarm without direct supervision Review of Resident #24's Fall incident Reports/Investigations indicated, but was not limited to, the following: -On 11/29/25, the Resident was in the Oyster Pond Unit dayroom seated in a recliner chair watching television. The Resident scooted toward the edge of the recliner and subsequently lost his/her balance, resulting in a fall onto the floor. There was no chair alarm in place and the fall was unwitnessed. Review of Resident #24's Rehabilitation Screen status post fall, dated 12/1/25, indicated the Resident was in the recliner at the time of the fall but his/her alarm was not placed on the recliner when the Resident was transferred out of his/her wheelchair. Review of Resident #24's Kardex indicated, but was not limited to, the following:-Personal Alarm without direct supervision Review of Resident #24's Progress Notes indicated that on 11/29/25, Resident #24 was in the Oyster Pond Unit dayroom in a recliner and scooted toward the edge of the recliner and had a fall. During an interview on 1/8/26 at 3:09 P.M., the DON said when Resident #24 had fallen on 11/29/25, his/her chair alarm was not in place. The DON said the alarm was not transferred with the Resident when he/she was transferred from the wheelchair to the recliner chair. The DON said the Resident should have been supervised in the dayroom and that was likely why the alarm was not moved. 3. Resident #84 was admitted to the facility in June 2023 and has hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) affecting the right dominant side following a stroke and a history of falls. Review of the MDS assessment, dated 1/6/26, indicated Resident #84 had severe cognitive impairment as evidenced by a BIMS score of 7 out of 15, and had history of falls. Review of Resident #84's Interdisciplinary Care Plans included but was not limited to: -Focus: Safety Plan: Resident has a potential for injury related to: confusion with decreased safety awareness; right hemiparesis and weakness (9/28/23) -Interventions: Assist Resident back to bed after breakfast, lunch and dinner (12/11/23); Keep personal items within reach (12/6/23); Non-skid strips on floor on window side of the bed leading into the bed (1/30/24); Wedge cushion to reduce chance of sliding in wheelchair (12/29/23); Motion sensor when in bed without direct supervision to alert staff of attempts to exit bed unassisted (12/8/23); Lock rear wheelchair brakes when out of bed in wheelchair (2/16/24); Encourage resident to stay in common areas to promote more supervision (3/3/24) -Goal: I want to reduce my risk for injury (9/28/23) Review of the safety Kardex indicated the following interventions were in place as of 4/12/25: -Assist resident back to bed after breakfast, lunch and dinner -Encourage resident to stay in common areas to promote more supervision -Fabric covered cushion to reduce chance of sliding in wheelchair -Motion sensor when in bed without direct supervision to alert staff of attempts to exit bed unassisted (set to chime) -Personal alarm without direct supervision -Provide staff escorts to activities, needs staff assistance with transfer, has poor safety awareness -Rear lock wheelchair brakes when out of bed in wheelchair -Slipper socks used at night while in bed -STOP sign on closet and on wall behind the bed to remind resident to call for assistance for transfers and ambulation Review of the medical record and fall investigations indicated Resident #84 had five falls from April 2025 to January 2026. Review of the falls indicated: -4/13/25 at 10:00 A.M., Resident #84 had an unwitnessed fall and was found lying on the floor on his/her back in front of a wheelchair in his/her room. The investigation revealed that after breakfast, Resident #84 was brought to his/her room by a student CNA who was unaware that the Resident should not be alone in his/her room. There were no injuries as a result of the fall. The following interventions were not in place at the time of the fall: assist Resident back to bed after breakfast, personal alarm without direct supervision. New interventions added to the care plan/safety Kardex: staff education on safety care plan and not leaving resident in wheelchair alone in room. -8/20/25 at approximately 11:45 A.M., Resident #84 had an unwitnessed fall and was found on the floor of his/her room next to the bed. The Resident's legs were on the side of the bed, and his/her head was in between the nightstand and tray table. The Resident sustained an abrasion to his/her left knee and left ear. The investigation revealed the Resident was last toileted after breakfast and put to bed. The following interventions were not in place at the time of the fall: Motion sensor when in bed without direct supervision to alert staff of attempts to exit bed unassisted. New interventions added to the care plan/safety Kardex: staff education on new intervention added to the care plan/safety Kardex: low bed with mats. -10/31/25 at 5:30 P.M., Resident #84 was in the dining room and was found on the floor by his/her wheelchair. The investigation revealed the Resident may have reached over the side of the wheelchair and it tipped and the Resident fell. Staff were in the room at the time of the fall but did not witness the fall. The Resident sustained an abrasion to the top of his/her scalp and right knee. Physical therapy evaluated and adjusted the wheelchair to lower the Resident's gravity to the floor. -11/21/25 at 6:30 P.M., Resident #84 was transported from the main dining room to the unit dayroom after dinner by a CNA to sit along with other residents. The Resident was later found on the floor in front of his/her wheelchair. There were no injuries as a result of the fall. The following interventions were not in place at the time of the fall: assist resident back to bed after breakfast, lunch and dinner and personal alarm without direct supervision in wheelchair. Staff were educated on the Resident's safety plan of care and getting the Resident to bed after dinner. -1/2/26 at 11:30 A.M., Resident #84 was brought to the nurse's station for supervision because he/she was anxious and having delusions. The nurse providing supervision left the nurse's station to respond to another resident's sounding safety alarm. When the nurse returned to the nurse's station, she found Resident #84 on the floor on his/her right side. The resident sustained an abrasion to the right side of his/her head. On 1/6/26 at 9:58 A.M. and 11:26 A.M., the surveyor observed Resident #84 lying in bed asleep. A mat was observed on the left side of the bed between halfway underneath his/her roommate's bed. The was no mat on the right side of the bed. On 1/6/26 at 1:18 P.M., the surveyor observed Resident #84 lying in bed awake visiting with his/her family member. A mat was observed on the left side of the bed between halfway underneath his/her roommate's bed. The Family Member said Resident #84 has had a few falls, and staff are supposed to put mats on the floor on either side of the bed, but there is only one mat in place. During an interview on 1/9/26 at 10:30 A.M., the surveyor and DON reviewed Resident #84's falls. The DON said that the safety team had reviewed each fall and found that for three of the five falls, staff did not implement interventions in place for the Resident's risk of falls. She said all fall interventions should be in place according to the safety care plan and CNA Kardex. 4. Resident #72 was admitted to the facility in December 2023 and has diagnoses including weakness and a history of falls. Review of the MDS assessment, dated 12/2/25, indicated Resident #72 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15, requires substantial to maximum assistance for activities of daily living and utilized a bed alarm daily. Review of Resident #72's medical record indicated but was not limited to the following comprehensive care plan for the Resident's fall risk: Focus: Safety Plan: Resident has a potential for injury related to: Fall history prior to admission [DATE]) Interventions: Bed alarm to alert staff when resident is exiting the bed unassisted (8/20/25); Low bed with mats (1/21/25); seat/chair alarm when out of bed in wheelchair (4/4/24) Goal: I want to reduce my risk for injury (1/4/24, target date: 5/5/25) On 1/6/26 at 10:04 A.M., the surveyor observed Resident #72 lying in bed awake. No mats were noted on the floor next to the Resident's bed. A bed alarm box was attached to the Resident's bed frame at the head of the bed. However, the alarm cord that was connected to a pressure pad on the Resident's bed was not connected to the box and was lying on the floor. On 1/7/26 at 9:40 A.M., the surveyor observed Resident #72 lying in bed awake. No mats were noted on the floor next to the Resident's bed. A bed alarm box was attached to the Resident's bed frame at the head of the bed. However, the alarm cord that was connected to a pressure pad on the Resident's bed was not connected to the box and was lying on the floor. On 1/7/26 at 12:18 P.M., the surveyor observed Resident #72 seated in a positioning chair in the unit dining room. No seat alarm was in place. During an observation with interview on 1/7/26 at 4:00 P.M., Unit Manager #3 and the surveyor observed Resident #72 lying in bed asleep. No mats were noted on the floor next to the Resident's bed. A bed alarm box was attached to the Resident's bed frame at the head of the bed. However, the alarm cord that was connected to a pressure pad on the Resident's bed was not connected to the box and was lying on the floor. She said it is the responsibility of all staff to ensure the fall mats are in place and the bed alarm is connected and functioning. During an interview on 1/9/26 at 10:30 A.M., the DON said staff should implement fall care plan interventions at all times.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for three Residents (#109, #84, #138), out of a total sample of 26 residents. Specifically, the facility failed:1. For Resident #109, to complete weekly skin assessments as ordered by the physician;2. For Resident #84, to implement a physician's order for head-of-bed elevation positioning; and 3. For Resident #138, to obtain a physician's order for an Registered Nurse (RN) pronouncement of death.Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, 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:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers 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.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. 1. Review of the facility's policy titled Skin Care Program, revised 4/2023, indicated, but was not limited to, the following:-All residents have a full body skin assessment to address any skin issues on a weekly basis.-Skin check is to be performed by a licensed nurse on a weekly basis on a previously assigned day (recommended day is a shower day if applicable).-Weekly skin check must be completed even if a shower does not occur.-Refusal of skin assessment must be documented in EHR (electronic health record) including interventions and re-education of the resident. Resident #109 was admitted to the facility in November 2025 with diagnoses including pressure ulcer of the right buttock, sepsis, and severe protein-calorie malnutrition. Review of Resident #109's Minimum Data Set (MDS) assessment, dated 11/18/25, indicated Resident #109 was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS assessment indicated Resident #109 had five unstageable pressure ulcers and a surgical wound present on admission to the facility and the Resident was receiving pressure ulcer care. Review of Resident #109's Care Plan indicated, but was not limited to, the following:Focus: The Resident has actual impairment to skin integrityRight gluteus unstageable pressure ulcer – present on admitInflammatory disorder of scrotumFirst degree burn of neck present on admitRight thigh three unstageable pressure area present on admitLeft plantar foot unstageable pressure area – present on admitOstomy scabbed from tape burns present on admitInterventions: Weekly skin assessment Review of Resident #109's Physician's Orders indicated, but was not limited to, the following:-Weekly Skin Assessment due. Document skin condition in a WEEKLY SKIN CHECK assessment every evening shift every 7 day(s) FRI 3-11 (order date: 11/12/25) Review of Resident #109's medical record failed to include documentation of weekly skin check assessments completed after 12/12/25. Review of Resident #109's Progress Notes failed to indicate that Resident #109 had refused weekly skin checks after 12/12/25. During an interview on 1/6/26 at 9:58 A.M., Resident #109 said he/she has a wound on his/her buttocks and the nurses at the facility perform wound care for him/her. During an interview on 1/8/26 at 10:16 A.M., Unit Manager #1 said Resident #109 is followed by the consulting wound physician and was admitted to the facility with multiple wounds. During an interview on 1/8/26 at 2:30 P.M., Unit Manager #1 said Resident #109 should have weekly skin assessments documented in the electronic medical record and the last one she could see was documented on 12/12/25. Unit Manager #1 said the weekly skin assessments should have been completed every week. During an interview on 1/8/26 at 3:09 P.M., the Director of Nursing (DON) said Resident #109 should have had his/her weekly skin assessment completed and documented in the medical record. 2. Resident #84 was admitted to the facility in June 2024 and had diagnoses including dysphagia (difficulty swallowing) following cerebral infarction, gastroesophageal reflux disease and shortness of breath. Review of the MDS assessment, dated 1/6/26, indicated Resident #84 had severe cognitive impairment as evidenced by a BIMS score of 7 out of 15, and required substantial/maximal assistance with bed mobility. Review of the medical record indicated a Physician's Order including, but not limited to: -Keep HOB (Head of bed) at 30-45 degrees, no lying flat, every shift for productive cough, chest congestion (2/1/25) On 1/6/26 at 9:58 A.M., the surveyor observed Resident #84 lying in bed asleep. The HOB was flat and not at 30-45 degrees according to physician's orders. On 1/6/26 at 11:26 P.M., the surveyor observed Resident #84 lying in bed asleep. The HOB was flat and not at 30-45 degrees according to physician's orders. On 1/6/26 at 1:18 P.M., the surveyor observed Resident #84 lying in bed awake. The HOB was flat and not at 30-45 degrees according to physician's orders. On 1/7/26 at 9:43 A.M., the surveyor observed Resident #84 lying in bed asleep. The HOB was flat and not at 30-45 degrees according to physician's orders. Review of the January 2026 Medication/Treatment Administration Record (MAR/TAR) was signed off by nursing that the Resident's HOB was positioned between 30 – 45 degrees at the time of the surveyor's observations of the bed being flat. On 1/7/26 at 3:51 P.M., the surveyor and Nurse #2 observed Resident #84 lying in bed asleep. The HOB was flat. Nurse #2 said the head of the bed is supposed to be elevated to between 30 - 45 degrees but it is not. During an interview on 1/7/26 at 4:00 P.M., Unit Manager #3 said nursing staff need to ensure the head of Resident #84's bed is always elevated to between 30 – 45 degrees according to the physician's order. During an interview on 1/9/26 at 10:30 A.M., the DON said Resident #84's head of the bed should be elevated and accurately documented according to physician's orders. 3. Review of the facility's policy titled Death of a Resident, documenting, dated 2001, indicated but was not limited to: -Appropriate documentation shall be made in the clinical record concerning the death of a resident -A resident may be declared dead by a licensed physician or registered nurse with physician authorization in accordance with state law. Resident #138 was admitted to the facility in December 2025 and had diagnoses including a displaced fracture of medial condyle of the right tibia and a history of falls. Review of the medical record indicated a nursing progress note, dated 12/31/25. The note indicated Resident #138 was working with physical therapy and occupational therapy staff in his/her room and began to experience shortness of breath and chest pain. The Resident was assessed and found to have a non-palpable pulse and became apneic (transient cessation of respiration). The heart monitor showed no survivable heart rate/rhythm and was pronounced dead at 10:20 A.M. Further review of the medical record failed to indicate an order for RN pronouncement of death was obtained. During an interview on 1/9/26 at 10:30 A.M., the DON reviewed Resident #138's medical record and said a physician's order for an RN pronouncement was not obtained as required.

Based on interviews and record reviews, the facility failed to notify the physician of a change in condition in order to reevaluate the potential need to alter the treatment plan for one Resident (#1), out of 26 residents sampled. Specifically, the facility failed to notify Resident #1's physician regarding a 5.27% significant weight loss over one month. Findings include:Review of the facility's policy titled Change in Resident's Condition or Status, undated, indicated but was not limited to the following:- The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: (d) a significant change in the resident's physical/emotional/mental condition.- A significant change in condition is a decline or improvement in the resident's status that: (a) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); (b) impacts more than one area of the resident's health status; (c) requires interdisciplinary review and/or revision to the care plan; and (d) ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii). Review of the facility's policy titled Weight and Measuring the Resident, undated, indicated but was not limited to the following:- Report significant weight loss/weight gain to the nurse supervisor. Ensure physician and health care proxy notified.- 1 month - 5% weight loss is significant: greater than 5% is severe. Resident #1 was admitted to the facility in January 2023 with diagnoses including cerebral infarction, moderate protein-calorie malnutrition, and abnormal weight loss. Review of Resident #1's weights in the medical record indicated a weight of 239.0 pounds (lbs.) on 11/28/25 after returning from a hospitalization. Review of Resident #1's weights indicated he/she weighed 226.4 lbs. on 12/22/25, triggering a 5.27% significant weight loss in one month. Further review of Resident #1's weights in the medical record indicated he/she continued to lose weight after 12/22/25:- 12/29/25: 226.0 lbs.- 5.44% weight loss from 11/28/25- 1/5/26: 221.6 lbs. - 7.28% weight loss from 11/28/25 Review of Resident #1's medical record failed to indicate notification of the physician (MD) and/or nurse practitioner (NP) of a significant weight loss. Review of Resident #1's MD/NP progress notes failed to indicate documentation related to his/her significant weight loss. During an interview on 1/8/26 at 10:57 A.M., Nurse #3 said all residents on the unit are either weighed weekly or monthly and their weights are inputted into the medical record. Nurse #3 said staff will get notification after putting the weight in the medical record if the resident has had any type of weight loss. Nurse #3 said staff would then alert the unit manager of the weight loss and they would follow up and address with the interdisciplinary team. Nurse #3 said normally the unit manager or dietitian would follow up with the weight loss. During an interview on 1/8/26 at 11:20 A.M., Nurse #4 said when a resident's weight is out of range it will be highlighted in red in the medical record. Nurse #4 said generally a re-weight is obtained if a resident's weight is out of range to confirm. Nurse #4 said staff would then notify the physician and/or the dietitian and document the notification in their progress notes. During an interview on 1/8/26 at 11:28 A.M., the Dietitian said she reviews weights weekly on Tuesdays for the facility as most weekly weights are obtained on Monday. The Dietitian said she also receives messages from the unit managers at the facility when a weight loss is identified. The Dietitian said once the weight loss is confirmed she will notify the physician via email. The Dietitian said she was not aware of Resident #1's significant weight loss on 12/22/25 until 1/6/26 when she reviewed the weights. The Dietitian said she had not notified the physician of a weight loss for Resident #1 as she was waiting for a reweight. During an interview on 1/8/26 at 11:44 A.M., the Director of Nursing (DON) said weights are reviewed weekly by the dietitian. The DON said the interdisciplinary team discusses residents who have had or was at risk for weight loss in their weekly team meetings. The DON said notification to the physician of the weight loss should be indicated in the medical record.

Based on observations, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#12), of 26 sampled residents. Specifically, the facility failed to ensure Resident #12's continuous positive airway pressure (CPAP - used to treat sleep apnea) mask and tubing was maintained in a sanitary manner. Findings include: Resident #12 was admitted to the facility in August 2025 with diagnoses including but not limited to dementia. Review of Resident #12's Physician's Orders indicated but were not limited to the following:- 8/12/25: CPAP applied at night, fill water chamber with distilled water to fill line prior to use; store parts and tubing in plastic beg (sic - bag) when not in use; one time a day. On the following dates/times, the surveyor observed Resident #12's CPAP mask and tubing left on his/her bedside nightstand resting on a telephone and left open to air:- 1/6/26 at 9:26 A.M. and 12:51 P.M.,- 1/7/26 at 8:41 A.M. and 12:16 P.M., and- 1/8/26 at 8:04 A.M. During an interview on 1/8/26 at 10:56 A.M., Nurse #3 said any resident utilizing CPAP equipment should have it stored in a dated plastic bag when it is not in use. During an interview on 1/8/26 at 11:20 A.M., Nurse #4 said any resident who utilizes CPAP equipment should have it stored in a bag when it is not in use. Nurse #4 said after the parts are cleaned, they should be stored away appropriately. During an interview on 1/8/26 at 11:43 A.M., the Director of Nursing (DON) said all CPAP equipment should be stored in a plastic bag when not in use.

Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure medication carts were locked when not in direct supervision of the licensed nurse; and 2. Ensure staff properly labeled all medications stored in three of four medication carts reviewed once opened. Findings include: Review of the facility's policy titled Storage of Medications, dated February 2019, indicated but was not limited to the following: -Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. -Certain medications or package types such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and/or the new date of expiration. 1. On 9/5/24 at 7:59 A.M., the surveyor observed Unit Manager (UM) #1 prepare medications for a resident from the Oyster Pond [NAME] medication cart which was positioned in the hallway next to the resident's room. UM #1 left the medication cart unlocked and unattended to retrieve an over the counter (OTC) medication in the medication room at the nurses' station which was not available in the medication cart. No other staff were in direct supervision of the cart. UM #1 returned to the medication cart approximately one to two minutes later and continued to prepare the remaining seven medications for administration. During an interview on 9/5/24 at 8:31 A.M., UM #1 said she was aware she did not lock her medication cart when she went to the medication room but should have. During an interview on 9/9/24 at 4:12 P.M., the Director of Nursing (DON) said medication carts should be locked when unattended. 2. Review of a facility document titled Medications with Shortened Expiration Dates, dated July 2015, indicated but was not limited to the following: Lantus (insulin glargine, treats diabetes) - good for 28 days after opening or removing from refrigerator. Review of [NAME] Timolol (timolol maleate) manufacturer's instructions for use, dated November 2017, indicated but was not limited to the following: Stability and Storage Recommendations: -The contents of [NAME] Timolol should not be used for more than one month after the date on which the container is first opened. Review of the Arkray Assure Platinum Reference Manual, revised August 2023, indicated but was not limited to the following: Storage and Handling -When you first open the bottle, write the date on the bottle label. Use the test strips within 3 months of first opening the bottle. Oyster Pond [NAME] medication cart: On 9/5/24 at 8:21 A.M., the surveyor reviewed the Oyster Pond [NAME] medication cart with UM #1 and observed the following: -One bottle of Assure Platinum glucometer test strips (small disposable plastic strips that are used with a blood glucose meter to measure blood sugar) stored inside the cart, seal broken indicating it had been opened, bottle not labeled with the date when opened or the new date of expiration During an interview on 9/5/24 at 8:21 A.M., UM #1 said she wasn't sure if they were supposed to label the bottle once opened and wasn't sure how long it was good for once opened. Pleasant Bay East medication cart: On 9/5/24 at 9:37 A.M., the surveyor reviewed the Pleasant Bay East Unit medication cart with Nurse #1 and observed the following: -one multidose vial of Lantus 100 units/milliliter (ml) stored inside the packaging box, pop top off the vial indicating it had been opened, packaging box and vial not labeled with the date when opened or the new date of expiration, labeled with a resident's name -One bottle of Assure Platinum glucometer test strips stored inside the cart, seal broken indicating it had been opened, bottle not labeled with the date when opened or the new date of expiration During an interview on 9/5/24 at 9:37 A.M., Nurse #1 said the insulin should have been labeled with the date when opened and was only good for one month. She said it had a short expiration because of the handling things and would have to discard because she did not know when it was opened. Nurse #1 said the test strip bottle was not labeled with the date when opened or the new expiration date but said they do not usually label them. She said she wasn't sure how long it would be good for but believed it was the manufacturer's expiration date on the bottle. Pleasant Bay North medication cart: On 9/5/24 at 9:52 A.M., the surveyor reviewed the Pleasant Bay North medication cart with Nurse #2 and observed the following: -One bottle of timolol maleate (treats glaucoma in the eye) 0.5% stored inside the packaging box, seal broken indicating it had been opened, packaging box and bottle not labeled with the date when opened or the new date of expiration, labeled with a resident's name -One bottle of Assure Platinum glucometer test strips stored on top of the cart, seal broken indicating it had been opened, bottle not labeled with the date when opened or the new date of expiration During an interview on 9/5/24 at 9:52 A.M., Nurse #2 said the eye drops should have been labeled with the date when opened on the packaging box and the bottle itself and was only good for 30 days. She said they don't usually label test strip bottles once opened and wasn't sure how long it would be good for. During an interview on 9/9/24 at 4:12 P.M., the DON said the process for the test strip bottles has been to use by the manufacturer's date of expiration, but she now knew this was different. She said the bottle was only good for 90 days once opened, per manufacturer's instruction, and should have been labeled with the new date of expiration once opened. The DON said Lantus is only good for 28 days after opening and was not sure how long the eye drops were good for as they weren't listed on the pharmacy's short expiration list. She said staff should have still labeled the bottle with the date when opened. She said the purpose of short expiration dates is to maintain potency and to not let bacteria get into the eye drop bottles.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to: 1. Ensure staff did not report to work or provide care to residents while acutely ill without testing to ensure they were not COVID-19 positive while in the facility; 2. Test Residents in accordance with current COVID-19 testing guidelines following a known exposure for 9 of 17 residents effected; and 3. Ensure staff properly handled medications to reduce the potential transmission of pathogens for Resident #19 during medication administration. Findings include: 1. Review of the facility's policy titled COVID-19 Test access protocol: Healthcare personnel (HCP), dated 3/14/24, indicated but was not limited to the following: - if employee presents with fever, signs/symptoms of lower respiratory illness (shortness of breath, cough, sore throat), nasal congestion, runny nose, fatigue, body aches, vomiting, diarrhea, or sudden onset of loss of taste or smell, do not report to work. - report condition to the facility, facility may test employee or employee may report to testing center/test at home - positive results should be reported by phone - if staff test is positive the facility Infection Preventionist (IP) will evaluate and conduct outbreak testing of all potentially exposed residents and staff regardless of vaccination status Review of the Centers for Disease Control and Prevention (CDC) guidance titled Infection Control Guidance: SARS-COV-2 / COVID-19, dated 6/24/24, indicated but was not limited to the following: Perform SARS-COV-2 Viral testing: - Anyone with even mild symptoms, regardless of vaccination status, should receive a viral test for SARS-COV-2 as soon as possible Review of the facility's tracking and tracing for COVID-19 positive staff member, Certified Nurse Assistant (CNA) #2 indicated but was not limited to the following: - staff member tested positive on 9/1/24 - tested at work due to headache and flu-like symptoms - was wearing a mask the entire shift - cared for seven residents who were identified in the contact tracing as having been exposed Review of the staff COVID-19 tracking log, provided by the facility, indicated but was not limited to the following: - CNA #2 came into work on 9/1/24 with symptoms including: nasal congestion, headache, shortness of breath, and achiness - CNA #2 felt progressively worse throughout their shift and took a test for COVID-19 and was found to be positive for COVID-19 and was sent home During an interview on 9/6/24 at 12:48 P.M., the IP said CNA #2 should have tested at the start of her shift if she didn't feel well and not just wore a mask. She said the expectation would be that she would not come into work if she felt sick or tested upon arrival if there were any potential signs or symptoms of a COVID-19 like illness to ensure she didn't potentially expose anyone. Review of the timecard for CNA #2, provided by the facility, indicated CNA #2 arrived to work at 7:12 A.M. and worked until 1:01 P.M., on 9/1/24. During an interview on 9/10/24 at 12:01 P.M., CNA #2 said she came into work on 9/1/24 feeling ill and said she had symptoms like the common cold or allergies but felt she was capable of working and decided to wear a surgical mask. She said she did not test for COVID-19 prior to coming into work or upon arrival to the facility prior to starting her assignment. She said as the shift went on, she began feeling worse and like she wasn't capable of continuing to work and told a nurse who told her she needed to test for COVID-19. She said she tested and was positive and went home. She said the following day the facility called her and she informed them she came in feeling sick and had nasal congestion, shortness of breath, a headache and body aches, and as the shift went on, she became very tired and found it difficult to work. She said they asked her which residents she worked with and spent 15 minutes or more with during the shift and she provided them with a list. She said she knew she was sick but felt she was still capable of working until about 1:00 P.M. During a follow up interview on 9/10/24 at 12:15 P.M., the IP said staff are informed not to come into work if they feel ill and to test at home prior to coming in or at the facility upon coming in to ensure they do not have COVID-19. She said CNA #2 should not have come to work in accordance with the guidelines. She said if she could locate any educational documents that the CNA had received this training she would provide it to the survey team. During an interview on 9/10/24 at 12:24 P.M., the Director of Nurses (DON) said staff are trained to not come into work if they are feeling sick and to either test at home or test immediately upon entering the facility if they feel ill to ensure they are not potentially exposing other staff and residents to COVID-19. She said CNA #2 did not follow the guideline and should not have come to work sick or waited until the afternoon to test herself for COVID-19 and the expectation for staff testing when symptomatic of COVID-19 was not met in this circumstance. No evidence that CNA #2 was educated to not attend work if she was ill or to test upon arriving at work could be provided to the survey team prior to exit. 2. Review of the facility's policy titled Post PHE IPC - caring for [Facility Name] Residents and Patients, dated 5/10/23, indicated but was not limited to the following: - It is the policy of the facility to follow state and federal guidance at the end of the federal health emergency, including guidelines for the management of COVID-19. TESTING: In addition to testing when symptoms are present, [Facility Name] is required to perform outbreak testing of residents and staff as soon as possible when a case is identified; if it is determined exposure occurred less than 24 hours (hrs.) ago, then testing is conducted after 24 hrs. from any exposure, if known. - Once a new case is identified the facility tests exposed residents and staff at least every 48 hrs. on the affected unit until the facility goes 7 days without a new case, unless otherwise directed by epidemiology. - In addition, the facility should immediately test any symptomatic residents or staff members. Review of the CDC guidance titled Infection Control Guidance: SARS-COV-2 (COVID-19), dated 6/24/24, indicated but was not limited to the following: Perform COVID-19 Viral testing: - Anyone with even mild symptoms, regardless of vaccination status, should receive a viral test for SARS-COV-2 (COVID-19) as soon as possible - asymptomatic patients with close contact with someone with COVID-19 infection should have a series of three viral tests for COVID-19 infection - testing is recommended immediately (but not sooner than 24 hrs. after the exposure) and, if negative again 48 hrs. (2 days) after the first negative and, if negative again 48 hrs. (2 days) after the second negative test (this is typically day 1, 3, and 5 - with the day of exposure being day zero) During an interview on 9/6/24 at 12:43 P.M., the IP said the facility is using contact tracing for positive COVID-19 staff or residents and testing those who are known to be exposed in accordance with the guidance. She said the residents who are known to be exposed are tested about 24 hrs. after a known exposure and then every two days until they are negative for seven days total. She said the information for resident testing is on the medication administration records (MAR) and/or in the progress notes for each affected resident. She said the facility is using an exposure time of 15 minutes or more within a 24-hr. period to determine if a resident or staff member has potentially been exposed to COVID-19 after having contact with a known positive case. Review of the staff COVID-19 tracking log, provided by the facility, indicated but was not limited to the following: - CNA #2 worked on 9/1/24 with symptoms and tested positive on 9/1/24 while at the facility for COVID-19 - Activity Assistant (AA) #1 was last in the workplace on 9/1/24 and tested positive for COVID-19 at this time (this is the date the facility became aware of the known confirmed exposure from 8/30/24), symptoms started on 8/31/24 in the evening (employee last worked on 8/30/24) Review of the facility's tracking and tracing for COVID-19 positive staff member, AA #1, indicated but was not limited to the following: - staff member experienced nasal congestion, shortness of breath, body aches, and headache on 8/31/24 and tested at the facility on 9/1/24 and was positive for COVID-19 - five Residents (#95, #28, #75, #109, #15) and two additional residents were exposed to AA #1 within the 48-hour look back timeframe (8/30/24), for a total of seven exposed residents on 8/30/24 Review of the facility's tracking and tracing for COVID-19 positive staff member, CNA #2, indicated but was not limited to the following: - staff member tested positive on 9/1/24 after working on that day - four Residents (#278, #427, #43, #87) and three additional residents were exposed to CNA#2 and required COVID-19 testing, for a total of seven exposed residents on 9/1/24 The following five Residents (#95, #28, #75, #109, and #15) were all exposed to AA #1 on 8/30/24, who developed symptoms of COVID-19 on 8/31/24 and notified the facility of a positive COVID-19 test on 9/1/24, prompting outbreak testing to be initiated with a first test date of 9/1/24 expected, in accordance with the guidance. Review of the MAR for Resident #95 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test scheduled to be done, but no documentation the testing was completed 9/8/24 - COVID-19 antigen test completed and negative on 9/9/24 (3 days after the second negative test) Review of the Progress notes for Resident #95 from 9/1/24 through 9/10/24 indicated but were not limited to: - resident was on antibiotic treatment for pneumonia prior to his/her COVID-19 exposure on 8/30/24 - tested negative for COVID-19 on 9/3/24, there were no other progress notes that indicated the Resident had been COVID-19 tested The medical record for Resident #95 failed to indicate the Resident was tested for COVID-19 exposure, as soon as possible following the known exposure, and was not initially tested until 9/2/24. In addition, the record failed to indicate the Resident was tested 2 days (48 hrs) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #28 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed on 9/8/24 and completed and negative on 9/9/24 Review of the Progress notes for Resident #95 from 9/1/24 through 9/10/24 failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #75 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/8/24 Review of the Progress notes for Resident #75 from 9/1/24 through 9/10/24 failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #109 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test scheduled to be done, but no documentation the testing was completed on 9/8/24 Review of the Progress notes for Resident #109 from 9/1/24 through 9/10/24 indicated a COVID-19 test was completed and negative on 9/8/24, however it failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #15 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test was completed on 9/8/24 (no documented results) Review of the Progress notes for Resident #15 from 9/1/24 through 9/10/24 failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. During an interview on 9/6/24 at 12:46 P.M., the IP said it appeared the Residents involved in this particular exposure for outbreak testing were not being tested as they should have been in accordance with the current guidance and could not explain the three-day timeframe following the 9/3/24 negative COVID-19 tests for all five residents involved. The following four Residents (#278, #427, #43 and #87) were all exposed to CNA #2 on 9/1/24, who had symptoms of COVID-19 on 9/1/24 and notified the facility of a positive COVID-19 test on 9/1/24, prompting outbreak testing to be initiated with a first test date of 9/2/24 expected, in accordance with the guidance. Review of the MAR for Resident #278 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/7/24 (4 days after the previous negative test) Review of the Progress notes for Resident #278 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested 2 days (48 hrs.) after a negative COVID-19 test or tested at all after 9/7/24 in accordance with the guidance. Review of the MAR for Resident #427 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/7/24 Review of the Progress notes for Resident #427 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested or attempted to be tested on [DATE] (the timeframe for the initial test following a known exposure), or was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #43 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/7/24 Review of the Progress notes for Resident #43 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested 2 days (48 hrs.) after a negative COVID-19 test or tested at all after 9/7/24 in accordance with the guidance. Review of the MAR for Resident #87 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/7/24 Review of the Progress notes for Resident #87 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested 2 days (48 hrs.) after a negative COVID-19 test or tested at all after 9/7/24 in accordance with the guidance. During an interview on 9/6/24 at 12:46 P.M., the IP said the guidance indicates the testing is within 24 hours of known exposure and then every two days after each negative test after that for a total of three tests or seven days. She said viewing the documentation it appears that the testing was not completed correctly and the guidance was not followed as it should have been. During an interview on 9/10/24 at 8:45 A.M., the Administrator said the facility had reviewed the testing concerns brought to their attention and the testing guidance was not followed as it should have been. During an interview on 9/10/24 at 3:25 P.M., the DON reviewed the MAR and progress note documentation for the referenced residents. She said the residents should have been tested 24 hours after the facility was aware of their exposure to a confirmed case of COVID-19 and then if negative every 48 hrs. or two days after that for a total of three negative tests until the facility went seven days without a new case. She said the testing for the nine Residents exposed to a known positive case of COVID-19 reviewed does not appear to have met the guidance as it should have. 42742 3. Review of the World Health Organization Glove Use Information Leaflet, revised August 2009, indicated but was not limited to the following: Rationale for using medical gloves: Medical gloves are recommended to be worn for two main reasons: 1. To reduce the risk of contamination of health-care workers hands with blood and other body fluids. 2. To reduce the risk of germ dissemination to the environment and of transmission from the health-care worker to the patient and vice versa, as well as from one patient to another. On 9/5/24 at 9:02 A.M., the surveyor observed Nurse #1 prepare nine oral medications (12 pills total) and place them into a medication cup to be administered to Resident #19. At 9:23 A.M., as Nurse #1 began to administer the medications, Resident #19's left hand accidentally made contact with the medication cup causing approximately 5-6 pills to fall out onto the disposable absorbent pad underneath the Resident's buttocks and the mattress's fitted sheet. Nurse #1 picked up the pills with her bare hand, placed them back into the medication cup, and proceeded to administer them to the Resident. Nurse #1 did not perform hand hygiene or don (put on) gloves prior to handling the medications or dispose of them due to potential environmental contamination and to avoid the potential transfer of pathogens from Nurse #1's hand to the medications being administered. During an interview on 9/5/24 at 9:32 A.M., Nurse #1 said she shouldn't have picked up the medications with her bare hand and should have worn gloves. She said she would have only disposed of them if they had fallen onto the floor. During an interview on 9/9/24 at 4:06 P.M., the DON said anything that falls out of the medication cup should have been identified and disposed of and replaced. She said Nurse #1 should not have picked the pills up without a glove.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accidents and hazards for one Resident (#19), out of a total sample of 24 residents. Specifically, the facility failed to ensure unauthorized medications were not left at the bedside for the Resident, who was legally blind, to self-administer without a proper assessment of the Resident's mental and physical capabilities to reduce the risk of any potential adverse consequences. Findings include: Review of the facility's policy titled Self-Administration of Drugs, undated, indicated but was not limited to the following: -As part of their overall evaluation, the nurse will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. -In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including but not limited to the resident's: 1. Ability to read and understand medication labels; 2. Comprehension of the purpose and proper dosage and administration time for his or her medications; 3. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them; and 4. Ability to recognize risks and major adverse consequences of his or her medications. -If the staff determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. -The nurse will ask residents who are identified as being able to self-administer medications whether they wish to do so. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. -Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party. Review of Allergan, Inc. manufacturer's product insert, revised June 2022, indicated but was not limited to the following: Refresh Tears Drug Facts: Purpose - Eye lubricant Uses - For the temporary relief of burning, irritation, and discomfort due to dryness of the eye or exposure to wind or sun. May be used as a protectant against further irritation. Warnings: -For external use only. -To avoid contamination, do not touch tip of container to any surface. Replace cap after using. -If solution changes color or becomes cloudy, do not use. -Stop use and ask a doctor if you experience eye pain, changes in vision, continued redness, or irritation of the eye, or if the condition worsens or persists for more than 72 hours. Directions: -Instill 1 or 2 drops in the affected eye(s) as needed. -Use before expiration date marked on container. Resident #12 was admitted to the facility in May 2024 with diagnoses including chronic kidney disease stage 3 and chronic diastolic heart failure. Review of the Minimum Data Set (MDS) assessment, dated 6/3/24, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 and had severely impaired vision. During an observation with interview on 9/4/24 at 8:59 A.M., the surveyor observed Resident #12 lying in bed. One bottle of Refresh artificial tears lubricant, 0.5 fluid ounces (oz.),15 milliliters (ml), was observed on top of the Resident's overbed tray table not stored in the packaging box and did not have a pharmacy label on it. Also observed on top of the tray table were 8 1/2 large round multicolored tablets stored inside a small white porcelain bowl. Resident #12 said the tablets were TUMS (antacids) and took them him/herself when needed. Both medications were highly visible to the surveyor. Resident #12 said the eye drop bottle was from home and used it in both eyes but did not answer as to how many drops he/she was using or how often he/she was using them and said he/she was legally blind. It was unclear if the Resident had requested to self-administer the medications. Review of current Physician's Orders indicated the following: -Calcium Carbonate (antacid) oral tablet chewable 500 milligrams (mg), give 2 tablets by mouth every 8 hours as needed for stomach upset, 5/28/24 Review of the medical record did not indicate a physician's order for the Refresh artificial tears or an order for Resident #12 to self-administer the medications or store them at the bedside. Further review of the medical record failed to indicate a proper assessment had been conducted to determine the Resident's mental and physical capabilities to self-administer medications to reduce the risk of any potential adverse consequences. During an observation with interview on 9/5/24 at 12:59 P.M. and 9/9/24 at 11:37 A.M., the surveyor observed Resident #12 sitting in a recliner chair next to the window. One bottle of Refresh artificial tears lubricant, 0.5 fluid oz., 15 ml was observed on top of the Resident's overbed tray table not stored in the packaging box and did not have a pharmacy label on it. Also observed on top of the tray table were 6 1/2 large round multicolored tablets stored inside a small white porcelain bowl. Resident #12 said he/she was legally blind but just feels for the medications to use them him/herself and knew where they were. The Resident said he/she took them as needed. On 9/9/24 at 11:44 A.M., Nurse #5 entered the room with the surveyor to observe the medications stored at the bedside and self-administered by the Resident. Nurse #5 said she was not aware the medications were at the Resident's bedside. Resident #12 said he/she used the medications as needed and preferred to administer them him/herself. The Resident said he/she used the eye drops a couple times a day but did not answer as to how many drops were used or in which eye or both. During an interview with Nurse #5 and Unit Manager (UM) #2 on 9/9/24 at 11:52 A.M., the surveyor reviewed Resident #12's medical record with Nurse #5 who said there was a physician's order for the antacids but no order to self-administer them or store them at the bedside. Nurse #5 said there wasn't an order for the eye drops and no assessment was done for self-administration of medications. She said the Resident had visual impairment. UM #2 said the Resident was legally blind and probably could not self-administer medications safely due to his/her visual impairment. UM #2 said a self-administration assessment was not done for the Resident. She said the Resident's family brings in medications for the Resident from home but if staff see medications stored at the bedside, they should remove them and notify her. She said she was not aware the Resident had the medications in his/her room. UM #2 said there wasn't a care plan with interventions to address the family bringing in medications for the Resident. Nurse #5 said if a resident wants to keep medications at the bedside, they'll do an assessment for self-administration and keep them stored in a drawer. UM #2 said there would be a physician's order to self-administer each medication and to store them at the bedside but there wasn't. During an interview on 9/9/24 at 4:34 P.M., the Director of Nursing (DON) said if residents have medications with them when they're admitted staff would check to see if there's an order for them and perform a self-administration assessment to see if it's safe for them to self-administer. The DON said she didn't think it was safe for Resident #12 to self-administer as he/she could not really see and could not tell staff how much or when to take them. She said there was no specific consent upon admission to self-administer. She said this is only done if residents have medications in their room and wish to self-administer and that the medications should be stored in a lock box in the room. The DON said staff should have seen the medications in the room and taken them out and if the Resident insisted on self-administering them, then an assessment would have been done. She said there was no physician's order for the eye drops. She said staff want to make sure a resident is capable of self-administering and it's safe to do so.

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for one Resident (#19), out of a total sample of 24 residents. Specifically, the facility failed to ensure nursing staff administered medications per physician's orders and manufacturer's recommendations. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated February 2019, indicated but was not limited to the following: -Five (5) Rights - right resident, right drug, right route, and right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration; 1) when the medication is selected, 2) when the dose is removed from the container, and finally 3) just after the dose is prepared and the medication put away. a. Check #1: Select the Medication - label, container and contents are checked for integrity, and compared against the Medication Administration Record (MAR) by reviewing the five rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the five rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the five rights. -Medications are administered in accordance with written orders of the prescriber. Review of the Asmanex Twisthaler package insert, U.S. Food and Drug Administration (FDA) website: www.fda.gov/drugsatfda, revised January 2008, indicated but was not limited to the following: Indications and Usage: -Asmanex Twisthaler (mometasone furoate inhalation powder) is a corticosteroid indicated for maintenance treatment of asthma as prophylactic therapy in patients 4 years of age and older. Dosage and Administration: -For oral inhalation only -Instruct patients to inhale rapidly and deeply and to rinse mouth after inhalation. Warnings and Precautions: -Candida albicans infection of the mouth and larynx. Monitor patients periodically for signs of adverse effects in the mouth and pharynx. Advise patients to rinse mouth after inhalation. Resident #19 was admitted to the facility in August 2024 and had diagnoses including malignant neoplasm of oropharynx, chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), malignant neoplasm of laryngeal cartilage, chronic cough, malignant neoplasm of floor of mouth, and malignant neoplasm of the tongue. Review of the Minimum Data Set (MDS) assessment, dated 8/21/24, indicated Resident #19 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had a pulmonary medical condition. Review of current Physician's Orders indicated the following: -Asmanex (14 metered Doses) Inhalation Aerosol Powder Breath Activated 220 micrograms (mcg)/ACT (mometasone furoate inhalation), 2 puffs inhale orally one time a day for asthma. Rinse mouth with water after use to reduce aftertaste and incidence of candidiasis. Do not swallow, 8/15/24 On 9/5/24 at 9:27 A.M., the surveyor observed Nurse #1 administer one puff of the Asmanex Twisthaler to Resident #19. Nurse #1 did not instruct the Resident to rinse his/her mouth after inhalation per physician's orders and manufacturer's recommendation to reduce aftertaste and the incidence of candidiasis. Further, Nurse #1 did not administer the second puff per physician's orders and began to exit the room with the medication. Upon inquiry by the surveyor, Nurse #1 returned to the Resident and administered the second puff at 9:30 A.M. During an interview on 9/5/24 at 9:32 A.M., Nurse #1 said she usually gives all the medications but gets nervous when someone is watching. She said all medications should be administered per physician's orders and should have given 2 puffs of Asmanex prior to surveyor intervention. During an interview on 9/5/24 at 11:40 A.M., Nurse #1 said she should have offered water to the Resident after administering the first puff of the Asmanex but didn't. During an interview on 9/9/24 at 4:06 P.M., the Director of Nursing said nursing staff should read the doctor's orders and follow them for medication administration.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services for one Resident (#12), out of a total sample of 24 residents. Specifically, the facility failed to ensure oxygen (O2) equipment was maintained to ensure sanitary conditions to help decrease the risk of potential contamination and infection. Findings include: Review of the facility's policy titled Oxygen Administration, undated, indicated but was not limited to the following: -store tubing in a plastic bag Resident #12 was admitted to the facility in May 2024 and had diagnoses including chronic kidney disease stage 3 and chronic diastolic heart failure. Review of the Minimum Data Set (MDS) assessment, dated 6/3/24, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, did not use oxygen, and had no current respiratory infection or pulmonary disease. The MDS also indicated the Resident had severely impaired vision. Review of current Physician's Orders indicated the following: -May have supplemental O2 for comfort every shift for shortness of breath, 7/30/24 During an observation with interview on 9/4/24 at 8:59 A.M., the surveyor observed Resident #12 lying in bed. His/her nasal cannula (NC) (lightweight tube which one end splits into two prongs which are placed in the nostrils from which a mixture of O2 and air flows) tubing was observed attached to an O2 concentrator which was in the off position. The remainder of the tubing was resting on the floor potentially exposing it to environmental contaminants. The tubing was not stored in the protective bag observed hanging from the concentrator. The exterior of the concentrator was laden with dust. Resident #12 said he/she used the Oxygen at night because he/she needed it. The Resident said staff turned off the Oxygen that morning and needed staff help because he/she did not know how to work it and needed help putting on and taking off the NC because he/she could not reach it. During an observation with interview on 9/9/24 at 11:32 A.M., the surveyor observed Resident #12 sitting in a recliner chair next to the window. The Resident's NC tubing was observed attached to an O2 concentrator which was in the off position. The tubing was observed hanging over the upper siderail which was in the upright position with the end of the tubing (prongs) resting on the floor potentially exposing it to environmental contaminants. The tubing was not stored in the protective bag observed hanging from the concentrator. The exterior of the concentrator was laden with dust. Resident #12 said he/she guessed the oxygen was for some sort of respiratory reason; wheezing, but only used it at night. The Resident said assistance was needed from staff because he/she could not do anything for him/herself due to being legally blind. Resident #12 said he/she couldn't see the tubing unless staff held it up close. On 9/9/24 at 11:41 A.M., Nurse #5 entered the Resident's room with the surveyor to observe the O2 equipment. Nurse #5 said the NC tubing should not have been on the floor and should have been stored in the plastic bag when not in use. She said the O2 concentrator should be wiped down in the morning when the NC tubing is removed from the Resident's nostrils and as needed when visibly dusty/soiled. During an interview on 9/9/24 at 11:45 A.M., the surveyor reviewed Resident #12's medical record with Nurse #5 who said there was no order to wipe down the concentrator, but it was a standard of practice to do so. She said the physician's order indicated the Resident used supplemental oxygen for comfort. During an interview on 9/9/24 at 4:30 P.M., the Director of Nursing said O2 tubing should be stored in a plastic bag when not in use. She said the machines do get dusty but there was no order to wipe the machines down, including on an as needed basis.

Based on document review, policy review, and interview, the facility failed to maintain and consistently implement an infection prevention and control program for the surveillance of potential illnesses based on the facility identified McGeer criteria. Findings include: Review of the facility's policy titled Infection Prevention and Control Programs, dated as revised October 2018, indicated but was not limited to the following: - Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring adherence to the infection prevention and control practices and detecting unusual pathogens with infectious implications. - Data gathered during surveillance is used to oversee infections and spot trends. Review of the March 2023 Facility Identified Surveillance Line Listing, indicated 30 different potential illness entries. Only 5 of the 30 separate entries included symptoms which was the facility's method to determine infection, and 13 separate entries were counted as infections in the facility. Review of the April 2023 Facility Identified Surveillance Line Listing indicated 36 different potential illness entries. Only 4 of the 36 separate entries included symptoms which was the facility's method to determine infection, and 12 separate entries were counted as infections in the facility. Review of the May 2023 Facility Identified Surveillance Line listing indicated 54 different potential illness entries. Only 2 of the 54 separate entries included symptoms which was the facility's method to determine infection, and 31 separate entries were counted as infections in the facility. During an interview on 6/27/23 at 3:39 P.M., the Infection Preventionist (IP) said the facility used a line listing surveillance form provided by their laboratory to monitor, track and trend illnesses in the facility which resulted in treatments with antibiotics. She said the facility used McGeer criteria (a widely accepted symptomology driven criteria to determine if an illness is at the level of infection) to complete infection surveillance. She said she did not monitor or place residents on surveillance who experienced potential signs and symptoms of an illness and did not begin some type of antibiotic or antimicrobial treatment. She said she was not trained to monitor or place residents on surveillance who were not actively being treated with antibiotics and was unaware the surveillance of all potential illnesses and infections was necessary. She said the nurses documented any resident changes in condition in the medical record, including potential signs and symptoms of an illness. The IP said she would have no way of identifying a trend or possible outbreak without reviewing individual medical records if those symptoms or illnesses did not result in antibiotic treatment. She said she did not document signs and symptoms of an illness consistently on her surveillance line listings for any residents. She reviewed the March through June line listings with the surveyor and said the line listings were incomplete and did not include symptoms for most residents on the surveillance forms. She said she felt she was still learning the process and needed to adjust her practice to meet the guidelines for surveillance of all potential resident illness and be able to identify potential trends of symptoms and illness in the facility. During an interview on 6/27/23 at 4:46 P.M., the Director of Nurses and Administrator were made aware of the surveyor's concerns regarding the missing information on the facility surveillance line listings. The Director of Nurses and the Administrator said they did not realize the surveillance documents required the symptom category to be completed if the symptoms were documented in the individual resident's medical records. During a follow up interview on 6/28/23 at 8:09 A.M., the Administrator said he reviewed the facility's surveillance line listings with the IP and agreed the surveillance could not be effectively accomplished without the symptom column of the line listings being completed for analyzing data and identifying potential infections in the facility and the forms should have been completed. He said it was not practical or the expectation for the IP to review every resident medical record daily for surveillance and the facility will be adjusting the process to complete the symptoms column on the surveillance sheets and ensuring they match the medical records for continuity. Review of the Facility Surveillance Listings for March 2023 indicated, but was not limited to the following for Resident #25: - an illness categorized as a skin problem with a date of onset of 3/4/23 - the section for symptoms indicated only one symptom of swelling - the form indicated the Resident had a healthcare acquired infection (HAI) and was being treated with Keflex (an antibiotic) - the form indicated the illness did count as an infection within the facility The facility line listing failed to indicate Resident #25's symptoms met McGeer criteria for a skin infection. Review of the medical record for Resident #25 indicated, but was not limited to the following: - the skin area was identified by the nurse practitioner (NP) on 3/3/23 and determined to be a possible ingrown toenail of the left great toe - 3/8/23: an infection note indicated the skin area was self-inflicted accidentally while Resident #25 was trimming his/her toenails independently - 3/8/23: a treatment of Keflex (an antibiotic) was ordered and initiated - 3/10/23: an infection note indicating 2 symptoms of potential infection including redness and tenderness - 3/21/23: a completed infection report indicating the following: a. date of onset 3/4/23 (one day after the documented date of onset) b. type of infection: skin, soft tissue c. two symptoms were identified as: swelling at affected site and tenderness or pain at affected site d. evaluation of infection: Criteria was not met for infection: only two of four criteria met; area improved after treatment The documentation in the medical record for Resident #25 did not match the information on the facility surveillance of the potential infection and discrepancies were not explained or resolved. The record indicated the area did not meet infection criteria to count as an infection and the facility surveillance list did count the area as an infection within the facility. Review of the Facility Surveillance Line Listings for April 2023 indicated, but was not limited to the following for Resident #7: - an illness categorized as a skin problem with a date of onset of 4/6/23 - the section for symptoms was left blank - the form indicated the Resident had a healthcare acquired infection (HAI) and was being treated with Diflucan (an antifungal) - the form indicated the illness did count as an infection within the facility Review of the medical record for Resident #7 indicated, but was not limited to the following: - 4/8/23: a nursing note indicating a bright red rash with itch and new order received for treatment with Diflucan - 4/25/23: a completed infection report indicating the following: a. date of onset 4/8/23 (2 days after the surveillance date of onset) b. type of infection: other c. two symptoms were identified as: red rash, itching d. evaluation of infection: criteria met The documentation in the medical record for Resident #7 did not match the information on the facility surveillance of potential infection and discrepancies were not explained or resolved. The date of onset was different by two days, all symptoms documented in the medical record were not documented on the surveillance and the type of infection in the medical record indicated other, while on the surveillance forms in use by the facility indicated skin. Review of the Facility Surveillance Line Listings for April 2023 indicated, but was not limited to the following for Resident #63: - an illness categorized as lower respiratory infection (LRI) with a date of onset of 4/11/23 - the section for symptoms was left blank - the form indicated a chest x-ray (CXR) was completed on 4/11/23, the results section of the form was blank - the form indicated the Resident had a HAI and was being treated with Azithromycin (an antibiotic) - the form indicated the illness did count as an infection within the facility Review of the medical record for Resident #63 indicated, but was not limited to the following: - 4/10/23 at 2:37 P.M., a nursing note indicating nonproductive cough, expiratory wheezes, decreased lung sounds - 4/10/23 at 8:48 P.M., a nursing note indicating moist nonproductive cough and notification of the physician with orders for CXR - 4/11/23: CXR results with findings of: no acute cardiopulmonary process - 4/12/23 at 10:49 P.M., a nursing note indicating congested cough - 4/13/23 at 10:23 P.M., a nursing note indicating low oxygen saturation of 88% earlier in the shift at 5:30 P.M., and treatment with Azithromycin and respiratory inhalers - 4/19/23; a completed infection report indicating the following: a. date of onset 4/11/23 (the day after the documented day of onset in the nursing notes) b. type of infection: lower respiratory c. four symptoms were identified as: new or increase cough, oxygen saturation of less than 94% on room air, new or change lung exam abnormalities, respiratory rate greater than 25 d. evaluation of infection: McGeer criteria was not met; symptoms improved with antibiotics The documentation in the medical record for Resident #63 did not match the information on the facility surveillance sheet, and discrepancies were not explained or resolved. The onset date was different, all symptoms were not documented on the surveillance and the surveillance form indicated the infection would be counted as meeting criteria, as the medical record indicated it did not meet criteria. Review of the facility surveillance line listings for May 2023 indicated, but was not limited to the following for Resident #269: - an illness categorized as urinary tract infection (UTI) with an onset date of 4/27/23 (not previously identified or documented on the April facility surveillance) - the section for symptoms was left blank - the form indicated a urine culture was completed on 4/27/23 and grew the organism Proteus - the form indicated the Resident had a HAI and was being treated with Monurol (an antibiotic) - the form indicated the illness did count as an infection in the facility Review of the medical record for Resident #269 indicated, but was not limited to the following: - 4/27/23: Nurse Practitioner (NP) encounter note indicating Resident self-report of increase urinary frequency, dysuria (painful urination) and incontinence and order for urinalysis and culture to be completed - 4/27/23: UTI SBAR note indicating new or worsening incontinence with frequency and dysuria; section A2 indicated criteria not met - 5/2/23: urinalysis and culture result report from the urine indicated the urine sample was cloudy and contained bacteria with two biotypes of the organism Proteus of counts exceeding 100,000 - 5/4/23: a completed infection report indicating the following: a. date of onset: 4/27/23 b. type of infection: urinary without a catheter c. symptom of acute dysuria d. evaluation of infection: criteria met The documentation in the medical record for Resident #269 did not match the facility surveillance information and discrepancies were not explained or resolved. The medical record reflected symptoms that the facility surveillance form lacked. Review of the Facility Surveillance Line Listings for May 2023 indicated, but was not limited to the following for Resident #268: - an illness categorized as PNU (pneumonia) with an onset date of 5/3/23 - the section for symptoms was left blank - the form indicated a CXR was completed on 5/2/23 and was positive (but specifics were not indicated) - the form indicated the Resident had an HAI and was being treated with Augmentin (a combination antibiotic) - the form indicated the illness did count as an infection in the facility Review of the medical record for Resident #268 indicated, but was not limited to the following: - 5/2/23: NP encounter note indicated: low oxygen saturations during skilled therapy without the use of supplemental oxygen, 79% at rest and 73% while walking (the American lung association indicates good oxygen saturation levels at over 90%); a CXR was ordered - 5/3/23 NP encounter note indicated: CXR of bilateral airspace opacities, patchy modest bilateral airspace disease; and to start antibiotics; resident must pause while speaking to catch his/her breath - 5/5/23: NP encounter note indicated: Resident complaint of catching a good breath and decreased oxygen saturations during skilled therapy, history of atrial flutter and history of pneumonia and respiratory failure with raised concern for possible pulmonary embolism (PE); transfer to emergency room to rule out the possibility of PE - 5/5/23: a completed infection report indicated the following: a. date of onset: 5/2/23 b. type of infection: lower respiratory c. symptoms of oxygen saturations less than 94% on room air and positive CXR d. evaluation of infection: criteria not met The documentation in the medical record for Resident #268 did not match the facility surveillance information and discrepancies were not explained or resolved. The medical record indicated symptoms that the surveillance lacked and the medical record indicated the illness did not meet infection criteria, however, the facility surveillance indicated the illness did meet criteria. During an interview on 6/28/23 at 10:25 A.M., the IP reviewed the records and surveillance line listings of the sampled Residents. She said the surveillance for Resident #25 was incomplete and lacked the documentation of symptoms on the surveillance monitoring tool in use by the facility and the determination of illness versus infection was not clarified as it should have been and the surveillance sheets were inaccurate. She said for Resident #7, the surveillance sheets were inaccurate for the onset date of illness and the record was inaccurate for category type, which should have been skin. She said for Resident #63, the surveillance monitoring tool used by the facility was incomplete and inaccurate as it lacked the necessary symptom documentation and the illness should not have been counted as an infection on surveillance as it did not meet criteria for an infection. She said for Resident #269, the surveillance tool in use by the facility was incomplete and did not reflect the symptoms the resident was experiencing and it should have. She said for Resident #268, the surveillance form was incomplete as it did not reflect the symptoms documented in the medical record and should have and the surveillance was inaccurate in its determination of category of illness as PNU, as it should have been an LRI with a note indicating the possibility of a PE (which is a non-infectious process) and because of the miscategorization of the illness it should not have been counted on the surveillance as an infection and was done so in error. She said she needs to adjust her process for surveillance and monitoring of illnesses for all residents, not just residents on antibiotic treatment. The IP said she needed to work on completing the surveillance sheets with accurate information documented in each section of the form that matches the information in the resident records. The IP said the current process does not enable her to identify trends or potential infections for analysis because the process is incomplete and inaccurate.

Based on document review, policy review, and interview, the facility failed to maintain professional standards for administering pain medication as ordered by a physician for one Resident (#265), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled Physician Medication Orders, dated as reviewed 2021, indicated but was not limited to the following: - No drugs shall be administered except upon the order of a person lawfully authorized to prescribe. - Orders for medications must include: name and strength of drug; dosage and frequency of administration; route of administration; reason or problem for which given. Resident #265 was admitted to the facility in June 2023 with diagnoses which included left femur (upper leg) fracture, osteoporosis, and chronic kidney disease. Review of the current Physician's Orders for Resident #265 included but was not limited to the following: - 6/21/23: Oxycodone HCL (narcotic pain medication) 5 milligram (mg) tablet. Give 0.5 tablet by mouth every 12 hours as needed (PRN) for pain 7-10; total dose 2.5 mg. Review of the Medication Administration Record (MAR) for June 2023 for Resident #265 indicated the following: - 6/22/23 at 6:02 A.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 4 - 6/22/23 at 7:02 P.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 5 - 6/23/23 at 8:43 A.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 3 - 6/24/23 at 10:52 A.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 4 During an interview on 6/27/23 at 10:56 A.M., Nurse #3 said the Resident rarely complains of pain and she herself has only provided one dose of Oxycodone to the Resident (on 6/24/23). Upon review of the MAR and physician's orders for the Resident, she said the Resident is only supposed to be receiving Oxycodone for a pain level of 7 or above, on a 0-10 pain scale and the medication should not have been administered to the Resident on 6/22, 6/23, and 6/24/23 because the pain rating was below the ordered rating for the medication parameters. During an interview on 6/27/23 at 11:14 A.M., Unit Manager #2 reviewed Resident #265's MAR and could not explain why the Resident was administered the PRN Oxycodone outside of the physician ordered parameters. During an interview on 06/27/23 at 2:43 P.M., the Assistant Director of Nurses said she was made aware of the concerns brought forward regarding Resident #265 receiving pain medication outside of the physician's ordered parameters and said the medication should not have been given and the administration of the Oxycodone was an error. She said the nurses should be following the physician's orders and parameters for pain medication and did not.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure his/her safety was maintained to prevent an incident/accident with injury, when nursing staff applied a hot pack to his/her right lower abdomen, and as a result Resident #1 sustained a large second degree burn (partial thickness burn, appears red, blistered, may be swollen and painful) to that area which required treatment with [MEDICATION(S)] (used to treat infections of second and third - degree [CONDITION(S)]) two times a day for 12 days, treatment was changed to Santyl ointment ([MEDICATION(S)] medication used to remove dead tissue from severely burned skin so that the skin can start to heal) and treatment was still on-going at the time of the survey. Findings include: The Policy titled, Hot Packs/Cold Packs - disposable, dated as reviewed March 2021, indicated that hot packs were to be used per physician order and that the treatment is monitored for adverse signs. The Policy indicated to: -place towels or cloth on pack; -the pack should not touch exposed skin; -resident should be checked after ten minutes or sooner; -20 to 30 minutes is the normal treatment time; -physician must prescribe length of time for treatment, frequency and duration; -remove pack and inspect skin; -document treatment effectiveness and any observations. The Dyanrex Instant Hot Pack, undated, indicated that the hot compress is a single use disposable hot pack that is activated by an instant chemical activation process and indicated: -adult supervision recommended; -to avoid contact with the skin; -wrap in a soft cloth before using; -applying the pack directly to the skin will result in injury; -test wrapped pack for temperature and comfort level; -cautioned that peak temperature may reach 160 degrees Celsius once activated; -do not use for longer than 30 minutes. Resident #1 was admitted to the Facility in January 2020, medical history included dementia with behavioral disturbances, [CONDITION(S)], cerebral infarction (stroke), muscle weakness, and muscle spasms. Review of Resident #1's Quarterly Minimum Data Sheet (MDS) Assessment, dated 02/16/22, indicated Resident #1 had moderately impaired cognition. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/28/22, indicated that on 03/24/22 Resident #1 was found with a reddened area on his/her right lower abdomen. The Report indicated that there were two disposable hot packs noted on his/her nightstand and that the Certified Wound Nurse Specialist assessed Resident #1's reddened area. The Report indicated the Wound Nurse noted Resident #1 had a second-degree burn on his/her right lower abdomen caused by the hot pack. The Report indicated that the Nurse Practitioner was notified and ordered [MEDICATION(S)] cream to be applied by nursing to his/her right lower abdomen. Review of the Resident #1's Incident Report, dated 03/24/22, indicated that he/she was found with a reddened area in his/her right lower abdomen that was assessed by the Certified Wound Nurse Specialist as a burn. The Report indicated that hot packs were noted on his/her bedside table, that the Nurse Practitioner was notified and ordered [MEDICATION(S)] cream to be applied to his/her right lower abdomen and that Resident #1 would be followed by the Wound Physician during wound rounds. During an interview on 04/12/22 at 1:50 P.M., the Certified Wound Nurse Specialist said that she assessed Resident #1's right lower abdomen and said he/she had sustained a second-degree burn from the application of a hot pack to his/her right lower abdomen. Review of Resident #1's Wound Evaluation Note, dated 03/24/22, indicated that he/she had a new in-house acquired right lower abdomen second-degree burn which measured 17.41 centimeters (cm) by 9.32 cm. The Note indicated that a physicians order was obtained for nursing to apply [MEDICATION(S)] cream to Resident #1's right lower abdomen. Review of a Wound Physician History and Physical Report, dated 03/29/22, indicated that Resident #1 sustained a second to third degree burn (full thickness burn, that destroys the outer layer of skin (epidermis) and the entire layer beneath) of the right lower abdomen which measured 17.6 cm by 7.8 cm and presented as a deep partial-thickness to full-thickness burn from a hot pack. The Report indicated to apply [MEDICATION(S)] cream to the area twice daily. Review of Nurse #1's written witness statement, dated 03/29/22, indicated that she gave Resident #1 a hot pack and that he/she would remove the hot pack after a few minutes. The statement indicated that when Nurse #1 went back to Resident #1's room, the hot pack was off. During an interview on 04/12/22 at 12:48 P.M., Nurse #1 said that Resident #1 asked her for a hot pack for back pain and that she got him/her a hot pack. Nurse #1 said that shortly afterward, Resident #1 began yelling out for the TV remote, said she went into his/her room and said the hot pack was no longer on his/her back. Nurse #1 said she could not recall if she went back again to check on the hot pack and said Resident #1 usually removes the hot pack himself/herself. Nurse #1 said she could not recall if she documented the application of the hot pack to Resident #1 but said she should have documented the administration of the hot pack to Resident #1 in his/her medical record. Review of Resident #1's Practitioner's Order Transcription Sheet, dated 03/11/22, indicated hot packs every 6 hours as needed (prn) to affected area for pain. Review of Resident #1's Physician Orders, dated 03/24/22 through 04/04/22, indicated nursing to topically apply [MEDICATION(S)] cream 1% to right lower abdomen twice daily for wound care. Review of Resident #1's Physician Progress Note, dated 04/05/22, indicated that he/she required surgical debridement of the right lower abdomen burn to remove nonviable tissue and establish margins of viable tissue. The Note indicated that [MEDICATION(S)] was discontinued and Santyl was ordered to the right lower abdomen burn. Review of Resident #1's Physician Orders, dated 04/05/22 (which were current and still in effect), indicated nursing to topically apply Santyl ointment 250 Unit/Gram ([MEDICATION(S)]) to right lower abdomen once daily for wound care. The Order indicated to cleanse the wound with normal saline, pat dry, apply ointment (nickel thick) to wound bed, cover with damp fluffed gauze and ABD pad (gauze used to absorb discharge from a heavily draining wound) and secure with large [MEDICATION(S)] (waterproof transparent adhesive dressing). During an interview on 04/21/22 at 11:12 P.M., the Director of Nurses (DON) said that Nurse #1 applied a hot pack to Resident #1 and said that when Nurse #1 went back to check on Resident #1, he/she had removed the hot pack. The DON said the next day, Resident #1 was found with a second degree burn to his/her right lower abdomen and said that two hot packs were found on his/her windowsill. The DON said that Resident #1's second degree burn was caused by a hot pack. The DON said there was no documentation in Resident #1's medical record to indicate that the hot pack was applied, where it was applied, that Resident #1's skin was assessed before, during and after the application of the hot pack or the effectiveness of the treatment. The DON said it was her expectation that staff document any treatment that is performed on a resident in their medical record. On 04/12/22, the Facility presented the Surveyor with a plan of correction that addressed the area of concern identified in this survey, the Plan of Correction provided is as follows: A) Resident #1 was immediately assessed by the Certified Wound Nurse Specialist and appropriate interventions and treatment to his/her second-degree burn was initiated. B) 3/29/22, Resident #1 was assessed by the Wound Physician and continues to be assessed by the Wound Physician weekly during wound rounds. C) 3/24/22, All hot packs were accounted for, and are stored/locked in nursing station medication rooms. D) 3/25/22, Facility wide audit was completed on all Resident's who had an order for a hot pack. E) 3/25/22 and 3/28/22, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator (SDC) conducted Educational In-services for nursing department staff on the proper procedure for using hot packs. F) 03/24/22, 03/25/22, 03/28/22 and 03/31/22, the ADON and/or SDC completed Educational In-services on hot packs, that administration is by a nurse only. G) 4/04/22, ADON and/or SDC completed Educational In-service's for nursing on the discontinuation of all disposable hot packs in the Facility. H) The ADON to complete Monthly Audits of Physician Orders to ensure that there are no orders for hot packs. I) The Director of Quarterly Facility Quality Assurance Performance Improvement (QAPI) will be responsible for ensuring on-going audits and will present the findings to the Monthly and Quarterly QAPI committee for 3 months for patterns, trends and continued recommendations for process monitoring and improvement. J) The Director of Nurses is responsible for overall compliance.

Based on interviews and record review the facility failed to prevent the development of an avoidable pressure injury for one Resident (#33) in a total sample of 23 Residents. The facility staff failed to implement effective interventions, failed to follow recommendations for treatment, and failed to follow their skin care program policy. Findings include: Resident #33 was admitted to the facility in May 2020 with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #33 scored a 13 out of 15 on the Brief Interview for Mental Status, indicating no cognitive impairment. The MDS indicated Resident #33 was at risk for pressure injuries, with no skin issues or pressure injuries at the time of assessment. A review of the medical record for Resident #33 indicated the following: On 8/8/20, a nursing note indicated the toes of Resident #33 had reddened areas and a new order was written for skin prep to toes on reddened areas and both heels, two times a day. There was no skin assessment to indicate where the reddened areas were. On 8/12/20 a visit note written by Nurse Practitioner #1 indicated per staff, has been wearing sneakers too small left second toe, hammer toe and to avoid sneakers with a plan for skin prep (a skin protectant) daily. A review of nursing notes following the Nurse Practitioner visit on 8/12/20, including medication and treatment administration documentation, assessments and care plans did not include any interventions between 8/12/20 and 8/22/20, besides the previously ordered skin prep. Ten days following the 8/12/20 Nurse Practitioner visit, a physician's order was written on 8/22/20 for no shoes until the toe healed. There was no additional information to describe the location or skin areas to be healed on the toe. On 8/23/20 a nursing note, written within the medication administration form order, indicated the toe on left foot was very red, inflamed in appearance and the center was dark. There was no documentation that the Nurse Practitioner or the physician was notified of the change in condition. On 8/26/20 a Nurse Practitioner visit note indicated Resident #33 was seen during wound rounds. The Nurse Practitioner described the following: pain over area, mild [DIAGNOSES REDACTED] surrounding with mild slough noted; approximately 5 to 7 millimeters (mm) by 4 to 5 mm; consistent with shoes; area cleaned, [MEDICATION NAME] applied and dressed. The plan written indicated to add [MEDICATION NAME] (antibiotic ointment) twice per day for 10 days and keep covered with gauze. There was never a physician's order written for the application of [MEDICATION NAME] to the wound. During an interview on 10/22/20 at 10:49 A.M., Nurse Practitioner #1 said Resident #33 developed a pressure injury on his/her left second toe related to shoes being worn during rehabilitation services. She said, during wound rounds, herself and the certified wound specialist would determine a treatment plan and then the certified wound specialist or the unit manager would enter the treatment orders in the electronic medical record. During an interview on 10/22/20 at 12:35 P.M., the Director of Rehabilitation services said the rehabilitation department was notified on 8/24/20 that Resident #33 should no longer wear shoes during rehab and provided a form that was signed and dated by the director of rehabilitation. This notification was 12 days after the identification that the shoes were too tight. During an interview on 10/22/20 at 3:13 P.M. the certified wound specialist/Assistant Director of Nurses said Resident #33 was a proud person and had not wanted to stop wearing their shoes. The wound specialist said there was no documentation of resident education regarding shoes and no documentation regarding efforts of alternatives to the shoes from 8/12/20 through 8/22/20. During an interview on 10/22/20 at 4:07 P.M. Resident #33 said he/she did not remember ever telling the staff that he/she refused to take off shoes. He/she indicated wanting to follow their plan of care by pointing to their whiteboard and reading the interventions, I know, no shoes, no socks in bed and use the bed cradle. A review of the August 2020 medication and treatment administration record did not include a treatment of [REDACTED]. During an interview on 10/22/20 at 3:13 P.M. the certified wound specialist said the team had only considered adding [MEDICATION NAME] on 8/26/20 and had decided to wait. She said there was no documentation of this discussion in the medical record. She said she was not sure why they would have done the [MEDICATION NAME] treatment on the day of the visit (8/26/20) and then not followed through with that treatment. She said a wound evaluation form was not completed for Resident #33 during wound rounds on 8/26/20. During an interview on 10/22/20 at 10:49 A.M. Nurse Practitioner #1 said she writes her visit notes as specific as possible, that way if she ordered something she will write what she ordered, or if the team was considering a treatment, she will write that it was being considered. She said she was unaware that the [MEDICATION NAME] treatment was not ordered following the wound rounds on 8/26/20. On 9/1/20 a nursing note indicated the progression of the facility acquired pressure injury to left second toe, measuring 1.8 centimeters (cm) x 1.8 cm, wound base thick yellow adherent slough, slight black eschar around periphery from 6 o'clock to 12 o'clock, surrounding tissue red, cleansed with normal saline, applied dry protective dressing. There was no mention of the [MEDICATION NAME] treatment or documentation that it was done. On 9/2/20 a Nurse Practitioner visit to follow up on the toe pressure injury indicated Resident #33 was seen per staff request, feels that left toe wound is worse. The wound base was approximately 15 mm x 15 mm, positive mild [DIAGNOSES REDACTED] noted surrounding positive scabbed. A plan indicated for the open wound to the left second toe to have a treatment of [REDACTED]. On 9/2/20 a physicians order was written as follows: wound care to left second toe, pustules on left arm cleanse with n/s (normal saline) apply [MEDICATION NAME] two times a day for wound. The order was written for two different body areas, there was no gauze noted and was written 7 days after the original recommendation for [MEDICATION NAME] twice per day with gauze. On 9/3/20 a new wound evaluation was completed for the pressure injury to the left second toe indicating a new (1 month old) unstageable pressure injury to the left second toe; measuring 1.33 cm by 1.24 cm with 100% eschar (dead tissue that sheds or falls off from the skin), the notes section indicated [MEDICATION NAME] and gauze wrap twice per day. This was the first wound evaluation for Resident #33, in the medical record, for the area to the left second toe. During an interview on 10/22/20 at 3:13 P.M. the certified wound specialist said she was not sure why the order for [MEDICATION NAME] was written for two different areas of the skin (left toe and left arm). She said she had not realized the order did not indicate gauze, as it did on the wound evaluation form dated 9/3/20 and from the Nurse Practitioner on 8/26/20. A review of the care plans for Resident #33 on 10/20/20 did not include any care plans for skin areas, skin breakdown or the pressure injury to the left second toe. On 10/22/20 at 7:45 A.M., the Director of Nurses said the skin care plan for Resident #33 was accidentally resolved. A review of the electronic medical record indicated the skin integrity care plan for Resident #33 indicated that the pressure injury was resolved on 8/24/20 and no additional revision had been made to the care plan since that time to clarify that the pressure injury was not resolved . A review of the facility policy for skin care program dated 1/24/20 indicated that Braden assessments were to be completed upon admission and quarterly to assess the risk for skin breakdown. A review of the medical record for Resident #33 indicated the last assessment for the Braden scale for predicting pressure sore risks was dated 5/29/20. At that time, the Braden scale indicated a score of 13, moderate risk to high risk. During an interview on 10/23/20 at 1:58 P.M. the Director of Nurses said there was not a quarterly review of the Braden scale completed for Resident #33 in August 2020, as indicated in their policy to re-evaluate the risk of pressure injury. Resident #33 developed an avoidable pressure injury at the facility. A review of the medical record indicated the unstageable pressure injury to the left second toe was re-evaluated as a Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) as of 10/7/20.

Based on observation and staff interview, the facility failed to ensure that for one Resident (#85), of a total sample of 23 residents, that the facility assessed the Resident to be able to safely self-administer medication prior to the nurse leaving the medication at the bedside. Findings include: On the Pleasant Bay Unit, on 10/22/20 at 8:00 A.M., the surveyor observed Nurse #1 administering medications to Resident #85 during the Medication Pass observation. Nurse #1 poured the following medications to administer to the Resident: -[MEDICATION NAME] 50 mg (milligrams) by mouth twice daily -treats high blood pressure -[MEDICATION NAME] 10 mg by mouth daily -treats allergy symptoms -[MEDICATION NAME] 324 mg, two tablets by mouth daily - treats or prevents [MEDICAL CONDITION] -[MEDICATION NAME], 17 grams, by mouth daily with 8 ounces of fluid of choice -treats constipation Nurse #1 proceeded to the Resident's bedside, informed the Resident that she had the Resident's medications and handed the Resident the [MEDICATION NAME], and [MEDICATION NAME], which the Resident proceeded to take. Nurse #1 said to the Resident that she had his/her [MEDICATION NAME] that was mixed in liquid. The Resident said to Nurse #1 that he/she didn't think he/she needed the [MEDICATION NAME]. The Resident then said to Nurse #1, I'll think about it, and instructed Nurse #1 to leave the medication on the nightstand, which the nurse did. The nurse then left the room with the Resident's [MEDICATION NAME] mixed in liquid on the nightstand without observing the Resident take the medication. After exiting the room, the surveyor questioned Nurse #1 as to why she left the [MEDICATION NAME] at the Resident's bedside, Nurse #1 said, I never leave medication at the bedside. The surveyor said to Nurse #1 that [MEDICATION NAME] is considered a medication and asked her what the facility's policy was on residents administering their own medication. Nurse #1 proceeded to go back to the Resident's room, removed the [MEDICATION NAME], and said to the surveyor that she would check with the nursing supervisor as she was not sure if she should have left the medication with the Resident to self-administer. Nurse #1 provided no evidence that a self-administration of medication assessment was available that determined that the Resident was assessed to administer his/her own medication. During interview on 10/22/20 at 1:45 P.M., the DON (Director of Nursing) said that nurses are required to observe Residents taking all medications prescribed by the physician and are not allowed to leave any medication at the bedside.

Based on observation, record review, policy review and staff interview, the facility failed to ensure that staff implemented a comprehensive, person centered care plan for two of three (#101 & #72) residents for prevention of impairment of their skin integrity related to pressure sore prevention, including monitoring the setting of a pressure relieving mattress. Findings include: Review of the facility policy for Use of Pressure Relieving Devices (undated), indicated the following: -the purpose and objective of the policy is to provide equipment the clinical team feels is necessary to prevent development of pressure injury and/or aid in healing process -air mattress is designed to decrease pressure on the bony prominences that come in contact with the bed. -air mattress initial inflation of the device is weight dependent -proper inflation is checked on a regular basis by wound team during wound rounds 1. For Resident #101, the facility staff failed to ensure that the pressure relieving mattress was set to the correct pressure as identified in the plan of care and failed to document the settings. Resident #101 was admitted in January 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . After a brief hospitalization , Resident #101 was readmitted to the facility on [DATE] with a Stage 2 pressure injury (partial thickness skin loss). Review of the most recent quarterly Minimum Data Set, completed on 9/30/20, indicated the Resident had a Stage 2 pressure ulcer and was receiving skin ulcer treatments, including a pressure reducing device while in bed. Review of the medical record indicated that Resident #101 had a medical decline and was evaluated and began to receive hospice service starting in October 2020. Further review of the medical record indicated that on 10/22/20 the Resident's Stage 2 pressure ulcer measured 2.26 cm (centimeter) X 1.53 cm. and was located on the Resident's coccyx. Review of the Resident's care plan indicated that the Resident has potential/actual impairment of skin integrity related to pressure area-Stage 2 located on the coccyx. One of the intervention indicated to have the pressure relieving air mattress set at 110. On 10/22/20 at 8:25 A.M. the surveyor observed Resident #101 in bed and the air mattress dial was set to 160 lbs. On 10/27/20 at 1:22 P.M. the Wound Care Specialist and the Director of Nurses were interviewed via phone and said it is the responsibility of the CNA staff to ensure that the pressure relieving mattress is set correctly as identified on the Resident's care card that the CNAs use to provide care. Review of the Resident's care card indicated that the pressure relieving air mattress should be set to 110 lbs. The Wound Care Specialist said that she checks all air mattress setting as she conducts her weekly wound rounds. The Wound Care Specials said that she last checked Resident #101's air mattress on 10/22/20, however there was no documented evidence that Resident's air mattress was set at 110 lbs. 2. Resident #72 was admitted to the facility in March 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment with a reference date of 9/2/20, indicated that Resident #72 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15, was dependent on staff for all activities of daily living including bed mobility, was incontinent of both bowel and bladder, and was at risk for developing pressure ulcers. The assessment indicated that Resident #72 had a pressure reducing device for their bed and chair. Review of the medical record indicated that Resident #72 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the interdisciplinary care plan for potential for pressure ulcer development related to a history of ulcers, immobility, incontinence, indicated that by 5/20/20, all wounds had been resolved. Preventative interventions included the use of a pressure relieving air mattress, set at 120 pounds (lbs), implemented on 3/2/2020. On 10/20/20 at 10:59 A.M., the surveyor observed Resident #72 lying in his/her bed awake. An air mattress was in place, functioning, and the dial was set at 160 lbs. On 10/21/20 at 8:47 A.M., the surveyor observed Resident #72 sitting upright in bed. The air mattress was in place, functioning, and the dial was set at 160 lbs. During interview with Unit Manager #3 on 10/22/20 at 10:23 A.M., she said that Resident #72 had an air mattress as a pressure relieving intervention because he/she is at high risk for developing pressure areas due to his/her bed bound status. The Unit Manager said that air mattresses are to be set according to the Resident's weight. The surveyor and Unit Manager reviewed Resident #72's care plan and the Unit Manager confirmed that the air mattress was to be set at 120 lbs. At 10:25 A.M the surveyor and Unit Manager #3 observed Resident #72 lying in bed awake. The air mattress was in place and functioning. The Unit Manager confirmed that the dial was set to 160 lbs, and not 120 lbs as care planned. The Unit Manager reviewed Resident #72's medical record and was unable to find documentation that proper inflation was checked or monitored on a regular basis.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure that Nurse #1 and Nurse #2 followed acceptable standards of practice when, on [DATE], Nurse #1 who was a licensed practical nurse (LPN), misrepresented himself as a physician and manually disimpacted Resident #1 while Nurse #2 observed. Nurse #1 and Nurse #2 had not consulted with Resident #1's physician about Resident #1's rectal pain or obtained an order for [REDACTED]. Findings included: Resident #1's most recently completed Minimum Data Set Assessment, dated [DATE], indicated that his/her cognitive patterns were moderately impaired. Resident #1's Care Plan indicated that he/she had altered gastrointestinal function and a history of constipation. Resident #1's Care Plan interventions included medications as ordered, observing for gastrointestinal distress and notifying the physician as needed. The Surveyor was unable to interview Resident #1 because he/she expired prior to the Survey. The Tenth Edition of the Lippincott Manual of Nursing Practice published in 2014 page 642 indicated that the Standard of Care for Gastrointestinal Dysfunction for a patient with any kind of gastrointestinal disorder indicated that any increased pain, bloating or change in stools should be reported to the health care provider promptly. The Facility Policy regarding fecal impaction indicated that disimpaction could only be performed by a registered nurse or advanced practice nurse with a physician order. The Policy indicated that disposable gloves and lubricating jelly were required equipment for the procedure. Nursing responsibilities for the procedure included: -Explain the procedure to the resident -turn the resident onto his/her side -apply gloves and lubricate the fingers -insert the forefinger into the tip of the resident's anus -attempt to break stool into small pieces while encouraging the resident to push the stool out -continue until the stool is evacuated or the resident becomes too uncomfortable to continue The Surveyor interviewed Certified Nurse Aide (CNA )#1 at 9:00 A.M., on [DATE] and reviewed CNA #1's written statement, dated [DATE]. CNA #1 said that on [DATE], Resident #1 complained of discomfort and difficulty moving his/her bowels. CNA #1 said although Nurse #2 gave Resident #1 an enema, Resident #1 remained unable to move his/her bowels. CNA #1 said that Nurse #1 came to Resident #1's bedside with Nurse #2 and told Resident #1 that he was going to help him/her. CNA #1 said Resident #1 asked Nurse #1 whether he was his/her physician and that Nurse #1 said that he was. CNA #1 said Nurse #1 conducted a procedure on Resident #1's backside. CNA #1 said although she could not see precisely what Nurse #1 was doing to Resident #1's backside because she kneeled at the head of Resident #1's bed to comfort Resident #1, she thought that Nurse #1 disimpacted Resident #1. CNA #1 said and her written statement indicated that Nurse #1 wore gloves and had lubricant in his hand. CNA #1 said and her written statement indicated, Resident #1 wanted Nurse #1 to stop. CNA #1 said that when Nurse #1 touched Resident #1's backside, Resident #1 screamed and on at least two occasions, Resident #1 screamed words to the effect of stop, and, that hurts. CNA #1 said when Resident #1 asked Nurse #1 to stop, Nurse #1 stopped for a while and resumed the procedure for another minute, and that Nurse #1 said words to the effect of there is more there I need to finish. The Surveyor interviewed Nurse #2 at 10:00 A.M. on [DATE] and reviewed her written statement (undated). Nurse #2 said she recalled the incident in which Resident #1 complained of discomfort and being unable to move his/her bowels. Nurse #2 said she administered an enema and Resident #1 was still unable to move his/her bowels. Nurse #2 said that while Resident #1 was in bed, she assessed him/her and observed a small hard stool at his/her rectum. Nurse #2 said that the stool was hard and she did not think that Resident #1 could pass the stool. Nurse #2 said Resident #1 asked to go to the hospital, said she did not contact Resident #1's physician but asked Nurse #1 for assistance with Resident #1. Nurse #2 said Nurse #1 stated words to the effect of he/she (Resident #1) is not going to the hospital impacted like that, I'll fix it. The Surveyor asked Nurse #2 what she thought Nurse #1 meant by that statement and Nurse #2 said that she thought that Nurse #1 meant that they could not send Resident #1 to the hospital until he/she moved his/her bowels. Nurse #2 said that Nurse #1 accompanied her to Resident #1's bedside. Nurse #2 said that Nurse #1 put on gloves and told Resident #1 that he/she was severely impacted and that he (Nurse #) was there to help him/her feel better. Nurse #2 said and her written statement indicated that Nurse #1 disimpacted Resident #1. Nurse #2 said and review of Resident #1's clinical record indicated that there was no physician order for [REDACTED].>Nurse #2's written statement indicated that Nurse #1 made three or four attempts to disimpact Resident #1 and Resident #1 screamed in pain. Nurse #2 said that ultimately, Nurse #1 removed stool from Resident #1's rectum. The Surveyor interviewed Nurse #1 at 8:20 A.M. on [DATE]. Nurse #1 said that he recalled the incident in which Nurse #2 told him that Resident #1 was constipated and complained of pain. Nurse #1 said that he went to Resident #1's bedside and Resident #1 complained of rectal pain. Nurse #1 said that he had not reported Resident #1's complaints of pain to Resident #1's physician. Nurse #1 said he applied lubricant to Resident #1's rectum to help the stool slide out and hit the stool off Resident #1's rectum without going into Resident #1's rectum. Nurse #1 said that Resident #1 did not have a physician order for [REDACTED]. Although Nurse #1 said he had not disimpacted Resident #1, he was unable to provide an explanation related to the consistent and corroborating statements of CNA #1 and Nurse #2, that indicated he had manually disimpacted Resident #1. Nurse #1's personnel file was reviewed and indicated that he/she was a Licensed Practical Nurse (LPN). Nurse #1 said that he/she had no specific training or competency evaluation by the Facility regarding the procedure to manually disimpact a resident. Nurse #1 said that he knew that the Facility Policy prohibited LPN's from disimpacting residents. Nurse #2 said that on [DATE] she was not aware that the Facility Policy prohibited LPN's from disimpacting residents. On [DATE], the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Nurse #1 was terminated [DATE]. B)Resident #1 was hospitalized on [DATE] and did not return to the Facility. C) On [DATE], the Director of Nurses and the Quality Assurance Director reviewed the care of the Facility residents and found no similar incident in which residents' changes in condition were not documented and reported or scope of practice for nurses regarding disimpaction was violated. D) By [DATE], all Facility Nurses received training on the Facility Policies and Procedures regarding Notifications of Changes, Scope of Practice with regard to disimpaction and Approach to Patients when initiating a procedure. E) The Director of Nurses and the Quality Assurance Director made on-going observations nurses' approach to resident care and documentation for 60 days. F) The Facility's Correction Plan was reviewed by the Quality Assurance Committee on [DATE].

Based on interviews and records reviewed for one of three sampled residents (Resident #1) the Facility failed to ensure that staff treated Resident #1 with dignity and respect, when on [DATE] at approximately 12:00 P.M., Nurse #1 told Resident #1 that he was the physician and manually disimpacted Resident #1 without a physician's orders [REDACTED].#1 to stop. Nurse #2 and Certified Nurse Aide (CNA) #1 stood at Resident #1's bedside comforting Resident #1 during the disimpaction and failed to intervene and stop Nurse #1 despite Resident #1's protests. Findings included: Resident #1's most recently completed Minimum Data Set Assessment, dated [DATE], indicated that his/her cognitive patterns were moderately impaired. Resident #1's Care Plan indicated, he/she had altered gastrointestinal function and history constipation. Resident #1's care plan interventions included medications as ordered, observing for gastrointestinal distress and notifying the physician as needed. The Surveyor was unable to interview Resident #1 because he/she expired prior to the Survey. The Surveyor interviewed Family Member #1 at 1:00 P.M. on [DATE]. Family Member #1 said that on [DATE] she visited Resident #1 at the Facility and Resident #1 told her about the alleged incident. Family Member #1 said that Resident #1 told her that a male nurse at the Facility sexually abused him/her and said it was a horrific and painful experience. Family Member #1 said that Resident #1 stated words to the effect of they put their fist into me. Family Member #1 said Facility staff members told her that Resident #1 was confused about a procedure staff members performed to help with his/her constipation, and Resident #1 alleged that he/she was raped during the procedure. The Surveyor interviewed CNA #1 at 9:00 A.M., on [DATE] and reviewed CNA #1's written statement, dated [DATE]. CNA #1 said that on [DATE], Resident #1 complained of discomfort and difficulty moving his/her bowels. CNA #1 said although Nurse #2 gave Resident #1 an enema, Resident #1 remained unable to move his/her bowels. CNA #1 said that Nurse #1 came to Resident #1's bedside with Nurse #2 and told Resident #1 that he was going to help him/her. CNA #1 said Resident #1 asked Nurse #1 whether he was his/her physician and that Nurse #1 said that he was. CNA #1 said Nurse #1 conducted a procedure on Resident #1's backside. CNA #1 said that although she could not see precisely what Nurse #1 was doing to Resident #1's backside because she kneeled at the head of Resident #1's bed to comfort Resident #1, she thought that Nurse #1 had disimpacted Resident #1. CNA #1 said and her written statement indicated, Nurse #1 wore gloves and had lubricant in his hand. CNA #1 said and her written statement indicated, Resident #1 wanted Nurse #1 to stop. CNA #1 said that when Nurse #1 touched Resident #1's backside, Resident #1 screamed and on at least two occasions, and said Resident #1 screamed words to the effect of stop, and, that hurts. CNA #1 said when Resident #1 asked Nurse #1 to stop, Nurse #1 stopped for a while and resumed the procedure for another minute, and said to Resident #1 words to the effect of there is more there I need to finish. The Surveyor interviewed Nurse #2 at 10:00 A.M. on [DATE] and reviewed her written statement, (undated). Nurse #2 said she recalled the incident in which Resident #1 complained of rectal discomfort and difficulty moving his/her bowels. Nurse #2 said she administered him/her an enema and Resident #1 was still unable to move his/her bowels. Nurse #2 said and her written statement indicated that Resident #1 had a 30 second syncopal ([MEDICAL CONDITION]) episode while on the commode and she and CNA #1 transferred Resident #1 into bed and started oxygen and a nebulizer treatment. Nurse #2 said that while Resident #1 was in bed, she assessed his/her rectal area and saw a small hard stool at his/her rectum. Nurse #2 said that the stool was hard and she did not think that Resident #1 could pass the stool even with administration of a second enema. Nurse #2 said and her written statement indicated, that Resident #1 said he/she wanted to go to the hospital. Nurse #2 said that she left Resident #1's room and told Nurse #1 that Resident #1 wanted to go to the hospital. Nurse #2 said and her written statement indicated, that Nurse #1 said words to the effect of (Resident #1) he/she is not going to the hospital impacted like that, I'll fix it. The Surveyor asked Nurse #2 what she thought Nurse #1 meant by the statement and Nurse #2 said that she thought that Nurse #1 meant that they could not send Resident #1 to the hospital until he/she moved his/her bowels. Nurse #2 said that Nurse #1 accompanied her to Resident #1's bedside. Nurse #2 said and her written statement indicated that Nurse #1 put on gloves and told Resident #1 that he/she was severely impacted and said he (Nurse #1) would help him/her to feel better. Nurse #2 said and her written statement indicated that Resident #1 asked Nurse #1 whether he was a doctor and that Nurse #1 said words to the effect of yes, I am. Nurse #2 said that although she was uncomfortable when Nurse #1 told Resident #1 he was a physician, she thought Nurse #1 was a more experienced nurse trying to get Resident #1 to trust him. Nurse #2 said and her written statement indicated that Nurse #1 disimpacted Resident #1. Nurse #2's written statement indicated that Nurse #1 made three or four attempts to disimpact Resident #1 while Resident #1 screamed in pain. Although Nurse #2's written statement indicated that Resident #1 screamed in pain, Nurse #2 said that she could not recall Resident #1 screaming and said that it was more like a powerful moan. Nurse #2 said that Resident #1 was uncomfortable. Nurse #2 said that Nurse #1 removed stool from Resident #1's rectum and she and CNA #1 cleaned Resident #1. The Surveyor interviewed Nurse #1 at 8:20 A.M. on [DATE]. Nurse #1 said that he recalled the incident in which Resident #1 was constipated and complained of pain. Nurse #1 said that he suggested that Nurse #2 administer an enema and Nurse #2 told him that despite the enema, Resident #1 had not moved his/her bowels and still complained of pain. Nurse #1 said he went to Resident #1's bedside and assessed Resident #1's rectum. Nurse #1 said Resident #1 had a hard stool which had mostly passed. Nurse #1 said that he applied lubricant to Resident #1's rectum to help the stool slide out and used his gloved hand to knock the stool off. Nurse #1 said that when he knocked the stool off he told Resident #1 to push and as more stool passed, Resident #1 said words to the effect of stop stop stop and grunted. Nurse #1 said he did not insert his finger or the lubricant into Resident #1's rectum. The Surveyor asked Nurse #1 whether he told Resident #1 he was a physician and he said that he had not. Nurse #1 was unable to provide an explanation regarding the consistent and corroborating statements of CNA #1 and Nurse #2, who both said that he disimpacted Resident #1 and told Resident #1 that he was a physician.

Based on record review and interviews, for one of five sampled residents, (Resident #1) the Facility failed to ensure Resident #1, who was at risk to fall, was provided a rear latching seat belt to prevent unassisted rising . On 11/11/12 at approximately 11:00 A.M., Certified Nurse Aide (CNA) #1 said he assisted Resident #1 to his/her wheelchair and failed to attach the rear latching seat belt. Resident #1 slid out of the wheelchair onto the foot rests, and sustained a left lower leg laceration that required 11 sutures to close. Findings include: Resident #1 was admitted to the Facility October of 2012, and [DIAGNOSES REDACTED]. The care plan, dated 9/22/12 indicated that Resident #1 was at risk to fall, and had falls on 6/9/12, 6/20/12, 8/23/12, 9/9/12, and 10/26/12, with no injury. Care plan interventions included hipsters which Resident #1 refused to wear, a walker that he/she refused to use, a motion sensor above the bed, a rear latching seat belt in the wheelchair, low bed with mats on the floor, and a wedge cushion in the wheelchair. Resident #1 was observed in the dining room at 8:45 A.M., but was not interviewed due to cognitive deficits. The Surveyor interviewed the Director of Nurses (DON), the Quality Assurance (QA) Nurse, and the Nursing Supervisor on 1/3/13 at 11:25 A.M. The DON, The QA Nurse, and the Nursing Supervisor said Resident #1 had no safety awareness, refused many fall prevention interventions, the falls team carefully assessed and implemented many fall interventions for Resident #1, and the last resort was a rear latching seat belt in the wheelchair. The DON, The QA Nurse, and the Nursing Supervisor said they balanced Resident #1's freedom with his/her safety needs and assessed his/her need for the rear latching seat belt. The safety/enabling device assessment, dated 10/24/12, indicated that Resident #1 required a rear locking seat belt for safety and comfort. The nurse's note and incident report, dated 11/11/12 at 12:00 P.M., indicated that Resident #1, who was sitting in the day room, was found sitting in front of his/her wheelchair, with a left lower leg laceration. The nurse's note indicated that the Physician was notified, and Resident #1 transferred to the Hospital for evaluation and treatment. The Surveyor interviewed Nurse #1 on 1/3/13 at 1:15 P.M. Nurse #1 said she worked on 11/11/12, and between 11:30 A.M. to 12:00 P.M., Resident #1 slid down in front of the wheelchair with his/her feet on the foot rests. Nurse #1 said Resident #1 sustained a large left leg laceration that bled profusely, she notified the Physician, and the Physician ordered Resident #1 transferred to the Hospital for evaluation and treatment. Nurse #1 said the seat belt on the wheelchair was not in place, and it appeared Resident #1 had actually sat on the seat belt. Nurse #1 said she questioned CNA #1 about the incident and CNA #1 said he had not attached Resident #1's seat belt, per plan of care. The Surveyor interviewed CNA #1 on 1/3/13 at 10:45 A.M. CNA #1 said he provided care to Resident #1 on 11/11/12, and assisted Resident #1 out of bed. CNA #1 said at approximately 11:00 A.M., Resident #1 was put back to bed and was provided incontinence care, and he/she was assisted back to his/her wheelchair. CNA #1 said he forgot to attach Resident #1's seat belt to the wheelchair, and he went to lunch. CNA #1 said when he returned to the unit, he found out Resident #1 slid out of the wheelchair, onto the floor. The Hospital emergency room report, dated 11/11/12, indicated that Resident #1 was treated for [REDACTED].#1 was provided an antibiotic to prevent infection.