Every finding on record at Life Care Center of Plymouth

Based on policy review, observation, and interview, the facility failed to maintain professional infection control practices. Specifically, the facility failed to 1. Ensure staff removed dirty gloves prior to reaching into a clean linen cart; 2. Wear surgical masks for source control while in clinical areas of the facility; and 3. Maintain proper personal protective equipment (PPE) use while obtaining and handling BinaxNow COVID-19 testing samples. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) guidelines for Hand Hygiene in Healthcare Settings, not dated, indicated hand hygiene reduces the spread of potentially deadly germs to patients. Further review indicated but was not limited to the following: - Multiple opportunities for hand hygiene may occur during a single care episode. - Hand hygiene should be completed immediately after touching a patient or a patient's environment prior to moving to the next task. - Gloves are not a substitute for hand hygiene. During an observation on 10/14/22 at 7:59 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 enter the room of Resident #6 after donning a gown and gloves to provide care. At 8:01 A.M., CNA #1 opened the room door with her gown and gloves on and proceeded to reach into a clean linen cart that was parked near the Resident's door with her gloves and gown on. During an interview on 10/14/22 at 8:06 A.M., CNA #1 said she needed to retrieve extra towels and that was the reason she reached into the shared clean linen bin outside of the Resident's room. She said she had already started providing care and her gloves and gown were dirty and she should have removed them and performed hand hygiene prior to retrieving more linens. She said she didn't realize until now that her actions contaminated the entire clean linen bin for the unit, and she shouldn't have done that. During an interview on 10/14/22 at 8:42 A.M., the surveyor made the Director of Nurses (DON) and Administrator aware of the infection control breech and staff reaching into a clean linen cart with dirty gloves. The DON and Administrator said staff know better than that and those actions did not meet the expectations of the staff to maintain a clean safe environment and violated the infection control guidelines. 2. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 2022, indicated but was not limited to the following: - Source control refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. - Source control options for healthcare providers (HCP) include a well-fitting facemask. During a tour of the [NAME] unit at 8:09 A.M., the surveyor observed Nurse #1 exit the room of Resident #7 with her facemask pulled down beneath her chin not covering either her nose or mouth and proceed to walk down the hall. Upon seeing the surveyor, she adjusted her mask up over her nose and mouth. During an interview on 10/14/22 at 8:11 A.M., Nurse #1 said she did have her mask pulled down, as she does that so the residents can hear her better. She said she is supposed to have a facemask on covering her nose and mouth at all times while in the resident or clinical care area and she was not following the facility protocols. During an interview on 10/14/22 at 8:42 A.M., the surveyor made the DON and Administrator aware of the PPE breech. The DON and Administrator said the staff know better and they are to wear a facemask in all areas of the facility, even the areas without active COVID-19 cases; this nurse did not follow the infection control guidelines. 3. The BinaxNOW COVID-19 Ag Card is a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes COVID-19 in respiratory specimens, for example nasal swabs. This is considered a form of rapid testing as the results are displayed in 15 minutes. Review of the BinaxNOW COVID-19 Ag Card product insert, revised April 2021, instructions for completing the test included but was not limited to the following: Precautions -Wear appropriate personal protective equipment (PPE) and gloves when running each test and handling specimens. -Inadequate or inappropriate sample collection, storage, and transport may yield false positive or false negative results. -Proper sample collection, storage, and transport are essential for correct results. Review of the CDC guidance titled Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 testing, dated December 2021, indicated but was not limited to the following: - For healthcare providers collecting specimens, maintain proper infection control and use recommended PPE including an N95, eye protection, gloves, and a gown Review of the facility's policy titled COVID-19 ([CONDITION(S)]-CoV-2) Resident testing, dated September 2022, indicated but was not limited to the following: - During specimen collection, facility must maintain proper infection control and use recommended PPE, which includes an N95, eye protection, gloves, and a gown, when collecting the specimen On 10/14/22 at 8:16 A.M., the surveyor observed Unit Manager (UM) #2 exit Resident #2's room without any gloves on carrying a used BinaxNow testing card and swab in her hand and place it in a large pink bin that housed many other testing cards. She then performed hand hygiene (HH) with alcohol-based hand rub (ABHR) and put on a pair of new gloves and entered the room of Resident #1 with a nasal swab, a BinaxNow testing card and a small developer bottle for the testing card. She was not observed to put on a protective gown during testing. She was observed to swab Resident #1's bilateral nares with 5 circles each, place the swab in the testing card, place the developer on the testing card, remove her gloves and perform HH with ABHR. She then picked up the testing card, exited the room and placed the card in the large bin with the other testing cards. She was not observed to have gloves on during the transportation of the used testing card. During an interview on 10/14/22 at 8:22 A.M., UM #2 said she was testing the residents on the unit for COVID-19. She said she did not know it was necessary to wear an isolation gown for protection while performing nasal swabs for COVID-19 testing. When asked about handling the specimens with no gloves on, she said she should not be handling the dirty specimens or placing her hands in a dirty bin without gloves but did not really think about it after she did the nasal swabs themselves. She said she realized she is not meeting the guidelines for the principles of infection control. During an interview on 10/14/22 at 9:57 A.M., the surveyor made the DON and Infection Preventionist (IP) aware of her observations of testing on the Massasoit unit. The DON and IP said a gown is required for testing and collecting specimens and a dirty specimen should not be handled without gloves. They said the nurse did not follow the infection control guidelines.

Based on policy review, document review, observation, and interview, the facility failed to perform BinaxNow, rapid antigen testing per manufacturer's guidelines. Findings include: The BinaxNOW COVID-19 Ag Card is a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes COVID-19 in respiratory specimens, for example nasal swabs. This is considered a form of rapid testing as the results are displayed in 15 minutes. Review of the BinaxNOW COVID-19 Ag Card product insert, revised April 2021, instructions for completing the test included but was not limited to the following: Precautions -Inadequate or inappropriate sample collection, storage, and transport may yield false positive or false negative results. -Proper sample collection, storage, and transport are essential for correct results. Test Procedure -The test card must be flat when performing testing, do not perform testing with the test card in any other positions -Read result window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. Results should not be read after 30 minutes. Note: False negative results can occur if test results are read before 15 minutes. On 10/14/22 at 8:16 A.M., the surveyor observed Unit Manager (UM) #2 exiting the room of Resident #2, carrying a used BinaxNow testing card and swab in her hand and place it in a large pink bin that housed many other used testing cards. The card was labeled with the room number, but not the resident's name or time that testing occurred. She then performed a second COVID-19 nasal swab test on Resident #1, using a nasal swab, a BinaxNow testing card, and a small developer bottle for testing. She was observed to swab Resident #1's bilateral nares with five circles each, place the swab in the testing card, place six drops of developer on the testing card, label the testing card with a room number, and place this testing card into the large pink bin on her mobile workstation. She did not label the card with a time or resident identifier. The surveyor observed that the used test cards that were awaiting results were not lying on a flat surface but in a pile in the bin. During an interview on 10/14/22 at 8:22 A.M., UM #2 said she was testing the residents on the unit for COVID-19. She said once she obtains the nasal swabs, she labels them with a room number, so she knows who needs their results logged. She said she does not time the testing cards because completing tests on one hallway generally takes about 15 minutes and then she reads all tests and logs all results for that hallway when she completes that hall. She said she doesn't know exactly what time each test was completed but each hall testing takes about 15 minutes and that is how she judges the time and why she does not time stamp the testing cards. She said she did not know that the testing cards needed to be lying flat during the testing process. She said she realizes she is not meeting the guidelines for the BinaxNow testing directions. During an interview on 10/14/22 at 9:57 A.M., the surveyor made the DON and Infection Preventionist (IP) aware of her observations of testing on the Massasoit unit. The DON and IP said tests should be timed to ensure they are read timely, and they must lay flat during the development time. They said the nurse did not following the testing guidelines.

Based on observation, interview, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections, including norovirus. Specifically, the facility failed to ensure staff: 1. Reported a Norovirus Outbreak; and 2. Discontinued enhanced barrier precautions when no longer warranted; and 3. Implemented the proper interventions for a resident with Clostridioides Difficile (C. diff) (bacterium which causes severe diarrhea and [CONDITION(S)] (inflammation of the colon)); and 4. Performed proper hand hygiene during a dressing change. Findings include: Review of the facility's Infection Prevention and Control Program (IPCP), dated 7/25/19, indicated, but was not limited to: Goals of the Infection Prevention and Control Program - Reduce the risk of acquisition and transmission of healthcare-associated infections. - Monitor for any occurrences of infection and implement appropriate control measures. - Identify and correct problems relating to infection prevention and control practices. - Ensure compliance with state, federal, and OSHA regulations and Joint Commission standards, when applicable. Outbreaks: - Outbreaks should be reported to your local board of health and/or the MDPH Division of Epidemiology and Immunization and your licensing or certifying agency. Long Term Care Facilities must report clusters to the Department of Public Health's Bureau of Health Care Safety & Quality by using the web-based Health Care Facility Reporting System (HCFRS). The facility must enter the incident type as epidemic/disease. 1. Review of the Outbreak Surveillance Form, dated 2/1/22 through 2/3/22, indicated a total of 11 residents residing on the first floor [NAME] Unit developed signs and symptoms of gastrointestinal illness. Review of the laboratory specimen collection, dated from 2/1/22 through 2/3/22, indicated a total of five residents tested positive for the Norovirus. During an interview on 4/5/22 at 12:43 P.M., the Infection Preventionist (IP) said she was not aware that the Director of Nurses (DON) was to complete a reportable in HCFRS to the Department of Public Health (DPH). She said, in this case, the DON did not report the Norovirus outbreak to the DPH. During an interview on 4/5/22 at 2:45 P.M., the DON said she inquired with the facility's corporate person and was told that a reportable was required for the gastrointestinal (GI) outbreak. The DON said the facility failed to complete a reportable for the GI outbreak. 2. Review of the facility's policy titled Transmission-based Precautions and Isolation Procedures, revised 10/05/21, indicated transmission-based precautions are implemented based upon the means of transmission of an infection in addition to standard precautions in order to prevent or control infection. It further indicated, but was not limited to the following: -the facility must establish written standards, policies and protocols that include when and how isolation should be used for a resident and the type and duration of the isolation -isolation should be least restrictive for the resident under the circumstances -enhanced barrier precautions refer to the use of a gown and gloves during high contact care activities that provide an opportunity for multi-drug resistant organisms to transfer to staff hands and clothes -high contact care activities include wound care, dressing, bathing, transferring Resident #73 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record indicated Resident #73 had developed [CONDITION(S)] in the surgical wound and suffered a chronic ulcer at the site of his/her left medial ankle since August 2019. Review of a wound culture of the left ankle confirmed the surgical wound to be positive for [CONDITION(S)], no other sites were indicated as being positive for the [CONDITION(S)] infection. During an observation with interview on 3/31/22 at 1:45 P.M., the surveyor observed an orange sign outside of the room of Resident #73. The sign indicated the Resident was on Enhanced barrier precautions. Unit Manager (UM) #3 said the sign indicated to the staff that Resident #73 had an infection that required the use of precautions. She said the Resident had [CONDITION(S)] in his/her wound which existed prior to admission to the facility. She said the Resident would remain on precautions until the wound was healed and the area would not be re-cultured as it demonstrated no signs or symptoms of infection. UM #3 reviewed the medical record with the surveyor and identified that the left medial ankle wound was healed on 3/14/22 and could not explain why the Resident remained on precautions at that time. Review of the Wound Observation Tool, dated 3/14/22, indicated the Resident was followed by the Wound MD and the left medial ankle wound was resolved, under section 6e. additional comments. Review of the Wound Care Progress Note, dated 3/28/22, indicated Resident #73 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It further indicated the only wound present at the time of assessment on 3/28/22 was the left plantar wound. Review of the Precaution Room Tracking, provided by the Infection Preventionist (IP), dated 3/31/22, indicated Resident #73 was on enhanced barrier precautions for [CONDITION(S)] in his/her left ankle wound. During an interview on 3/31/22 at 3:03 P.M., the IP said she believed the Resident still had an open wound and required precautions for the wound. She reviewed the medical record information with the surveyor and said she believed an error was made. The Wound Nurse joined the conversation and said Resident #73 only had one open area and it was on his/her left plantar foot and the area that was positive for the [CONDITION(S)] infection had resolved on 3/14/22. The Wound Nurse said she did not inform the IP the infected wound had healed, nor did she follow up with the attending physician to discontinue the precaution or treatment order. Both the IP and the Wound Nurse reviewed the Resident information with the surveyor and said the enhanced barrier precautions for the [CONDITION(S)] infection should have been discontinued at the time the wound to the left medial ankle had resolved on 3/14/22. The IP said the policy for precautions had not been followed for the discontinuation of precautions. 3. Review of the facility's policy titled [CONDITION(S)] (Clostridioides) Difficile, reviewed 7/25/19, indicated but was not limited to: Contact Precautions: Residents with diarrhea caused by C. difficile should be assigned to a private room with a bathroom that is solely for use by that resident. When private rooms are of limited availability, residents who are fecally incontinent are preferentially assigned to those private rooms. If a private room is not available, the Infection Prevention and Control Team and Regional Clinical Nurse will assess the risks and work with the Resident Care Team to determine the best resident placement options. If the infected resident has to share a room, both residents in that room must have their own commodes and neither resident uses the shared bathroom toilet. According to the Centers for Disease Control and Prevention (CDC), C. difficile spores can be transmitted between patients via environmental surfaces and contaminated hands of health care personnel. Thus, efforts to prevent [CONDITION(S)] Difficile Infection (CDI) must focus on two goals: reducing patient susceptibility to CDI and preventing organism transmission. Prevention of C. difficile transmission is especially challenging because the organism forms spores that can persist on environmental surfaces for months and are resistant to commonly used cleaning agents and alcohol-based hand gels. Resident #373 was admitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . difficile). On 3/31/22 at 11:00 A.M., during the initial tour, the surveyor heard the Maintenance Director and Maintenance Staff #1 questioning each other as to which resident was to receive a commode and where the commode should be placed. The surveyor exited the unit and further investigation indicated: -The Maintenance staff had been discussing a resident that had been admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) -The Resident had not been admitted to a private room; the residents sharing the room had not been provided individual commodes for use. During an interview on 3/31/22 at 1:30 P.M., the Director of Nursing (DON) said the evening staff had known that the Resident was positive for C. diff and did not put the correct interventions into place. During an interview on 3/31/22 at 1:45 P.M., the Infection Preventionist (IP) said the staff should have placed commodes in the room for both residents. She further said that all the equipment is available on the off shifts and the extra commodes are kept in the shower room. She said there is a policy as to what needs to be implemented when a resident is admitted to the facility with C. diff. The IP said the policy states that if a private room is not available, both residents should have a commode placed in the room. The IP said the staff did not follow the policy/protocol for admitting a resident with C. diff. During an interview on 3/31/22 at 2:12 P.M., the DON said the interventions for a resident who was admitted with C. diff should have been put in place and they were not. 4. Resident #70 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Lippincott Nursing Procedures, Eighth Edition, indicated, but was not limited to the following: Hand Hygiene is a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to hand washing, antiseptic hand washing, and antiseptic hand rubbing. Hand hygiene is the single most important procedure in preventing infection. Using an alcohol-based hand sanitizer is appropriate for decontaminating the hands before putting on gloves, after removing gloves, and wound dressings (if hands aren't visibly soiled). Always perform hand hygiene before putting on gloves to avoid contaminating the gloves with microorganisms from your hands. During an observation with interview on 4/4/22 at 9:04 A.M., the surveyor observed Unit Manager (UM) #2 performing Resident #70's sacral wound dressing change. UM #2 removed the old dressing, disposed of it, then removed and discarded her gloves. She put on a new pair of gloves without first performing hand hygiene. UM #2 then measured the wound and removed and discarded her gloves. She again put on a new pair of gloves without first performing hand hygiene. UM #2 said she should have performed hand hygiene between each glove change but did not. During an interview on 4/5/22 at 2:31 P.M., the Infection Control Nurse said staff should be performing hand hygiene prior to putting on gloves and after removing their gloves.

Based on observation and interview, the facility failed to ensure one Resident (#53) could comfortably manipulate their surroundings from a wheelchair level, out of a total sample of 24 residents. Findings include: Resident #53 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/31/22 at 2:02 P.M., Certified Nurse Assistant #2 said Resident #53 gets up and dressed prior to, or at the very beginning, of the day shift and is independent with his/her care. During an observation with interview on 3/31/22 at 2:21 P.M., Resident #53 said that he/she had difficulty completing some of his/her tasks and experienced discomfort. He/she said the sink and mirror were too high as well as the closet bar and, since he/she sits in a wheelchair, he/she has to stretch upward and twist taking frequent rest periods to complete tasks like shaving or removing clothing from the closet. The surveyor observed the Resident demonstrate reaching and stretching for the faucet in the bathroom and for a clear view of the mirror, as well as attempts to reach his/her clothes hanging from the closet bar that was approximately five feet high. Resident #53 said it was uncomfortable and thought the facility could lower the bar and boost the chair to help him/her have an easier time completing the tasks while maintaining his/her independence. During an interview on 4/1/22 at 8:46 A.M., Resident #53 said he/she washed and dressed him/herself independently, but experienced discomfort while reaching, twisting, and stretching to complete the tasks independently. The Resident said he/she had difficulty seeing in the bathroom mirror, reaching the sink, and reaching in the closet related to the height of the closet bar. The Resident further said he/she would like to not have to reach, stretch, or twist to be able to perform the tasks with ease and less discomfort, but was relegated to remain at wheelchair level. Review of the March 2022 activities of daily living (ADL's) documentation for Resident #53 indicated he/she performed dressing and personal hygiene at an independent level. Review of the Occupational Therapy (OT) discharge documentation, dated 12/20/21, indicated Resident #53 was discharged from skilled services at an independent level with his/her ADL's and was moderately independent for wheelchair mobility while safely navigating the environment, and was limited by pain for sink side ADL tasks. During an interview on 4/1/22 at 8:49 A.M., Nurse #2 was made aware of the Resident's concerns and the surveyor's observations and said an OT screen would be an appropriate next step. She said dropping the closet bar could be completed by Maintenance and OT could look at the Resident for an accommodation of his/her wheelchair or mirror in the bathroom and adaptive equipment the Resident may benefit from. Review of the Nursing-Rehab Therapy Referral Screen, dated 4/1/22, indicated Resident #53 was referred to services for grooming and hygiene with upper body pain and complaints of the mirror in the bathroom and the closet bar being too high resulting in the Resident's need to reach and stretch causing back pain from the wheelchair level. During an interview on 4/1/22 at 11:02 A.M., Occupational Therapist #1 said the Resident would be an evaluation for services only and required a different chair cushion to boost him/her up to a height in which he/she could better see in the mirror and reach the faucets for sink use without discomfort. She said Maintenance should lower the Resident's closet bar for ease of use and to allow Resident #53 to remain at an independent level comfortably. During an interview on 4/1/22 at 1:29 P.M., the Director of Nurses said the need for accommodations for Resident #53 should have been noticed by the staff and the expectation was that residents that have the capability of being independent have everything they need within easy reach in their rooms.

Based on interviews and record review, the facility failed to initiate a significant change Minimum Data Set (MDS) for a Resident (#34) with significant weight loss and a new indwelling catheter. Findings include: Resident #34 was admitted to the facility in January 2022. Review of the medical record for Resident #34 indicated on 02/03/22, the Resident weighed 242.1 pounds and on 03/03/22, the Resident weighed 228.4 pounds which was a 5.66% significant weight loss in one month. Review of the medical record indicated Resident #34 complained of [CONDITION(S)] and Resident #34 returned from the Emergency Department on 2/26/22 with an indwelling catheter. Record review indicated the catheter was still in place at the time of the survey on 3/30/22. During an interview on 4/5/22 at 11:44 A.M., the MDS Coordinator said Resident #34 had not been reviewed for a significant change in status and she would review the medical record and follow-up. During an interview on 4/5/22 at 12:39 P.M., the MDS Coordinator said Resident #34 had two changes in condition, the significant weight loss, and the indwelling catheter, and should have had a significant change assessment.

Based on record review, policy review, and interview, the facility failed to ensure that staff developed and provided to residents, a baseline care plan within 48 hours of the resident's admission, that included but was not limited to services and treatments to be administered by the facility, for one Resident (#373), out of a total sample of 24 residents. Specifically, for Resident #373, the facility failed to provide a baseline care plan that included/ addressed oxygen use and transmission-based precautions for Clostridioides difficile (C. diff) (a bacterium that causes severe diarrhea and [CONDITION(S)] (inflammation of the colon)). Findings include: Review of the facility's policy titled Baseline Care Plan, last revised 5/19/21, included but was not limited to: -A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. -In addition, the facility must establish and implement a system, including who to notify, for early detection and management of a potentially infectious, symptomatic resident at the time of admission. This includes the identification and use of appropriate transmission-based precautions. This is important to incorporate into the resident's baseline care plan that must be developed within 48 hours of admission and include the minimum healthcare information necessary to properly care for a resident including physician orders. Resident #373 was admitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . diff. Review of the medical record failed to indicate that a baseline care plan or a comprehensive care plan had been developed within 48 hours of the Resident's admission to the facility that addressed the C. diff, the required transmission-based precautions for residents with C. diff, and oxygen use. During an interview on 4/21/22 at 2:00 P.M., the Director of Nursing said that although the Resident was provided a baseline care plan within 48 hours of admission, it did not address the information for the transmission-based precautions and oxygen use.

Based on interviews and record review, the facility failed to ensure comprehensive care plans were developed for a Resident (#34) with significant weight loss and Resident (#21) for pain management, out of a total sample of 24 residents. Findings include: 1. Resident #34 was admitted to the facility in January 2022. Review of the medical record for Resident #34 indicated on 02/03/22, the Resident weighed 242.1 pounds and on 03/03/22, the Resident weighed 228.4 pounds which was a 5.66% significant weight loss in one month. Review of the Dietitian's Progress Note, dated 3/3/22, indicated the Resident had a weight loss since admission and the nurse practitioner was notified with a plan for the Resident to have ice cream every afternoon from the ice cream shop. Review of the Care Plans for Resident #34 failed to include any information regarding goals or interventions regarding the Resident's nutritional status or weight loss. During an interview on 04/05/22 at 12:08 P.M., the Registered Dietitian said she had not incorporated the Resident's weight loss into the plans of care with personal goals and interventions for Resident #34. 2. Resident #21 was admitted to the facility in November 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -To assess and document the Resident's pain level every shift on a scale of 0-10. -Administer: -Acetaminophen (used to treat Pain) 500 milligrams (MG) tablets, Give two tablets to equal to (1,000 MG), -Excedrin (used to treat pain) Extra Strength Tablets 250-250-65, Give one tablet by mouth every 24 hours as needed for back pain, -[MEDICATION(S)] (used to relieve nerve pain) Capsule 300 MG, Give one capsule by mouth two times a day for pain, -[MEDICATION(S)] Capsule 400 MG, Give one capsule by mouth at bedtime for pain, -[MEDICATION(S)] (used to relieve severe pain) HCL Tablet 5 MG, Give one half tablet (2.5 MG) by mouth every 12 hours for moderate pain (4-6) on a scale of zero to ten, -[MEDICATION(S)] HCL Tablet 5 MG, Give two half tablets (5 MG) by mouth every 6 hours for pain. During an interview on 4/1/22 at 10:15 A.M., Resident #21 said his/her pain level was above 10 on a scale of 0-10. The Resident expressed back pain and general discomfort. During an interview on 4/5/22 at 09:44 A.M., the Resident indicated he/she received [MEDICATION(S)] for pain, [MEDICATION(S)], and extra strength Tylenol. Resident #21 said his/her comfort level was not as good as it should be. Review of the Resident's Care Plans included no Pain Management care plan to address Resident care needs for back pain and general discomfort, despite receiving multiple medications for pain. During an interview on 4/1/22 at 01:45 P.M., Nurse #3 said she does not do care plans and would not know if the care plan was implemented. During an interview on 4/5/22 at 8:30 A.M., Nurse #4 said she was not aware that the Resident's Care Plan for back pain and general discomfort needed to be developed. Nurse #4 said the Minimum Data Set Nurse takes care of the care plans and she would inform the Unit Manager. Nurse #4 said the care plan was not developed.

Based on observation, record review, policy review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for one Resident (#372), out of a total sample of 24 residents. Findings include: Review of the facility's policy titled Oxygen Administration, revised 11/19/21, included but was not limited to: -Verify the Practitioner's order for oxygen therapy because oxygen is considered a medication or therapy and requires a prescription. Documentation: - Record the date and time of oxygen administration; the type of delivery device; the oxygen flow rate; the patient's vital signs, skin color, respiratory effort, and breath sounds. Resident #372 was admitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Oxygen, 1 to 3 Liters (L) every shift to maintain an oxygen saturation (O2 sat) above 90%. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 3:00 P.M.), Evening (3:00 P.M. to 11:00 P.M.) and Night (11:00 P.M. to 7:00 A.M.) shifts. Record review indicated there was documentation on 4/2/22 at 2:25 P.M., 4/1/22 at 2:58 P.M., and 3/31/22 at 3:52 P.M., 2:58 P.M., and 2:52 P.M., as to the liter flow of the oxygen. Further record review indicated there was no documentation as to the exact liter flow (1, 2 or 3) the Resident was receiving on each shift with the corresponding O2 sat for: - 4/1/22- on the evening and night shifts, - 4/2/22-on the evening and night shifts, and - 4/3/22-on the day, evening, and night shifts as to the liter flow of the oxygen to maintain O2 saturations above 90%. Per the facility's policy, the documentation should include the liter flow of oxygen the Resident is receiving. There was no documentation as to the liter flow during the evening and night shifts as indicated above. The documentation that indicated the liter flow of the oxygen had been included in the daily notes for the above dates, however, the order indicated the oxygen saturations are to be checked every shift and should include the liter flow of the oxygen according to the facility's policy and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/5/22 at 1:44 P.M., the Director of Nursing said the facility failed to document the exact liter flow of the oxygen the Resident was receiving according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and staff interview, the facility failed to conduct weekly surveillance testing of staff as indicated in the Centers for Medicare & Medicaid Services (CMS) memo QSO-20-38 NH for two of three staff in the sample. Findings Include: Centers for Medicare & Medicaid Services (CMS) memo QSO-20-38-NH, dated 8/26/20, indicates surveillance testing guidelines for all Long Term Care Facilities. Table 2 of this memo references county positivity rates and the frequency for staff surveillance testing. On 12/10/20, the county positivity rate for the facility was 6.10%, on 12/17/20 it was 7.20%, on 12/24/20 it was 7.48 %, and on 12/31/20 it was 8.20 %. Because the county positivity rate was above 5%, CMS recommended weekly testing for all staff in the facility. 1. During a record review on 1/13/21, Employee # 1, an Occupational Therapist, was scheduled and worked 32 hours weekly during the month of December 2020. Employee #1 was tested twice during the month on 12/2/20 and 12/13/20. This employee did test negative on January 5, 2021. 2. Record review on 1/13/21, Employee # 2, a Licensed Nurse, was scheduled and worked 24 hours weekly during the month of December 2020. Employee #2 was tested twice during the month on 12/2/20 and 12/18/20. This employee did test negative on January 5, 2021 and again on January 12, 2021. During an interview on 1/13/21 at 5:15 P.M., the Infection Preventionist and the Administrator said that the employees did not meet the facility requirement for weekly surveillance testing of staff during the month of December 2020.

Based on record review and staff interview, the facility staff failed to develop a comprehensive policy/procedure to ensure safe and sanitary storage, handling and reheating of food brought to the facility for Residents, from family and visitors. Findings include: During the survey Entrance with the Administrator on 6/11/19, the Surveyor requested to review the facility policy regarding food brought into the facility from visitors for the Residents. Review of the facility policy titled Food brought into the facility from outside sources dated 11/17/17, indicated that the policy was established to meet or exceed the safety and sanitation requirements for Residents as set forth by local, federal and state regulations when food consumed by Residents was not procured or prepared by the facility to reduce the risk of food borne illness. The guidelines indicated that food stored, prepared and distributed in accordance with professional standards for food safety and education for visitors will include safe cooling/reheating process, hot cold temperatures, preventing cross contamination, good hand hygiene, proper storage and appropriate transport of food. On 6/13/19 at 8:00 A.M. the Food Director was interviewed and the Surveyor identified that the Food Policy did not address how the food would be stored, labeled and dated. The policy also did not address what is the proper temperature for reheating in the microwave. The Food Director indicated that there was a posting in each nourishment kitchen identifying how to reheat beverages, food and dating and labeling of Resident's food from home. The posting was reviewed with the Food Director which indicated that reheating beverages in the microwave cannot exceed 140 degrees Fahrenheit and meals should be heated to 160 degrees Fahrenheit then left to cool to 140 degrees Fahrenheit before providing to the Resident. The Surveyor identified to the Food Director that the reheating temperatures were inadequate for food safety based on food safety standards set forth by the Food and Drug Administration and the (YEAR) Food Code.

Based on record review, observation and staff and Resident interviews, the facility staff failed to ensure that Residents who self administer medication were assessed to determine that it is safe to do so and ensure that the medication is secured at the bedside when not in use for 1 (#37) Sampled Resident, from a total sample of 30 Residents. Review of the facility policy for Self Administration of Medications, revised 9/6/17, indicated that if a Resident desires to self administer medication an order would be obtained from the physician, an assessment would be conducted by the interdisciplinary team of the Residents cognitive, physical and visual ability to carry out this responsibility. After the Resident has been assessed and determined to be able to self administer, a further assessment is conducted of the safety of the bedside medication storage, all medications will be secured in a lockable draw. Findings include: For Resident #37, the facility staff failed to follow their policy regarding self administration of medications to ensure that the Resident was safe to do so. Resident #37 was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. The most current Minimum Data Set, as completed on 4/4/19, indicated that the Resident had a Brief Interview for Mental status score of 15 of 15 indicating that the Resident was alert and oriented. On 6/11/19 at 12:00 P.M. the Surveyor observed a nasal spray bottle of [MEDICATION NAME] located on the Resident's tray table, in their room. The Resident was not in his/her room at the time. On 6/12/19 at 8:53 A.M. the Resident was interviewed and asked about the medication, which was again located on the tray table next to the Resident's bed. Resident #37 said that he/she used the [MEDICATION NAME] for allergies [REDACTED]. Resident #37 said that he/she usually used it at night before going to bed. On 6/13/19 at 2:00 P.M. the [MEDICATION NAME] was again observed placed on the Resident's tray table in their room. Review of the medical record indicated that the Resident had a physician's order for ([MEDICATION NAME]) [MEDICATION NAME] (nasal [MEDICATION NAME]) 50 mcg, 1 spray to each nostril at bedtime. The order did not identify if the Resident could self administer this medication. Further review of medical record did not provide documented evidence that the Resident had been assessed or a care plan developed for self administration of medication. On 6/13/19 at 2:15 P.M. Unit Manager #1 was interviewed and asked if Resident #37 had been assessed for self administration for the medication [MEDICATION NAME]. Unit Manager #1 was unable to locate an assessment, a care plan or an order that supports that the Resident could self administer the medication [MEDICATION NAME], as well as leave it at his/her bedside unsecured.

Based on record review and staff interview, the facility failed to ensure that for 5 Residents (#8, #17, #23, #70, #96), out of a total sample of 29 Residents, a comprehensive assessment was completed accurately to reflect the use of restraints (bed bolster mattress and bilateral body pillows). Findings include: 1. Resident #8 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 10/26/17, indicated that Resident #8 had a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had severe cognitive impairment, required assistance with activities of daily living, utilized bed and chair alarms, and had an invoked Health Care Proxy. The MDS did not reflect the use of bed bolsters or body pillows. On 2/8/18 at 6:36 A.M., the Resident was observed in bed lying on a bilateral bolster air mattress with two body pillows positioned along the bilateral bolsters, tucked under a fitted sheet, and two 1/4 side rails in the up position. 2. Resident #70 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 12/14/17, indicated that Resident #70 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living, and had an invoked Health Care Proxy. The MDS did not identify the use of bed bolsters or body pillows. On 2/05/18 at 10:48 A.M., Resident #70's bed was observed to have a bolster air mattress with 2 body pillows, one on each side of the mattress, tucked under a fitted sheet, and two 1/4 side rails in the up position. 3. Resident #96 was admitted to the facility in 12/2012 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 12/28/17, indicated that Resident #96 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living, and had an invoked Health Care Proxy. The MDS did not reflect the use of bed bolsters or body pillows. On 2/07/18 at 12:04 P.M., Resident #96's bed was observed to have bilateral body pillows positioned on either side of the mattress, covered tightly to the mattress by a fitted sheet, with a blanket draped over the mattress, and two 1/4 side rails in the up position. During interview with the Director of Nursing (DON) on 2/8/18 at 9:00 A.M., she said that she was not aware that bed bolsters and body pillows would be considered a restraint. 4. For Resident #17, the facility failed to conduct a comprehensive assessment to accurately reflect the use of restraints (bed bolster mattress and bilateral body pillows). Resident #17 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 1/23/18, indicated that the assessment did not address the use of the bed bolsters and bilateral body pillows (as restraints). The body pillows were secured under the fitted sheets on both sides of the Residents bed. The Resident also had inflatable bed bolsters on both sides of the bed. At 7:00 A.M. on 2/8/18 the Resident was observed in bed with the body pillows secured under the sheets and blankets. The Resident had no access to get out of bed because of the body pillows/bolsters. The Residents movements were severely restricted and would not be able to move about in the bed. On 2/8/28 at 7:09 A.M. the Director of nursing viewed the Resident in bed was made aware of the potential for the secured body pillows and bolsters to be a restraint. 5. For Resident #23, the facility failed to conduct a comprehensive assessment to accurately reflect the use of restraints (bed bolster mattress and bilateral body pillows). Resident #23, was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 11/9/17, indicated that the assessment did not address the use of the bed bolsters and bilateral body (as restraints). On 2/8/28 at 7:09 A.M. the Director of nursing was made aware of the potential for the secured body pillows and bolsters to be a restraint.

Based on record review, observation and Resident and staff interviews, the facility failed to ensure that bilateral bed bolsters, which restricted the Resident's freedom of movement in bed, and therefore restrained the Resident, was not used for convenience for 5 Residents (#8, #17, #23, #70, #96), out of a total sample of 29 Residents. Findings include: Review of the facility's policy and procedure for Restraints, last revised 11/2017, indicated that a restraint of any type would not be used as a substitute for more effective medical and nursing care for the convenience of facility staff. The intent is for each Resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience and prohibits the use of physical restraints to unnecessarily inhibit a Resident's freedom of movement or activity. The facility failed to implement the following components of the policy: -Assess Resident's need for restraint use -Obtain a physician's orders [REDACTED]. -The Resident/Representative must sign the Physical Restraint Informed Consent prior to its use -Develop an individualized, person-centered care plan based upon the Resident's condition and medical symptoms that must be treated and must include the type of restraint, reason for use, alternate methods to be used and method of application. -Interdisciplinary team will review restraint use at the time of the initial interdisciplinary Resident care review, quarterly and when a change is instituted -Documentation must include: the medical symptom being treated, an active plan to decrease usage or for the eventual removal of the restraint 1. Resident #8 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 10/26/17, indicated that Resident #8 had a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had severe cognitive impairment, required assistance with activities of daily living, utilized bed and chair alarms, and had an invoked Health Care Proxy. On 2/8/18 at 6:36 A.M., the Resident was observed in bed lying on a bilateral bolster air mattress with two body pillows positioned along the bilateral bolsters, and bilateral 1/4 side rails up. Review of the medical record indicated a physician's orders [REDACTED]. However, there was no indication for use which included the condition and/or medical symptom that warranted restraint use. Further review of the medical record failed to indicate an initial assessment, written informed consent, documentation of ongoing re-evaluation of the need for the restraint, and a care plan for the use of a restraint which restricted the Resident's freedom of movement, and therefore restrained the Resident. 2. Resident #70 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 12/14/17, indicated that Resident #70 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living, and had an invoked Health Care Proxy. On 2/05/18 at 10:48 A.M., Resident #70's bed was observed to have a bolster air mattress with 2 body pillows, one on each side of the mattress. Review of the medical record indicated a physician's orders [REDACTED]. However, there was no indication for use which included the condition and/or medical symptom that warranted restraint use. Further review of the medical record failed to indicate an initial assessment, written informed consent, documentation of ongoing re-evaluation of the need for the restraint, and a care plan for the use of the restrain which restricted the Resident's freedom of movement, and therefore restrained the Resident. On 2/8/18 at 6:45 A.M., Resident #70 was observed lying in bed sleeping with a bolster air mattress inflated, and 2 body pillows in positioned on either side of the Resident's body with a white blanket tucked around the body pillows and along the side of the air mattress, and bilateral 1/4 side rails up. During subsequent observation with the Director of Nursing (DON) on 2/8/18 at 9:00 A.M., Resident #70 was again seen lying in bed sleeping with a bolster air mattress inflated, and 2 body pillows positioned on either side of the Resident's body with a white blanket covering the Resident and tucked around the body pillows and along the side of the air mattress. The DON lifted the sheet to expose bilateral body pillows under fitted sheet, preventing the Resident from rising and getting out of bed. The DON said that the fitted sheet should not be tucked over the body pillows. 3. Resident #96 was admitted to the facility in 12/2012 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 12/28/17, indicated that Resident #96 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living, and had an invoked Health Care Proxy. On 2/07/18 at 12:04 P.M., Resident #96's bed was observed to have bilateral body pillows positioned on either side of the mattress, covered tightly to the mattress by a fitted sheet, with a blanket draped over the mattress, and bilateral 1/4 side rails up. Review of the medical record indicated a physician's orders [REDACTED]. However, there was no indication for use which included the condition and/or medical symptom that warranted restraint use. Further review of the medical record failed to indicate an initial assessment, written informed consent, documentation of ongoing re-evaluation of the need for the restraint, and a care plan for the use of a restraint which restricted the Resident's freedom of movement, and therefore restrained the Resident. 4. For Resident #17, the facility failed to conduct a restraint assessment to evaluate the use of the bolsters and body pillows. Resident #17 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 1/23/18, indicated that Resident #17 had a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had severe cognitive impairment, required extensive assistance with activities of daily living, utilized bed and chair alarms, and had an invoked Health Care Proxy. Surveyor observations on 2/7/18 through out the day, indicated that Resident was out of bed and in Day room on the unit. Room observations indicated that there were two body pillows in the Resident's room. The body pillows were approximately 50 inches long and approximately 12 inches wide. There was one body pillow that was secured under the fitted sheet on the right side of the Residents bed and the other body pillow was laid across the top of the bed. The Resident also had inflatable bed bolsters on both sides of the bed. Clinical record review indicated that there was no restraint assessment or no informed consent from the Resident's health care proxy, or no evaluation for the use of the bolsters and body pillows. At 7:00 A.M. 2/8/18 the Resident was observed in bed with the body pillows secured under the sheets and blankets. The Resident had no access to get out of bed because of the body pillows/bolsters. The Residents movements were severely restricted and would not be able to move about in the bed. On 2/8/28 at 7:09 A.M. the Director of nursing viewed the Resident in bed and was made aware of the potential for the secured body pillows and bolsters to be a restraint. 5. For Resident #23, the facility failed to conduct a restraint assessment to evaluate the use of the bolsters and body pillows. Resident #23, was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 11/9/17, indicated that Resident #23 had a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had cognitive impairment, required extensive assistance with activities of daily living, utilized bed and chair alarms, had floor mats on both sides of the bed and had an invoked Health Care Proxy. Surveyor observations on 2/7/18 through out the day indicated that there were two body pillows that was secured under the fitted sheets on either side of the Residents bed. The Resident also had inflatable bed bolsters on both sides of the bed. Clinical record review indicated that there was no restraint assessment and no informed consent from the Resident's health care proxy, or no evaluation for the use of the bolsters and body pillows. At 7:00 A.M. 2/8/18 the Resident was observed in bed with the body pillows secured under the sheets and blankets. The Resident had no access to get out of bed because of the body pillows/bolsters. The Residents movements were severely restricted and would not be able to move about in the bed. On 2/8/28 at 7:09 A.M. the Director of nursing viewed the Resident in bed was made aware of the potential for the secured body pillows and bolsters to be a restraint.

Based on record review, observation and staff interview, the Facility failed to ensure that for 5 Residents (#8, #17, #23, #70, #96), of a total sample of 29 sampled Residents, that a Comprehensive Care Plan was developed to address the Residents' use of restraints (bilateral bolsters and bilateral body pillows). Findings included: 1. Resident #8 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 10/26/17, indicated that Resident #8 had a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had severe cognitive impairment, required assistance with activities of daily living, utilized bed and chair alarms, and had an invoked Health Care Proxy. On 2/8/18 at 6:36 A.M., the Resident was observed in bed lying on a bilateral bolster air mattress with two body pillows positioned along the bilateral bolsters, tucked under a fitted sheet, and two 1/4 side rails in the up position. Review of the medical record failed to indicate that an interdisciplinary, person centered care plan was developed for the use of restraints (bilateral bolsters and bilateral body pillows in bed which restricted the Resident's movement). 2. Resident #70 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 12/14/17, indicated that Resident #70 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living, and had an invoked Health Care Proxy. On 2/05/18 at 10:48 A.M., Resident #70's bed was observed to be a bolster air mattress with 2 body pillows, one on each side of the mattress, tucked under a fitted sheet, and two 1/4 side rails in the up position. On 2/8/18 at 6:45 A.M., Resident #70 was observed lying in bed sleeping with a bolster air mattress inflated, and 2 body pillows in positioned on either side of the Resident's body with a white blanket tucked around the body pillows and along the side of the air mattress, and bilateral 1/4 side rails up. Review of the medical record failed to indicate that an interdisciplinary, person centered care plan was developed for the use of restraints (bilateral bolsters and bilateral body pillows in bed which restricted the Resident's movement). 3. Resident #96 was admitted to the facility in 12/2012 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 12/28/17, indicated that Resident #96 had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living, and had an invoked Health Care Proxy. The MDS did not reflect the use of bed bolsters or body pillows. On 2/07/18 at 12:04 P.M., Resident #96's bed was observed bilateral body pillows positioned on either side of the mattress, covered tightly to the mattress by a fitted sheet, with a blanket draped over the mattress, and two 1/4 side rails in the up position. Review of the medical record failed to indicate that an interdisciplinary, person centered care plan was developed for the use of restraints (bilateral bolsters and bilateral body pillows in bed which restricted the Resident's movement). During interview with the Director of Nursing (DON) on 2/8/18 at 9:00 A.M., she said that she was not aware that bed bolsters and body pillows would be considered a restraint. 4. For Resident #17, the facility failed to develop a Comprehensive Care Plan to address the Residents' use of restraints (bilateral bolsters and bilateral body pillows). Resident #17 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 1/23/18, indicated that Resident #17 had a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had severe cognitive impairment, required extensive assistance with activities of daily living, utilized bed and chair alarms, and had an invoked Health Care Proxy. Surveyor observations on 2/7/18 through out the day, indicated that Resident was out of bed and in Day room on the unit. Room observations indicated that there were two body pillows in the Residents room. The body pillows were approximately 50 inches long and approximately 12 inches wide. There was one body pillow that was secured under the fitted sheet on the right side of the Residents bed and the other body pillow was laid across the top of the bed. The Resident also had inflatable bed bolsters on both sides of the bed. At 7:00 A.M. 2/8/18 the Resident was observed in bed with the body pillows secured under the sheets and blankets. The Resident had no access to get out of bed because of the body pillows/bolsters. The Residents movements were severely restricted and would not be able to move about in the bed. Clinical record review indicated that there was no interdisciplinary, person centered care plan developed for the use of restraints (bilateral bolsters and bilateral body pillows in bed which restricted the Resident's movement). On 2/8/28 at 7:09 A.M. the Director of nursing viewed was made aware of the potential for the secured body pillows and bolsters to be a restraint and that a comprehensive care plan was not completed. 5. For Resident #23, the facility failed to develop a Comprehensive Care Plan to address the Residents' use of restraints (bilateral bolsters and bilateral body pillows). Resident #23, was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 11/9/17, indicated that Resident #23 had a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had cognitive impairment, required extensive assistance with activities of daily living, utilized bed and chair alarms, had floor mats on both sides of the bed and had an invoked Health Care Proxy. Clinical record review indicated that there was no interdisciplinary, person centered care plan developed for the use of restraints (bilateral bolsters and bilateral body pillows in bed which restricted the Resident's movement). On 2/8/28 at 7:09 A.M. the Director of nursing viewed was made aware of the potential for the secured body pillows and bolsters to be a restraint and that a comprehensive care plan was not completed.

Based on record review and interview, the facility staff failed to include, in their Facility Assessment, the resources including equipment (medical and non-medical), that are necessary to meet the needs of the residents. Finding include: Review of the Facility Assessment indicated it did not include bed rails in an evaluation of how the facility needs to be equipped and maintained to protect and promote the health and safety of Residents. During an interview on 2/8/18 at 3:20 P.M., the Administrator reviewed the Facility Assessment with the Surveyor and said it was incomplete and did not include bed rails in the evaluation of how the facility needs to be equipped and maintained to protect and promote the health and safety of Residents.

Based on record review and staff observation, the facility failed for 2 of 24 sampled residents ( #9 and 21) to ensure the medications and treatments were administered as ordered by the physician. Findings include: 1. For Resident #9, the Facility failed to ensure that sliding scale (insulin administered according to the blood glucose levels) insulin order was followed according to the physician's orders [REDACTED].>Findings include: 1. Resident #9 was admitted to the Facility 5/2015, and his/her [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. - obtain the blood glucose level before meals and bedtime. - if the blood glucose level was between 150-200 administer 2 units of insulin - if the blood glucose level was between 201-250 administer 3 units of insulin. - if the blood glucose level was between 251-300 administer 4 units of insulin - if the blood glucose level was between 301-350 administer 5 units of insulin - if the blood glucose level was between 351-400 administer 6 units of insulin. - if the blood glucose level was between 401-450 administer 7 units of insulin - if the blood glucose level was between 451-500 administer 8 units of insulin. - if the blood glucose level was between 501-550 administer 9 units of insulin The Surveyor reviewed the MAR for June and July of 2015 and observed the following errors: - on 6/19/15, Resident #9's blood glucose level was 258 at 11:30 A.M. and 3 units was administered to Resident #9 instead of 4 units, per physician's orders [REDACTED].>- on 6/27/15, Resident #9's blood glucose level was 318 at 11:30 AM., and 3 units of insulin was administered instead of 5 units per physician's orders [REDACTED].>-on 6/28/15 Resident #9's blood glucose level was 263 at 4:30 P.M., and 3 units of insulin was administered instead of the 4 units, per physician's orders [REDACTED].>- on 7/1/15, at 4:30 P.M., Resident #9's blood glucose level was 287 and 3 units of insulin was administered instead of the 4 units per physician's orders [REDACTED].>The DON said she investigated the errors on 7/2/15. The DON said Resident #9 did not want the ordered insulin so staff would alter the order, at Resident #9's request. The DON said the Physician was not aware that Resident #9 was not administered the sliding scale insulin, per physician's orders [REDACTED].>2. Resident #21 had been admitted to the facility in 6/2015, for short term placement. The Resident's [DIAGNOSES REDACTED]. Review of the 7/2015 Treatment Administration Record (TAR), indicated that a nurse had transcribed a treatment that included that the nursing staff were to monitor an open area on the right lower back for signs and symptoms of infection; and to apply Alleyvn (a moist dressing for treatment and management of wounds) as needed. The TAR indicated that the treatment had been signed as done on 7/2/15 and 7/3/15. A late entry nurse's note dated 7/3/15 for 7/2/15, indicated the nurse had identified several small open areas on the Resident's back and that he/she complained of itching. The note indicated she applied Sarno (a topical anti-itch cream) and a topical (unnamed) protective ointment and then applied the Alleyvn dressing. Review of the physician orders [REDACTED]. During interview on 7/3/15 at 10:15 A.M., Nurse #1 said that she had not done the treatment yet. The Surveyor inquired about the application of the Sarno and the topical ointment and Nurse #1 said that she would look into it. During interview on 7/3/15 at 2:15 P.M., the Assistant Director of Nurses (ADON) said that the staff had not obtained a physician's orders [REDACTED]. The ADON said that the nursing staff would call the physician to obtained the order and that they would clarify that the Sarno was to be used for itching and was not part of the treatment to the open areas.

Based on record review and interview for 2 of 24 sampled residents (9 and #15), the facility failed to provide services in accordance with the physician's plan of cared. Findings include: 1. For Resident #9, the Facility failed to ensure that sliding scale (insulin administered according to the blood glucose levels) insulin order was followed according to the physician's orders [REDACTED].#9 was admitted to the Facility 5/2015, and his/her [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. - obtain the blood glucose level before meals and bedtime. - if the blood glucose level was between 150-200 administer 2 units of insulin - if the blood glucose level was between 201-250 administer 3 units of insulin. - if the blood glucose level was between 251-300 administer 4 units of insulin - if the blood glucose level was between 301-350 administer 5 units of insulin - if the blood glucose level was between 351-400 administer 6 units of insulin. - if the blood glucose level was between 401-450 administer 7 units of insulin - if the blood glucose level was between 451-500 administer 8 units of insulin. - if the blood glucose level was between 501-550 administer 9 units of insulin Review of the physician's orders [REDACTED]. - if the blood glucose level was between 301-350 administer 2 units of insulin. - if the blood glucose level was between 351-400 administer 3 units of insulin. - if the blood glucose level was between 401-450 administer 3 units of insulin. - if the blood glucose level was between 451-500 administer 4 units of insulin - if the blood glucose level was between 501-550 administer 5 units of insulin. The Surveyor reviewed Resident #9's Medication Administration Record [REDACTED] -there were no blood glucose levels obtained for Resident #9 on the following dates: 6/4/15 at 11:30 AM., 6/7/15 at 7:30 A.M., 6/18/15 at 11:30 A.M., 6/21/15 at 10:00 P.M., 6/24/15 and 6/25/15 both at 4:30 P.M. and 10:00 P.M. and on 6/30/15 at 4:30 PM The Surveyor interviewed the Director of Nurses (DON) on 7/2/15 at 11:00 A.M. The DON said that she investigated the omissions on 7/2/15. The DON said Resident #9 was outside the Facility during the omissions and staff failed to obtain the blood glucose levels because Resident #9 said he/she obtained the levels him/herself. The DON said there was no indication that staff followed up on the missed blood glucose levels. The Surveyor reviewed the MAR for June and July of 2015 and observed the following errors: - on 6/19/15, Resident #9's blood glucose level was 258 at 11:30 A.M. and 3 units was administered to Resident #9 instead of 4 units, per physician's orders [REDACTED].>- on 6/27/15, Resident #9's blood glucose level was 318 at 11:30 AM., and 3 units of insulin was administered instead of 5 units per physician's orders [REDACTED].>-on 6/28/15 Resident #9's blood glucose level was 263 at 4:30 P.M., and 3 units of insulin was administered instead of the 4 units, per physician's orders [REDACTED].>- on 7/1/15, at 4:30 P.M., Resident #9's blood glucose level was 287 and 3 units of insulin was administered instead of the 4 units per physician's orders [REDACTED].>The DON said she investigated the errors on 7/2/15. The DON said Resident #9 did not want the ordered insulin so staff would alter the order, at Resident #9's request. The DON said the Physician was not aware that Resident #9 was not administered the sliding scale insulin, per physician's orders [REDACTED].>2. For Resident #15, the facility failed to ensure the physician order [REDACTED].>Resident #15 was admitted to the facility in 12/2012 and had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], the Resident was alert, oriented and capable of making decision. The MDS indicated the Resident required staff assistance for his/her activities of daily living. Review of the physician orders [REDACTED]. On 4/25/15, the medical record indicated that the nursing staff had made an initial telephone call to arrange the sleep study. However, further review of the medical record, from 4/25/15 through record review on 7/3/15, failed to indicate that the Resident had received the sleep study, as ordered by the physician. During interview on 7/3/15 at 1:00 P.M., Resident #15 said he/she did not know what happen with the sleep study. The Resident said the physician had told him/her to have one and that's all he/she knew. During interview on 7/7/15 at 3:30 P.M., the Director of Nurses said that the process for obtaining the sleep study had been problematic. She said that the staff supplied the sleep study service with information they had requested, but that the appointment had never been scheduled. She said that the physician had not been notified of the delays in obtaining the appointment, as ordered, but that the facility had notified him today (7/7/15).

Based on record review and interviews, for 2 residents (#19 and #24) of a total sample of 24 residents, the facility failed to ensure that care and treatment to each Resident's PICC (peripherally inserted central catheter) line was provided in accordance with the facility's policy. Findings include: 1. Resident #19 was admitted in 05/2015 with [DIAGNOSES REDACTED]. Record review on 7/3/15, revealed the resident was admitted with a PICC (Peripherally Inserted Central Catheter) and had an order to receive intravenous [MEDICATION NAME] 2 grams every four hours via the PICC for a total of 32 days. Review of the Midline and [MEDICAL CONDITION] (Central Venous Access Device) Documentation Form on 7/3/15, revealed that, according to the facility policy, the PICC line dressing was due to be changed every 7 days and PRN (as needed). Documentation on the form indicated that the PICC line dressing was changed on 5/31/15 and should have been changed 7 days later on 6/7/15. The PICC line dressing was not documented as being changed again until 6/11/15. There was also no documentation in the nurses notes to indicate the dressing had been changed at any time prior to 6/11/15. Additionally, the facility's policy for intravenous tubing changes for residents with intermittent infusions, was to change the tubing every 24 hours. Review of the Infusion Therapy Medication Administration Record [REDACTED]. During interview with both the Unit Manager and the Infection Control Coordinator on 7/3/15, both said that the facility's policy for the care and treatment of [REDACTED]. 2. Resident #23 had been admitted in 6/2015 and had [DIAGNOSES REDACTED]. Review of the closed medical record indicated the Resident was to be administered two antibiotics via a PICC, that was located in the left upper extremity and had two lumens (access ports). The antibiotics were [MEDICATION NAME] 1250 mg (milligram), twice a day (6:00 A.M. and 6:00 P.M.) for 12 days and [MEDICATION NAME] 2000 mg, twice a day (12:00 A.M. and 12:00 P.M.) for 12 days. Review of the facility policy for flushes of PICCs was to flush each lumen with 10 ml (milliliters) of saline pre-use, post-use, every 8 hours and at minimum intervals/as needed (PRN). Review of the infusion therapy Medication Administration Record [REDACTED] On 6/6/15, 6/7/15, 6/8/15 there was no evidence the nursing staff flushed the PICC line before and after the administration of the 6:00 A.M. dose of [MEDICATION NAME]; and there was no evidence on 6/7/15 at 12:00 A.M. that the PICC line had been flushed pre and post administration of the [MEDICATION NAME]. Further review indicated that staff had not indicated the lumens were flushed every 8 hours when not in use on 6/5/15, 6/6/15 and 6/7/15, and was flushed 2 out of the 3 times on 6/8/15. During interview on 7/7/15 at 4:30 P.M., the Director of Nurses (DON) said that the staff should be flushing the PICC before and after administration of medication and that it should be clearly documented. The DON said that sometime the nurses document in the nurses notes. Subsequent to the interview with the DON, the nurses' notes were reviewed but did not indicate when flushes were being done and with what solution. The notes failed to consistently document that a nurse had flushed the line as ordered in accordance with the facility's policy.

Based on record review, observation and interview, the facility failed to ensure that it had a medication error rate less than 5%. Based on 2 medication timing errors of 23 total opportunities for error, the facility medication error rate was 8.7%. Findings include: Resident #21 was observed during the initial observation of the medication pass on the morning of 7/2/15 at 10:22 A.M. The Resident was observed on medication pass prior to record review. During observation of medications administered to the resident the medications administered included [MEDICATION NAME] (narcotic [MEDICATION NAME]) 50 mg by mouth and [MEDICATION NAME] (diuretic) 40 mg by mouth. Per interview with Nurse #1, who was administering the medication to the resident, both medications were scheduled for administration at 8:00 A.M. The medications were administered whole with 180 cubic centimeters (cc's) of water. Per review of the Medication Administration Record [REDACTED].M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. and [MEDICATION NAME] (diuretic) 40 mg by mouth at 8:00 A.M. and 2:00 P.M. Nurse #1 when interviewed on 7/2/15 at 10:25 A.M. said, the Medication Administration Record [REDACTED].M. on 7/2/15 and that the next dose of [MEDICATION NAME] was due at 2:00 P.M. on 7/2/15. Nurse #1 said that she normally did not work the day shift and that the facility had no method of alerting the nursing staff to medications that had tight administration times. The facility Director of Nurses and Regional Consultant nurse were interviewed on 7/2/15 at 3:30 P.M. Both said that the facility notified the resident's physician and rescheduled the medications to ensure adequate time between doses. Both said that the facility would create a system that would alert the nursing staff, especially those staff who were new or working outside their normal hours, to resident's who had medications that were time sensitive.

Based on record review and staff interviews, the facility failed to maintain complete clinical records for 2 sampled Residents (#20 and 22) from a total of 24 residents. Findings include: 1. For Resident # 22, the facility failed to ensure that a complete assessment for the RN (Registered Nurse) pronouncement of death was documented in the closed medical record for the Pronouncement of Death that was ordered by the physician. A review of the closed medical record indicated Resident #22 had resided in the facility since ,[DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. A review of the nurses' notes for [DATE] indicated the Licensed Practical Nurse (LPN) observed the resident with shortness of breath and discomfort at 12:30 P.M. Pain medication was administered at 3:45 P.M., 4:45 P.M., 5:45 P.M. and at 7:00 P.M., and after each administration the resident was noted as comfortable. Comfort care, mouth care, positioning and toileting needs were provided for shifts ,[DATE] and ,[DATE]. The resident was found expired. The physician was notified and a RN pronouncement order was given. The clinical record failed to included the assessment by the Registered Nurse of the resident's condition specific to declaration of death. Interview on [DATE] at 3:45 P.M., the Unit Manager #2 said that she was present the date the resident expired and had misunderstood that the nurse (LPN) had completed the nurses' note for the death. The Unit Manager #2 said that she had completed the Pronouncement of Death form required for the State's Registry of Vital Records & Statistics. During interview on [DATE] at 3:50 P.M., the Director of Nurses agreed that the nurse's note for the RN pronouncement was not completed as required. 2. Resident #20 had been admitted in ,[DATE], and had [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the Resident had cognitive impairment and had required assistance of staff for his/her activity of daily living. Review of the admission signed physician's orders [REDACTED]. Review of the ,[DATE] Medication Administration Record [REDACTED]. Review of the ,[DATE] MAR's documentation and nurses notes for the [DATE] and [DATE] time period failed to include any documentation of medication errors. During interview on [DATE] at 3:30 P.M., the Director of Nurses said that the nurse who signed the MAR indicated [REDACTED].

Based on observation, record review, staff interview and resident interview, the facility failed to have systems in place to prevent, to the extent possible, the onset and spread of an outbreak of gastrointestinal illness in the facility. Between 1/7/11 and 2/1/11, a total of 50 residents, 30 staff and 2 visitors developed gastrointestinal illness. The facility failed to implement effective infection control policies and practices to prevent the spread of gastrointestinal illness as follows: 1. The facility failed to contain an outbreak of a highly virulent gastrointestinal infection when first identified in the facility by failing to cohort residents and staff in an effort to prevent the spread of the infection. The facility failed to identify and consistently implement appropriate precautions to prevent cross contamination to other residents and staff. On 1/24/11 and 1/25/11 (1st 2 days of survey), 19 residents were affected by the outbreak, no residents with GI (gastrointestinal) symptoms were observed to be on Contact Precautions. Observations of improper precautionary measures included: staff observed in rooms of residents displaying symptoms without appropriate protective equipment, staff not following proper hand hygiene procedures and handling of infectious waste, the sharing of medical equipment between residents, i.e. blood pressure cuffs, pulse oximeter, stethoscopes, and the lack of appropriate signage per Facility policy to alert staff and visitors to potential infection risks. 2. The facility failed to implement appropriate surveillance, investigation and monitoring measures to reduce the spread of infection by monitoring residents and staff for symptoms of illness, identifying the location of those infected, and determining when previously infected residents and staff were no longer contagious. Prior to the initial tour of the facility, the survey team was informed that the facility was in the midst of a gastrointestinal disease outbreak. The facility administration reported that the illness entered the facility after residents were admitted from a local hospital that had an outbreak of Norovirus. I. Containment The facility failed to provide proper interventions to contain an outbreak of Norovirus in the facility from 1/7/11 to 2/1/11. The facility failed to contain an outbreak of a highly virulent gastrointestinal infection when first identified in the facility on 1/7/11 by failing to cohort residents and staff in effort to prevent the spread of the infection. The facility continued to transfer residents and staff between units. Residents from unit(s) with an outbreak of the illness attended activities and meals in common areas with residents from other areas of the facility without regard for the spread of the disease. Residents and staff recovering from the illness were not restricted from contact with other residents despite being infectious for three days after having symptoms. Health care facilities including dialysis centers, home health agencies, wound clinics and long term care facilities accepting residents for transfer, were not informed of resident illness or of the outbreak in the facility. Visitors including ombudsmen staff and volunteers were not informed that the facility had an outbreak of illness. Beginning on 1/7/11, clusters of Norovirus emerged on the facility units. Between 1/7/11 and 1/8/11, 10 residents on the Massasoit unit developed symptoms that included nausea, vomiting and diarrhea. Between 1/13/11 and 1/15/11, 5 residents on the Massasoit unit and 6 residents on the facility's Alden unit became infected. On 1/19/11 and 1/20/11, the illness spread to the facility's Standish unit, a unit that had not previously been affected. Two new cases of illness developed on those days. On 1/22/11, 11 additional cases developed on the Standish unit. On 1/24/11, the Massasoit unit became reinfected. By 2/1/11, the day of exit, 50 residents and 30 staff had been affected by the virus. A. Contact Precautions The facility failed, from the beginning of the outbreak on 1/7/11 until the time of survey team inquiry on 1/25/11, to place affected residents on contact precautions to minimize the opportunity for transmission of the illness. Contact precautions are required due to the high incidence of transmission of the illness through direct contact with the symptomatic resident as well as through indirect transmission of Norovirus, such as contact with a contaminated object. Contact precautions need to be maintained for 72 hours after the last symptom of illness, as the virus can still be transmitted. During the initial tour, 1st day and 2nd day of survey (1/24/11, 1/25/11,) no personal protective equipment or identification of the room with a "please see nurse before entering" sign, per facility policy, was observed outside the room. Staff, including nurses, nurse aides and housekeeping staff, were noted to be moving between affected resident rooms and non-affected resident rooms without wearing personal protective equipment and performing proper hand hygiene by washing with soap and water. During the initial tour of the Standish unit, 14 residents in 10 rooms were identified as having recent Norovirus. Of the 25 rooms on the Standish unit only 2 were set up for contact precautions and these were for two residents with infections other than Norovirus. On 1/24/11, during interview with the facility infection control nurse (1 PM) and Standish unit manager (during the initial tour), the facility was not maintaining proper contact precautions and was not aware that residents remained contagious for 72 hours after their last symptom. During interview with the facility Director of Nurses and infection control nurse on 1/25/11 at 4 PM, both reported that the residents who had Norovirus were considered to be on contact precautions. Both could not explain why procedures for these residents were not applied like any other resident on contact precautions (i.e. PPE (personal protection equipment)outside room and signage outside room to alert staff/visitors.) They reported that personal protective equipment was available in the clean utility room for staff to use. They could not explain why staff was not using the equipment. Following surveyor inquiry on 1/25/11 and 1/26/11, signage and PPE setups were placed outside rooms affected with Norovirus. Staff were not aware that residents exhibiting evidence of infection required the use of Contact Precautions. For example: 1. Resident #18 was admitted from the local hospital for rehabilitation following a hip fracture requiring surgical repair. Per record review, on 1/24/11 the resident developed signs and symptoms of Norovirus including loose stools and abdominal pain. On 1/25/11 at 4 PM, a Massasoit Certified Nurse Aide (CNA) was observed assisting Resident #18 who was in a wheelchair in the hallway, asking for assistance and visibly upset. A 3-11 licensed staff member provided additional assistance to the CNA to help settle resident #18 into the bed. Both staff members were observed without the use of gown's, gloves or masks. The CNA exited the room without washing her hands. Both staff members were interviewed following exiting the room and acknowledged that they had not applied the appropriate personal protective equipment in order to prevent the transmission of Norovirus. The CNA confirmed that she had not washed her hands prior to leaving the room but that she would do so. 2. On 1/26/11 at 7:20 A, a male CNA (Certified Nursing Assistant) was observed in room [ROOM NUMBER], an isolation room on the Standish Unit. The CNA was wearing an isolation gown, gloves, and a mask on while in the contaminated room. However, he left the room while still wearing his contaminated PPE. He then removed the contaminated PPE while in the hallway, and disposed of it in a white, metal trash container outside the room. Interview with the male CNA acknowledged that he should have removed and disposed of the contaminated PPE while in the resident's room. Interview with the DON (Director of Nursing) immediately following the observation, acknowledged that the CNA's actions were unacceptable. The DON indicated that the CNA had already been educated regarding infection control practices surrounding the Norovirus. However, she stated that he would be given additional education. 3. On 1/26/11 at 7:50 A, there were no masks on either of the two isolation carts between contact isolation rooms #202 and #204 on the Massasoit Unit. 4. On 1/27/11 at 8:48 A, a female CNA (certified nursing assistant) was observed in room [ROOM NUMBER] on the Standish Unit. The residents in the room were identified as being contaminated with the Norovirus. The CNA had a yellow isolation gown on at the time. The gown was observed to be open at the back, exposing the nursing assistant's uniform to the potential for contamination. The Director of Nursing was informed of the inappropriate use of PPE by this CNA. 5. During the medication pass on 1/27/11 at 11:05 AM, interview with the medication nurse confirmed that she used her own personal pulse oximeter to assess oxygen saturation levels on residents who required it. The nurse was observed checking the oxygen saturation of the resident in room [ROOM NUMBER]. The nurse confirmed that this resident's roommate had developed loose stools that morning, and had been placed on contact precautions. Further interview with the nurse acknowledged that use of medical equipment between infectious and non-infectious residents was unacceptable. 6. On 1/27/11 at 11:30 A, the ADON (Assistant Director of Nursing) was interviewed regarding the shared-use of stethoscopes, blood pressure cuffs, pulse oximeters, and patient care equipment, among residents. He indicated that nursing staff had been sharing blood pressure cuffs and stethoscopes between residents affected and non-affected residents. However, he stated that staff wiped the equipment down between use. The ADON later informed the surveyor that the facility was obtaining new blood pressure cuffs and stethoscopes that afternoon, so that nursing staff would no longer have to share equipment between infected and non-infected residents. 7. On 1/28/11 at 12:30 PM, a facility therapist was observed in room [ROOM NUMBER] and was providing direct care for the resident in the A bed. Both the therapist and family member were observed for a prolonged period of time wearing a mask down below the mouth/ nose over the chin area. The staff person moved the mask in to proper position after looking out the door at the surveyor. B. Cohorting of Residents and Staff The facility failed to consider the restricting of exposed residents and staff to prevent the spread of infection to other residents and staff in the facility. There was no cohorting of infected residents. Affected and non affected residents continued to share the same room. The facility continued to transfer residents within the facility without consideration of the potential to contaminate other units. After discussion with the surveyors on 1/25/11, the facility stopped resident transfers between units on 1/26/11. The facility failed to consider which staff was caring for the sick residents and tailor the nursing assignments to minimize the opportunity for transmission. After discussion with the surveyors on 1/25/11, the facility restructured staff assignments on 1/26/11. 1. Resident #23 was admitted from a local hospital to the facility on [DATE] for short term rehabilitation. On 2/1/11 the facility's speech language pathologist was interviewed. The therapist explained that she was out of work on 1/13/11 and 1/14/11 with a gastro-intestinal illness. The therapist further explained that she returned to work on 1/14/11 and that services were provided to Resident #23 on that day. Nurses notes, dated 1/16/11, described that Resident #23 exhibited gastro-intestinal signs and symptoms and that a liquid diet for 24 hours was ordered by the physician. The facility failed to track whether staff that floated unit to unit had been exposed to the illness and consider stopping the practice of floating to minimize the opportunity for transmission between units. On 1/26/11, the facility reported to the surveyors that the practice of floating staff was minimized on 1/13/11. However, the facility could provide no evidence that floating was being monitored and, throughout the survey, when asked about floating, the facility administration had to comb through the schedule to figure out who floated and where. 2. The facility failed to stop affected and non-affected residents from dining in the same location, and failed to put a timely stop to group activities. The facility initially closed the main dining room on 1/7/11, but reopened the dining room on 1/10/11 (including a breakfast buffet) despite the development of symptoms by 4 new residents on 1/8/11 and 1/9/11. When the facility decided to limit activities and dining to the nursing units again on 1/13/11, no consideration was given to the types of activities that should be conducted or whether affected and non-affected residents should participate in dining and activities together on the unit. Activities that involved food and resident to resident contact continued on the units. Both affected and non affected residents were observed eating together in the Standish day room on 1/24/11 and 1/25/11. Staff moved freely between residents without regard to the status of the resident. The facility failed to consider how to manage room assignments of new admissions in order to minimize their potential exposure. The facility was admitting residents into rooms with sick residents from 1/7/11 until 1/25/11. It was not until after discussion with the surveyors on 1/25/11 that the facility decided to stop new admissions on 1/26/11. On 1/11/11, the facility admitted a new resident (Resident #16) into the room of an infected resident (room [ROOM NUMBER]). The infected resident, according to the guidelines, would have been considered contagious until 1/14/11. On 1/15/11, four days after admission, Resident #16 became symptomatic for Norovirus. C. Handwashing The facility failed to ensure that staff was instructed on the importance of hand washing with soap and water, rather than reliance on alcohol based gel, as alcohol gel has been found to be much less effective at sanitizing Norovirus from the hands when compared to soap and water, and failed to institute a more rigorous program of resident hand washing with soap and water. (Please refer to CDC -Norovirus: Technical Fact Sheet 2/2/10). The facility reported that, after the outbreak on 1/7/11, that staff was educated on hand washing. Per review of the inservice, the emphasis was placed on using alcohol gel rather than handwashing with soap and water as recommended by the Centers for Disease Control and Massachusetts Department of Public Health. During interview with the facility administration on 1/25/11 at 4 PM, the facility administrator and director of nurses reported that extra hand sanitizer stations were placed throughout the building in response to the outbreak. Both reported that the facility hand sanitizer would be sufficient against Norovirus. During observation of the lunch meal on the Standish unit on 1/24/11 and 1/25/11, staff was observed moving between affected and non affected residents using hand sanitizer in between residents. Staff was in and out of rooms setting up and feeding residents and in the day room assisting residents to eat. On 1/25/11 at 2:25 PM CNA staff were observed on the Massasoit unit moving from room to room including those affected by the Norovirus (resident #14) passing out nourishments. After surveyor inquiry on 1/25/11 the practice was limited to separate carts for the affected residents. On 1/26/11 at 7:50 A, the alcohol sanitizer dispenser on the wall between contact isolation rooms #202 and #204 was observed to be empty. The nearest alcohol sanitizer dispenser was observed to be on the wall at the end of the hallway just before leaving the Massasoit Unit near room [ROOM NUMBER]. The facility failed, from 1/7/11 to the time of exit on 2/1/11, to develop a systematic handwashing program for residents that utilized soap and water as recommended. The facility reported that an inservice was completed on 1/7/11. Per review of the inservice sign in sheet, staff were instructed to encourage resident handwashing. The inservice did not include that alcohol gel was not a replacement for handwashing with soap and water. D. Environment cleaning The facility failed to ensure that staff responsible for cleaning infected areas were wearing proper personal protective equipment and were modifying cleaning assignments to minimize the opportunity for transmission of the illness. The facility failed to develop a comprehensive environmental disinfection program to minimize the opportunity for transmission of the illness. On 1/26/11, the facility reported that housekeeping staff began a more rigorous environmental cleaning schedule on 1/7/11 in response to the outbreak. However, the facility could provide no evidence of any monitoring or a detailed plan to accomplish the cleaning. It was not until surveyor inquiry on 1/25/11 that the facility began ensuring that housekeeping staff was wearing PPE in affected rooms and had a detailed cleaning schedule to minimize the spread of illness. On 1/26/11 at 4:17P, a male maintenance staff member entered, exited, and re-entered room [ROOM NUMBER] on the Standish Unit. A sign was posted on the door alerting visitors to see the nurse before entering the room. The male maintenance staff member was observed to have no PPE (personal protective equipment) on while in the contaminated room. Interview with a staff nurse on duty at the time, indicated that both of the residents in room [ROOM NUMBER] were on contact precautions. Interview with the maintenance staff member confirmed that he had received in-service education on the Norovirus. He acknowledged that he should have been using the appropriate PPE while in the contaminated room. On 1/26/11 at 7:52 A, the round, white, trash receptacle in room [ROOM NUMBER] on the Standish Unit was noted to be full, with yellow and blue contaminated gowns spilling over onto the floor. On 1/26/11 at 7:58 A, a large, white, metal trash receptacle was observed in the hallway outside of room [ROOM NUMBER] on the Standish Unit. The trash receptacle was filled with foul-smelling PPE and other waste. E. Notification 1. Visitors On 1/25/11 at 11 a.m. the surveyor was contacted by the Regional Ombudsman Director to report that the Facility Ombudsman and the Volunteer Ombudsman were both ill with Norovirus which they developed following visits to the facility. According to the Ombudsman Director, the Volunteer Ombudsman visited all facility units on 1/15/11 and developed the Norovirus on 1/17/11. The Volunteer Ombudsman reported that on her 1/15/11 visit there was no signage alerting visitors of an illness outbreak in the building. The Volunteer Ombudsman visited all units again on 1/22/11. At the conclusion of the visit the Volunteer Ombudsman was alerted by a staff member that the residents in the facility had a flu bug for a couple of weeks. The Volunteer Ombudsman reported that there was no signage alerting visitors of an illness outbreak in the building on 1/22/11. The Volunteer Ombudsman redeveloped the Norovirus on 1/24/11. The Volunteer Ombudsman contacted the facility administration on 1/25/11 to question the process for alerting visitors of an illness outbreak in the building as there were no alerts posted on the 2 consecutive weekends that she visited the facility's residents. The facility administration could not explain why signage was not posted on her visits and was told that the receptionist should have done it. 2. Resident Notification: 1. On 1/25/11 at 11 AM, Resident #11 who was recently admitted to the Massasoit unit for rehabilitation was interviewed. Resident #11 was unaware of an outbreak of Norovirus in the building. On 1/25/11 at P.M the Director of Nurses was asked about how residents were notified about the Norovirus outbreak and was told that the Activity Director had the responsibility to inform residents. Following surveyor inquiry, the facility social worker was observed on 1/25/11 at 2:30 going room to room to discuss and have resident's sign that they received information related to "GI upset and more unit based activities." 2. On 1/25/11 at 2 PM the surveyor observed Resident #14 who was recently admitted to the facility following acute illness, seated on the edge of her bed rubbing her abdomen. As the surveyor entered the room Resident #14 held up her hand in a stop motion and cautioned the surveyor not to get any closer because she was feeling sick to her stomach. "I'm getting sick with something." The resident told the surveyor that she had loose stool earlier that morning felt better and then attended a therapy session in the company of other residents in the rehabilitation room but had to leave early because she didn't feel well. Resident #14 was unaware of other resident's in the building complaining of a viral illness. The Surveyor reported the resident's complaints to the Massasoit Unit Manager who accompanied the surveyor back to the resident's room and observed the facility social worker exiting the room. Upon entering the room Resident #14 stated that she was just informed (by the social worker) that there was an outbreak of GI illness in the building. 3. Notification of other health care providers A. Per record review, resident #12 a new dialysis resident attends dialysis three times per week in the afternoon. On 1/25/11, the surveyor was informed that resident #12's roommate had developed sign and symptoms of Norovirus. Review of the clinical record and dialysis communication book with the Assistant Director of Nurses on 1/27/11 revealed the facility failed to provide any documented evidence of communication to the dialysis center that resident #12 had been exposed to the Norovirus. B. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Per review of the 1/26/11 "Outbreak Surveillance Form" listed that the resident developed Norovirus from 1/8/11 with illness duration ending on 1/8/11 and cleared of infection on 1/12/11. Further review of the form identified that the resident redeveloped Norovirus on 1/13/11 with cessation of symptoms on 1/14/11 and cleared of infection on 1/18/11. Review of the clinical record and dialysis communication book with the Assistant Director of Nurses on 2/1/11 revealed that the facility failed to provide any documented evidence to the dialysis center that resident #17 had Norovirus. C. Resident #15 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Nurses' notes indicated that the resident was seen at the wound clinic, located at a local hospital, on 1/19/11. A wound culture of the right great toe bunion was done at that time. There was no indication that the facility informed the wound clinic that the facility was in the midst of an outbreak of Norovirus. Nurses notes, dated 1/22/11, indicated that Resident #15 was sent to the emergency room because the tissue surrounding the wound on the right great toe was noted to be warm to touch and red. There was no indication that the facility informed the emergency room that the facility was in the midst of an outbreak of Norovirus. D. Resident #22 was readmitted to the facility on [DATE] and was transferred to another skilled nursing facility on 1/17/11. The resident had resided on the Standish unit. The facility had an outbreak of the Norovirus starting 1/7/11 and continued as of 2/1/11. Record review indicated that the resident was screened and accepted by the skilled nursing facility on 1/14/11. Review of the "Referral Summary and Follow-up" form indicated that the resident was given a notice of transfer on 1/14/11, was discharged to a dementia unit in another skilled nursing facility on 1/17/11 and a follow-up call was made on 1/24/11. A "Resident Transfer Form" indicated that the resident had resided on the Standish unit, that the resident "wanders around unit ...agitation at times", and was being transferred to another skilled nursing facility on 1/17/11. Record review showed no evidence that Resident #22 was affected by the virus while at the facility, however, there was no documented evidence that the accepting facility had any information regarding the resident's possible exposure to the Norovirus. E. Social service notes, dated 1/20/11 indicated that Resident #23 requested to be discharged home on[DATE]. A referral was made to a visiting nurses agency for physical therapy, social services and nursing services. Review of the "Social Service Referral Summary and Follow-Up" form indicated that the resident was admitted to the facility on [DATE], that a referral was made to a visiting nurses agency for home services, and that the resident was discharged home on[DATE]. Review of the "Resident Transfer Form" indicated that the resident had lived on the Massasoit unit at the facility and was being discharged home with medications and services. There was no information documented in the "Isolation/Precaution" portion of the form. There was no documented evidence that any information was shared with the visiting nurses agency regarding the resident's Norovirus exposure while at the skilled nursing facility. II. Surveillance The facility failed, from the beginning of the outbreak on 1/7/11 until the time of survey team inquiry on 1/24/11, to develop a line listing of residents that included the onset of symptoms, the duration of the symptoms and the timeframe in which symptomatic residents would be considered no longer contagious (72 hours after symptom resolution per standard guidelines.) During interview with the facility infection control nurse on 1/24/11 at 1 PM, the facility did not have an accurate list of affected residents. The surveyors were handed a loose leaf piece of paper that had 34 resident names on it, room numbers and symptoms. The names were grouped into period of days, rather than exact date of onset of symptoms. It did not contain the duration of illness, or when the resident would be considered no longer contagious. Despite that the facility infection control nurse reported that the list was accurate as of the time it was presented, when comparing it to a partial list compiled during tour, 3 residents from the Standish unit that were identified as recently infected were not included on the list. Per interview with the Director of Nurses and Infection Control Nurse on 1/25/11 at 1 PM, the facility had no policy and procedure for managing an outbreak of gastrointestinal illness. The facility reported that they followed what the infection control nurse at the local hospital "told them to do." During the initial tour of the Standish unit on 1/24/11, 11 residents were identified as having experienced recent Norovirus illness. The unit manager recalled the resident's from memory and had no reference to determine exactly when the residents became affected and were last symptomatic. Some of the residents identified were seen moving about the unit, including the hallways and unit day room, with other unit residents that were not affected. On 1/26/11, when the facility compiled an accurate list, the actual count for 1/24/11 was 13 residents for that unit. Review of the Infection Control Nurse's handwritten notes provided on 1/24/11 listed the names and dates of illness for 6 employees (nursing and an activity staff member) reporting "stomach bug" symptoms for the timeframe 1/7/11 through 1/24/11. There was no information related to the onset of the employee symptoms, duration of symptoms and the timeframe in which symptomatic employees would be considered not contagious (72 hours after symptom resolution.) On 1/25/11 at 10:30 AM, the Infection Control Nurse reported no additional illness had been reported at morning meeting. The Infection Control Nurse stated that it was the responsibility of the department heads to report employee illness to her during morning report. The Infection Control Nurse stated that employees with sign and symptoms of the virus were informed by their respective managers to "stay home for 3 days." According to Massachusetts Department of Public Health Guidelines for Long Term Facilities, Division of Epidemiology and Immunization, revised February 2009, employees are to remain out of work for 3 days following cessation of symptoms. At a meeting with surveyors on 1/25/11 at 4:30 PM, the facility administration presented a performance improvement plan that included the initiation of a formalized surveillance process for tracking employee illness. The Administrative staff was asked about staff education related to Norovirus and what direction staff were given about the length of time they should be out of work following symptom resolution. The administrative staff was unable to explain if they had formalized any education for staff. Following the 1/25/11 meeting, the facility initiated staff education on the CDC's Norovirus Illness key facts. Review of a 1/26/11 "Outbreak Surveillance Form - Staff" with the Infection Control Nurse at 11:30 a.m. identified that 10 employees from the nursing and activities departments were affected with symptoms of the virus from 1/7 - 1/21/11. The Infection Control Nurse could not explain the discrepancies in the numbers of staff initially reported on 1/24/10 and was unable to explain if the prepared list was comprehensive as it did not contain information from any of the ancillary services. The Infection Control Nurse indicated that she would check. On 1/26/11 at 1 PM, a second list was produced that contained a list of 19 employees affected with symptoms of the virus for the timeframe 1/6 - 1/24/11. In addition to nursing staff, dietary cooks, rehabilitation and activity staff were identified. On 1/27/11 at 3 PM an updated staff surveillance list revealed that 5 new cases of employee illness were reported for a total of 24 employees. Further review of the surveillance data revealed that nurses, rehabilitation staff and cook staff had not remained out of work for the required 3 days following the cessation of symptoms. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Per review of the clinical record and confirmed by the Assistant Director of Nurses on 2/1/11 at 11 AM, Resident #17 began complaining of loose stools at 5 AM on 1/7/11 and continued complaining of loose stool through 1/11/11. Review of the 1/26/11 "Outbreak Surveillance Form" inaccurately listed that the resident developed nausea, vomiting and diarrhea from 1/8/11 with illness duration ending on 1/8/11 and cleared of infection on 1/12/11. The surveillance form then identified that the resident redeveloped nausea, vomiting and diarrhea beginning 1/13/11 with cessation of symptoms on 1/14/11 and cleared of infection on 1/18/11. III. Trending/Tracking Education The facility failed to ensure that a comprehensive education program was provided. Per review of facility inservices completed before 1/24/11, no curriculum was associated with any of the teaching sheets. Education relied on the memory of the presenter. The facility could provide no evidence of comprehensive education other than a brief description about the topic and employee signatures. The facility began including curriculum after discussion with the survey team on 1/25/11. From 1/7/11 to exit on 2/1/11, no trending or tracking by location or nursing assignment was completed. No analysis to determine possible contributing factors to the spread of the illness was completed to determine whether common traits between affected residents could be identified. From 1/7/11 to exit on 2/1/11, no "master" float list was maintained and analyzed to determine who floating staff had worked with and whether floating staff could be carrying the virus to non infected areas. The facility reported that on 1/7/11, they had begun reviewing all residents that had symptoms of gastrointestinal illness w