Every finding on record at Lydia Taft House

Based on record review and interview, the facility failed to notify residents, families, and/or resident representatives of COVID-19 positive staff cases that occurred in the facility by 5:00 P.M., the next calendar day during the recent COVID-19 outbreak in April 2023, as required. Findings include: Review of the Centers for Medicare and Medicaid Services Interim Final Rule Updating Requirements for Notification of Confirmed or Suspected COVID-19 Cases of Residents and Staff in Nursing Homes, Reference: QSO-20-29-NH dated May 6, 2022, indicated: - 3) Inform residents, their representatives, and families of those residing in facilities by 5 P.M., the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . Review of the facility's Positive Result COVID Employees list, dated 4/8/2023, indicated one positive COVID-19 case among staff on 4/1/23. During an interview on 5/2/23 at 4:02 P.M., the Director of Nursing (DON) said facility staff would contact resident families and representatives via telephone to inform them about positive COVID-19 cases and that a nursing note would be written in the resident's medical record to indicate that this occurred. She further said that there was no notification for the COVID-19 positive case, as required, during the April 2023, COVID-19 outbreak.

Based on interview and policy review, the facility failed to ensure that an infection prevention and control program was implemented in order to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to ensure its staff followed an infection prevention and control cleaning program for an area identified as high risk (the kitchen ice machine) for the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building water system and cause lung infections) within the facility. Review of the facility policy, Legionella Water Management Program (Legionella), undated, indicated the following: -Kitchen ice machine: clean monthly per the manufacturer's instructions. Review of the Equipment Maintenance Log, Ice Machine, undated, indicated the following dates of inspection: -January 12, 2022 -April 13, 2022 -July 12, 2022 -October 12, 2022 -December 12, 2022 -March 15, 2023 During an interview on 5/2/23 at 4:05 P.M., the Maintenance Director said the kitchen ice machine was cleaned quarterly and was not cleaned monthly as indicated in the Water Management Program.

Based on observation, policy review, and interview, the facility failed to adhere to food storage requirements in the main kitchen and dining room nourishment kitchen, and practiced standard sanitary procedures during food handling. Specifically, the facility staff failed to: 1. Label, date, and seal open food items meant for resident consumption in the main kitchen's dry storage area and refrigerator, 2. seal open food items stored in the dining room nourishment kitchen, and 3. wear hair restraints to fully cover hair during food handling and meal service. Findings include: Review of the facility's Dry Storage Areas Policy, dated 2008, included the following: -Dry storage areas will be kept in a condition which protects stored foods from infestation. -Containers with tight fitting covers should be used for storing cereal, grain products, dried vegetables, and broken lots of bulk food. Review of the facility policy for practicing standard sanitary procedures in the kitchen, undated, indicated: -All kitchen employees will practice standard sanitary procedures. -All employees shall wear hair restraints. 1. The facility failed to ensure its staff labeled, dated, and sealed open food items meant for resident consumption in the main kitchen's dry storage area and refrigerator. During the initial kitchen walk through on 5/1/23 at 7:49 A.M., the surveyor observed the following opened, unlabeled and undated food items in the dry storage area and refrigerator: -1 bag of corn flakes, folded shut -1 large unsealed bag of potato chips (open to air) -1 used whipped topping piping bag with dirty tip laying on a shelf 42761 2. The facility failed to ensure its staff adhered to sanitary food handling practices in the facility's dining room and main kitchen, to reduce the risk for food contamination and foodborne illness, when staff prepared and handled food items meant for resident consumption. On 5/2/23 at 8:54 A.M., the surveyor observed the following during point of service meal distribution in the facility's dining room: - The Cook wore a hair restraint that did not fully cover her hair; the hair restraint extended to approximately the base of the Cook's skull and her hair extended out from under the hair restraint to the base of her neck. - Nursing staff read the meal tickets off to the Cook and the Cook loaded resident plates with food items read to her by the Nursing staff. - The Cook handed the loaded plates containing resident food to the Nursing staff. The food was not covered and the Nursing staff did not wear hair restraints. - The Nursing staff carried the food from the steam table area to a table in the dining room where they placed the plates on trays, then covered the food. - Nursing staff also stood at a counter top next to the steam table, poured dry cereal into bowls and poured drinks, then applied covers to the bowls and cups. - Nursing staff exited the dining room with the trays and delivered them to resident rooms. On 5/2/23 at 11:02 A.M., the surveyor observed the Cook handling food in the facility's main kitchen. The Cook removed a tray of chicken from the oven, placed it on the counter and inserted a thermometer into one of the pieces of chicken. The Cook wore a hair restraint that did not fully cover her hair; the hair restraint extended to approximately the base of the Cook's skull and her hair extended out from under the hair restraint to the base of her neck. At this time, the Food Service Director (FSD) said the Cook was supposed to have her hair fully covered when handling food, as required. 3. The facility failed to ensure its staff adhered to dry food storage requirements in the facility's dining room nourishment kitchen, in order to reduce risk for foodborne illness and infestation. On 5/2/23 at 9:00 A.M., the surveyor observed the following in the facility's dining room nourishment kitchen cabinet: - One large open bag of potato chips, approximately one quarter full. There was a tear in the bag that extended from the top of the bag approximately one quarter of the way down the bag. The top of the bag was folded over, but was not sealed. - One four pound bag of cane sugar, less than one quarter full, open to air On 5/2/23 at 10:30 A.M., the surveyor observed the following in the facility's main kitchen: - Two bags of dry cereal, approximately half-full and unsealed. Neither bag of dry cereal was labeled or dated. - Two covered plastic containers containing dry cereal, approximately one quarter full, undated. - Two packages of English muffins with a 'fresh through' date of 4/29/23 stored on the bread rack. During an interview on 5/2/23 at 10:35 A.M., the FSD said food packages were to be labeled, dated, and sealed after being opened. The FSD said the potato chips and cane sugar should have been sealed after they were opened and stored in the cabinet in the facility's dining room nourishment kitchen. He also said the bags of dry cereal stored in the main kitchen's dry storage area should have been labeled, dated, and sealed after they were opened and that the plastic containers of dry cereal should have been labeled and dated, as required. The FSD said the English muffins with a fresh through date of 4/29/23 could still be used for resident consumption as long as it looked okay and the Cook inspected it prior to serving. He said the fresh through date didn't really matter because they grilled the English muffins before serving them to residents.

Based on observation, policy review, and interview, the facility failed to ensure its staff provided an environment as free of accident hazards as possible, relative to hot water temperatures, in two out of three resident unit hallways. Specifically, the facility failed to ensure its staff provided safe hot water temperatures in resident care areas when the facility water temperature was increased for running the dish machine, which also increased the water temperature on resident units, increasing the risk for injury of accidental burns. Findings include: Review of the undated Water Temperature Policy provided by the facility included: - Water temperatures in resident areas are maintained at temperatures between 106 and 120 degrees Fahrenheit (F). - Temperatures are set at the water source to assure adequate and comfortable temperature levels in resident areas. Review of the Resident Bed List Report provided by the facility, dated 5/1/23, indicated there were a total of 14 residents housed in the unit hallway containing rooms 10 through 19. Further review of the report indicated there were a total of eight residents housed in the unit hallway containing rooms 30 through 39. On 5/2/23 at 10:38 A.M., the surveyor observed the dish machine during its wash cycle in the facility's main kitchen. The temperature gauge on the front of the dish machine indicated the temperature was running at 110 degrees F. At this time, the Maintenance Director said the dish machine was a low temp machine and was required to wash at a temperature of 120 degrees F. The Maintenance Director said he just needed to make an adjustment to the water temperature in the back room and give it a few minutes, then he could run the dish machine again. The surveyor then observed the Maintenance Director enter the Mechanical Room and adjust a valve at a box on the wall. The Maintenance Director said that the valve he adjusted would increase the temperature of the water for the dish machine. The Maintenance Director further said the valve also controlled the hot water that fed the resident units. When asked whether adjusting the valve would increase a risk for resident water becoming too hot, the Maintenance Director said, it shouldn't. On 5/2/23 at 11:50 A.M., the surveyor entered room [ROOM NUMBER]'s bathroom. The surveyor turned on the hot water and placed their hand under the running water. The surveyor was unable to keep their hand under the running water due to it being too hot. During an interview on 5/2/23 at 11:53 A.M., the Maintenance Director said he checked water temperatures in resident rooms regularly and that he would check the water temperature at that time. The Maintenance Director then turned on the hot water at the sink in the bathroom of room [ROOM NUMBER] and placed a thermometer in the water, but he could not get the thermometer to turn on. The Maintenance Director then said the thermometer was not working. He then placed his hand under the running water briefly, removed his hand from under the running water, and said it was way too hot and that it needed to be adjusted. During a follow-up interview on 5/2/23 at 12:04 P.M., the Maintenance Director said he had to adjust the water temperature for resident areas by turning the valve in the Mechanical Room down and that once the water was run through the system, the temperature would decrease. The Maintenance Director then said he obtained another thermometer and would proceed to check water temperatures in resident areas with the surveyor. The following water temperatures were obtained: - room [ROOM NUMBER]: 129 degrees F - room [ROOM NUMBER]: 125 degrees F At this time, the Maintenance Director said the hot water for the resident units increased when he adjusted the mixing valve in the Mechanical Room to increase the water temperature for the dish machine. He said the water temperature in the resident areas was too hot and needed to be adjusted down for safety.

Based on record review and interview, the facility failed to implement requirements relative to outbreak testing and return to work testing criteria, in order to prevent the spread of infection, when the facility experienced an outbreak of COVID-19. Specifically, the facility failed to: 1. Initiate outbreak testing timely for one staff (Nurse #2), out of three sampled staff, 2. Complete outbreak testing every 48 hours until the facility went 7 days without a new case for three Residents (#17, #33 and #46), out of a sample of three residents, and 3. Document a negative test result for one staff member (Employee #1) prior to his/her return to work after testing positive for COVID-19. Findings include: 1. The facility failed to initiate required COVID-19 outbreak testing for Nurse #2 after Employee #1 tested positive for COVID-19 while working at the facility on 4/1/23. Review of facility policy COVID-19 Prevention and Control dated 3/14/23, indicated the following: -Once a new case is identified, the facility should initiate outbreak testing. Outbreak testing should include: -Testing exposed staff and residents on the affected unit(s) must take place as soon as possible. If the long-term care facility, identifies that the resident or staff member's first exposure occurred less than 24 hours ago, then they should wait to test until, but not earlier than 24 hours after any exposure, if known . Review of Employee #1's timecard indicated that he/she worked at the facility on 4/1/23 from 6:38 A.M., to 11:53 A.M. Review of the facility's surveillance line listing, dated 4/8/2023, indicated Employee #1 tested positive for COVID-19 on 4/1/23. Review of Nurse #2's timecard indicated that he/she worked at the facility on 4/1/23, 4/2/23, and 4/3/23. Review of the facility's Weekly Employee COVID-19 Testing Log, dated 4/2/23 through 4/8/23, indicated no evidence that Nurse #2 completed initial outbreak testing for COVID-19 24 hours after exposure (4/2/23) and that he/she was not tested until 4/3/23. Further review of the Log indicated only three staff members were tested for COVID-19 on 4/2/23. During an interview on 5/2/23 at 4:02P.M., the Director of Nursing (DON) said when Employee #1 tested positive for COVID-19 on 4/1/23, outbreak testing was initiated due to the Employee working in an area where he/she interacted with multiple staff and residents, and they could not contact trace. The surveyor and the DON reviewed the Weekly Employee COVID-19 Testing Logs from 4/2/23 through 4/8/23. The DON said initial outbreak testing was not completed for Nurse #2 on 4/2/23, but it should have been. No evidence that initial outbreak testing began for all staff on 4/2/23, as required, was provided prior to the end of the recertification survey. 2. The facility staff failed to complete outbreak testing for three Residents (#17, #33 and #46) every 48 hours for seven days until no new positive cases were identified, as required, during a COVID-19 outbreak. Review of the Centers for Disease Control and Prevention (CDC) document, titled Strategies to Mitigate Healthcare Personnel Staffing Shortages, dated 9/23/22, included that Day 0 was: a. the date symptoms first appeared for individuals symptomatic and positive for COVID-19, or b. the date of a positive test for an asymptomatic individual. Review of the facility policy COVID-19 Prevention and Control dated 3/14/23, indicated the following: -Once the facility has completed the requisite initial outbreak testing ., the facility should test staff and residents every 48 hours on the affected unit(s) until the facility goes seven days without a new case or a DPH epidemiologist directs otherwise . Review of the facility's surveillance line listing, dated 4/8/2023, indicated Employee #1 tested positive for COVID-19 on 4/1/23. Review of the clinical records for Residents #17, #33 and #46 indicated they had been tested for COVID-19 on 4/2/23 (day one), 4/4/23 (day three), and 4/6/23 (day five), but included no evidence they had been tested on [DATE] (day seven), as required, to complete a seven-day period with no new positive cases of COVID-19. The facility's staff provided no evidence that an Epidemiologist provided direction for alternate testing instructions. During an interview on 5/2/23 at 1:03P.M., the DON said Employee #1 was symptomatic and tested positive for COVID-19 on 4/1/23. She said the facility initiated outbreak testing of all residents on Day 1 (4/2/23), and continued on Day 3 (4/4/23) and Day 5 (4/6/23), and there were no additional positive cases. The DON was unable to provide evidence that COVID-19 testing was completed every 48 hours, including testing on 4/8/23, as required, to complete a seven-day period with no new positive cases of COVID-19 for Residents #17, #33 and #46. 3. The facility staff failed to ensure that Employee #1, who had been positive for COVID-19, returned to work with a documented negative test for COVID-19, as required. Review of the facility Covid-19 Prevention and Control policy, dated 3/14/23, indicated: Review of the facility Procedure for Staff and Resident testing, undated, indicated: -Facility staff can be tested elsewhere (e.g by another employer) if it is completed in the same timeframe and the results are documented by the facility. Review of the facility's Surveillance Line Listing, dated 4/8/2023, indicated one positive COVID-19 cases among staff from 4/1/23- 4/8/23. Employee #1 was listed as a positive Covid-19 case on 4/1/23. Review of Employee #1's time-card indicated he/she worked on 4/1/23 and returned to work on 4/7/23. Review of the facility weekly COVID-19 staff testing logs from 4/2/23 through 4/8/23 indicated that Employee #1 was listed as NA (Not Applicable). During an interview on 5/3/23 at 12:41 P.M., the Administrator said there was no documented evidence as required, that a negative COVID-19 test result was obtained prior to Employee #1 returning to work.

Based on record review, policy review and interviews, the facility failed to arrange an Optometry appointment for one Resident (#33) out of a total sample of 12 residents. Specifically, the facility failed to address the Resident's vision impairment. Findings include: Review of the facility policy titled Dental, Vision, Hearing and Podiatry Services, undated, indicated that the facility will ensure that all resident's/patient's dental, vision, hearing and podiatry needs are addressed. Resident #33 was admitted to the facility in July 2019 with a diagnosis of Glaucoma (a group of eye conditions that can cause blindness). During an interview on 5/1/23 at 10:00 A.M., Resident #33 told the surveyor that he/she had not seen the eye doctor since his/her admission to the facility. The Resident further said that he/she did not think the reading glasses they currently used were adequate. Review of Resident #33's record revealed: -Resident #33 signed a consent to receive Eye Care Services on 3/9/21. -Resident #33's activated Health Care Proxy (HCP- the legal document used to tell medical providers who should make decisions about care if you are not competent to do so) signed a consent for Eye Care Services on 3/17/22. -no documented evidence that Resident #33 had been seen for Eye Care Services. Review of the Minimum Data Set (MDS) assesment, dated 4/4/23, indicated that Resident #33 had a vision impairment, used corrective lenses, and had a diagnosis of Glaucoma. Review of Resident #33's care plan for impaired vision, dated 4/28/23, indicated interventions to monitor for worsening vision loss and Optometry consult as indicated. Review of Resident #33's Physician's orders for May 2023 indicated an order for Optometrist consult as needed with a start date of 9/20/18. During an interview on 5/2/23 at 7:38 A.M., Nurse #1 said that all residents should receive vision services if they have an eye issue such as Glaucoma. During an interview on 5/2/23 at 8:47 A.M., Nurse #1 said that Resident #33 should have received vision services and that he/she did not.

Based on observation, record review, and interview, the facility failed to maintain an accurate clinical record for one Resident (#8) out of a total sample of 12 residents. Specifically, facility staff failed to maintain an accurate record relative to: a. the Resident's use of CPAP [continuous positive airway pressure]: machine that uses a predetermined pressure to keep the airways open during sleep) and b. the Resident's physical status when his/her Diazepam (medication used to treat anxiety) was not administered due to the Resident being sedated. Findings include: Resident #8 was admitted to the facility in July 2019 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD - disease that causes airflow blockage and breathing related problems) and anxiety disorder. a. The facility staff failed to maintain an accurate clinical record for Resident #8 relative to the Resident's use of a CPAP machine during hours of sleep and the Resident's Medical Orders for Life Sustaining Treatment (MOLST) indicated not to CPAP. Review of the Resident's MOLST, dated 6/4/2019, included: Do Not Use Non-Invasive Ventilation (e.g. CPAP). Review of an active Physician's order, initiated 2/27/21, included: Resident to wear CPAP at hs (hour of sleep) when in bed. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) of 13 out of 15. Review of the Advance Directive Care Plan, dated 3/24/23, included: Complete new MOLST if [Resident] wants to make changes. On 5/2/23 at 9:02 A.M., the surveyor observed Resident #8 lying awake in bed. There was a CPAP machine with tubing on the night stand to the left side of the Resident's bed, next to the window. At this time, Resident #8 said he/she used the CPAP when he/she slept because of his/her history of Sleep Apnea and COPD. During an interview on 5/3/23 at 11:45 A.M. Nurse #1 said Resident #8 used a CPAP because he/she had Sleep Apnea. Nurse #1 said Resident #8 needed to use the CPAP machine when he/she slept so that he/she would not stop breathing. Nurse #1 said she thought the information on the MOLST was only used if the Resident required transfer to the hospital and did not think the Resident's choice to use the CPAP needed to be reflected on the MOLST, even though the Resident used a CPAP machine to sustain breathing while sleeping. b. The facility staff failed to maintain an accurate medical record for Resident #8 relative to his/her physical status when his/her Diazepam (medication used to treat anxiety) was not administered due to the Resident being sedated. Review of Resident #8's April 2023 Physician's orders included: Diazepam five milligram (mg) tablet; give one tablet by mouth three times daily . Review of Resident #8's April 2023 Medication Administration Record (MAR) included that the Resident's scheduled 2:00 P.M. dose of Diazepam was not administered on 4/16/23 due to the Resident being too sedated. Further review of the MAR indicated this entry was made at 1:32 P.M. on 4/16/23. Review of the Nurse Note, dated 4/16/23 and entered into the record at 1:55 P.M., indicated: - Resident #8 was alert and oriented at baseline, able to make needs known with clear and concise speech . - All medications were administered as ordered. Review of the clinical record included no evidence the Physician was contacted relative to Resident #8's Diazepam being held due to the Resident being sedated. During an interview on 5/3/23 at 1:02 P.M., Nurse #1 said if a resident appeared sedated and medication needs to be held, the Nurse is required to contact the Physician/Nurse Practitioner (NP) to alert them of the resident's status, that the medication needed to be held, and to obtain further instruction. She further said the Nurse was required to document thisinformation in the resident's medical record. Nurse #1 said the NP had been notified of the need to hold Resident #8's Diazepam on 4/16/23 due to the Resident being sedated and the NP did not provide any new orders at that time. Nurse #1 said the Nurse's Note written on 4/16/23 did not accurately reflect Resident #8's condition, as required. She further said the Nurse's Note should have reflected the communication with the NP, and the results of that communication, but it did not.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was cognitively intact, and dependent on two staff members for transfers, the Facility failed to ensure Resident #1's right to self-determination was honored and that staff supported his/her choices, when on 11/16/22, sometime in the early morning, during the 11:00 P.M. to 7:00 A.M. shift, Resident #1 requested help to get out of bed because he/she was uncomfortable, Certified Nurse Aide #2 did not honor his/her request, and told Resident #1 he/she could not get out of bed. Findings include: Review of the Facility's Policy titled, Your Rights and Protections as a Nursing Home Resident, undated and included in the Facility's Admission Packet, indicated that as a Nursing Home Resident there are certain rights and protections under Federal and State Law that help ensure residents get the care and services they need. The Policy indicated residents have the following rights: - self-determination and the right to make their own schedule, and the right to decide when they go to bed and when they rise in the morning, - the right to be treated with dignity and respect, - the right to participate in decisions that affect care, and - the right to be free of interference, coercion, discrimination, and reprisal from the Facility in exercising his/her rights. Resident #1 was admitted to the Facility in September 2022, diagnoses included cervical (neck) spinal stenosis (narrowing of the spinal canal) polyneuropathy (peripheral nerve damage), gastro-esophageal reflux disease, and acute respiratory failure. Review of Resident #1's Minimum Data Set (MDS) Significant Change Assessment, dated 10/06/22, indicated Resident #1 was cognitively intact, exhibited no behavioral symptoms, and the right to choose his/her own bedtime was very important to him/her. Review of Resident #1's Comprehensive Care Plans related to Pain and Activities of Daily Living (ADLs), dated 10/27/22, indicated Resident #1 reported moderate to severe pain secondary to spinal stenosis and neuropathy, and staff should reposition for comfort. The Care Plan also indicated Resident #1 was dependent for transfers. Review a written Interview with Resident #1 conducted by the Director of Social Services on 11/16/22, indicated Resident #1 said that on 11/16/22 at approximately 3:30 A.M. he/she wanted to get into his/her wheelchair, CNA #2 was not happy about this request, and sat Resident #1 up in bed (elevated head of bed) instead of getting him/her out of bed, as requested. During an interview on 01/11/23 at 12:42 P.M., the Director of Social Services said Resident #1 was able to make his/her needs known. The Director said Resident #1 told her he/she was pissed off because he/she wanted to get into his/her wheelchair and CNA #2 refused to assist him/her to get out of bed and into his/her wheelchair as requested. The Director said if a resident asks to get out of bed, he/she should be allowed to do so, regardless of what time it is. During an interview on 01/11/23 at 10:55 A.M., and review of CNA #2's written Witness Statement, undated, CNA #2 said she cared for Resident #1 during the night shift that began 11/15/22 at 11:00 P.M., and ended on 11/16/22 at 7:00 A.M. CNA #2 said she could not remember the exact time, but that early in the morning, Resident #1 told her he/she wanted to get out of bed. CNA #2 said she did not get Resident #1 out of bed because it was very busy, and she was not familiar with Resident #1's routine. CNA #2 said Resident #1 was upset with her all night because she told Resident #1 that he/she could not get out of bed. During an interview on 01/12/23 at 1:47 P.M., CNA #3 said she worked the night shift that began 11/15/22 at 11:00 P.M., and ended on 11/16/22 at 7:00 A.M. on Resident #1's unit, but said she was not assigned to Resident #1. CNA #3 said Resident #1 required an assist of two staff members for transfers, and said CNA #2 never asked her for help to get Resident #1 out of bed during the shift. During an interview on 01/12/23 at 11:35 A.M. and review of CNA #1's written Witness Statement, dated 11/16/22, CNA #1 said Resident #1 was dependent for transfers and repositioning because he/she was not able to move much on his/her own. CNA #1 said on 11/16/22, sometime in the afternoon, while she provided care for Resident #1, Resident #1 reported to her that early that morning (11/16/22), he/she asked a CNA (later identified as CNA #2) to get him/her out of bed because he/she was uncomfortable. CNA #1 said Resident #1 reported to her that CNA #2 told him/her that he/she could not get out of bed and refused to help get him/her up. CNA #1 said she reported this to a nurse immediately. During an interview on 01/20/23, Nurse #2 said as far as she can recall, CNA #2 had not asked her about Resident #1 getting out of bed early in the morning on 11/16/22. Nurse #2 said if Resident #1 had wanted to get out of bed, he/she had the right to get up regardless of what time it was. During an interview on 01/11/23 at 11:57 A.M., Nursing Supervisor #1 said Resident #1 was able to make his/her needs known. Nursing Supervisor #1 said Resident #1 had the right to get out of bed anytime he/she wanted, even if it was not his/her normal routine to get up early in the morning. During an interview on 01/11/23 at 2:45 P.M., the Director of Nurses (DON) said if Resident #1 wanted to get out of bed, he/she had the right to get out of bed and should have been allowed to, but he/she was not. .

Based on observation, interview, and policy review the facility failed to store food in accordance with professional standards for food service safety. Findings include: On 12/3/21 at 7:19 A.M., the surveyor observed the following items not labeled and dated: -In the walk-in freezer: *one open bag of crab meat *one open bag of chicken breasts *one open package of hot dogs -In the walk-in refrigerator: *one open package of sliced cheese *one open large container of yogurt On 12/07/21 at 7:37 A.M., the surveyor observed the following items not labeled and dated: -In the walk-in freezer: *one open bag of chicken breasts *one open package of raviolis *one open package of waffles *one open package of beef patties -Under the prep table was a large plastic bin of flour with no label or date. During an interview on 12/7/21 at 7:45 A.M., Dietary Aide #1 and Cook #1 said anything that was open should have been labeled and dated. Review of the facility's policy for food storage, dated 2008, indicated the following: -Policy: Food is stored by methods designed to prevent contamination. *Plastic containers with tight-fitting covers must be used for storing flour .all containers must be legible and accurately labeled. *Refrigeration: all foods should be covered, labeled and dated *Frozen foods: all foods should be covered, labeled and dated

Based on observation, record review, and interview the facility failed to properly store nebulizer (a small machine that turns liquid medicine into a mist and has a hose that goes from the machine to either a face mask or a mouthpiece) equipment when not in use, for two residents (#25 and #29) out of 12 sampled residents. Findings include: 1. Resident #25 was admitted to the facility in April 2021. Review of the December 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/03/21 at 9:28 A.M., the surveyor observed the Resident in his/room eating breakfast. The Resident had audible congestion, and was coughing phlegm into a tissue. The nebulizer machine was on the window sill and the mouthpiece was uncovered. On 12/03/21 at 2:09 P.M., the surveyor observed the nebulizer machine on the window sill with the mouthpiece uncovered. On 12/07/21 at 8:05 A.M., the surveyor observed the Resident asleep in bed. The nebulizer machine was on the window sill with the mouthpiece uncovered. 2. Resident #29 was admitted to the facility in November 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/03/21 at 7:56 A.M., the surveyor observed the nebulizer machine on the window sill with the facemask laying directly on the sill, uncovered. On 12/07/21 at 8:15 A.M., the surveyor observed the nebulizer facemask and tubing laying on top of the night stand, uncovered. On 12/07/21 at 8:19 A.M., the surveyor and nurse #1 observed both Resident #25 and Resident #29's nebulizer equipment. Nurse #1 said the nebulizer equipment should be placed in bags when not in use. Review of the facility's undated policy titled, Administering Medications through a Small Volume Nebulizer, indicated the following: -Purpose of the procedure is to safely and aseptically administer aerolized particles of medication into the resident's airway. -When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup. -When equipment is completely dry, store in a plastic bag with the resident's name and date on it.

Based on policy review and interview, the facility failed to provide evidence that all staff were screened for COVID-19 symptoms before each shift, as required. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long Term Care Facility Guidance, dated April 2, 2020, indicated: -Long-term care facilities should immediately implement symptom screening for all, and every individual .including staff . should be asked about COVID-19 symptoms. Review of the facility's Employee/Visitor Screening Policy, undated, indicated the following: -Lydia Taft House has implemented a screening process for every individual entering the facility, including staff members, to limit the transmission of the [MEDICAL CONDITION]. -Each individual is asked a series of questions related to COVID-19 symptoms. -Each subsequent day an employee enters the facility, they will be screened and will document either Yes or No to the question of any signs or symptoms on the temperature log sheet. Review of the Temperature Check/Screening log, indicated that 3 staff members entered the facility for the 7 A.M.-3 P.M. shift on 11/18/20 and had not answered Yes or No to the question regarding COVID-19 signs or symptoms. During an interview on 11/18/20 at 1:37 P.M., the Director of Nurses (DON) said the question regarding signs or symptoms of COVID-19 had not been answered on the Temperature Check/Screening log for 3 staff members that signed in for the 7:00 A.M.-3:00 P.M. shift on 11/18/20. She further said she was unable to provide evidence that the 3 staff members did not have signs or symptoms of COVID-19 when they began their shift today.

Based on observation and interview, the facility failed to ensure one staff member on the quarantine unit implemented infection control requirements related to respirator use, to prevent the spread of COVID-19. Findings include: Review of CDC guidelines for health care personnel titled Personal Protective Equipment (PPE): Questions and Answers, updated 8/8/20, indicated the following: -Respirators with exhalation valves protect the wearer from [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, but may not prevent [MEDICAL CONDITION] spreading from the wearer to others (that is, they may not be effective for source control). Until data are available to describe how effective respirators with exhalation valves are in preventing the spread of [DIAGNOSES REDACTED]-CoV-2 from the wearer to others: *Wear a respirator without an exhalation valve when both source control and respiratory protection are required. *If only a respirator with an exhalation valve is available and source control is needed, cover the exhalation valve with a surgical mask, procedure mask, or a cloth face covering that does not interfere with the respirator fit. During an observation of the quarantine unit at 12:05 P.M. on 11/12/2020, Nurse #1 was at the medication cart wearing a face shield and a white, cup shaped respirator with yellow bands and an exhalation valve. The respirator was worn alone, not covered with a surgical mask. During an interview on 11/12/2020 at 12:07 P.M., Nurse #1 said she had brought in the respirator from home and was not aware that it only protected the wearer. During the interview the Nurse disposed of the respirator with the valve and donned (put on) a readily available facility issued respirator. During an interview on 11/12/2020 at 2:00 P.M., the Director of Nurses said that respirators with exhalation valves would only be used as a last resort (and covered by a surgical mask) when supplies were low and that Nurse #1 had not received the mask from the facility. She further said she was not sure why the nurse chose to wear a respirator from home and said the facility had a sufficient supply of approved respirators.

Based on interview, observation and policy review, the facility failed to ensure staff implemented proper infection control measures related to (A) the use of Personal Protective Equipment (PPE), (B) cleaning shared equipment, and (C) failed to provide evidence that every employee is asked if they are experiencing signs of symptoms of COVID-19 prior to every shift. Findings include: During an interview on 11/6/20 at 7:45 A.M., the Director of Nurses (DON) said that the A Hall was for residents in quarantine. The residents either never tested positive for COVID-19 or had recovered from COVID-19 greater than 3 months ago. She said the B and C Halls were both COVID-19 positive areas. A1. On 11/6/20 at 8:25 A.M., the surveyor observed A Hall (quarantine) and most of the residents' doors were closed. All of the doorways had signs, created by the Centers for Disease Control and Prevention (CDC) that indicated the residents in that hall were on droplet/contact precautions. The sign indicated that staff was to wear full PPE (mask, eye protection, gown, and gloves) upon entrance to the room and the PPE was to be removed prior to exiting the room. The sign further illustrated the order to don (put on) PPE, first apply the mask, then eye protection (the mask and eye protection can be worn between residents for extended use and conservation of PPE) followed by the gown, and lastly the gloves. On 11/6/20 at 8:35 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 in the A Hall. CNA #1 came out of a resident room holding a dirty gown up against her uniform and carried it down the hallway to a receptacle. She then used hand sanitizer, donned a pair of gloves (should have been the last item to don) and put on a new gown to go to another resident's room. CNA #1 came out of that resident's room with the dirty gown in a ball, up against her uniform, and carried it down the hallway to the receptacle. She then used hand sanitizer, donned a pair of gloves and put on a new gown. During an interview on 11/6/20 at 8:47 A.M., CNA #1 said she put her gloves on first then the gown. She said the only place to put the used gowns was in the hallway receptacle. CNA #1 said she didn't know that she was supposed to put her gown on before her gloves. 2. During an observation and interview on 11/6/20 at 9:35 A.M., the surveyor observed Nurse #1 on the A Hall (quarantine) exit a resident room with a gown and gloves on, holding medication boxes. She walked down the hallway, put the medication boxes on the medication cart and then doffed the gown and gloves in the hallway receptacle. Nurse #1 said the only place to put the used gowns was in the hallway receptacle. She said there was no place to take them off and discard them prior to exiting a resident's room. 3. During an observation and interview on 11/6/20 at 10:10 A.M., the surveyor observed Nurse #2 in the B Hall (COVID-19 positive area) in full PPE at her medication cart. Nurse #2 then walked off the B Hall, across a designated clean area, then to the Nurses Station to retrieve a container of bleach wipes. She picked up the container of wipes and came back to the B Hall. Nurse #2 said that the facility hadn't set up a doff (take off) area on the unit yet so she kept her PPE on to get the wipes. She said if there had been a doffing area she would have removed her gown and gloves prior to exiting the COVID 19 positive hallway. Review of an undated, untitled policy, indicated it was the policy of the facility to follow CDC guidance for donning and doffing PPE during the COVID-19 pandemic. Review of the CDC document, titled Using PPE, dated August 19, 2020, indicated the following: How to Don PPE Gear: -Perform hand hygiene using hand sanitizer. -Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel . -Put on gloves. Gloves should cover the cuff (wrist) of gown. -Healthcare personnel may now enter patient room. How to Take Off (Doff) PPE Gear -Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). -Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in .receptacle. -Healthcare personnel may now exit patient room. B1. On 11/6/20 at 9:00 A.M., the surveyor observed CNA #1 in the A Hall (quarantine). CNA #1 donned a gown and gloves and entered a resident room holding a pulse oximeter (a device used to measure the amount of oxygen in the blood) and a thermometer. Upon exiting the resident's room, the CNA removed the gown and gloves. She reached into her uniform pocket and took out the dirty pulse oximeter and the thermometer and put them on a cart. She got a paper towel and put Hand Sanitizing Foam that was in a wall dispenser, onto the paper towel, and cleaned both the thermometer and the pulse oximeter. During an interview on 11/6/20 at 9:10 A.M., CNA #1 said she had used both of the devices on a resident and then put them in her clean pocket. She said she didn't know what she was supposed to use to clean them so she used the Hand Sanitizing Foam. She said she knew she had to clean them because she needed them for other residents. During an interview on 11/6/20 at 1:20 P.M., the DON said that they didn't have a written policy to reflect the cleaning product to be used but the facility standard was bleach wipes for all equipment that is shared between residents. She said that was the process even before COVID-19. C1. Review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long Term Care Facility Guidance, dated April 2, 2020, indicated the following: -Long-term care facilities should immediately implement symptom screening for all. In accordance with previous CMS guidance, every individual regardless of reason entering a Long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked. Review of the undated facility policy for Employee/visitor screening indicated the following: -Lydia Taft House has implemented a screening process for every individual entering the facility, including all staff members to limit the transmission of the coronavirus. -Each individual is asked a series of questions related to COVID-19 symptoms, if it is the individual's first time in the facility a formal questionnaire is to be completed and signed by the individual entering. -Each individual is also subject to having their temperature taken each time they come into the building. If their temperature is 100.4 of above they are not permitted to enter . Review of the facility's Temperature Log for All Staff/Essential Personnel or Persons Entering the Building, indicated columns for date, name of employee/visitor, and temperature which had to be 100.0 degrees Fahrenheit (F) or below to enter after answering questionnaire x 1. Temperature 100.0 degrees F and above many not enter the building. Further review indicated no column to document the absence of COVID-19 symptoms. Review of the facility's Coronavirus and Influenza Essential Staff Restriction Baseline Questionnaire, revised April 30, 2020, indicated: -Everyone must have their temperature taken every day by the charge nurse or another trained employee and all staff must answer the following questions: -Symptoms: In the past 14 days are you experiencing fever, cough, shortness of breath, sore throat, sudden loss of taste/smell, GI distress or respiratory symptoms? -Current temperature must be .less than 100.0. Further review indicated a space for the employee to sign and date. On 11/6/20 at 7:25 A.M., the surveyor's temperature was taken by a staff member and then the DON asked the surveyor a series of questions related to COVID-19 symptoms, but did not document the absence of symptoms nor had the surveyor fill out the questionnaire. During an interview on 11/6/20 at 1:00 P.M., the Administrator said the employees sign in and have their temperature taken prior to working. He said they only have to fill out the questionnaire once and after that the screener asks if they have the symptoms, but don't record the absence of symptoms.

Based on record, policy review and interview, facility staff failed to provide written information/notice to the residents/representatives, prior to transfer to the hospital, that specified: duration of the state bed hold policy; reserve bed payment policy; and nursing facility policy regarding bed hold periods upon transfer for 6 sampled residents (#18, #25, #32, #36, #42 and #45) out of a total of 12 sampled residents. Findings include: Review of the facility Bed Hold policy, identified in the Admission Agreement, indicated the following: - When we hold a bed for you, at your request, and/or the charges for the bed are not covered by insurance, you are responsible for paying our daily charges for bed for each day we hold it. Requirements are set forth in Appendix B to this agreement. - Appendix B - Bed Hold Policy: Federal regulations requires a nursing facility must provide written information to the resident/family member/legal representative that specifies the duration of the bed hold policy under Medicaid state plan (Medicaid will pay for up to 10 days for Mass Health residents during Medical Leaves of Absence (MLOAs)), during which the resident is permitted to return and resume residence in the facility. In addition, a nursing facility is required to establish and follow written policy under which a resident whose hospitalization exceeds the bed hold period under Medicaid state plan. Medicare does not pay for medical leaves of absence (MLOA). 1. For Resident #42 the facility staff failed to provide the either the resident or the residents representative with a written Bed Hold policy. Resident #42 was admitted to the facility 4/2019 According to documentation in progress notes, Resident #42 was sent out to the hospital on [DATE], and was admitted . There was no evidence a Bed Hold written notice had been provided to either the resident and/or the family member, as required. 2. For Resident #36, admitted in 9/2018 under Medicaid insurance coverage, had been hospitalized at least three times, and each occurrence, a Bed Hold written notice had not been provided. Review of the clinical record indicated on 9/29/18, the resident fell , and was transferred to the hospital and admitted . Further review, indicated there was no Bed Hold written notice provided to the resident/representative for this transfer to the hospital. The resident returned 10/1/18. Review of a 10/5/18 progress note indicated Resident #36 fell , and was transferred the hospital. There was no written notice of a Bed Hold provided to the residents/representative, as required. Review of a 5/3/19 progress note indicated the resident fell , and was transferred to the hospital. There was no Bed Hold written notice provided to the resident/representative. During interview on 7/9/19 at 3:55 P.M., the Social Worker (SW) said she never gives written bed hold notices, regardless of insurance. The SW said she hasn't done this as long as she has been here and there has never been an issue with it. The SW said she has been a SW for [AGE] years, and was unaware this was a regulation/requirement. During interview on 7/9/19 at 4:30 P.M., the surveyor had asked the Administrator for the bed hold policy, and he said that it was part of the admission agreement in Appendix B. The Administrator said he has been at the facility for almost 6 years, and has never given written bed hold notices to residents., family member or legal representatives, despite the facility's policy and federal regulation requires the notice. Please refer to F689. 3. For Resident #18, the facility staff failed to notify the resident of the facility's policy for a bed hold. Resident #18 was admitted to the facility in 3/2018 with a [DIAGNOSES REDACTED]. Record review indicated the resident was sent to the hospital on [DATE] and re-admitted to the facility on [DATE]. On 7/09/19 at 3:20 P.M. during an interview with the SW she said that the facility had never issued bed hold policy to any resident when they were sent to the hospital. She said that the facility always takes the resident back when they are ready to return. 4. For Resident #25, the facility staff failed to notify the resident's representative of the bed hold policy. Resident #25 was admitted to the facility in 8/2017. Record review indicated the resident was admitted to the hospital on [DATE]. On 7/10/19 at 11:38 [NAME]M. during an interview with the SW she said the bed hold policy was not given. 5. For Resident #32, the facility staff failed to issue a written notice of a bed hold policy to the resident when he/she was sent to the hospital for an evaluation. Resident #32 was admitted to the facility in 5/2019 with [DIAGNOSES REDACTED]. Review of a nurse's note, dated 6/23/19, indicated the resident was sent out to the emergency room for an evaluation after he/she complained of weakness, shortness of breath and a low pulse oximeter reading. A nurse's note, dated 6/24/19, indicated the resident was admitted to the hospital. A nurse's note, dated 7/5/19, indicated the resident returned to the facility after being hospitalized . Further review of the clinical record indicated there was not a notice of a bed hold provided to the resident or representative at the time of this hospitalization . During an interview on 7/10/19 at 11:30 [NAME]M., the SW said that she, nor any other facility staff, issued the resident or representative a notice of the bed hold policy. The SW said she was on vacation at the time of the resident's transfer to the hospital but the notice of the bed hold policy should have still been provided. 6. For Resident #45, the facility staff failed to issue a written notice of a bed hold policy to the resident or representative when he/she was sent to the hospital for an evaluation. Resident #45 was admitted to the facility in 4/2019 with a [DIAGNOSES REDACTED]. Review of a nurse's note, dated 5/10/19, indicated the resident had a fall in his/her room and sustained injury. A physician's orders [REDACTED]. During an interview on 7/10/19 at 3:08 P.M., the SW said she did not provide the resident or representative with a written notice of a bed hold policy when the resident was transferred to the hospital, as required.

Based on observation and interview the facility staff failed to ensure that proper food storage was maintained to prevent the risk of food borne illnesses. Findings include: Review of the facility's Food Storage Policy, dated 2008, indicated the following; Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of bulk foods. All containers must be legible and accurately labeled. During an initial tour of the kitchen on [DATE] at 7:46 [NAME]M., the following was observed: -A bag of Splenda (artificial sweetener) and instant potatoes flakes were open to the air and were undated when opened. During a second tour of the kitchen on [DATE] at 11:50 [NAME]M., the following were observed: -The same bag of Splenda and instant potatoes flakes remained open to the air and were undated when opened. -Additionally the following items were open to the air and undated when opened: a box of pancake mix, a box of cream of farina (instant hot cereal), a bag of brown and a bag of white sugar. -The opened box of cream of farina cereal was observed to have an expiration date of ,[DATE]. The FSD said it had been used to make hot cereal. In the dry storage room, the remaining 5 boxes of this same cereal were also expired (,[DATE]). During an interview on [DATE] at 12:45 P.M., the FSD said the expired cereal should not have been used. He said the other food items should have been dated when opened and not left opened to the air.

Based on observation, record review, and interview, the facility staff failed to ensure a significant change Minimum Data Set (MDS) assessment had been completed for 1 sampled resident (#36) from a total sample of 12 residents. Findings include: Resident #36 was admitted to the facility in 9/2018 with multiple [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 9/27/18, indicated the resident was cognitively impaired, evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15; required limited assist of 1 staff member for bed mobility, transfers and toilet use; had balance problems coded as a 1; was occasionally incontinent of bladder; always continent of bowels; and had one fall with injury, except major since being admitted . Review of the 9/24/18 progress note indicated the resident fell . Review of a 9/29/18 progress note indicated the resident fell and was transferred to the hospital. Resident #36 returned from hospitalization on [DATE]. Review of 10/5/18 progress note indicated Resident #36 fell , and was sent to the hospital. Review of a Quarterly MDS assessment, dated 12/25/18, indicated the resident's BIMS score was unchanged at 7; now required extensive assist for all activities of daily living (ADLs), as the previous assessment coded the resident as requiring limited assist; toileting now required extensive assist of one staff; the resident's balance had declined; was now frequently incontinent of bladder, and had 1 fall with injury, except major. Review of the 2/19/19 progress note indicated Resident #36 fell while being transferred by a staff member. Review of the Quarterly MDS assessment, dated 3/19/19, indicated the resident's BIMS score remained unchanged at 7; bed mobility was now coded as being dependent on two staff; transfer required extensive assist of two staff; the resident did not ambulate; toilet use required extensive assist of one staff; had balance problems; now, was always incontinent of bladder and frequently incontinent of bowel; and had one fall with injury, except major. During interview on 7/10/19 at 4:00 P.M., the MDS Coordinator said the resident has had a decline in bed mobility, transfer, ambulation, balance, toilet use, bladder and bowel incontinence status. The MDS coordinator said Resident #36 had a significant change in condition and that an MDS assessment should have been completed for Resident #36, as required. Please refer to F689.

Based on observation, record, policy review and interview, the facility staff failed to ensure investigations into injuries of unknown origin for 1 sampled resident (Resident #36), out of a total sample of 12 residents. Findings include: Review of the facility's Abuse Prevention policy (undated) indicated there was no policy for investigating injuries of unknown origin For Resident #36, facility staff failed to investigate cuts to the resident's face, bruises to the hands, face, neck and back. Resident #36 was admitted to the facility in 9/2018 with multiple [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 9/27/18, indicated Resident #36 had cognitive impairment evidence by a Brief Interview for Mental Status (BIMS) score of 7 out of 15; had no mood or behavior problems and received 7 days of an anti-coagulant medication ([MEDICATION NAME]). Review of the current physician's orders [REDACTED]. Review of the progress notes indicated the following: - 10/20/18 while removing facial hair, staff nicked the underside of the resident's chin, the area bled, pressure and a dressing was applied. The dressing was later removed by the resident and the area oozed blood. There was no investigation to determine how the resident's face had been cut/nicked, for this resident who was on [MEDICATION NAME]. - 11/7/18: Resident #36 was noted to have an ecchymotic (under the skin, spot of bleeding) area on the left jaw to his/her neck. There was no investigation to determine the cause of the bruising to the resident's jaw and neck, an injury of unknown origin. - 11/15/18: Resident #36 was noted to have a small cut the right side of face. The cut was cleansed due to bleeding, and a dressing was applied. There were no investigations as to how this resident obtained a cut to his/her face. - 1/11/19: Resident #36 was found with bruises to bilateral hands and right, upper, outer back. Resident stated he/she did not know how he/she got them. There was no investigation into the bruises of unknown origin. Review of three Quarterly MDS assessments, dated 12/25/18, 3/19/19, 6/2019, indicated the resident with cognitive impairment, evidenced by a BIMS score of 7 out of 15, had no behavior problems, and received 7 days of an anti-coagulation medication ([MEDICATION NAME], then changed to Eliquis 3/4/19, thereafter). On 7/9/19 at 8:10 [NAME]M., the surveyor observed Resident #36 in a wheelchair (w/c) in the doorway of the resident's room. The resident was fully dressed and wearing a sweater covering both arms. The resident wore long pants, shoes and socks. The resident refused to be interviewed by the surveyor. The resident's face was clear. On 7/10/19 at 4:45 P.M., the surveyor requested copies of investigations conducted by the facility into the bruises, the resident's chin being nicked, and a cut on the resident's cheek from the Director of Nursing (DON). During an interview on 7/11/19 at 10:50 [NAME]M., with the DON, she said she did not investigate any of the bruises, cuts on the resident's chin and face, but did ask the resident if he/she felt safe, or if staff had harmed him/her, and each time the resident said no, so she did not feel an investigation was warranted. The DON said she should have investigated each bruise, cut, and when the resident's chin had been nicked during shaving chin whiskers, and required treatment. The DON said she had found out a staff member used a sharp razor to shave chin whiskers from the resident's chin, and inadvertently nicked the underside of the chin. The DON said interventions, such as, not using any sharp instruments, especially for this resident on a blood thinning medication with fragile skin, had never been implemented to prevent further injury. The DON said she did not know how the resident got a cut on his/her cheek, bruises to the jaw, neck, bilateral hands, and upper-outer back.

Based on record review and interview, facility staff failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status, related to behaviors for 1 of 12 sampled residents (Resident #42). Findings include: For Resident #42 the facility failed to ensure the Admission MDS assessment had been accurately coded for behaviors. Resident #42 was admitted to the facility in 5/2019 with multiple [DIAGNOSES REDACTED]. Review of a progress note, dated 5/14/19, indicated Resident #42 was alert and oriented to person only, remained restless, continuously asking to call wife, but does not recall phone number. Review of the 5/17/19 progress note indicated Resident #42 refused to get into bed from the wheelchair (w/c), was restless, moving legs everywhere, and staff told the resident how unsafe it was to sleep in a w/c. Resident refused and continued to be restless; refused abductor pillow (used to keep legs apart in order to stabilize hip, after surgical repair from fracture), despite education for leaving pillow in place, continued to remove the pillow several times, further education with little effect. Review of 5/19/19 progress note indicated the resident refused care; refused to go to bed, and [MEDICAL CONDITION] (puffiness caused by excess fluid) had increased in legs. Review of 5/20/19 progress note indicated the resident refused care; had been incontinent of bladder at midnight, and was resistive to care. Review of the Admission MDS assessment, dated 5/21/19, indicated the resident scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment, and had no behaviors, despite what had been documented in the clinical record/progress notes. During interview on 7/10/19 at 3:00 P.M., the MDS Coordinator said there were no behaviors coded. The surveyor pointed out the resident's behaviors in the progress notes. The MDS Coordinator said that a 1 should have been coded for behaviors on the initial MDS, indicating the refusal/rejection of care occurred 1-3 days. However, the MDS Coordinator said the Social Worker is the person who codes behaviors. During interview on 7/11/19 at 2:30 P.M., the Social Worker (SW) said that she is the one who coded the resident had no behaviors, and felt justified coding the behaviors, as such, as the behaviors did not really impact the resident/staff, subsequently she coded no behaviors, and continued to maintain the MDS had been accurately coded. Please refer to F655, F740 and F742.

Based on record review and interview, the facility staff failed to notify in the resident and/or the resident's representative in writing, the reason for a transfer for 3 residents (#18, #25 and #32) out of a total sample of 12 residents. Findings include: 1. For Resident #18, the facility staff failed to notify the resident in writing the reason for the transfer/discharge to the hospital. Resident #18 was admitted to the facility in 3/2018 with a [DIAGNOSES REDACTED]. Record review indicated the resident was sent to the hospital on [DATE] and re-admitted to the facility on [DATE]. On 7/09/19 at 3:20 P.M. during an interview with the Social Worker (SW) she said that when the resident went out to the hospital on [DATE] she was on vacation so the transfer/discharge notice was not given. The surveyor asked the SW when she is on vacation who issues the transfer/discharge notices and she said that she did not know. 2. For Resident #25, the facility staff failed to notify the resident's representative in writing the reason for a transfer to the hospital. Resident #25 was admitted to the facility in 8/2017. Record review indicated the resident was admitted to the hospital on [DATE]. On 7/10/19 at 11:38 [NAME]M. during an interview with the SW, she said a transfer/discharge notice was not issued to the resident's representative when he/she was admitted to the hospital on [DATE] because she was not working that day. 3. For Resident #32, the facility staff failed to issue a written notice of transfer to the resident when he/she was sent to the hospital for an evaluation, and failed to notify the ombudsman of the transfer. Resident #32 was admitted to the facility in 5/2019 with [DIAGNOSES REDACTED]. Review of a nurse's note, dated 6/23/19, indicated Resident #32 was sent out to the emergency room for an evaluation after he/she complained of weakness, shortness of breath and a low pulse oximeter reading. A nurse's note, dated 6/24/19, indicated the resident was admitted to the hospital. Further review of the clinical record indicated there was not a notice of transfer provided at the time of this hospitalization and there was no confirmation that the ombudsman office was notified. During an interview on 7/10/19 at 11:30 [NAME]M., the SW said that she, nor any other facility staff, issued the resident or representative a notice of transfer. The SW said she was on vacation at the time of the resident's transfer to the hospital, but the notice should have still been provided. She also said the ombudsman's office was not notified of the transfer, but should have been.

Based on record, policy review and interview, facility staff failed to develop and implement a baseline care plan within 48 hours of the resident's admission, for 2 sampled residents (#36 and #42), from a total sample of 12 residents, that included instructions needed to provide effective and person-centered care. Findings include: Review of the facility's Falls Prevention Management policy (undated) indicated the following: - All residents are considered to be at risk for falls. - The interdisciplinary team (IDT) will initiate a fall risk care plan on admission, and develop falls prevention interventions. 1. For Resident #36 the facility failed to complete a baseline care plan for falls. The comprehensive care plan had not been developed within 48 hours of admission, in place of the baseline care plan. Resident #36 was admitted to the facility in 9/2018 with multiple [DIAGNOSES REDACTED]. Review of the admission fall risk assessment, dated 9/20/18, indicated Resident #36 was at a low risk for falling, with a fall risk score of 4. However, the assessment score did not accurately reflect all factors which may contribute to the resident falling, such as, checking the resident did not have dementia or weakness ([DIAGNOSES REDACTED]. In addition, the Fall prevention and Management policy indicated that all residents are considered to be at risk for falling, and a care plan will be developed on admission. Review of the admission care plans indicated there was no baseline falls care plan completed within 48 hours of admission, and per policy. Further review of the record indicated the resident fell on [DATE], 9/29/18 and 10/5/18. During interview on 7/10/19 at 11:30 [NAME]M., the Minimum Data Set (MDS) Coordinator said that since the resident scored a 4, he/she was considered a low risk for falls; the resident did not require a falls care plan within 48 hours of admission. 2. For Resident #42 the facility failed to ensure a behavior baseline care plan had been developed within 48 hours of admission, specifically for behavior management. Resident #42 was readmitted back to the facility in 5/2019, after falling and fracturing his/her hip, requiring open reduction internal fixation (ORIF) surgical repair and has multiple [DIAGNOSES REDACTED]. Review of a progress note, dated 5/14/19, indicated Resident #42 was alert and oriented to person only; remained restless; continuously asking to call wife, but does not recall phone number. Further review indicated there was no baseline behavioral health care plan completed within 48 hours of admission. Review of 5/17/19 progress note, indicated the resident refused to get into bed from the w/c, was restless, moving legs everywhere, and staff told the resident how unsafe it was to sleep in a w/c. Resident #42 refused to cooperate and continued to be restless. The resident refused an abductor pillow (used to keep legs apart in order to stabilize hip, after surgical repair from fracture) even after being educated regarding leaving the pillow in place at all times. Review of 5/19/19 progress note, indicated Resident #42 refused care; refused to go to bed; and [MEDICAL CONDITION] had increased in legs. Review of 5/20/19 progress note, indicated Resident #42 refused care; had been incontinent of bladder at midnight, and was resistive to care. Review of the Admission MDS assessment, dated 5/21/19, indicated Resident #42 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment, had no behaviors, despite what had been documented in the clinical record. Section V of this MDS indicated the following Care Area Assessments (CAAs): - Cognitive impairment: Displayed disorganized thinking; unspecified mental disorder; confusion disorientation, forgetfulness; impulsivity; psychiatric mood d/o, hearing and vision impairment may have an impact on ability to process information. The Analysis of Findings section indicated, resident is confused, has cognitive impairment, anxiety, depression and [MEDICAL CONDITION], which contribute at risk for increased confusion. Care plan will be developed to inform staff of cognitive impairment. Referral to Psychiatrist. Review of a care plan, initiated 6/3/19 indicated Psyche consult, as needed. The comprehensive care plan had not been completed within 48 hours, in place of the baseline care plan. During interview on 7/10/19 at 3:00 P.M., the MDS Coordinator said a baseline care plan had not been developed as there were no behaviors coded. The surveyor pointed out the resident's behaviors in the progress notes. The MDS Coordinator said that a 1 should have been coded for behaviors on the initial MDS, indicating that refusal/rejection of care occurred 1-3 days. During interview on 7/11/19 at 2:30 P.M., the Social Worker (SW) said that she is the one who coded the resident had no behaviors, and felt justified coding the behaviors, as such, and felt there was no need for a baseline behavioral management care plan.

Based on observation, record review and interview, the facility failed to prevent the development of a pressure sore to the left lateral heel for one resident (#6) in a total sample 12. Findings include: Prior to admission, Resident #6 fell sustaining a right [MEDICAL CONDITION]. On 8/4/13, the resident had a surgical repair of the right hip. Resident #6 was admitted on ,[DATE] for short term rehabilitation, with [DIAGNOSES REDACTED]. Resident #6 is alert and oriented able to understand and communicate. The admission assessment, dated 8/7/13, documented right hip surgical wound and no pressure ulcers present. A Norton skin assessment was completed on 8/8/13, with a score of 11, which indicates a high risk for skin breakdown. A pressure reducing/relieving mattress was provided on the bed upon admission. On 9/17/13, review of the resident's initial 7 day care plan, dated 8/7/13, addressed falls, pain, and rehabilitation. The care plan lacked any intervention for skin or prevention of skin breakdown. Review of the Minimum Data Set (MDS), with the assessment reference date (ARD) of 8/14/13, identified the following: extensive staff assistance for bed mobility; no pressure ulcers at stage 1 or higher, at risk of developing pressure ulcers; right hip surgical wound with wound care, turning /repositioning program and pressure reducing device for chair and bed. The care area assessment (CAA) summary, dated 8/17/13, read, "at risk for skin breakdown related to decreased mobility." The CAA resident care plan completion date was 8/19/13. The CAA summary read "to proceed to care plan." Review of the care plan updated after the CAA lacked evidence of interventions for prevention of pressure areas. Review of a nurses note entry dated 8/21/13 at 12:31 A.M., read " found 2 inch round eschar wound on left heel", " Report was made to NP (Nurse Practioner) and new order was given : pillow under left heel with skin prep every shift." Nurse's note dated 8/21/13, at 8:05 A.M., read "left heel assessed for a 4.5 cm by 2.5 cm eschar area surrounding tissue red and soft". A care plan for actual skin impairment was dated 8/21/13 with interventions. On 9/17/13,at 4:00 P.M., Resident #6, during an interview, said " I did not have any problem with my left heel, now look , I'm not happy. " On 9/17/13 at 4:45 P.M., the Director of Nursing, said the Resident did not have a pressure ulcer on the left heel on admission. In addition, on 9/18/13 at 2:30 P.M., Director of Nurses said there was no pressure relief provided to the resident's heel prior to the development of the pressure ulcer. On 9/19/13, review of the facility's weekly pressure wound assessment sheet dated 9/18/13, of the left heel read "Eschar drying, 4.8 centimeter (cm.) by 4.4 cm., unable to stage." During a treatment observation on 9/19/13 at 1:50 P.M., of the black eschar area on left heel, the treatment nurse stated that the area had not changed in size or character since being measured on 9/18/13.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 received adequate supervision and assistance to prevent a fall, when on 11/30/12, Volunteer #1, who was not a certified nurse aide (CNA) and did not provide hands on assistance to residents, was left alone in the activity room with residents, who were at risk for falls. Resident #1, who had a history of [REDACTED]. Findings include: The Identification and Summary sheet indicated that the staff admitted Resident #1 to the Facility in March, 2012. The Problem Oriented record indicated that Resident #1's [DIAGNOSES REDACTED]. The plan of care, related to Resident #1's risk for falls, dated 3/6/12, included: ambulates/transfer with assist of 1 with walker and gait belt and clip alarm in chair. The Fall Risk assessment, dated 9/20/12, indicated that Resident #1's risk factors for falls included: altered mental status, weakness or vertigo, unsteady gait, neurological disease or deficit, incontinence, and use of a walker for ambulating. The Quarterly Minimum Data Set (MDS) assessment, completed on 10/1/12, indicated that Resident #1 understood others and made himself/herself understood. The MDS assessment indicated that Resident #1 had temporal orientation issues. The MDS assessment indicated that Resident #1 required extensive assist of one staff for transfer activities and toilet use. The MDS assessment indicated that Resident #1 required limited assist of one staff for ambulating. The MDS assessment indicated that Resident #1 was not steady when moving from a seated to a standing position. The MDS assessment indicated that Resident #1 used a walker. The nurse's note, dated 10/1/12, indicated that Resident #1 unclipped the personal alarm and toileted himself/herself without staff assistance. The nurse's note indicated that the staff applied a pressure alarm to Resident #1's chair. The activity note, dated 11/6/12, indicated that Resident #1 had decreased safety awareness, often self rose, ambulated without supervision, and was sometimes forgetful. The Surveyor interviewed Administrative Assistant #1 on 1/22/13, at 11:01 A.M. The Surveyor interviewed Administrative Assistant #2 on 1/22/13, at 11:25 A.M. Administrative Assistant #1 and Administrative Assistant #2 said some of their job duties included answering the telephone in the lobby next to the activity room. Administrative Assistant #1 and Administrative Assistant #2 said usually one administrative assistant was in the lobby answering the telephone between 7:00 A.M. and 5:00 P.M. Administrative Assistant #2 said she was not able to visualize the activity room from the seat where she sat. Administrative Assistant #1 and Administrative Assistant #2 said sometimes the activity staff asked them to watch the residents in the activity room for a few minutes, while they transported residents to and from the activity room. Administrative Assistant #1 and Administrative Assistant #2 said during those times, they were alone with residents in the activity room. Administrative Assistant #1 and Administrative Assistant #2 said they did not have current CNA certifications and did not provide hands on assistance to residents. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on 1/22/13 at 10:00 A.M. The Surveyor interviewed CNA #2 on 1/23/13 at 12:00 P.M. The Surveyor interviewed CNA #3 on 1/22/13 at 1:28 P.M. The Surveyor interviewed CNA #4 on 1/23/13 at 2:13 P.M. CNA #1, CNA #2, CNA #3, and CNA #4 said Resident #1 had an unsteady gait and had a history of [REDACTED]. CNA #1, CNA #2, CNA #3, and CNA #4 said when Resident #1 was in the dining room, there was always a CNA in the dining room. CNA #3 said when Resident #1 stood from the chair, he/she usually wanted to use the bathroom. CNA #3 said the CNAs usually toileted Resident #1 shortly after Bingo. CNA #4 said on 11/30/12, she , CNA #2, and CNA #3 checked the alarms in the activity room shortly after 3:00 P.M. CNA #4 said she checked Resident #1's alarm, which sounded and functioned appropriately. The Surveyor interviewed the Activity Director on 1/22/13, at 12:35 P.M. The Activity Director said on 11/30/12, between 3:05 P.M. and 3:12 P.M., CNA #1, CNA #2, and CNA #3 came to the activity room, checked the alarms on the 3 residents that used alarms, and all 3 alarms sounded. The Activity Director said CNA #1, CNA #2, and CNA #3 left the activity room after they checked the alarms. The Activity Director said she left the activity room shortly after CNA #1, CNA #2, and CNA #3 left the activity room . The Activity Director said Activity Aide #1 and Volunteer #1 remained in the activity room. Activity Aide #1's written statement, dated 11/30/12, indicated that she transported a resident to the main dining room and stayed in the main dining room until a CNA came to the main dining room. Activity Aide #1's statement indicated that when she came back to the activity room, she observed a commotion outside the entrance doorway to the activity room. The Surveyor interviewed Activity Aide #1 on 1/22/13, at 2:50 P.M. Activity Aide #1 said shortly after the Activity Director left the activity room, one of the residents wanted to be transported to the dining room. Activity Aide #1 said the dining room was a short distance from the activity room. Activity Aide #1 said she left Volunteer #1 in the activity room without a staff member. Activity Aide #1 said she transported the resident to the dining room. Activity Aide #1 said when a CNA came to the dining room, she told Nurse #1 to send the CNAs to the activity room, and returned to the activity room. The Surveyor interviewed Nurse #1 on 1/22/13, at 12:50 P.M. Nurse #1 said on 11/30/13, after she received report from the day nurse, she and the day nurse started the narcotic count. Nurse #1 said during the count, Activity Aide #1 asked her to have the CNAs come to the activity room to transport the residents back to the nursing unit. Nurse #1 said she asked Activity Aide #1, who was monitoring the residents? Nurse #1 said Activity Aide #1 told her that someone was with the residents. Nurse #1 said she told Activity Aide #1 that she would send the CNAs to the activity room as soon as she completed the narcotic count. Nurse #1 said within a few minutes, someone told her that Resident #1 sustained a fall. Volunteer #1's verbal statement provided to the Director of Nurses (DON), dated 11/30/12, indicated that Volunteer #1 walked to the sink in the activity room for a few minutes. Volunteer #1's statement indicated that when Volunteer #1 returned to the table, she observed Resident #1 on the floor. Volunteer #1's statement indicated that Resident #1's alarm did not sound. The Surveyor interviewed Volunteer #1 on 1/23/12, at 1:10 P.M. Volunteer #1 said on 11/30/12, after bingo ended, Activity Aide #1 transported a resident to the dining room. Volunteer #1 said she put some items in the cabinet near the sink and had her back away from the residents. Volunteer #1 said she heard a noise and turned around. Volunteer #1 said Resident #1 was on the floor. Volunteer #1 said Resident #1's alarm did not sound. Volunteer #1 said Resident #1's walker was not near him/her. Volunteer #1 said she was not aware there was a call light in the activity room to summon help. Volunteer #1 said Activity Aide #1 came back to the activity room a few minutes after Resident #1 fell . The activity note, dated 11/30/12, indicated that at 3:45 P.M., Resident #1 stood from his/her chair and fell near the activity room. The activity note indicated that Resident #1 needed reminders and cueing all day. The activity note indicated that Resident #1 said he/she did not want to wait. Activity Aide #1 said Resident #1 told her that she wanted to go to the bathroom and did not want to wait for the staff to assist him/her. The Event report, dated 11/30/12, indicated that Resident #1 unplugged the chair alarm, stood to go to the bathroom, and fell . The Surveyor interviewed the Director of Nurses (DON) on 1/22/13, at 10:45 A.M. The DON said Resident #1 had right hip pain and denied hitting his/her head. The DON said the emergency medical technicians transported Resident #1 to the Hospital. The DON said the staff checked Resident #1's alarm, which sounded and functioned correctly after his/her fall. The Cat (computed axial tomography)scan of the right hip, dated 11/30/12, indicated that Resident #1 had a comminuted intertrochanteric fracture of the right femur. The DON said prior to Resident #1's fall on 11/30/12, the activity staff monitored the residents in the Activity room during the activity. The DON said there were usually 2 people in the room. The DON said sometimes there were 2 activity staff and sometimes there was an activity staff and a volunteer. The DON said although the activity staff could be alone in the activity room with residents, the volunteers and the administrative assistants were not allowed to be alone in the activity room without a nurse, CNA, or activity person. The DON said Volunteer #1's job functions did not include hands on nursing care to residents. The DON said Activity Aide #1 did not call or ask another staff member to transport the resident to the dining room or monitor the residents while she transported the resident to the dining room. The DON said during the time that Volunteer #1 was in the activity room with the residents by herself, Resident #1 stood from his/her chair, and fell . .