Every finding on record at Notre Dame Long Term Care Center

Based on observations, and interviews, the facility failed to ensure staff stored and labeled all drugs and biologicals in accordance with accepted professional standards of practice, as required, for two (Cuvilly Unit High Side and Cuvilly Unit Low Side) of the three medication carts reviewed.Specifically, for the Cuvilly Unit High Side medication cart and the Cuvilly Unit Low Side medication cart, the facility failed to ensure that medications were appropriately stored and labeled in the two medication carts when loose, unlabeled pills were observed in both medication carts. Findings include:Review of the facility policy titled Medication Cart Cleaning, dated December 2023, included:-All Medication Carts will be cleaned and organized weekly on the 11-7 shift On 5/6/26 at 8:20 A.M., the surveyor and Unit Manager (UM) #3 observed in the Cuvilly Unit High Side medication cart thirty-five loose pills, paper remnants and elastics, as well as powder in the corners of the drawer that holds resident specific medication cards. During an interview at the time, UM #3 said the concern would be that the loose medications could have been dropped by the Nurse leading to an omission of prescribed medications. UM #3 said her expectation was that the medication carts would be clean and free of loose medications and debris. UM #3 said it was the day-to-day responsibility of the Nurse assigned to the medication cart to keep the cart clean but, ultimately, as the manager, it was her responsibility to ensure that the carts were clean. On 5/6/26 at 9:20 A.M., the surveyor and Nurse #4 observed in the Cuvilly Unit Low Side medication cart fifty loose pills, paper remnants, and elastics, as well as powder in the corners of the drawer that holds resident specific medication cards. During an interview at the time, Nurse #4 said she would need to ask UM #3 who was responsible for ensuring that the medication cart was clean and free of debris, as she was unsure. During an interview, on 5/6/26 at 4:57 P.M., the Director of Nursing (DON) said it was his expectation that the medication carts were clean. The DON said that it was the responsibility of the Nurse assigned to the cart to clean the cart at the end of their shift.

Based on observations, interviews, and record review, the facility failed to ensure that a person-centered care plan, relative to eating assistance and supervision, was implemented for one Resident (#12) out of a total sample of 24 residents. Specifically, for Resident #12, the facility failed to implement supervision by one staff and assist of one staff as needed to set up meals as required, when the Resident experienced a significant weight decline and was care planned for feeding assistance and supervision.Findings include:Review of the facility policy titled Meal Serving, revised February 2012, included but was not limited to:*All residents able to receive oral feeding are properly positioned to facilitate eating. Any resident requiring assistance with meals receives help as needed. Adaptive equipment is provided as ordered to assist individual residents as needed.-Residents who are able to eat outside of their rooms are served in the dining areas.-Residents incapable of feeding themselves will be assisted by trained staff. Review of the facility policy titled Nutritional Assessment, revised October 2017, included but was not limited to:*As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident.-The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition.-As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk or with impaired nutrition.-Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences. -Individual care plans shall address to the extent possible:>Goals and benchmarks for improvement. Review of the facility policy titled Change in a Resident's Condition or Status, revised December 2025, included but was not limited to:*The facility promptly notifies the resident, resident's attending physician or provider, and the resident representative of changes in the resident's condition and/or status.-A significant change of condition is a major decline or improvement in the resident's status that:>Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention (is not self-limiting).>Requires interdisciplinary review and/or revision to the care plan. Resident #12 was admitted to the facility in November 2025 with diagnoses including moderate protein calorie malnutrition, Dysphagia, Hypothyroidism, and Hypo-Osmolality and Hyponatremia. Review of Resident #12's Weight Summary from 11/12/25 (weight 106.1 pounds [lbs.]) through 5/5/26 (weight 88.8 lbs.) indicated a significant weight loss of 16.31 percent (%) over a six-month period. Review of Resident #12's Speech Care Plan, revised 11/14/25, indicated:-the Resident had a swallowing problem related to swallowing assessment results.>Check mouth after each meal for pocketed food and debris.>Resident to eat only with supervision. Review of Resident #12's Nutritional Risk assessment dated [DATE], indicated: *Swallowing Disorder Data:>Swallowing disorder indicated.>Holding food in mouth/cheeks or residual food in mouth after meals.>Coughing or choking during meals or when swallowing medications.*Physical and Functional Data:>Independent.>Setup assistance and supervision. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of 15 -was holding food in mouth and cheeks or residual food in mouth after meals-had weight loss-required a mechanically altered diet and required change in texture of food or liquids-required set up and assistance with eating Review of Resident #12's Activity of Daily Living (ADL) Care Plan, revised 3/21/26, indicated:-the Resident had an ADL self-care performance deficit related to weakness, fractures, and decreased activity tolerance. >eating: the Resident required a setup and assistance as needed. Supervised for meals. Review of Resident #12's Dietician Progress Note dated 4/14/26, indicated: -Reweight obtained 90.1 lbs. (4/9/26) and remains low.-Reflects an 8.2 percent (%) significant weight loss x (times) one month and 12.6% significant weight loss x six months. Review of Resident #12's Kardex Report (summary of Resident's daily care needs, including eating), dated 5/7/26, included but was not limited to:>check mouth after meal for pocketed food and debris.>set-up and assist as needed.>supervised for meals.>Resident to eat only with supervision. Review of Resident #12's May 2026 Physician's orders, indicated:-Regular diet pureed texture, thin consistency, fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) DIET (certain sugars that may cause intestinal distress), No Straws, Supervised dining all meals, initiated 11/11/25.-OWYN non-dairy protein shake, vanilla flavor 330 milliters (ml) by mouth (PO) three times a day (TID) (daughter will bring in shakes) with meals for supplement, initiated 4/8/26. Review of Resident #12's Alteration in Nutrition Care Plan interventions, revised 5/6/26, indicated:>Dysphagia>Weight loss>Underweight body mass index -18.5 (BMI- a screening tool that uses a person's height and wight to estimate the amount of body fat)>Ongoing supervision at meals/encouragement and assistance when ableOn 5/6/26 at 9:05 A.M., the surveyor observed a staff member entering Resident #12's room and alerted the Resident that the breakfast meal was ready. The surveyor further observed the staff member place the breakfast meal on a bedside table and elevated the Resident's head of the bed, set the meal up for the Resident and exited the room. On 5/6/26 at 9:16 A.M., the surveyor observed Resident #12 seated on his/her bed in his/her bedroom with the head of the bed elevated and a bedside table in front of the Resident with a breakfast meal. The meal included a bowl of gluten free oatmeal, pureed pancake with syrup, pureed eggs and two nosey cups (an adaptive drinking aid featuring a U-shaped cutout on one side, the cutout provides space for the nose, allowing individuals to drink without tilting their head back or extending their neck) containing Lactaid milk. Resident #12 was observed with a clothing protector around his/her chest area and was eating the breakfast meal. Resident #12 spilled most of the oatmeal on his/her clothing during the meal. Resident #12 was observed to pick up the nosey cup and place the notched side of the cup to his/her mouth, spilled the drink on his/her clothing and placed the nosey cup back on his/her meal tray. The surveyor did not observe any staff members returning to the room to assist after the breakfast meal was set up for the Resident. On 5/6/26 at 9:38 A.M., the surveyor observed Resident #12 lying in his/her bedroom with the head of the bed elevated and the breakfast meal on a bedside table. The pureed pancake and pureed eggs were observed to be untouched by the Resident. The surveyor observed the Resident picking up the nosey cup, placed the notched side of the cup to his/her mouth and spill the drink on his/her clothing. Resident #12 was observed moaning and placed the cup on his/her tray. The surveyor did not observe a staff member present in the room with the Resident. On 5/7/26 at 8:40 A.M., the surveyor observed Nurse #2 enter the Resident's room with the breakfast meal. Nurse #2 placed the breakfast meal on a bedside table and alerted the Resident that the breakfast meal was ready. Nurse #2 elevated the head of the bed for the Resident, positioned the meal tray in front of the Resident and then exited the room. On 5/7/26 at 8:48 A.M. through to 9:15 A.M., the surveyor observed the Resident's room for the reminder of the mealtime and did not observe any staff members entering the room. The Resident was observed seated on his/her bed with the head of the bed elevated and a breakfast meal on a bedside table in front of the Resident. The meal included pureed scrambled eggs, gluten free pureed muffin with syrup in a lip plate, gluten free oatmeal, Owyn shake, and two nosey cups each containing Lactaid milk. Resident #12 was observed to pick up a black handled spoon to eat his/her breakfast meal and spill the oatmeal and pureed scrambled eggs on his/her clothing. The surveyor observed the gluten free pureed muffin and pureed scrambled eggs remained untouched by the Resident and the gluten free oatmeal spilled on the Resident's clothing. During an interview on 5/7/26 at 9:29 A.M., CNA #2 said that Resident #12 required supervision during meals. CNA #2 said that supervision indicated that a staff member must be present during meals to supervise the Resident. CNA #2 said that the risk for Resident #12 not being supervised during his/her breakfast meal was the risk of choking. During an interview on 5/7/26 at 9:31 A.M., Unit Manager (UM) #1 said that Resident #12 required supervision during meals and a staff member should have been in the room supervising the Resident during the breakfast meal. UM #1 said that Resident #12 had weight loss and supervising the Resident during meals ensures that the Resident consumed his/her meals to prevent additional weight decline and nutritional deficiencies. During an interview on 5/7/26 at 3:13 P.M., the Speech Therapist (ST) said that she evaluated Resident #12 to determine if the Resident's diet could be upgraded to a different meal texture as a request by the Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself). The ST said Resident #12 was evaluated with ground textured meals, but the Resident was unable to swallow the food. The ST said she recommended that Resident #12 stay on a pureed textured diet with supervision for encouragement. The ST said that Resident #12 would benefit from staff encouragement and supervision with meals. During an interview on 5/7/26 at 3:30 P.M., the Registered Dietician (RD) said Resident #12 was referred to her due to significant weight loss and request for a speech evaluation. The RD said she did meal rounds and observed that on several occasions Resident #12's head was down and he/she was not touching his/her food during meals. The RD said that she updated Resident #12's care plan to include supervision with meals because the Resident was eating his/her meals in the dining room and expected staff members to be present with the Resident during meals. The RD said that she was not aware that Resident #12 was eating his/her meals in his/her bedroom. The RD further said that Resident #12 should have been provided with supervision for risk of additional weight decline and nutritional deficiencies. During an interview on 5/8/26 at 7:20 A.M., the Staff Development Coordinator (SDC) said all newly hired CNA's were paired with seasoned CNA's for training on all floors and were given a check list to complete during the orientation process. The SDC said that all CNA's should review the resident's Kardex every day prior to providing resident care to determine each resident care needs. The SDC said that if Resident #12's Kardex indicated supervision with meals, the CNA should be in the room with the Resident to provide supervision. The SDC said that the risk to Resident #12 not being provided with supervision during meals would be aspiration.

Based on observations, interviews, and record review, the facility failed to ensure that medications were administered per professional standards of practice for two Residents (#90 and #104) out of a total sample of 24 residents, resulting in two significant medication errors. Specifically, 1.for Resident #90, the facility staff failed to obtain a blood pressure reading per the Physician's order, prior to administering Amlodipine Besylate (medication used to treat high blood pressure) and to hold (not give) the Amlodipine Besylate medication for a Systolic Blood Pressure (SBP- top number of a blood pressure reading) that measured less than 110 millimeters of Mercury (mmHg) in accordance with the Physician's order, placing the Resident at risk for cardiac compromise, hypotension (extremely low blood pressure) and related complications such as dizziness, fainting and vision changes. 2.for Resident #104, the facility staff failed to hold Amlodipine Besylate, Torsemide (diuretic medication used to treat fluid retention and high blood pressure), and Valsartan (medication used to treat high blood pressure, heart failure, and to improve survival after a heart attack) in accordance with the Physician's order to hold the medications for a SBP that measured less than and/or equal to 105 mmHg and Diastolic Blood Pressure (DBP- bottom number in a blood pressure reading) that measured less than and or equal to 60 mmHg, placing the resident at risk for cardiac compromise such as dizziness, lightheadedness and fainting. Findings include: Review of the facility policy titled Vital Signs and Weight, revised 8/00, included but was not limited to:*Vital signs of residents are monitored regularly.-It is the policy of the facility to monitor vital signs on a regular basis to ensure maximum health and well being of the residents.>Pulse and blood pressure are taken on all residents on admission, monthly, as ordered, and when needed.>The charge nurse is responsible for comparing the current vital signs and weight with the previous results and for taking appropriate action when variances are noted.>Nursing judgment must be used when resident health status changes (e.g., symptoms of congestive heart failure). These residents have vital signs monitored more frequently as a nursing measure. Physicians are notified of significant changes. >Resident care plans are updated as needed. Review of the facility policy titled Administering Medications, revised January 2026, included but was not limited to:*Medications shall be administered in a safe and timely manner, and as prescribed.-Medications must be administered in accordance with the orders, including any required time frame. -The following information must be checked/verified for each resident prior to administering medications.>Vital signs, if necessary. Review of the facility policy titled Vital Signs-Blood Pressure, revised 2/11, included but was not limited to:*A blood pressure (BP) is taken to determine the force of the blood flowing through the blood vessel and to obtain objective criteria to assess physical condition of residents.-Blood pressures are taken only by licensed staff.-Blood pressures are taken on admission, monthly, as ordered by physician, and when needed.-Blood pressures are taken weekly for resident receiving anti-hypertensive medications.-Document on vital sign flow sheet and write a clinical note for an abnormal blood pressure (low or high).-Report significant variance to Physician. 1.Resident #90 was admitted to the facility in July 2022 with diagnoses including Essential (Primary) Hypertension, Chronic Kidney Disease Stage 3A, Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 and sequelae of Cerebral Infarction. Review of Resident #90's May 2026 Physician's orders included:-Amlodipine Besylate Oral Tablet 2.5 milligrams (mg). Give 2.5 mg by mouth in the morning related to Essential (Primary) Hypertension. Hold if SBP is less than (<) 110, initiated 5/24/24. Review of the Resident #90's March 2026, April 2026 and May 2026, Medication Administration Record (MAR) indicated:-Amlodipine Besylate Oral Tablet 2.5 mg was administered to Resident #90 with no blood pressure assessment documented in the clinical record relative to the administration of the medication daily. During an interview on 5/7/26 at 12:07 P.M., the surveyor and Nurse #1 reviewed Resident #90's Physician's orders and MAR and Nurse #1 said the Physician's orders indicated to hold Amlodipine Besylate medication if the Resident's SBP was less than or equal to 110 mmHg. Nurse #1 said the check mark on Resident #90's MAR indicated that the Amlodipine Besylate had been administered to the Resident and the medication should not have been administered because there was no SBP assessment documented relative to administration of the medication. Nurse #1 said that the risk of not assessing the SBP prior to administering the Amlodipine Besylate to the Resident was undetected hypotension as the Resident's blood pressure had not been assessed relative to administering the medications. The surveyor and Nurse #1 reviewed the Resident's vital signs records and Nurse #1 said that the Resident's blood pressure was being assessed weekly and should have been assessed daily, prior to the medication being administered as ordered by the Physician. During an interview on 5/7/26 at 12:28 P.M., the surveyor, the Director of Nursing (DON) and Unit Manager (UM) #1 reviewed Resident #90's Physician's orders, MARs for March 2026, April 2026, and May 2026, and the Resident's vital signs records. UM #1 said that Resident #90's blood pressure should have been assessed prior to the administration of the Amlodipine Besylate. UM #1 also said that Resident #90's blood pressure should have been assessed and evaluated by nursing staff daily and not weekly. UM #1 further said that her expectation for nursing staff administering medication was to follow the Physician's orders. UM #1 said the risk of Resident #90 receiving Amlodipine Besylate when the Resident's blood pressure was not assessed was hypotension. 2. Resident #104 was admitted to the facility in February 2026 with diagnoses including Chronic Diastolic (Congestive) Heart Failure, Unspecified Atrial Fibrillation, Chronic Kidney Disease Stage 3B, Essential (Primary) Hypertension and presence of cardiac pacemaker. Review of Resident #104's active Physician's orders included:-Amlodipine Besylate Oral Tablet 2.5 MG. Give 2.5 mg by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION. Hold for SBP less (<) or equal (=) to 105 or DBP less (<) or equal (=) to 60, initiated 2/18/26. -Torsemide Oral Tablet 20 MG. Give 1 tablet by mouth one time a day related to ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE. Hold for SBP < or = 105, and DBP < or = 60, initiated 2/19/26. -Valsartan Oral Tablet 160 MG. Give 1 tablet by mouth every 12 hours related to ESSENTIAL (PRIMARY) HYPERTENSION. Hold for SBP < 105 or DBP < 60, active 2/18/26 Review of Resident #104's February 2026 MAR indicated: >Torsemide Oral Tablet 20 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows: -On 2/24/26 at 9:00 A.M.: DBP was documented as 54 mmHg. >Valsartan Oral Tablet 160 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows:-On 2/19/26 at 9:00 P.M.: DBP was documented as 56 mmHg.-On 2/24/26 at 9:00 P.M.: DBP was documented as 58 mmHg. Review of Resident #104's March 2026 MAR indicated: >Amlodipine Besylate Oral Tablet 2.5 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows:-On 3/1/26 at 9:00 A.M.: DBP was documented as 55 mmHg.-On 3/17/26 at 9:00 A.M.: DBP was documented as 58 mmHg.-On 3/31/26 at 9:00 A.M.: DBP was documented as 54 mmHg.>Torsemide Oral Tablet 20 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows: -On 3/1/26 at 9:00 A.M.: DBP was documented as 55 mmHg.-On 3/17/26 at 9:00 A.M.: DBP was documented as 58 mmHg.-On 3/31/26 at 9:00 A.M.: DBP was documented as 54 mmHg.>Valsartan Oral Tablet 160 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows:-On 3/1/26 at 9:00 A.M.: DBP was documented as 55 mmHg.-On 3/1/26 at 9:00 P.M.: DBP was documented as 52 mmHg.-On 3/3/26 at 9:00 P.M.: DBP was documented as 51 mmHg.-On 3/5/26 at 9:00 P.M.: DBP was documented as 56 mmHg.-On 3/13/26 at 9:00 P.M.: DBP was documented as 55 mmHg.-On 3/17/26 at 9:00 A.M.: DBP was documented as 58 mmHg.-On 3/31/26 at 9:00 A.M.: DBP was documented as 54 mmHg.-On 3/31/26 at 9:00 P.M.: DBP was documented as 51 mmHg. Review of Resident #104's May 2026 MAR indicated:>Amlodipine Besylate Oral Tablet 2.5 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows:-On 5/3/26 at 9:00 A.M.: DBP was documented as 58 mmHg.>Torsemide Oral Tablet 20 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows: -On 5/3/26 at 9:00 A.M.: DBP was documented as 58 mmHg.>Valsartan Oral Tablet 160 mg was administered to Resident #104 outside of the Physician's ordered parameters as follows:-On 5/3/26 at 9:00 A.M.: DBP was documented as 58 mmHg. During an interview on 5/7/26 at 12:03 P.M., the surveyor and Nurse #1 reviewed Resident #104's Physician's orders and the February 2026, March 2026, and May 2026 MARs. Nurse #1 said the check mark on the MARs indicated the medications were administered to Resident #104. Nurse #1 said that the Physician's orders indicated to hold the anti-hypertensive medications if the SBP was less than or equal to 105 mmHg or DBP was less than or equal to 60 mmHg. Nurse #1 said the Amlodipine Besylate 2.5 mg, Torsemide 20 mg and Valsartan 160 mg should not have been administered to Resident #104 because the Resident's DBP was less than 60 mmHg on the dates listed. Nurse #1 said the Physician should have been notified if Resident #104's DBP was less than or equal to 60 mmHg and the medication had to be held. Nurse #1 said that the risk to Resident #104 was hypotension which could lead to dizziness. During an interview on 5/7/26 at 12:20 P.M., the surveyor, the Director of Nursing (DON) and UM #1 reviewed Resident #104's Physician's orders and MARs for February 2026, March 2026, and May 2026. UM #1 said that Resident #104's anti-hypertensive medications should have been held and not administered to the Resident. UM #1 said that the Physician should have been notified that the Resident's DBP was less than 60 mmHg. UM #1 said that the risk of the Resident receiving the anti-hypertensive medications when it should not have been administered was the risk of hypotensive complications. During an interview on 5/7/26 at 2:12 P.M., the Nurse Practitioner (NP) said if a resident had blood pressure parameters, her expectation was that nursing staff would assess and monitor the resident's vital signs including blood pressure monitoring as ordered. The NP said that she expected nursing staff to notify her if Resident #104's DBP was low. The NP said that it was important that nursing staff notify her so she could adjust Resident #104's medication to prevent complications.

Based on observation, and interview, the facility failed to ensure that a Licensed Nurse (Nurse #2) had the specific competencies and skill sets necessary to provide wound care for one Resident (#84). Specifically, the facility failed to ensure that Nurse #2 had the knowledge, competency and skills relative to infection control practices when providing wound care for Resident #84. Findings include: Review of the facility policy titled, Competency, undated, indicated: -Facility would ensure all nursing staff maintain high standards of patient care and safety. -Each nurse is responsible for maintaining their competency through training, evaluation, and professional development. -Nurses are required to periodically demonstrate continued proficiency in their roles through assessments, evaluations or skills check. -Common areas assessed include clinical skills, patient care, medication administration, infection control practices, communication skills and ethical decision-making. -Nurses undergo regular performance evaluations where their competencies are assessed by supervisors or managers. -All competency assessments, training activities, and evaluations are documented to ensure transparency and accountability. Review of the facility policy titled Enhanced Barrier Precautions, dated 2001, revised August 2022, included but was not limited to: -Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. -EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Review of the facility policy titled Handwashing/Hand Hygiene, dated 2001, indicated: -All personnel are trained and regularly in-serviced to the importance of hand hygiene in preventing the transmission of healthcare-associated infections . -Hand hygiene is indicated immediately after glove removal. Resident #84 was admitted to the facility in March 2024 with diagnoses including Unstageable Pressure Ulcer to coccyx and Methicillin Resistant Staphylococcus Aureus (MRSA) Infection. Review of Resident #84's February 2024 Physician orders indicated: -Unstageable pressure ulcer on coccyx (a small triangular-shaped bone located at the bottom of the spine), clean with normal saline, pat dry, apply Santyl (used to remove damaged tissue from chronic skin ulcers), pack with Calcium Alginate (wound exudate absorbing agent) then cover with a silicone border foam dressing daily, initiated on 1/24/25. On 2/11/25 at 10:05 A.M., the surveyor observed the following during a wound care observation for Resident #84: -An Enhanced Barrier Precaution (EBP) sign at the Resident's door indicating the Resident was on precautions. -Nurse #2 washed her hands with soap and water in the Resident's bathroom, then donned (put on) a gown and gloves. -Nurse #2 repositioned the Resident to his/her side, and removed the old wound dressing. -Nurse #2 doffed (removed) her gloves, did not wash or sanitize her hands, and donned new gloves. -Nurse #2 cleansed the Resident's wound bed with wound cleanser, pat dried the wound, doffed her gloves, did not wash or sanitize her hands, and donned new gloves. -Nurse #2 reached into her pocket and took out scissors, did not disinfect the scissors, then cut a piece of Calcium Alginate and placed the piece of Calcium Alginate on the overbed table. -Nurse #2 doffed her gloves, did not wash or sanitize her hands, and donned new gloves. -Nurse #2 applied Santyl to the Resident's wound bed, then applied the Calcium Alginate. -Nurse #2 doffed her gloves, did not wash or sanitize her hands, reached into her pocket and took out a pen, then donned new gloves. -Nurse #2 opened the silicone foam protective dressing, dated the foam dressing, put the pen back in her pocket and applied the foam dressing to the Resident's wound. -Nurse #2 doffed the old gloves, did not wash or sanitize her hands, donned new gloves, then repositioned the Resident. -Nurse #2 removed a trash bag from the Resident's bedside table and dropped the trash bag in the Resident's bathroom trash can, doffed her gloves, did not wash or sanitize her hands, donned new gloves and assisted the Certified Nurses Aide (CNA) with transferring the Resident out of bed. During an interview on 2/11/25 at 10:48 A.M., Nurse #2 said she thought washing her hands with soap and water in the beginning was sufficient when completing Resident 84's wound care. During an interview on 2/11/25 at 10:58 A.M., the Infection Preventionist (IP)/Staff Development Coordinator (SDC) said she had not performed nursing competency relative to infection control during wound care with the Nurses and she should have. During a follow-up interview on 2/11/25 at 11:35 A.M., Nurse #2 said she should have cleaned or sanitized her hands between removing gloves, but she had not. Please Refer to F880

Based on observation, record review, and interview, the facility failed to provide Adaptive Eating Equipment for one Resident (#75) out of a total sample of 23 residents. Specifically, the facility failed to provide built-up handled adaptive utensils for meals as required to preserve Resident #75's current level of function during meals. Findings include: Review of the facility policy titled Adaptive Equipment, undated, indicated: -Adaptive equipment for meal service in a nursing home is designed to help residents with varying physical abilities eat independently, safely, and comfortably. -Built-up Handle Utensils: These have thicker handles to make gripping easier for people with limited hand strength or dexterity . Resident #75 was admitted to the facility in April 2021 with diagnoses including Unspecified Dementia and Muscle Weakness (Generalized). Review of the Resident's Activities of Daily Life (ADL) care plan, revised 6/3/24, included an intervention for eating of .Black Silverware .during meals. Review of the Nutritional Risk Assessment, dated 12/4/24, indicated that the Resident required an intervention of black handled utensils. Review of the Resident's Nutrition Care Plan, revised 12/4/24, included an intervention of adaptive equipment with meals. Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/6/24, indicated that the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 possible points. Review of the Resident's Occupational Therapy (OT) Discharge Summary, dated 12/27/24, indicated: - .instructed patient and primary caregivers in use of adaptive utensils in order to preserve current level of function . On 2/7/25 at 9:05 A.M., the surveyor observed Resident #75 lying in bed, with a breakfast meal tray set-up in front of him/her. The diet slip on the tray indicated that adaptive equipment including Black Silverware was required. The surveyor observed the silverware on the breakfast meal tray was silver in color and of standard size, and the food served on the plate included scrambled eggs. The surveyor further observed the Resident attempt to feed himself/herself the eggs using the spoon provided, but when the Resident picked up the spoon with scrambled eggs on it, the spoon tipped and the scrambled eggs spilled onto the Resident's chest. Review of Resident #75's Certified Nurses Aide (CNA) Kardex, dated 2/10/25, indicated that the CNA should ensure the Resident was provided with Black silverware for meals. On 2/10/25 at 8:45 A.M., the surveyor and Nurse #1 observed the Resident feeding himself/herself in bed. The Resident's breakfast meal included scrambled eggs, home fries, a muffin, and orange juice in a clear plastic cup. The silverware observed on the meal tray was silver in color and of standard size. The Resident was observed attempting to use the silver handled spoon to feed himself/herself some scrambled eggs. The Resident was unable to keep the eggs on the spoon, he/she grabbed both ends of the spoon to steady it, but was unable to get the spoon to his/her mouth. The Resident then grabbed the eggs with his/her hand and put the eggs in his/her mouth. The surveyor and Nurse #1 reviewed the diet slip located on the breakfast tray, dated 2/10/25, which indicated Adaptive Equipment: Black Silverware. During an interview at the time, Nurse #1 said that Resident #75 required the black handled utensils to be able to feed himself/herself, because the black handled utensils were built-up and easier to grab. During an interview on 2/10/25 at 9:00 A.M., CNA #1 said Resident #75 required the black handled utensils because those utensils were built up and easier for him/her to grasp. CNA #1 said that if the Resident did not get those utensils at meals it was a mistake because the diet slip said to provide them. CNA #1 said that the adaptive equipment required was highlighted in yellow on the diet slip and the staff serving the breakfast trays were supposed to check any special needs before serving the meal tray. During an interview on 2/12/25 at 1:00 P.M., the Staff Development Coordinator (SDC) said that the staff were trained in meal tray delivery, and the adaptive equipment listed on the diet slip should be provided. The SDC said that both the CNA and the Licensed Nurse should check each meal tray before delivery to the residents, to ensure that the correct diet and adaptive devices have been provided.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for two Residents (#103 and #84) out of a total sample of 23 residents, increasing the risk of contamination and the spread of infection to the Residents and other residents within the facility. Specifically, the facility failed to: 1. For Resident #103, ensure that staff appropriately followed Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact care. 2. For Resident #84, ensure that staff adhered to infection control standards and hand hygiene practices while performing wound care. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, dated 2001, revised August 2022, included but was not limited to: -Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. -gloves and gown are applied prior to performing the high contact resident care activity -examples of high contact care activities requiring the use of gown and gloves for EBPs include: device care or use (central line, urinary catheter (a device inserted into the bladder to drain urine), feeding tube, tracheostomy/ventilator, etc.) -EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 1. Resident #103 was admitted to the facility in September 2024 with diagnoses including Age Related Cognitive Decline, other specified Disorders of the Kidney and Ureter, and Type 2 Diabetes Mellitus with other Circulatory Complications. Review of Resident #103's Care Plan for Enhanced Barrier Precautions, initiated 12/9/24, included: -Enhanced Barrier Precautions related to implanted medical device. -High risk for MDRO transmission Resident with an implanted medical device - Foley catheter (urinary catheter). Review of Resident #103's Care Plan for Hospice, initiated 1/13/25, included: -All aspects of care to be coordinated with the Hospice Care Team. Review of Resident #103's Minimum Data Set (MDS) Assessment, dated 1/17/25, indicated that the Resident: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 points. -had an indwelling urinary catheter. -required substantial/maximal assistance with personal hygiene. -was now under the care of Hospice services. Review of Resident #103's Physician's orders for February 2025 included: -16 Fr (Fr-French a metric size of a catheter) 10 ml (milliliters) Foley (urinary) catheter to continuous drainage every shift, start date 12/6/24 -Enhanced Barrier Precautions r/t (related to) Foley catheter every shift, start 12/9/24 -Admit to Hospice services via Hospice, as of 1/12/25 On 2/7/25 at 11:11 A.M., the surveyor observed an Enhanced Barrier Precaution sign posted outside Resident #103's doorway, which indicated: -Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities Device care or use: central line, urinary catheter, feeding tube, tracheostomy. On 2/10/25 at 9:00 A.M., the surveyor observed an EBP sign in the Resident's doorway, PPE supplies, and a waste receptacle at the doorway. Upon entering the room the surveyor observed Hospice Staff #1 standing beside the Resident's bed and was not wearing a gown. The surveyor observed Hospice Staff #1 adjust the Resident's urinary catheter drainage bag and tubing. Hospice Staff #1 was observed to adjust the Resident's blankets. Hospice Staff #1 told the surveyor that she was about to provide morning care for Resident #103. During an interview on 2/10/25 at 9:05 A.M., Hospice Staff #1 said that she had not noticed the Enhanced Barrier Precaution sign posted outside the Resident's doorway, and was not sure the sign was there when she first entered the Resident's room. Hospice Staff #1 said that the Resident had been on Hospice services for about two months and she cared for the Resident about two times each week. Hospice Staff #1 said that she last cared for the Resident last week. Hospice Staff #1 said that she had never worn a gown to care for the Resident. Hospice Staff #1 said that she was not exactly sure what Enhanced Barrier Precautions stood for but after reading the sign it seemed she should have been wearing a gown when she cared for the Resident. Hospice Staff #1 said that she had been trained on putting on Personal Protective Equipment (PPE) but she just made a mistake because she did not see the sign. During an interview on 2/10/25 at 9:10 A.M., Nurse #1 said that the Resident was on EBP because he/she had an indwelling urinary catheter. Nurse #1 said that the Resident had been on EBP since before entering onto Hospice Services just over one month ago. Nurse #1 said that anyone providing direct care to the Resident should wear a gown and gloves. Nurse #1 said that Hospice Staff #1 should not have provided care for the Resident's urinary catheter without wearing a gown. During an interview on 2/12/25 at 1:00 P.M., the Staff Development Coordinator (SDC) said that the expectation was that the Hospice Staff were trained in precautions and use of PPE. The SDC said that Hospice Staff #1 should have donned (put on) a gown before she provided direct care to the Resident. 47901 Review of the facility policy titled Handwashing/Hand Hygiene, dated 2001, indicated: -All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -Personnel are educated regarding ways to prevent contact dermatitis and other skin irritations and provided with supplies that support healthy hand skin. -Hand hygiene is indicated immediately after glove removal. Resident #84 was admitted to the facility in March 2024 with diagnoses including Unstageable Pressure Ulcer to coccyx and Methicillin Resistant Staphylococcus Aureus (MRSA) Infection. Review of Resident #84's Minimum Data Set (MDS) Assessment, dated 12/6/24, indicated that the Resident: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) Score of 8 out of a possible 15 points. -was dependent on staff for his/her Activities of Daily Living (ADL - washing, grooming and dressing) care. Review of Resident #84's February 2024 Physician orders indicated: -Unstageable pressure ulcer on coccyx (a small triangular-shaped bone located at the bottom of the spine), clean with normal saline, pat dry, apply Santyl, pack with Calcium Alginate then cover with a silicone border foam dressing daily, initiated 1/24/25. On 2/11/25 at 10:05 A.M., the surveyor observed the following during a wound care procedure for Resident #84: -An Enhanced Barrier Precaution (EBP) sign at the Resident's door indicating the Resident was on precautions. -Nurse #2 washed her hands with soap and water in the Resident's bathroom, then donned a gown and gloves. -Nurse #2 repositioned the Resident to his/her side, and removed the old wound dressing. -Nurse #2 doffed (removed) her gloves, did not wash or sanitize her hands, and donned new gloves. -Nurse #2 cleansed the Resident's wound bed with wound cleanser, pat dried the wound, doffed her gloves, did not wash or sanitize her hands, and donned new gloves. -Nurse #2 reached into her pocket and took out scissors, did not disinfect the scissors, then cut a piece of Calcium Alginate and placed the piece of Calcium Alginate on the table. -Nurse #2 doffed her gloves, did not wash or sanitize her hands, and donned new gloves. -Nurse #2 applied Santyl to the Resident's wound bed, then applied the Calcium Alginate. -Nurse #2 doffed her gloves, did not wash or sanitize her hands, reached into her pocket and took out a pen, then donned new gloves. -Nurse #2 opened the silicone foam protective dressing, dated the foam dressing, put the pen back in her pocket and applied the foam dressing to the Resident's wound. -Nurse #2 doffed the old gloves, did not wash or sanitize her hands, donned new gloves, then repositioned the Resident. -Nurse #2 removed a trash bag from the Resident's bedside table and dropped the trash bag in the Resident's bathroom trash can, doffed her gloves, did not wash or sanitize her hands, donned new gloves and assisted the Certified Nurses Aide (CNA) with transferring the Resident out of bed via hoyer lift. During an interview on 2/11/25 at 10:48 A.M., Nurse #2 said she thought washing her hands with soap and water before initiating the dressing change was enough to complete the wound care. During a follow-up interview on 2/11/25 at 11:35 A.M., Nurse #2 said she should have cleaned or sanitized her hands between removing gloves, but she did not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had recently sustained a fractured left tibia (lower leg) of unknown origin and whose comprehensive plan of care indicated he/she required assistance of two staff members for bed mobility, the Facility failed to ensure staff consistently implemented followed this interventions, therefore placing the resident at risk for potential injury. Findings include: Review of the Facility's policy, titled Care Plans- Comprehensive, dated 10/2010, indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs would be developed for each resident. Resident #1 was admitted to the Facility in June 2021, diagnoses included poly-osteoarthritis (multiple joints with arthritis that occurs when flexible tissue at the ends of bones wears down) and frontotemporal neurocognitive disorder (dementia affecting the front and temporal lobes of the brain). Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 09/06/24, indicated he/she had long and short-term memory impairment with severely impaired decision-making ability, was non-ambulatory, and was dependent on staff for bed mobility (rolling side to side) and bed to chair transfers. Review of Resident #1's Activities of Daily Living (ADL) care plan related to dementia and impaired mobility, reviewed and renewed with his/her September 2024 MDS, indicated that interventions include the need for two staff members for assistance with bed mobility. Review of Resident #1's Nurse Progress Notes, dated 10/31/24, indicated Resident #1 moaned in pain when his/her left leg was touched during morning personal care. The Notes included Resident #1 had an x-ray to the left tibia which indicated there was a fracture. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/01/24, indicated Resident #1 moaned in pain when a staff member attempted to put his/her left leg compression stocking on the morning of 10/31/24. The Report indicated Resident #1's x-ray confirmed a fractured left tibia. Further review of the Report indicated the Facility was unable to determine how Resident #1 sustained the left tibia fracture. Review of Resident #1's Certified Nurse Aide (CNA) flow sheet for the month of October 2024 indicated on the evening shift (3:00 P.M. through 11:00 P.M.) on 10/30/24, CNA #1 coded (documented) that she provided one assist for repositioning at 1600 (4:00 P.M.), 1800 (6:00 P.M.), 2000 (8:00 P.M.), and 2200 (10:00 P.M.). During an interview on 11/20/24 at 3:56 P.M., Certified Nurse Aide (CNA) #1 said she usually worked the day or evening shift and was familiar with Resident #1. CNA #1 said she provided Resident #1 with incontinent care and repositioning, when Resident #1 was in bed, without the assistance of another staff member. CNA #1 said she knew Resident #1 required assistance of two staff members for [mechanical] lift transfers, but nothing else. Further review of the Flow Sheet indicated on the night shift (11:00 P.M. through 7:00 A.M.) on 10/30/24, CNA #5 coded (documented) that she provided one assist for repositioning at 0000 (midnight), 0200 (2:00 A.M.), 0400 (4:00 A.M.), and 0600 (6:00 A.M.). During a telephone interview on 11/20/24 at 9:24 A.M., Certified Nurse Aide (CNA) #5 said that she usually worked the night shift and was familiar with Resident #1. CNA #5 said she did not need help from other staff members to reposition or change Resident #1. CNA #5 said I do it myself. During a telephone interview on 11/21/24 at 9:48 A.M., Nurse #3 said he was the nurse on duty for the night shift on 10/30/24 and was familiar with Resident #1. Nurse #3 said he had never been called to assist other staff with Resident #1's personal care. During a telephone interview on 11/22/24 at 1:10 P.M., the Director of Nurses (DON) said her expectation was that staff always followed each resident's plan of care.

Based on observation, policy review and interview, the facility failed to accurately and safely ensure that routine and emergency medications and pharmaceutical services were provided to meet the needs of each facility resident. Specifically, the facility staff failed to ensure that: 1. expired medications were removed from the medication carts on two units (West and Harmony Village) out of three units observed. 2. three open medication Emergency Box Kits on one unit (South) were re-ordered as required. Findings include: 1. Review of the facility policy titled, Medication Storage in the Facility, dated 2017, indicated: -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to the procedures for medication disposal. -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Review of the facility polity titled, Medication Cart Cleaning, undated, indicated: -All medication Carts will be cleaned weekly on the 11:00 P.M. to 7:00 A.M. (11-7) shift. -All Medication Carts will be checked for expired medications weekly on the 11-7 shift. -All Medication Carts will be cleaned and organized weekly on the 11-7 shift. On 12/12/23 at 3:42 P.M., the surveyor and Nurse #2 observed the medication cart on the [NAME] Unit. Hydroxyzine (medication used to treat high blood pressure) medication containing one tablet for one resident, with an expiration date of 10/20/23, was found in the medication cart. During an interview at the time, Nurse #2 said the Hydroxyzine medication had expired and should have been removed from the medication cart. On 12/12/23 at 4:18 P.M., the surveyor and Nurse #4 observed the medication cart on the Harmony Village Unit. The surveyor observed a resident's medication card that contained two capsules of Doxycycline (antibiotic) medication, with an expiration date of 11/20/23. The resident's name was deleted with a black marker. During an interview at the time, Nurse #4 said the card of expired medication should have been removed from the medication cart, but this was not done as required. During an interview on 12/12/23 at 4:35 P.M., Unit Manager (UM) #3 said the expired medications should have been removed from the medication cart, but they were not removed as required. 44222 2. Review of the facility policy titled Emergency Boxes (EBOX), undated, included: -Each EBOX will be locked with a tamper resistant lock indicating if the box has been opened. -Each box that is opened needs to be returned to the pharmacy for replenishment. -When reordering EBOX, the Nurse will use the usage form provided by the pharmacy located inside each corresponding EBOX This will ensure the EBOX are kept at par. During an interview and review on 12/12/23 at 4:37 P.M., of the medication storage room on the South Unit with Unit Manager (UM) #2, the surveyor observed that three out of five EBOX kits were not sealed. The following EBOX kits: a) Insulin, (medication used to regulate blood sugar) b) Intravenous [IV] therapy (therapy performed or occurring within or entering by way of a vein) c) Narcan (medication used to treat a narcotic overdose in an emergency situation) were open with no indication of what had been removed from the kit, on what date, or for which resident. There was also no documentation evidence that any of the three open EBOX kits had been re-ordered from the pharmacy. UM #2 said that the Insulin kit was missing a Lispro (a fast acting type of Insulin) Insulin pen but she was not aware of when or for whom it was removed. She said that the Insulin EBOX kit only stocks one Lispro pen, so there was none currently available in the facility in the event of an emergency, as no other medication storage room had EBOX kits. When the surveyor asked about the facility policy for opening EBOX kits, UM #2 said when an EBOX kit was opened, the staff member removing the medication should record on the sheet what item was removed, when it was removed, and for whom it was used, then the EBOX kit should be re-ordered from the pharmacy. UM #2 was unable to show the surveyor any evidence that the three open EBOX kits were re-ordered from the pharmacy as required. During an interview on 12/13/23 at 11:19 A.M., the Director of Nurses (DON) said that the expectation was that if a Nurse opens an EBOX kit, the Nurse should fill out the form to indicate what medication was taken, by whom, and for which resident. The DON said that the Nurse should also call the pharmacy to notify them that the EBOX kit had been opened and that a fax request to have the EBOX kit replaced by the pharmacy was being sent. The DON could not provide any evidence to the surveyor that this process had been done for the three open EBOX kits on the South unit.

Based on observation, interview, policy and record review, the facility failed to adhere to infection control standards for three Residents (#98, #171 and #70) who tested positive for COVID-19, on three out of three units observed, and for one Resident (#75) during treatment and care of a wound, out of a total sample of 24 residents. Specifically, the facility staff failed to ensure: 1. For Residents (#98 and #171), that staff performed appropriate hand hygiene and wore personal protective equipment (PPE) when caring for COVID-19 positive residents, to mitigate the spread of infection during a COVID-19 outbreak in the facility. 2. For Resident #70, that staff implemented Isolation Precautions and posted appropriate signage outside of the Resident's room after they tested positive for COVID-19. 3. For Resident #75, that the staff performed hand hygiene during a pressure ulcer wound care procedure. Findings include: Review of the facility policy for Infection Control Personal Protective Equipment Policy, last revised 10/7/21, indicated that PPE will be provided to and worn by all personnel as appropriate. Review of the facility policy for Infection Control Transmission Based Precautions (TBP), undated, indicated: -Transmission based precautions recommendations from . the Massachusetts Department of Public Health (DPH) are used as guidelines for procedures. Review of the Massachusetts Memorandum titled Comprehensive PPE Guidance, dated 5/5/23, included: -PPE for patients with suspected or confirmed COVID-19 -DPH recommends that a fit tested N95 filtering facepiece respirator or alternative and eye protection be used when caring for patients with suspected or confirmed COVID-19 -N95 respirators should always be discarded after doffing (removing), such as when leaving a room. -Disposable eye protection should be discarded when it is removed for any reason; it should not be reused. Reusable eye protection should be cleaned and disinfected when visibly soiled and after removal/doffing. -Nonsterile, disposable isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by health care personnel (HCP) when caring for patients with suspected or confirmed COVID-19 when there is any contact with potentially infectious material. -Gloves should be worn when there is any contact with potentially infectious material. HCP should perform hand hygiene prior to donning (putting on) and after doffing gloves. Review of the Isolation Precaution sign utilized by the facility indicated the following: -STOP. Special Droplet/Contact Precautions in addition to Standard Precautions. Staff and Providers Must: -Clean hands when entering and exiting. -Gown - Change between each resident. -N95 Respirator. -Eye Protection (goggles or face shield). -Gloves - Change between each resident. 1a. Resident #98 was admitted to the facility in October 2021 with diagnoses including Dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities) and COVID-19, and resided on the Harmony Village Unit. Review of the clinical record indicated Resident #98 tested positive for COVID-19 infection on 12/4/23. On 12/13/23 at 8:29 A.M., the surveyor observed Certified Nurses Aide (CNA) #2 entering Resident #98's room wearing a surgical mask. CNA #2 was not observed to perform hand hygiene prior to entering or after exiting the Resident's room, and also did not don any PPE (gown, gloves, N95 mask or eye protection) that was indicated on the signage posted outside of the room. During an interview on 12/13/23 at 8:57 A.M., CNA #2 said that she should have performed hand hygiene and put on goggles, N95 mask, gown, gloves prior to entering Resident's #98 room and she did not. CNA #2 also said that she should have performed hand hygiene after exiting the room but she did not do so as required. On 12/13/23 at 9:21 A.M., the surveyor observed CNA #1 exiting Resident #98's room with an unsecured N95 mask with the bottom strap hanging in front of her face. CNA #1 was observed to be wearing a surgical mask underneath the N95 mask, and was not wearing eye protection. During an interview at the time, CNA #1 said that she should not be wearing a surgical mask underneath the N95 mask and that she should have been wearing eye protection and she was not. On 12/14/23 at 9:04 A.M., the surveyor observed Housekeeping Staff #1 enter Resident #98's room. Housekeeping Staff #1 did not perform hand hygiene prior to entering or exiting the Resident's room, and also did not don all of the PPE that was indicated on the signage posted outside of the Resident's room and was available for use within the cabinet outside of the room. Housekeeping Staff #1 was observed to have a N95 mask on, donned gloves after entering the room, doffed the gloves in the Resident's bathroom and then exited the room. Housekeeping Staff #1 did not change his mask as required after exiting the room. During an interview on 12/14/23 at 9:19 A.M., the Infection Preventionist (IP) said that Housekeeping Staff #1 should have performed hand hygiene, donned all the required PPE prior to entering Resident #98's room, doffed all PPE in the trash receptacle outside of the room, performed hand hygiene and then put on a new mask. 37400 1b. Review of the facility matrix, provided by facility administration on 12/12/23 of the Recertification Survey, indicated Resident #171 was on Transmission Based Precautions (TBP) for a COVID-19 infection. On 12/14/23 at 12:14 P.M., the surveyor observed the following signage posted outside of Resident #171's room: -Stop. Special Droplet/Contact Precaution signage in addition to Standard Precautions -Only essential personnel should enter this room -Everyone Must: (including visitors, doctors, and staff): --clean hands when entering and leaving the room --wear mask --wear eye protection (face shield or goggles) --gown and glove at the door --keep door closed On 12/14/23 at 12:14 P.M., the surveyor observed CNA #3 exit Resident #171's room with a gown, gloves and N95 mask in place. CNA #3 had regular eyeglasses on, and was not wearing eye protection. The surveyor observed CNA #3 remove her gown, gloves and N95 mask and perform hand hygiene. During an interview at the time, CNA #3 said she thought her regular eyeglasses counted as eye protection so she did not put on a face shield or goggles prior to entering the Resident's room. When the surveyor asked CNA #3 about disinfection of reusable equipment, she said that she would use alcohol wipes to disinfect her eyeglasses. During an interview on 12/14/23 at 12:26 P.M., the IP said that full PPE which included gown, gloves, an N95 mask and eye protection should be worn prior to entering a COVID-19 positive resident room. The IP further said that eye protection included goggles or a face shield, and that regular eyeglasses did not count as PPE because it did not protect exposure completely around the eye. The IP said if reusable eye protection was used, then it needed to be disinfected with the appropriate product (Super Sani- Cloth Germicidal Disposable Wipes) and that alcohol wipes were not appropriate for cleaning and disinfecting reusable equipment for COVID-19 positive rooms. 2. Resident #70 was admitted to the facility in November 2023, was diagnosed with COVID-19 on 12/6/23, and resided on the South Unit. Review of the facility matrix, provided by the facility on 12/12/23, indicated Resident #70 was on Transmission Based Precautions for a COVID-19 infection. On 12/12/23 at 11:07 A.M., the surveyor observed the following signage posted outside of Resident #70's room: -Stop. Quarantine: Droplet and Contact Precautions in addition to Standard Precautions -Only essential personnal should enter this room -Everyone Must: (including visitors, doctors, and staff): -- clean hands when entering and leaving the room --wear a mask --wear eye protection (face shield or goggles) --gown and glove for high contact care . --keep door closed when performing an aerosol generating procedure During an interview on 12/13/23 at 7:59 A.M., the IP said the TBP signage for Resident #70 was changed to the Special Droplet/Contact Precaution signage which indicated that all persons have to don full PPE (N95 mask, eye protection, gown and gloves) prior to entering the Resident's room. She further said the Resident was retested for COVID-19 on 12/11/23 and remained positive so the Special Droplet/Contact Precautions needed to remain in place. The IP said the Quarantine signage that was placed in error outside the Resident's room, was intended for someone exposed to the virus but had not yet tested positive and was not appropriate signage for Resident #70. 3. Review of the facility policy titled Dry/Clean Dressings, revised February 2014, indicated the purpose of the procedure was to provide guidelines for the application of dry, clean dressings. The policy included the following: -Verify that there was a Physician's order for the procedure -clean the bedside stand. Establish a clean field. -Place the clean equipment on the clean field -Tape a biohazard bag on the bedside table or use a waste basket below the clean field -Position the resident and adjust clothing to provide access to affected area -wash and dry hands thoroughly (perform hand hygiene) -put on clean gloves -remove soiled dressing and discard . -perform hand hygiene -open dry, clean dressing .touching only the exterior surfaces ., label and date and place on clean field -using clean technique, open other products . -perform hand hygiene -put on gloves and assess the wound and surrounding area. Cleanse the wound, pat dry and apply ordered dressing -discard disposable items . -perform hand hygiene -make the resident comfortable . -clean the bedside stand -perform hand hygiene Resident #75 was admitted to the facility in November 2019 with a diagnoses including Alzheimer's Disease (progressive mental deterioration of the brain that affects memory, thinking and behavior) and change in skin texture. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #75 had severe cognitive impairment as evidenced by staff interview, was at risk for pressure ulcers (injury to the skin from prolonged pressure) and had one unstagable pressure ulcer (full thickness injury in which the base is not visible due to accumulated dead skin cells) present during the assessment reference period. Review of the December 2023 Physician's orders included the following: -weekly wound measurement on Wednesdays, initiated 10/24/23 -Apply Santyl (prescription ointment that removes dead tissue from wounds) 250 unit/gram apply to the right elbow every day and evening shift -clean the right elbow with normal saline (mixture of sodium chloride and water) -dry -apply small amount of Santyl ointment to the wound center -apply Maxsorb (specialized wound dressing) with silver wrap with non-stick dressing -and wrap with kling x times a day, initiated 11/7/23 On 12/13/23 at 11:27 A.M., the surveyor observed wound care provided by Nurse #1 as follows: -a bedside stand had a towel and needed supplies placed on it -Nurse #1 washed and dried her hands, donned gloves and assisted the Resident's right arm out of his/her clothing to allow access to the wound -Nurse #1 removed her gloves, donned new gloves without performing hand hygiene, and opened supplies that had been placed on the bedside stand. -Nurse #1 then removed the Resident's old dressing and discarded it. -Nurse #1 removed her gloves and donned new gloves without performing hand hygiene, then cleansed the Resident's wound, measured the wound, performed the ordered treatment to the wound, discarded gloves and then performed hand hygiene. During an interview on 12/13/23 at 11:50 A.M., Nurse #1 said that hand hygiene should occur after removing gloves and prior to donning new gloves but she forgot to do this for two opportunities during the wound care procedure. During an interview on 12/13/23 at 1:07 P.M., the surveyor reviewed the wound observation with the IP and the Director of Nurses (DON). The IP said that after removing gloves, hand hygiene should be performed prior to donning new gloves.

Based on record review, policy review and interview, the facility failed to execute Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for one Resident (#318), out of a total sample of 24 residents. Specifically, for Resident #318, the facility staff failed to ensure that Advanced Directives on a completed (prior to facility admission) Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form were honored per the Resident's wishes. Findings include: Review of the facility policy for MOLST, undated, indicated that Residents admitted with a completed MOLST form: -Upon admission the nurse will note the existence of the MOLST FORM and review the form for completeness. A completed MOLST is a legal medical order and is immediately actionable. -The MOLST should be copied, and the date of the copy written on the form. This copy and the original MOLST form should be put in the Advance Directive section of the patient/resident chart. -When the attending physician's orders are verified, the order for MOLST instructions will be written, it is the attending physician's responsibility to review this order with respect to the patient/resident's wishes and goals of care. -If Do Not Resuscitate is indicated on the MOLST the facility procedures for Do Not Resuscitate will be followed. -The initial review and any discussion about continuing, revising or revoking the MOLST should be documented in the medical record. Resident #318 was admitted to the facility in [DATE] with diagnoses including right arm fracture and history of falls. Review of Resident #318's clinical record indicated Resident had no orders pertaining to Advanced Directives. During an interview on [DATE] at 9:15 A.M., Unit Manager (UM) #3 said there were no orders for Resident #318 pertaining to Advanced Directives and since there were no orders, the Resident was a full code (meaning that CPR [cardiopulmonary resuscitation] and intubation [inserting a breathing tube] would be performed should his/her heart stop and if unable to breathe on his/her own). Further review of the Resident's hospital discharge paperwork indicated Resident #318 had a signed MOLST form completed in the hospital and dated [DATE], which stated he/she desired to be Do Not Resuscitate, Do Not Intubate (DNR/DNI - do not perform CPR/ do not insert a breathing tube). During a follow-up interview on [DATE] at 4:04 P.M., UM #3 said the admission Nurse should have reviewed the MOLST paperwork with the admitting Physician and obtained an order for DNR/DNI, but this was not done as required.

Based on observation, interview, record and policy review, the facility failed to implement an individualized plan of care for one Resident (#5), out of a total sample of 24 residents. Specifically, for Resident #5 who was identified as being at nutritional risk, the facility staff failed to ensure that weekly weights were obtained per Physician order and the nutrition care plan. Findings include: Review of the facility's policy titled, Weight Monitoring Program, revised 1/12, indicated: -There will be a systematic and interdisciplinary approach to monitoring resident weights. -All new admissions will be weighed on admission and at least weekly unless the Physician order states otherwise. -When transferring residents between units, resident weight will be re-weighed/reconciled in comparison to the previous weight whenever necessary. Resident #5 was admitted to the facility in March 2023 with diagnoses including Abdominal Aortic Aneurysm without rupture (AAA- an enlargement of the aorta [the main blood vessel that delivers blood to the body] at the level of the abdomen), Acute Kidney Failure (a condition in which the kidneys suddenly cannot filter waste from the blood), Hypertension (high blood pressure), and Dysphagia (difficulty swallowing). Review Resident #5's Nutrition Care Plan revised 9/29/23, indicated the Resident was at nutritional risk due to Dysphagia with a need for mechanically altered diet texture and included the following intervention: obtain weight as ordered. Review of the Resident's Physician's orders dated 11/16/23, indicated to obtain a weights weekly, on shower days - every evening shift on Fridays. Review of Resident #5's weight record indicated that no weights had been recorded since 10/26/23. During an interview on 12/14/23 at 9:22 A.M., Nurse #6 said that all residents are weighed weekly on their shower days. The surveyor and Nurse #6 reviewed the weight documentation and Nurse #6 said Resident #5 had not been weighed weekly as ordered by the Physician. During an interview on 12/14/23 at 10:08 A.M., Unit Manager #3 said that Resident #5 should have been weighed weekly but he/she was not weighed weekly as required.

Based on observations, interviews, record and policy review, the facility failed to ensure that required Physician orders were in place for the administration of Oxygen therapy for one Resident (#55), of three applicable residents receiving Oxygen, out of a total sample of 24 residents. Specifically, the facility staff failed to ensure that Physician orders that included the concentration of Oxygen, the method of Oxygen delivery, the frequency of use and the indications for supplemental Oxygen were in place for Resident #55. Findings include: Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the purpose of the procedure was to provide guidelines for safe Oxygen administration and included: -verify that there is a Physician's order for the procedure -review the Physician's orders or facility protocol for Oxygen administration -review the resident's care plan to assess for any special needs Resident #55 was admitted to the facility in August 2023 with a diagnosis of Congestive Heart Failure (CHF- chronic condition where the heart is unable to pump blood efficiently to the rest of the body). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of 15 and did not require any special treatments including Oxygen therapy during the assessment reference period. On 12/12/23 at 4:00 P.M., the surveyor observed Resident #55 seated in a stationary chair in his/her room. Oxygen was being administered to Resident #55 via a nasal cannula (pronged tube inserted into the nose to allow Oxygen flow) which was connected to an oxygen concentrator (device that filters room air into Oxygen and then delivers the Oxygen to the patient) set at a flow rate of 3.5 liters per minute (LPM: flow rate of Oxygen delivery). The surveyor observed the Resident intermittently coughing and during an interview at the time said that he/she was not feeling well and will be better once he/she was able to get the junk out of his/her lungs. Review of the Resident's December 2023 Physician's orders and active Care Plan did not indicate any orders for the use of Oxygen including the liter flow rate to be administered, whether the use should be continuous or PRN (as needed) and monitoring parameters (including oxygen saturation levels) as required. Review of a Nurse Practitioner (NP) Progress Note dated 12/12/23, indicated Resident #55 was informed of chest X-Ray results and for him/her to continue Oxygen therapy. On 12/13/23 at 9:44 A.M., the surveyor observed Resident #55 seated in a stationary chair in his/her room. Oxygen was being administered via a nasal cannula which was set at a flow rate of 3.5 LPM and was connected to an oxygen concentrator in the room. On 12/13/23 at 2:10 P.M., the surveyor observed the Resident lying in bed with his/her eyes closed. Oxygen was being administered via nasal cannula and the oxygen concentrator was set at a flow rate between 3.5 LPM and 4 LPM. Review of a NP Progress Note dated 12/13/23, indicated Resident #55 was not able to tolerate being on room air (without Oxygen therapy) and was on 2 LPM of Oxygen. On 12/14/23 at 9:10 A.M., the surveyor observed Resident #55 reclining in an upright position in bed. Oxygen was being administered via a nasal cannula with the oxygen concentrator set at a flow rate of 3.5 LPM. On 12/14/23 at 10:22 A.M., the surveyor and Nurse #6 observed Resident #55 lying in bed with Oxygen being administered at 3.5 LPM via nasal cannula through the oxygen concentrator. Nurse #6 said the Resident had been on a flow rate of 3.5 LPM and had an oxygen saturation level (measurement of oxygen available in the blood with normal levels being between 95-100 percent [%]) of 92%. Nurse #6 further said that she was unsure of what the Resident's Physician's orders indicated for the flow rate of Oxygen but she would check for that information. On 12/14/23 at 10:29 A.M., the surveyor and Unit Manager (UM) #3 reviewed Resident #55's clinical record. UM #3 said that there were no Physician's orders for the administration of Oxygen therapy for Resident #55. She further said that Resident #55 was started on Oxygen on 12/12/23, when his/her oxygen saturation level was measured to be in the 80's range. UM #3 said at that point, orders should have been obtained for the use of Oxygen and included the goal of oxygen saturation level, range of Oxygen liter flow to be used, and the care and services needed for Oxygen administration.

Based on observation, record review and interview, the facility failed to provide accomodations to meet the specific dietary needs of one Resident (#318) out of a total sample of 24 residents. Specifically, the facility staff failed to accommodate the individualized request for Resident #318 to have his/her food items cut-up prior to receiving his/her meals, as the Resident had an arm injury that made it difficult to be independent with cutting food items. Findings include: Review of the facility policy titled Interdepartmental Notification of Diet (Including Changes and Reports), revised October 2008, indicated the following: -Nursing Services shall notify the Food Services Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. -When a new resident is admitted , or a diet has been changed, the Nurse Supervisor shall ensure that the Food Services Department receives written notice of the diet order. Resident #318 was admitted to the facility in December 2023 with a diagnosis of Displaced Fracture of Surgical Neck of Right Humerus (the largest bone of the upper extremity that defines the arm). On 12/13/23 at 8:15 A.M., the surveyor observed Resident #318 sitting in a chair next to his/her bed. The surveyor observed the Resident's right arm in a sling (provides arm support and immobilization). During an interview at the time, Resident #318 said he/she had a concern that was brought to the attention of the Dietitian but had not been resolved. The Resident said he/she had requested that food items be cut-up because his/her right arm was broken and he/she had to utilize a sling, but the request had not been done. Resident #318 further said that he/she found it difficult to cut-up food items with only the use of his/her left arm. The surveyor observed that the Resident received his/her breakfast tray at 8:30 A.M., and the tray included french toast that was not cut-up as requested. Review of Resident #318's Nutrition Follow-up Note dated 12/11/23, indicated nursing requested that the kitchen provide a cut-up diet texture to ensure that Resident #318 received his/her foods in a form that he/she could handle. Recommended to change the diet texture to cut-up. Review of Resident #318's Nursing Progress Note, dated 12/11/23, indicated a new dietary recommendation: add cut-up foods to diet. During an interview on 12/13/23 at 10:15 A.M., Unit Manager (UM) #3 said she was not aware that Resident #318 was having difficulty cutting his/her food items as required. During an interview on 12/13/23 at 12:51 P.M., the Dietitian said she had spoken to the nursing staff about Resident #318's concern and had written a recommendation for nursing staff to fill out a communication slip to the dietary department requesting for food items to be cut-up. During an interview on 12/13/23 at 12:53 P.M., the Food Service Manager (FSM) said she had not received any communication from the nursing staff pertaining to Resident #318's request for food items to be cut-up. During a follow-up interview on 12/13/23 at 1:05 P.M., the Dietitian said Resident #318 should have received his/her meals cut-up from the kitchen, but this had not been done as required.

Based on interview, record and policy review, the facility failed to ensure the policy relative to Pneumococcal Vaccinations was revised and up to date with current Centers of Disease Control and Prevention (CDC) recommendations.The facility also failed to provide the Pneumococcal Vaccine for one Resident (#27) and assess two Residents (#74 and #83), out of five applicable residents, for the eligibility to receive or decline the Pneumococcal Vaccine, placing them at risk for contracting facility acquired Pneumonia. Specifically, the facility failed to: 1) ensure that staff administered the Pneumococcal Vaccine after consent was obtained and there was no history of previous Pneumococcal Vaccinations for Resident #27. 2) provide education on the Pneumococcal Vaccine, assess for eligibility and offer the vaccine based on the CDC recommendations for Residents #74 and #83. Findings include: Review of the facility policy titled Pneumococcal Vaccination, revised 11/25/19, indicated: -There were two types of Pneumococcal Vaccinations -The CDC recommends Pneumococcal Conjugate Vaccines (PCV), PVC13, for all adults 65 and older and people less than 65 with certain medical conditions -The CDC recommends the Pneumococcal Polysaccharide 23 Vaccine (PPSV23) for for all adults 65 or older people with certain medical conditions or who smoke less than [AGE] years of age. -Each resident is offered a Pneumococcal vaccine unless medically contraindicated, or resident/resident representative refuses or the resident has already been immunized. -After assessment and practitioner recommendation, a second Pneumococcal Vaccination may be given after five years following the first unless medical contraindications or refusal. -upon admission a licensed Nurse will provide education using the current Pneumococcal Vaccine Information Sheet (VIS) to all residents -a licensed Nurse will offer the Pneumococcal Vaccine to all current and new residents year round (it can be administered anytime during the year) -A Physician's order and consent of the resident/resident representative is required prior to vaccine administration. -if the vaccination status is unknown, the resident should receive the vaccine Review of the CDC Pneumococcal Vaccine Timing for Adults Schedule, dated 3/15/23, indicated the following: -Adults greater than or equal to [AGE] years of age who have not received any previous Pneumococcal Vaccination should receive either the Pneumococcal Conjugate Vaccines (PCVs, specifically PCV15 and PCV20). If the PCV15 was administered, a dose of PPSV23 should be administered greater or equal to one year later. -If the PPSV23 only was previously received at any age: administer either the PCV20 or the PCV15 greater than or equal to one year later -If the PCV13 only was previously received at any age: administer either the PCV20 or the PPSV23 greater than or equal to one year later -If the PCV13 was previously administered at any age and the PPSV23 previously administered prior to [AGE] years of age: administer either the PVC20 or PPSV23 greater than or equal to 5 years after previous doses. -If the PCV13 was previously administered at any age and the PPSV23 was administered at or after the age of 65: the PVC20 can be administered greater than or equal to 5 years after the previous doses. 1. Resident #27 was admitted to the facility in February 2020 with diagnoses including Type II Diabetes (a medical condition that affects how the body processes blood sugar), Cerebrovascular Accident (CVA: damage to the brain due to interrupted blood flow), and was over the age of 65. Review of the clinical record indicated the Resident/Resident Representative consented to the administration of the Pneumococcal Vaccine on 2/10/20. Review of the Massachusetts Immunization Information System (MIIS) Sheet, located in the clinical record and dated 8/11/22, indicated no documented evidence that the Pneumococcal Vaccine was administered. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident did not have a Pneumococcal Vaccine that was up to date and that the vaccine status was not assessed. Review of the December 2023 Physician's orders included the following: -may have the Pneumovax (type of Pneumococcal vaccine) . Review of Resident #27's clinical record indicated no evidence that he/she had or refused the Pneumococcal Vaccine. During an interview on 12/14/23 at 1:45 P.M., the Infection Preventionist (IP) said that vaccines including the Pneumococcal Vaccine were reviewed when a resident was admitted to the facility.The IP further said if the resident/resident representative indicated they would like to have the vaccine administered, a consent was completed, the VIS was provided and the Physician was updated to obtain the order to administer the vaccine. She said the consent was signed for Resident #27 to receive the Pneumococcal Vaccine on 2/10/20, and the vaccine should have been administered. 45429 2a. Resident #74 was admitted to the facility in October 2020 with diagnoses including Alzheimer's Disease (a common form of Dementia that affects memory, thinking and behavior) and chronic cough. Review of the Resident's Physician's orders for December 2023 indicated an order to receive Pneumovax, dated 10/26/20. Review of Resident #74's clinical record did not indicate that the Resident had been offered education or administration of the Pneumococcal Vaccine since his/her admission in 2020. 2b. Resident #83 was admitted to the facility in July 2022 with diagnoses including Alzheimer's Disease and Chronic Obstructive Pulmonary Disease (COPD- a type of progressive lung disease characterized by long term respiratory problems and limited airflow). Review of the Resident's Physician's orders for December 2023 did not indicate any orders to receive the Pneumococcal Vaccine. Review of Resident #83's clinical record did not indicate that the Resident had been offered education or administration of the Pneumococcal Vaccine since their admission in 2022. During an interview on 12/15/23 at 11:27 A.M., the IP reviewed the vaccinations for Residents #74 and 83. The IP said that she was unaware of the updated CMS guidance. The IP further said that the Residents should have been offered the Pneumococcal Vaccine.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Comprehensive Plan of Care (POC) indicated he/she required extensive assistance of two staff members, a gait belt and rolling walker for all transfers, the Facility failed to ensure staff implemented and followed interventions from his/her Plan of Care related to his/her individual needs during a transfer. When on 8/17/22 Certified Nurse Aide (CNA) #1 manually transferred Resident #1 by herself, from his/her wheelchair onto the toilet, and then using a mechanical lift by herself, CNA #1 then transferred Resident #1 from the toilet back to the wheelchair, and then from the wheelchair back to bed. Early the next morning, Resident #1 complained of right shoulder pain, was transferred to the Hospital Emergency Department for evaluation and diagnosed with a fractured right clavicle (collarbone). Findings Include: The Facility's Policy titled Comprehensive Care Plans, dated 9/2010, indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. The Facility's Policy titled Using the Care Plan, dated 8/2006, indicated the Care Plan would be used in developing the resident's daily care routines and would be available to staff personnel who had responsibility for providing care to the resident. Resident #1 was admitted to the Facility in May 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Activities of Daily Living Care Plan, dated as revised on 2/21/22, indicated he/she required two staff members to assist with rolling walker and a gait belt for transfers and toileting. Review of Resident #1's Care Kardex (used as a quick reference for caregivers, and updated to reflect the most current Care Plan), indicated he/she required two staff assistance for all transfers. Review of the X-ray Report, dated 8/18/22, indicated Resident #1 had an acute oblique fracture of the right clavicular mid shaft with superior displacement. Review of the Facility's Investigation Summary, dated 8/22/22, indicated that on the morning of 8/18/22 Resident #1 complained of right shoulder pain, was transferred to the Hospital Emergency Department, and diagnosed with a right clavicle fracture. The Investigation Summary indicated, on 8/17/22 during the 3:00 P.M., to 11:00 P.M., shift, that CNA #1 had (manually) transferred Resident #1 by herself onto the toilet, then from the toilet to the wheelchair utilizing the Sara Lift (assistive device that lifts a person from seated to standing position, used for the purpose of transferring from one seated position to another, also requires the person being transferred to hold on to handles with both hands), then from the bedside chair to the bed, again utilizing the Sara lift, all without any other staff member present to assist. The Investigation Summary indicated CNA #1 said Resident #1 cried out in pain during transfers, and she forgot to inform the nurse. During interview on 9/09/22 at 1:38 P.M., Certified Nurse Aide (CNA) #1 said that on 8/17/22 on the 3:00 P.M., to 11:00 P.M., shift, she was assigned to care for Resident #1. CNA #1 said she was not familiar with Resident #1 and said she did not review his/her Care Kardex before beginning care. CNA #1 said she physically (manually) transferred Resident #1 by herself from his/her bed to the wheelchair before dinner and said he/she complained of right shoulder pain at that time. CNA #1 said after dinner, she physically (manually) transferred Resident #1 to the toilet by herself, and said Resident #1 was unable to stand up to get off the toilet, at which time she notified Nurse #1. CNA #1 said Nurse #1 told her to get the Sara Lift to transfer Resident #1, and said she then used the Sara lift to transfer Resident #1 from the toilet to the wheelchair, then from the wheelchair to the bed, without assistance from any other staff member. CNA #1 said Resident #1 complained of pain at his/her right shoulder during the transfers, and said she forgot to notify Nurse #1 that he/she complained of pain. During interview on 9/09/22 at 12:09 P.M., Nurse #1 said that on 8/17/22 at 6:00 P.M., CNA #1 told her that she was unable to transfer Resident #1 from the toilet by herself, and said she told CNA #1 that Resident #1 required two staff members for assistance for transfers. Nurse #1 said CNA #1 did not tell her Resident #1 had complained of pain. During interview on 9/08/22 at 1:23 P.M., Unit Manager #1 said that on 8/18/22 in the early morning Resident #1 complained of pain and had bruising at his/her right shoulder and said Resident #1 told her he/she had been transferred the night before by CNA #1 using a machine he/she had never seen before (later identified as the Sara Lift). Unit Manager #1 said Resident #1 was transferred to the Hospital Emergency Department and diagnosed with a fractured collarbone. Unit Manager #1 said staff members were responsible for logging in to the electronic system and reviewing each resident's Care Kardex prior to care each shift and said CNA #1 should have reviewed Resident #1's Care Kardex before transferring him/her. Unit Manager #1 said Resident #1 required two staff members to assist him/her with transfers and said the use of the Sara Lift was not an intervention in Resident #1's Plan of Care. During interview on 9/08/22 at 12:45 P.M., the Director of Nurses (DON) said CNA #1 should have reviewed Resident #1's Care Kardex before care, should have had another staff member assist her to transfer Resident #1, and should not have used the Sara Lift to transfer Resident #1. On 9/08/22, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. On 8/19/22, the Facility held a Quality Assurance Performance Improvement meeting, review of the Plan of Action Meeting Minutes indicated Facility developed a plan to correct the deficient practice. B. On 8/18/22, Interviews were conducted with Other Residents, Notes indicated the Social Worker interviewed other residents and no concerns with care were identified. C. On 8/22/22, staff education was conducted, the In-Service Sign Off Sheet indicated staff were re-educated to review resident Care Kardex daily, and to sign off that they had reviewed the Care Kardex before the start of each shift. D. 8/22/22, The Facility's Investigation Summary indicated residents' transfer status was added to the paper CNA assignment sheets. E. 8/26/22, the In-Service Sign Off Sheet indicated staff were re-educated to the Facility's Policy, titled, Resident Lifts/Slides. F. 8/26/22, Gait Belts Audits were conducted by Unit Managers, and indicated each resident room was audited for presence of Gait Belts. G. Accidents and Incidents will be monitored monthly at QAPI meetings H. The Director of Nurses and Administrator will be responsible for monitoring and ensuring ongoing compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members assistance for transfers, the Facility failed to ensure he/she was provided with the required level of staff assistance to maintain his/her safety and prevent incident/accident resulting in injury. On 8/17/22, Certified Nurse Aide #1, who was assigned to care for Resident #1, physically (manually) transferred Resident #1 out of bed to his/her wheelchair to the toilet, she then used a mechanical lift to transfer him/her from the toilet back to the wheelchair, and then into bed, all of which she did by herself without another staff member present to assist her. Early the next morning, Resident #1 complained of right shoulder pain and was transferred to the Hospital Emergency Department and diagnosed with a fractured right clavicle (collarbone). Findings Include: The Facility's Policy titled Comprehensive Care Plans, dated 9/2010, indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. The Facility's Policy titled Using the Care Plan, dated 8/2006, indicated the Care Plan would be used in developing the resident's daily care routines and would be available to staff personnel who had responsibility for providing care to the resident. The Facility's Policy titled Resident Lifts/Slides, dated 02/20, indicated two staff members would always be present for mechanical lift transfers to avoid injury to the resident. Resident #1 was admitted to the Facility in May 2021, diagnoses included [CONDITION(S)], dementia, and chronic obstructive pulmonary disorder. Review of Resident #1's Activities of Daily Living Care Plan, dated as revised on 02/21/22, indicated he/she required two staff members to assist with rolling walker and a gait belt for transfers and toileting. Review of Resident #1's Care Kardex (used as a quick reference for caregivers, and updated to reflect the most current Care Plan), indicated he/she required two staff member assistance for all transfers. Review of the X-ray Report, dated 8/18/22, indicated Resident #1 had an acute oblique fracture of the right clavicular mid shaft with superior displacement. Review of the Facility's Investigation Summary, dated 8/22/22, indicated that on the morning of 8/18/22 Resident #1 complained of right shoulder pain, was transferred to the Hospital Emergency Department, and diagnosed with a right clavicle fracture. The Investigation Summary indicated that on 8/17/22 during the 3:00 P.M., to 11:00 P.M., shift, CNA #1 had physically (manually) transferred Resident #1 by herself to the toilet, from the toilet to the bedside chair utilizing the Sara Lift (assistive device that lifts a person from seated to standing position, used for the purpose of transferring from one seated position to another, also requires the person being transferred to hold on to handles with both hands), then from the bedside chair to the bed, again utilizing the Sara lift, all without any other staff member to present to assist her. The Investigation Summary indicated CNA #1 said Resident #1 cried out in pain during transfers, and she forgot to inform the nurse. During interview on 9/09/22 at 1:38 P.M., CNA #1 said that on 8/17/22 on the 3:00 P.M., to 11:00 P.M., shift, she was assigned to care for Resident #1. CNA #1 said she was not familiar with Resident #1 and said she did not review his/her Care Kardex before beginning care. CNA #1 said she physically (manually) transferred Resident #1 from his/her bed to the wheelchair before dinner and said he/she complained of right shoulder pain at that time. CNA #1 said after dinner, she physically transferred Resident #1 to the toilet by herself, and said Resident #1 was unable to stand up to get off the toilet, at which time she notified Nurse #1. CNA #1 said Nurse #1 told her to get the Sara Lift to transfer Resident #1, and said she then used the Sara lift to transfer Resident #1 from the toilet to the wheelchair, then from the wheelchair to the bed, without assistance from any other staff member. CNA #1 said Resident #1 complained of pain at his/her right shoulder during the transfers, and said she forgot to notify Nurse #1 that he/she complained of pain. During interview on 9/09/22 at 12:09 P.M., Nurse #1 said that on 8/17/22 at 6:00 P.M., CNA #1 told her that she was unable to transfer Resident #1 from the toilet by herself, and said she told CNA #1 that Resident #1 required two staff members for assistance with transfers. Nurse #1 said she did not tell CNA #1 to use the Sara Lift, and said CNA #1 did not tell her Resident #1 had complained of pain. During interview on 9/08/22 at 1:23 P.M., Unit Manager #1 said that on 8/18/22 in the early morning Resident #1 complained of pain and had bruising at his/her right shoulder and said Resident #1 told her he/she had been transferred the night before by CNA #1 using a machine he/she had never seen before (later identified as the Sara Lift). Unit Manager #1 said Resident #1 was transferred to the Hospital Emergency Department and diagnosed with a fractured collar bone. Unit Manager #1 said staff members were responsible for logging in to the electronic system and reviewing each resident's Care Kardex prior to care each shift. Unit Manager #1 said CNA #1 should have reviewed Resident #1's Care Kardex before transferring him/her. Unit Manager #1 said Resident #1 required two staff members to assist him/her with transfers and said the use of the Sara Lift was not in Resident #1's Plan of Care. During interview on 9/08/22 at 12:45 P.M., the Director of Nurses (DON) said CNA #1 should have reviewed Resident #1's Care Kardex before care, should have had another staff member assist her to transfer Resident #1, and should not have used the Sara Lift to transfer Resident #1. On 9/08/22, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. On 8/19/22, the Facility held a Quality Assurance Performance Improvement meeting, review of the Plan of Action Meeting Minutes indicated Facility developed a plan to correct the deficient practice. B. On 8/18/22, Interviews were conducted with Other Residents, Notes indicated the Social Worker interviewed other residents and no concerns with care were identified. C. On 8/22/22, staff education was conducted, the In-Service Sign Off Sheet indicated staff were re-educated to review resident Care Kardex daily, and to sign off that they had reviewed the Care Kardex before the start of each shift. D. 8/22/22, The Facility's Investigation Summary indicated residents' transfer status was added to the paper CNA assignment sheets. E. 8/26/22, the In-Service Sign Off Sheet indicated staff were re-educated to the Facility's Policy, titled, Resident Lifts/Slides. F. 8/26/22, Gait Belts Audits were conducted by Unit Managers, and indicated each resident room was audited for presence of Gait Belts. G. Accidents and Incidents will be monitored monthly at QAPI meetings H. The Director of Nurses and Administrator will be responsible for monitoring and ensuring ongoing compliance.

Based on observation, record review and interview, the facility failed to ensure the staff treated one Resident (#77), with dignity and respect relative to responding in a timely manner to the Resident's requests for assistance, out of a total of 24 sampled residents. Findings include: Resident #77 was admitted to the facility in January 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #77's fall care plan, initiated on 2/9/21, indicated that the Resident needs a prompt response to all requests for assistance. On 5/25/22 at 10:37 A.M., Resident #77 could be heard from the hallway saying hello repeatedly. The surveyor was unable to observe the Resident from the hallway as the curtain was pulled and obstructed the view of the Resident, calling out from the second bed. The surveyor entered the room and observed the Resident sitting in his/her wheelchair between the bed and the window, holding a pink drink in a small plastic cup. The call bell was not visible. The surveyor observed the following on 5/25/22: -10:41 A.M. an employee walked by the Resident as he/she continued to say, hello from behind the curtain. -10:43 A.M. The Resident said, I don't know what's what .hello .hello hello. -10:45 A.M. an employee walked by Resident's room and the nurse was observed in the hallway passing medications. The Resident continued to call out hello, now increasing his/her volume. No response by staff. -10:46 A.M. The Resident continued to loudly say, hi hi .hi .hi. An employee could be seen a few doors away, leaning on the wall utilizing a facility tablet. The same staff walked by the Resident's room as the Resident loudly said hi hi hi. -10:49 A.M. Three employees walked by the Resident's room as the he/she loudly said, hiiiiiiiiiiii. -10:49 A.M. One employee entered the room. Resident #77 wanted someone to take the cup he/she was holding. The employee took the cup, emptied the contents of the cup and left the room. The Resident continued to sit behind the curtain in a wheelchair and the call bell was not within reach. -10:51 A.M. The Resident continued to loudly say, hi .hello. -10:52 A.M. The Resident said, please please come .come hello hi. -10:58 A.M. Unit Manager (UM) #1 entered the Resident's room as he/she had continued to call out and asked how she could assist. The Resident asked what time it was, the UM responded, placed the call bell within reach, opened the curtain and provided a snack. -11:02 A.M. Resident was no longer calling out. During an interview on 5/25/22 at 11:14 A.M., UM #1 said she went into the Resident's because she heard the Resident calling out. She said the Resident wanted to know what time it was. UM #1 said that she moved the call bell to be within reach of the Resident as the call bell was not within reach, as required. She continued to say that the Resident has a special call bell due to her visual impairment. She also said that the Resident likes to see what is going on around him/her as his/her vision field is poor and pulled the curtain open, so that he/she could see. She said the curtain should have been pulled open so the Resident could see, and it was not. On 5/25/22 at 11:17 A.M. the surveyor observed that the Resident was no longer calling out. Refer to F558

Based on observation, record review and interview, the facility staff failed to ensure access to a call light for one Resident (#77), out of a total of 24 sampled residents. Findings include: Resident #77 was admitted to the facility in January 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #77's fall care plan, initiated on 2/18/21, indicated the following: -Be sure the Resident's call light is within reach and encourage the Resident to use it for assistance. -The Resident needs a prompt response to all requests for assistance. Review of Resident #77 activities of daily living care plan, initiated on 2/9/21, indicated staff to pin the call light to the Resident's bed or keep in easy reach. On 5/25/22 at 10:37 A.M., Resident #77 could be heard from the hallway saying hello repeatedly. The surveyor was unable to observe the Resident from the hallway as the curtain was pulled and obstructed the view of the Resident, calling out from the second bed. The surveyor entered the room and observed the Resident sitting in his/her wheelchair between the bed and the window, holding a pink drink in a small plastic cup. The call bell was not visible. On 5/25/22 at 10:49 A.M. the surveyor observed an employee enter the Resident's room as he/she had continued to call out. Resident #77 wanted someone to take the cup he/she was holding. The employee took the cup, emptied the contents of the cup and left the room. The Resident continued to sit behind the curtain in a wheelchair and the call bell was not within reach. On 5/25/22 at 10:58 A.M., the surveyor observed Unit Manager (UM) #1 enter the Resident's room as he/she had continued to call out and ask how she could assist. The Resident asked what time it was. The UM responded, placed the call bell within reach, opened the curtain and provided a snack. On 5/25/22 at 11:02 A.M., the surveyor observed that the Resident was no longer calling out. During an interview on 5/25/22 at 11:14 A.M. the UM said she went into the Resident's because she heard the Resident calling out. She said the Resident wanted to know what time it was. The UM said that she moved the call bell to be within reach of the Resident as it was not and should have been. She continued to say that the Resident had a special call bell due to his/her visual impairment.

Based on observation, interview, and record review the facility failed to ensure staff implemented a doctor's order for weekly skin checks resulting in bruising not being identified and documented for one resident (#7) out of 24 sampled residents. Findings Include: Review of the facility policy titled Skin Assessment and Surveillance, undated, indicated the following: Licensed Nurses are responsible for ensuring each resident's skin is checked once a week and results of the skin check are documented on the resident's individual weekly skin assessment form in the treatment administration record (TAR). Resident #7 was admitted to the facility February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/25/22 at 9:41 A.M., the surveyor observed that Resident #7 had quarter sized bruises on each forearm. Review of the May 2022 Physicians Orders indicated an order to complete weekly skin checks and document findings on Fridays 3:00-11:00 P.M. shift, with a start date of 2/10/22. Review of the Skin care plan indicated an intervention of weekly skin checks with a start date of 2/21/22. Review of the last two Weekly Skin Assessments dated 5/12/22 and 5/19/22 indicated no new skin issues and no documentation that the Resident had any rashes, bruises, skin tears, reddened areas, surgical sites, pressure areas, or other skin conditions present at the time the skin assessment was completed. On 5/31/22 at 10:07 A.M., the surveyor observed Resident #7 still had quarter sized bruises on each forearm. Review of the May TAR indicated a skin assessment was due to be completed on 5/26/22. There was no documented evidence that the skin assessment had been completed. Review of the Nursing Notes dated from 5/25/22 through 5/31/22 indicated no documentation that the Resident had bruising on his/her forearms and no documentation on why the weekly skin assessment was not completed on 5/26/22. During an interview on 5/31/22 at 10:12 A.M., Nurse #2 said Resident #7 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 said the resident should have had a weekly skin assessment completed on 5/26/22 which would have identified the bruising on his/her forearms, but the weekly skin assessment had not been completed as ordered and there was no documentation in the nursing notes why the skin assessment was not completed. During an interview on 5/31/22 at 11:00 A.M., Unit Manager #2 said Resident #7 should have had a weekly skin assessment completed on 5/26/22 and it was not completed, as required.

Based on observation, interviews and record review, the facility failed to ensure staff implemented a physician's order to assess heart rate and blood pressure prior to the administration of a blood pressure medication for one Resident (#108) out of a total of 24 sampled residents, potentially putting the Resident at risk for [CONDITION(S)] (low blood pressure). Findings include: Resident #108 was admitted to the facility in January 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy, Administering Medications included the following: - The following information must be checked/verified for each resident prior to administering medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2021 Physician's Orders included the following: - [MEDICATION(S)] (a medication used to treat high blood pressure), 50 milligrams (mg), give 50 mg by mouth one time a day, with the following parameters: hold for systolic blood pressure (the first number of a blood pressure reading that indicates the pressure caused by the heart contracting and pushing out the blood) less than 100 millimeters of mercury (mm Hg) or heart rate less than 60 beats per minute, initiated 2/3/21. During an observed medication pass on 5/31/22 at 8:30 A.M., the surveyor observed the medication card that indicated both heart rate and blood pressure parameters were included with the Losartan order. Nurse #3 said that the Resident's vital signs are only checked weekly on shower days. She reviewed the order in the computer and said there were no parameters ordered relative to the Resident's Losartan medication and administered the medication without first assessing his/her blood pressure and heart rate. On 5/21/22 at 10:02 A.M., Unit Manager #1 reviewed Resident #108's medication orders with the surveyor and said the Physician's order indicated there were parameters in place and the nurse should have assessed the Resident's blood pressure and heart rate prior to administering his/her Losartan. On 5/31/22 at 10:20 A.M., Nurse #3 said she should have assessed the Resident's heart rate and blood pressure prior to administering his/her Losartan as ordered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from physical abuse with use of a restraint, when Certified Nurse Aide (CNA ) #1 was witnessed by a staff member restraining Resident #1 by the wrists when Resident #1 became agitated and resisted care. Resident #1 was assessed after the incident and found to have sustained a skin tear to his/her the left upper arm and a bruise above the left wrist. CNA #1 also witnessed hitting the bathroom door in anger, in front of Resident #1, in an intimidating manner. Finding include: The Facility's Policy titled, Abuse, Neglect, Mishandling, Mistreatment, Exploitation, Misappropriation, Involuntary Seclusion, not dated, indicated that it is the policy of the Facility to ensure each resident is free from verbal, physical and mental abuse. The Policy indicated that every resident in the Facility will be treated with respect and dignity. The Policy indicated residents will not be subjected to abuse by anyone including, but not limited to facility staff. Resident #1's medical history included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 01/11/22, indicated he/she usually understood others, made himself/herself understood, displayed verbal behavioral symptoms towards others, required an extensive one person assist with dressing, required an extensive two person assist for toileting and was determined to have severe cognitive functioning impairment during a Brief Interview for Mental Status evaluation. Review of Resident #1's Care Plan, reviewed and renewed with the MDS in January 2022, indicated he/she had self care deficits related to weakness and decreased mobility, interventions indicated to toilet with a one person extensive assist. Review of Resident #1's Care Plan related to psychosocial well-being, reviewed and renewed with the MDS in January 2022, indicated he/she has an alteration in coping mechanisms related to adjustment to nursing home placement and accepting own limitations and losses. Interventions included to orient to nursing facility routine, encourage maximum level of function and participation, honor care preferences and choices whenever possible, and provide opportunities for expression of feeling related to a situational stressor. Review of the Facility's Resident Incident Report, dated 03/06/22, indicated that on 03/06/22 at 8:00 P.M. Resident #1 was reported to have been yelling, swearing and was agitated. The Report indicated Resident #1 sustained a left upper lateral arm skin tear measuring 4 centimeters (cm) by 2 cm with skin flap. The Report indicated it was moist with scant frank blood, [CONDITION(S)] below the skin tear with a faint purple bruise emerging, and reddish purple bruising around the skin tear. The Report indicated Resident #1 had a slight raised purple bruised area measuring 2 cm by 2 cm on his/her left lower arm above the wrist. The Report indicated the CNA (later identified as CNA #1) assigned to Resident #1 was removed from the room, spoke with the Nursing Supervisor and was sent home. During an interview on 03/15/22 at 01:05 P.M., Non-Certified Nurse Aide (NCNA) #1 said CNA #1 told her he intended to change Resident #1 into pajamas since he/she was already in the bathroom. NCNA #1 said while in the hallway she heard Resident #1 scream out twice, words to the effect of you're breaking my [OBSCENITY] ing arm and get the [OBSCENITY] away from me, I don't ever want to see you again, get out of here. NCNA #1 said she ran to Resident #1's bathroom doorway, and said she saw Resident #1, who was seated on the toilet, and that CNA #1 was squatted down in front of Resident #1. NCNA #1 said she saw CNA #1 reaching down with one of his hands to attach an incontinent brief on Resident #1's leg while his other hand held both of Resident #1's hands together. NCNA #1 said CNA #1 was holding both of Resident #1's hands up in the air, had extended them as high as he could above him, reaching the height of Resident #1's mouth. NCNA #1 said with Resident #1's hands held together, his/her elbows were bent, raised and pointed outward in a horizontal manner. NCNA #1 said when Resident #1 saw her, he/she cried out words to the effect of get him away from me. NCNA #1 said she told CNA #1 that Resident #1 was agitated, that he needed to leave the bathroom and that she would care for Resident #1. NCNA #1 said CNA #1 got up, and with an open hand hit (hard and loud) the bathroom door and exited. NCNA #1 said she was horrified that CNA #1 displayed such anger in front of Resident #1, and said that it would have made anyone become even more afraid. NCNA #1 said Resident #1 asked if CNA #1 would return, and said she reassured Resident #1 that he would not. NCNA #1 said within minutes of the incident while Resident #1 remained seated in the bathroom, she saw a wet spot on Resident #1's red long sleeved sweater above his/her elbow. NCNA #1 said she removed the sweater to see the wetness was blood coming from a skin tear on Resident #1's left arm and also observed a bruise just above his/her left wrist. During an interview on 03/17/22 at 12:00 P.M. and 2:15 P.M., CNA #1 said Resident #1 was usually changed into pajamas and assisted to bed after 10:30 P.M., which was when he/she was tired and more receptive to assistance from staff with care. CNA #1 said at approximately 8:00 P.M. on 03/06/22, he decided to change Resident #1 into his/her pajamas since he/she had already been brought in to the bathroom by NCNA #1. CNA #1 said he tried to remove the soiled incontinent brief from Resident #1, but he/she grabbed it, grabbed him and became increasingly agitated. CNA #1 said Resident #1 said words to the effect of I don't want it, get away from me, leave me alone and called for help. CNA #1 said the more agitated Resident #1 got, the more agitated he got. CNA #1 said he yelled over Resident #1's voice to get his/her attention, but was unable to redirect him/her. CNA #1 said Resident #1 resisted care, struck at and grabbed him with his/her hands and fingernails. CNA #1 said he tried to block his face from Resident #1. CNA #1 said he quickly removed the soiled brief and squatted down in front of Resident #1. CNA #1 said he tried to put a clean incontinent brief around Resident #1 legs with one hand and with his other hand, he held both of Resident #1's wrists together. CNA #1 said he extended his hand upwards, holding Resident #1's hands together as high up and away from him as possible to keep Resident #1's hands from hitting him. CNA #1 said NCNA #1 entered the room and took over caring for Resident #1. CNA #1 said, with an open hand, he slammed (struck) the door on his way out of the bathroom. CNA #1 said he was unaware of any bruises, skin tears or injuries potentially sustained to Resident #1's arms or hands. CNA #1 said he held Resident #1's hands together by the wrists, but said he did not grab Resident #1's arms, remove any of his/her clothing or assist Resident #1 to stand. CNA #1 said he was furious with himself. CNA #1 said he should have left sooner when Resident #1 initially resisted having the soiled brief removed, and said he should have asked another staff member to provide the care, but he wanted to get the job done. CNA #1 said he came to work under a high level of personal stress that day, and said he was not in the right state of mind to deal with surprise stressors. During an interview on 03/18/22 at 10:10 A.M., the Nursing Supervisor said after becoming aware of the allegation, CNA #1 was immediately removed from the Unit. The Nursing Supervisor said CNA #1 repeatedly told him words to the effect of I lost it, it's not me, and apologized. The Nursing Supervisor said CNA #1 told him he hit the bathroom door because Resident #1 directed racial expletives at him. The Nursing Supervisor said he asked CNA #1 why Resident #1 sustained a large laceration to the arm. The Nursing Supervisor said CNA #1 told him he did not know why and said he had tried to remove Resident #1 sweater, but did not use force. The Nursing Supervisor said Resident #1 was unable to coherently provide an accurate account of the incident, however made statements that indicated he/she felt a man treated him/her roughly with force, and thought areas of his/her body were being struck. A reasonable person with intact cognitive functioning would have experienced mental anguish and physical pain.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of one staff person with a gait belt for ambulation, the Facility failed to ensure staff implemented and followed his/her plan of care when Certified Nurse Aide (CNA) #1 was ambulating Resident #1 without a gait belt, left him/her standing unattended in the hallway, and he/she fell and sustained a back injury. Findings include: Review of the Facility's Investigation Report, dated 01/02/20, indicated that Certified Nurse Aide (CNA) #1 was ambulating Resident #1 without a gait belt, left Resident #1 standing unattended in the hallway to go and get Resident #1's wheelchair from the shower room located down the corridor, and he/she fell . Review of Resident #1's Progress Notes, dated 01/02/20, indicated that he/she fell and had facial grimacing with movement. The Note indicated the Nurse Practitioner was notified and ordered a [MEDICATION NAME] and LS (lumbar/spine) x-ray. Review of Resident #1's Progress Notes, dated 01/03/20, indicated that the Nurse Practitioner ordered a new pain medication [MEDICATION NAME] (narcotic) to be administered twice a day and as needed for pain. During an interview on 01/09/20 at 1:35 P.M., the Nurse Practitioner said she assessed Resident #1 on 01/02/20 after he/she experienced a fall in the hallway, and said Resident #1 complained of back pain. The Nurse Practitioner said she ordered an x ray which showed Resident #1 had a compression fracture and that, even though Resident #1 had a history of [REDACTED].#1 had acute pain to his/her back area. The Nurse Practitioner said she prescribed pain patches for Resident #1's back, [MEDICATION NAME] to be administered twice a day and as needed, and Tylenol as needed for pain. Review of Resident #1's Medication Administration Record [REDACTED]. Further review of Resident #1's MAR, dated 01/01/20 through 01/31/20, indicated that Resident #1 received [MEDICATION NAME] for pain scheduled twice a day starting on 01/04/20 and he/she also received additional PRN (as needed) doses of [MEDICATION NAME] for pain on 01/04/20 and 01/07/20. Review of Resident #1's Activities of Daily Living (ADL) Plan of Care, dated 10/31/19, indicated that Resident #1 ambulated with a gait belt and was dependent on one staff person for ambulation. Resident #1's Significant Change Minimum Data Set (MDS), dated [DATE] indicated that Resident #1 required a physical assist of one staff person for locomotion on the unit. The Facility's Policy titled, Fall Management Program & Fall Risk Assessment, dated (MONTH) (YEAR), indicated that, following the interdisciplinary assessment, the resident's nursing and Certified Nurse Aide (CNA) plan of care will include strategies to reduce the risk for falls as identified through the minimum data set (MDS) assessment process. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. During an interview on 01/10/20 at 1:12 P.M., Certified Nurse Aide (CNA) #1 said she left Resident #1 in the hallway during ambulation to go get his/her wheelchair and that Resident #1 fell . CNA #1 said she knew Resident #1 was dependent on staff's assistance with ambulation, said that she knew he/she required a gait belt for safety with ambulation and said that she did not follow the interventions that were on Resident #1's plan of care. During an interview on 01/09/20 at 11:00 [NAME]M., Certified Nurse Aide (CNA) #2 said on 01/02/20, she saw CNA #1 ambulating Resident #1 without a gait belt and not walking by his/her side. CNA #2 said she immediately called out to CNA #1 and reminded her of Resident #1's fall risk with intervention to walk at close proximity with a gait belt when ambulating Resident #1. CNA #2 said approximately 10 minutes after redirecting CNA #1, Resident #1 fell in the hallway and that she was surprised that CNA #1 left him/her unattended even after the reminder she had just provided to CNA #1. During an interview on 01/09/20 at 1:30 P.M., the Assistant Director of Nurses (ADON) said that Resident #1 needed gait belt and staff assistance with ambulation and that this was not the first time CNA #1 failed to follow and implement a residents' plan of care.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of one staff person with a gait belt for ambulation, the Facility failed to ensure staff provided adequate care and supervision when Certified Nurse Aide (CNA) #1 was ambulating Resident #1 without a gait belt, left him/her standing unattended in the hallway, and he/she fell and sustained a back injury. Findings include: Review of the Facility's Investigation Report, dated 01/02/20, indicated that Certified Nurse Aide (CNA) #1 was ambulating Resident #1 without a gait belt, left Resident #1 standing unattended in the hallway to go and get Resident #1's wheelchair from the shower room located down the corridor, and he/she fell . Review of Resident #1's Progress Notes, dated 01/02/20, indicated that he/she fell and had facial grimacing with movement. The Note indicated the Nurse Practitioner was notified and ordered a [MEDICATION NAME] and LS (lumbar/spine) x-ray. Review of Resident #1's Physician Order, dated 01/02/20, indicated that an x-ray was ordered for his/her back area because Resident #1 had back pain. Review of the Radiology Report, dated 01/02/20, indicated Resident #1 had osteoporotic compressions involving T10 and T11 vertebrae and that the age of the compression was old or indeterminate. Review of Resident #1's Progress Notes, dated 01/03/20, indicated that the Nurse Practitioner ordered a new pain medication [MEDICATION NAME] (narcotic) to be administered twice a day and PRN (as needed) for pain. During an interview on 01/09/20 at 1:35 P.M., the Nurse Practitioner said she assessed Resident #1 on 01/02/20 after he/she experienced a fall in the hallway, and said Resident #1 complained of back pain. The Nurse Practitioner said she ordered an x ray which showed Resident #1 had a compression fracture and that, even though Resident #1 had a history of [REDACTED].#1 had acute pain to the back area. The Nurse Practitioner said she prescribed pain patches for Resident #1's back, [MEDICATION NAME] to be administered twice a day and as needed, and Tylenol as needed for pain. Review of Resident #1's Medication Administration Record [REDACTED]. Further review of Resident #1's MAR, dated 01/01/20 through 01/31/20, indicated that Resident #1 received [MEDICATION NAME] for pain scheduled twice a day starting on 01/04/20 and he/she also received additional PRN (as needed) doses of [MEDICATION NAME] for pain on 01/04/20 and 01/07/20. Review of Resident #1's Activities of Daily Living (ADL) Plan of Care, dated 10/31/19, indicated that Resident #1 ambulated with gait belt and was dependent on one staff person with ambulation. Resident #1's Significant Change Minimum Data Set (MDS), dated ,[DATE] indicated that Resident #1 required a physical assist of one staff person for locomotion on the unit. The Facility's Policy titled, Fall Management Program & Fall Risk Assessment, dated (MONTH) (YEAR), indicated that, following the interdisciplinary assessment, the resident's nursing and Certified Nurse Aide (CNA) plan of care will include strategies to reduce the risk for falls as identified through the minimum data set (MDS) assessment process. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. During an interview on 01/10/20 at 1:12 P.M., Certified Nurse Aide (CNA) #1 said she left Resident #1 in the hallway during ambulation to go get his/her wheelchair and that Resident #1 fell . CNA #1 said she knew Resident #1 was dependent on staff's assistance with ambulation, that she knew he/she needed a gait belt for safety with ambulation and that she did not follow interventions that were on Resident #1's plan of care. During an interview on 01/09/20 at 11:00 [NAME]M., Certified Nurse Aide (CNA) #2 said on 01/02/20, she saw CNA #1 ambulating Resident #1 without a gait belt and not walking by his/her side. CNA #2 said she immediately called out on CNA #1 and reminded her of Resident #1's fall risk with intervention to walk at close proximity with a gait belt when ambulating Resident #1. CNA #2 said approximately 10 minutes after redirecting CNA #1, Resident #1 fell in the corridor and that she was surprised that CNA #1 left him/her unattended even after the reminder she had just provided to CNA #1. During an interview on 01/09/20 at 1:30 P.M., the Assistant Director of Nurses (ADON) said that Resident #1 needed gait belt and staff assistance with transfers and ambulation and that this was not the first time CNA #1 failed to follow and implement residents' plan of care.

Based on observation, record review and staff interview, facility staff failed to ensure that 3 of 23 sampled residents (#7, #8 and #10) was free of accidents and hazards. Findings include: 1. For Resident #8, facility staff failed to assist/supervise the resident while drinking hot coffee in the unit dining room. The resident sustained [REDACTED]. Resident #8 was admitted to the facility in 4/2014. [DIAGNOSES REDACTED]. Review of the Nutrition Care Plan (developed 12/7/15) indicated to provide assistance for the resident during meals as needed. Review of the 8/19/16 Quarterly Nutrition Assessment, indicated the resident required physical assistance for dining ability and was unable to drink without assistance. Review of the OT Progress and Discharge Summary note of 9/1/16 indicated under Precautions: the resident has resting hand tremor. The Significant Change in Status MDS (Minimum Data Set) Assessment of 9/28/16 indicated the resident: could make self understood and could understand others; had short and long term memory loss with poor decision-making skills; was fidgety or restless and moving around a lot more than usual nearly everyday; required extensive assistance for eating; had a mechanically altered diet; was receiving a scheduled pain medication regime; showed indicators of pain 3-4 days during the observation period; was receiving antipsychotic, antianxiety and antidepressant medications, as well as an antibiotic medication; was receiving Hospice services and had developed an unstageable pressure ulcer (unavoidable). A Progress Note of 9/29/16 indicated that at 8:45 A.M., the resident was in the dining room and spilled hot coffee in his/her lap during breakfast. The resident had on a clothing protector at the beginning of the meal, but had pulled it off later during coffee intake. Staff applied cold compresses and ice to the upper inner thighs. The left inner thigh had a reddened area measuring 6.4 x 3.0 cm. (centimeters), and the right inner thigh had a reddened area measuring 6.0 x 2.5 cm. (both areas later blistering). The NP (Nurse Practitioner) ordered Silvadene Cream (topical antimicrobial drug used to treat burns) to be applied to red/blistering areas on both inner thighs twice daily until healed. A 9/29/16 Physician's Progress Note written by the NP indicated the resident had redness and superficial blistering on both inner thighs. The note included, .Local 2nd degree burn on upper inner thighs - need to address cover on cup and temperature of coffee Review of the investigative report of 9/29/16 indicated the resident was handed a cup of hot coffee, and staff turned away to help another resident. The resident told staff that he/she spilled coffee in the lap. The report indicated that staff would remove hot drinks from the resident if they needed to step away from the resident's table, and that extra clothing protectors would be placed in the resident's lap at meal time. A physician's orders [REDACTED]. Apply Silvadene followed by a Telfa (non-stick) dressing and secure with paper tape twice daily and as needed for 15 days. On 10/4/16 at 10:45 A.M., the surveyor observed the dressing change. Both inner thighs had open, red blisters. Silvadene was applied as ordered. During interview on 10/4/16 at 2:30 P.M., the Director of Nurses (DON) said that coffee temperatures were not being monitored. She said that the Food Service Director (FSD) told her that when coffee leaves the kitchen, it is between 170 and 179 degrees Fahrenheit per gauge on the Coffee Maker. During interview on 10/4/16 at 3:30 P.M., the FSD said that temperatures for hot liquids (boiling water and coffee) are not monitored before being sent from the kitchen to the units for meals and coffee socials. She said that only food is monitored for correct temperatures. On 10/5/16 at 8:30 A.M., the surveyor observed the resident in the Unit dining room. The resident had on 2 clothing protectors and was able to hold a cold drink with close supervision. The resident was not offered hot beverages. Unit Manager #2 said that if the resident is offered hot coffee, that staff add milk and thickener first. She said that the resident does not have a cup with a cover, although the NP progress note of said to address cover on cup and temperature of coffee. 2. For Resident #7, facility staff failed to ensure that an instant hot pack was properly wrapped before being applied to the resident's upper back/neck. The resident sustained [REDACTED]. Resident #7 was admitted to the facility in 7/2013 with multisystem atrophy secondary to Parkinson's Disease (decreased sensation), peripheral vascular disease (decreased skin sensation), anxiety disorder and depression. Review of the Plan of Care addressing pain (developed 8/13/15) indicated the resident had the potential for pain, and that pain would be monitored and treated as ordered. Interventions included: - Monitor for pain every shift. if resident is medicated for pain or discomfort, monitor effectiveness of pain medication. - Assist with positioning for discomfort. A physician's orders [REDACTED].M., when the resident gets out of bed. The order did not specify what to wrap the warm pack in or how long it was supposed to remain on the resident. Review of the TARs (Treatment Administration Records) from 2/18/16 to 5/29/16 had no evidence the resident's skin was monitored for redness or signs and symptoms of burns after application of the warm packs. Review of the Quarterly MDS Assessment of 4/29/16 indicated the resident: was alert and oriented to person, place and time; required total assistance from staff for all activities of daily living and was unable to ambulate. Review of the clinical record indicated that on the morning of 5/28/16, a superficial red area with a yellow base measuring 5.0 x 3.0 cm. was found on the resident's mid upper back. The resident indicated that he/she received the burn from the warm pack the day before. Review of the investigation of 5/28/16 indicated the nurse who applied the warm pack on 5/27/16, wrapped it in a facecloth and placed it underneath the resident's shirt collar, resting on the resident's upper back/neck area. The nurse returned in about 10 minutes, and the resident had already removed the pack. There was no documentation in the clinical record to indicate the resident's upper back/neck area was checked or monitored on 5/27/16 for redness and/or blistering. Further review of the clinical record indicated that facility staff called the Physician at approximately 1:00 P.M. on 5/28/16 to report the burn and get an order to treat. The Physician ordered the burn medication Silvadene Cream and a non-stick dressing to be applied to the area twice daily. Review of a Progress Note of 6/3/16, indicated the burn had resolved, and the Silvadene Dressing was discontinued During interview on 10/3/16 at 1:30 P.M., the DON said the warm packs that were being used were not hot enough, so the facility changed vendors just prior to the resident's burn (unknown date of change). The DON said the facility had no policy/procedure in place for the use of warm packs until after the resident sustained [REDACTED]. 3. For Resident #10, the facility staff failed to utilize a gait belt during a transfer and the resident sustained [REDACTED]. Resident #10 was admitted to the facility in 4/2014 with a [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 3/31/16, indicated that the resident was moderately cognitively impaired, as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated that the resident required limited assistance for transfers and ambulation and had no falls since the last MDS assessment. Review of the Activities of Daily Living (ADL) care plan, dated 4/6/16, indicated the following intervention: - Transfer with 1 assist and gait belt. Review of the nurses note, dated 5/24/16, indicated that on 5/23/16 at 9:45 A.M. the resident sustained [REDACTED]. The skin tear was sustained during a transfer. Review of the facility's internal investigation, indicated that the Certified Nurse Aide (CNA) transferred the resident without using a gait belt, and the resident sustained [REDACTED]. The surveyor observed Resident #10 on 10/5/16 at 8:45 A.M. Resident #10 was seated in a wheelchair in the unit dining room at a table. He/she wore non-skid socks on the feet. During an interview with Unit Manager (UM) #3 on 10/5/16 at 12:00 P.M. she said that the CNA should have utilized a gait belt when transferring the resident. During an interview with CNA #1 on 10/5/16 at 12:15 P.M. she said that she was familiar with Resident #10. She said that the resident required the use of a gait belt during transfers.