Every finding on record at Oakdale Rehabilitation & Skilled Nursing Center

Based on observation, interview, and record review, the facility failed to implement infection control practices in accordance with professional standards to prevent the potential spread of infection for one Resident (#187), out of a total sample of 19 residents. Specifically, the facility staff failed to ensure the required personal protective equipment (PPE) was adhered to when Resident #187 was admitted with a surgical abdominal wound and an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine) that required Enhanced Barrier Precautions, increasing the Residents' risk for infection and preventing the potential spread of multidrug-resistant organisms (MDROs) during high-contact resident care activities. Findings include: Review of Centers for Disease Control and Prevention (CDC) Guideline for Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised June 28, 2024, retrieved from, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html indicated: - Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. - Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). - Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. - Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). - Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Resident #187 was admitted to the facility in June 2025 diagnosis of Malignant Neoplasm of Prostate, Surgical Abdomen Wound with a Wound Vac and Foley catheter. Review of Resident #187's Brief Interview for Mental Status Evaluation completed on 6/8/25 indicated that the Resident is cognitively intact with a Brief Interview for Mental Status score of 15 out of a total of 15. On 6/8/25 at 9:27 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 holding Resident #187's Foley catheter drainage bag and also holding onto the Resident while the Resident was ambulating to the bathroom. CNA #1 was not wearing an isolation gown. There was a sign outside the Resident's room indicating the Resident was on Enhanced Barrier Precaution (EBP). During an interview on 4/8/25 at 9:27 A.M., CNA #1 said she was not aware that Resident #187 was on EBP. On 6/8/25 at 9:33 A.M., the surveyor observed two staff members enter Resident #187's room with no PPE and close the door. At 9:36 A.M., CNA #3 exited the Resident's room and said she should have worn a gown and gloves before entering the Resident's room, but she did not. At the same time CNA #2 exited the room. CNA #2 said she was a new CNA at the facility and was in training. CNA #2 said she assisted Resident #187 off the toilet, and into his/her bed but was not aware she needed to wear a gown during the high contact care. During an interview on 6/9/25 at 7:45 A.M., the Infection Preventionist/Staff Development Coordinator (IP/SDC) said the CNAs had been educated on Enhanced Barrier Precaution. IP/SDC further said the CNAs should have adhered to the EBP sign at the door to Resident #187, but they did not.

Based on observation, interview, and record review, the facility failed for one Resident (#187), with an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine), out of a total sample of 19 residents, to maintain his/her Foley catheter in a privacy bag to maintain their dignity. Findings include: Review of Agency for Healthcare Research and Quality (AHRQ) article titled Catheter Care and Maintenance, published March 2017, retrieved from: https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-care/slides.html indicated: -Residents sometimes prefer leg bags, which can improve mobility and dignity Resident #187 was admitted to the facility in June 2025 with a diagnosis of Malignant Neoplasm of the Prostate. Review of Resident #187's Brief Interview for Mental Status Evaluation completed on 6/8/25 indicated that the Resident was cognitively intact with a score of 15 out of 15. On 6/8/25 at 9:33 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 ambulate Resident #187 in the Resident's room. The Resident's Foley catheter was not covered in a privacy bag. During an observation with interview on 6/8/25 at 4:14 P.M., the surveyor observed Resident #187 seated in a chair in his/her room watching television. The Foley catheter drainage bag was not observed in a privacy bag. The Resident did not have a leg bag. Resident #187 said the facility staff had not offered him/her a leg bag and that he/she wanted one. Review of Resident #187's June 2025 Physician's Orders indicated: - Assure urinary drainage and privacy bag, keep off the floor every shift for dignity, initiated 6/5/25. - Change leg bag weekly on bath/shower day, initiated 6/5/25. During an observation with interview on 6/9/25 at 6:53 A.M., the surveyor and the Rehab Director observed Resident #187's Foley catheter during morning care and the drainage bag was not in a privacy bag. The Rehab Director said the Foley catheter was not in a privacy bag and it should have been. During an interview on 6/9/25 at 7:02 A.M., Unit Manager (UM) #1 said Resident #187's Foley catheter should have been in a privacy bag, but it was not. UM #1 further said the Resident should have a leg bag when he/she was out of bed, but this has not been done. During an interview on 6/9/25 at 8:42 A.M., the Director of Nursing Services (DON) said when Resident #187 was admitted to the facility, the Resident's Foley catheter bag should have been switched to the facility's specific urinary drainage bag as that would have allowed for the drainage bag to be covered and maintained for privacy and dignity. The DON said the facility staff failed to change Resident #187's Foley catheter drainage bag to the Assure urinary drainage and privacy bag as ordered by the Physician.

Based on observation, interview, and record review, the facility failed to provide appropriate care and nutrition services relative to an altered texture diet for one Resident (#14), out of a total sample of 19 residents. Specifically, the facility failed to provide Resident #14 with thickened beverages in accordance with the Resident's plan of care, placing Resident #14 at risk for swallowing complications. Findings include: Review of the facility's policy titled Therapeutic Diets, undated, indicated the following: -A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet or to alter the texture of a diet i.e.: altered consistency diet -A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider) The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law -If a mechanically altered diet is ordered the provider will specify the texture modification Resident #14 was admitted to the facility in November 2023 with diagnoses including Dysphagia (difficulty swallowing), unspecified and Cerebral Infarction due to Thrombosis. Review of the Minimum Data Set (MDS) assessment, dated 5/16/25, indicated Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #14's active Physician's Orders, dated 6/9/25, indicated the following order initiated 6/18/24: -No Added Salt (NAS) diet, Ground texture, Nectar thick Consistency, no hard dry bread, no mixed consistencies, no fruit with high water content allowed on diet. Review of a Nutritional Risk Assessment, dated 5/12/25, indicated Resident #14 was prescribed a ground texture diet with nectar thickened liquids. Review of a Speech Language Pathology (SLP) Discharge summary, dated [DATE] through 5/2/25, indicated that Resident #14 required a minced moist diet with mildly thickened liquids. On 6/8/25 at 9:14 A.M., the surveyor observed Resident #14 seated in bed with a breakfast meal in front of him/her. The surveyor observed a clear plastic cup one quarter full of cranberry juice and a plastic mug one half full of hot tea. Resident #14 said the tea wasn't warm but he/she liked it anyway. The surveyor observed that both the cranberry juice and the tea were of a thin, regular consistency. On 6/9/25 at 12:32 P.M., the surveyor and Unit Manager #2 (UM #2) observed Resident #14's lunch meal tray together. UM #2 said that she saw an issue with the beverages on the Resident's meal tray. UM #2 said Resident #14 required nectar thickened liquids and that the two cups of hot tea on the Resident's meal tray were not thickened to the appropriate consistency. UM #2 further said that Resident #14 had a physician's order for nectar thick consistency beverages and Resident #14 should not have been provided with any beverages that were not thickened as ordered. During a follow up interview on 6/9/25 at 3:18 P.M., the SLP said during the evaluation of Resident #14 she noted the Resident would cough occasionally while drinking thin consistency beverages because the thin consistency beverages moved too fast down the Resident's throat and end up going the wrong way into the windpipe. She said it is safer for Resident #14 to have nectar thick consistency beverages because they don't move as quickly down his/her throat and that Resident #14 should not have had any thin consistency beverages provided on his/her meal trays.

Based on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for two Residents (#188 and #10), out of a total sample of 19 residents. Specifically, 1. For Resident #188, the facility failed to ensure that Physician orders with the appropriate liter flow were obtained for oxygen use when the Resident was being administered oxygen. 2. For Resident #10, the facility failed to obtain active Physician orders for the use of PRN (as needed) oxygen with the required liter flow when the Resident was being administered PRN oxygen. Findings include: Review of the facility's policy titled Oxygen, dated 2001, indicated: -Verify that there is a Physician's order for this procedure. -Review the Physician's orders for oxygen administration. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All Oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for Oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily >Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. 1. Resident #188 was admitted to the facility in April 2025 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Acute Respiratory Failure with Hypoxia and Pleural Effusions. Review of the Minimum Data Set (MDS) assessment, dated 5/16/25, indicated Resident #188: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. -was dependent on staff for activities of daily living (ADLs - bathing, grooming, dressing, hygiene). -required the use of oxygen related to shortness of breath (SOB). During an interview on 6/8/25 at 9:45 A.M., Resident #188 said he/she required the use of oxygen but was not sure of the rate (liter flow) of the oxygen being administered. Resident #188 further said he/she was recently hospitalized with hypoxia (low oxygen in the blood) and needed to use oxygen. The surveyor observed the oxygen liter flow was set at 1 liter per minute (LPM) on the oxygen concentrator. Review of Resident #188's June 2025 Physician's orders failed to indicate any oxygen orders and the prescribed liter flow of oxygen to be administered to the Resident. Review of Resident #188's Respiratory Care Plan, initiated 5/9/25, indicated the Resident required the use of oxygen related to altered respiratory status, difficulty breathing related to COPD, Acute Respiratory Failure with Hypoxia and was dependent on oxygen. On 6/10/25 at 6:52 A.M., the surveyor observed Resident #188 lying in bed asleep with the nasal cannula in place in his/her nostrils. The surveyor also observed that the oxygen concentrator was turned off. During an interview at the time, Resident #188 said that he/she was not aware the oxygen had been shut off and how long the oxygen had been turned off. During an interview on 6/10/25 at 7:05 A.M., Nurse #1 said he was the Nurse that worked on the 11:00 P.M. to 7:00 A.M. shift (night shift). Nurse #1 said the Resident's oxygen concentrator was turned off when he came on shift and Nurse #1 had not turned the Resident's oxygen on. During an interview on 6/10/25 at 7:25 A.M., Unit Manager (UM) #1 said Resident #188 required the use of Oxygen. UM #1 said she was not aware the Resident's oxygen was turned off. UM #1 further said that Resident #188 did not have a Physician's order for the use of oxygen. During a follow-up interview on 6/10/25 at 9:45 A.M., UM #1 said Resident #188 did not have a Physician's order for the use of oxygen and that the Resident required oxygen and had been using the oxygen. UM #1 said there should have been a Physician's order but there was not. During an interview on 6/10/25 at 11:05 A.M., the Director of Nursing (DON) said the Physician should have been notified by the facility staff to obtain oxygen orders based on the Resident's need but that had not been done. 2. Resident #10 was admitted to the facility in September 2023, with diagnoses including COPD, Congestive Heart Failure (CHF), Obstructive Sleep Apnea, and Obesity Hypoventilation Syndrome. Review of the MDS assessment, dated 5/23/25, indicated Resident #10: -was cognitively intact as evidenced by a BIMS score of 15 out of 15 -utilized oxygen -utilized a non-mechanical ventilator Review of Resident #10's active Physician's Orders indicated the following: -C-PAP is to be worn at night. Please ensure it is on, every night shift related to Dependence of Supplemental oxygen, document if refused, initiated 11/15/23. -C-PAP with Home settings @ bedtime, attach 2 liters oxygen, at bedtime for OSA. Please fill cannister with distilled water Daily, initiated 9/8/23. Further review of Resident #10's June 2025 Physican's orders failed to indicate any order for the use of intermittent oxygen, and the prescribed liter flow to administer PRN oxygen. Review of the Physician's Progress Note, dated 5/2/25 at 19:34 (7:34 P.M.), indicated: -Resident was recently hospitalized for CHF exacerbation and returned 5/1/25. -Resident was admitted with acute infection as well as CHF exacerbation. -Resident had chronic hypoxia due to COPD, CHF, and obesity hypoventilation syndrome. -He/she required 3 Liters (L) of supplemental Oxygen on admission to the hospital and is now saturating well on room air following treatment of fluid overload. -He/she uses nocturnal Oxygen 2L with CPAP overnight. -He/she is on 1 to 2L nasal cannula at baseline with intermittent daytime use and continuous overnight use with CPAP. On 6/8/25 at 9:05 A.M., the surveyor observed Resident #10 lying in bed with a CPAP machine connected to an oxygen concentrator which was running and set at 2 LPM. During an interview at the time, the Resident said that staff assist him/her in donning (putting on) the CPAP at night and removing it in the morning. Review of Resident #10's medical record indicated the following: -Nursing Skilled Note on 5/6/25 at 5:50 A.M.: on Oxygen at 2L (liters) via nasal cannula. -Nurse Practitioner (NP) Progress Notes documenting on intermittent daytime O2 [oxygen] on: >5/9/25 at 9:15 A.M. [late entry] >5/21/25 at 10:18 A.M. >5/22/25 at 13:40 (1:40 P.M.) >5/28/25 at 18:41 (6:41 P.M.) >6/5/25 at 11:52 A.M. -Nursing Shift Note on 6/8/25 at 14:30 (2:30 P.M.): O2 (Oxygen) used to good effect (no liter flow was documented). Further review of Resident #10's medical record failed to indicate any NP orders for the use of intermittent daytime oxygen and the prescribed liter flow, when the NP documentation indicated oxygen was used intermittently from 5/9/25 through 6/5/25. On 6/10/25 at 9:38 A.M., the surveyor and Nurse #2 observed Resident #10 lying in bed and wearing oxygen via nasal cannula. During an interview at the time, Resident #10 said he/she was tired today. The surveyor observed Nurse #2 obtain pulse oximetry measurements from each hand, reading between 86% and 87%. Nurse #2 said that she would clarify the MD order for PRN oxygen use as sometimes the MD order has a range of liter flow rates and includes parameters for SPO2 (oxygen saturation) levels. The surveyor and Nurse #2 reviewed Resident #10's chart and Nurse #2 said there were no MD orders in place for supplemental oxygen (daytime use). Nurse #2 said based on her observation and assessment from this morning, the Resident had an acute change in condition and O2 SATS were below 90%. Nurse #2 said that typical nursing practice is to provide PRN oxygen at 2 LPM. During an interview on 6/10/25 at 9:48 A.M., UM #2 said when PRN oxygen is administered there should be a Physician's order in place. During a follow-up interview on 6/10/25 at 11:02 A.M., UM #2 said that Resident #10 did not have current orders for oxygen usage and there should have been.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent foodborne illness to residents. Specifically, the facility failed to: 1. Ensure that food items were stored properly labeled and dated as required; and 2. Ensure that the dietary staff were wearing hair coverings in the kitchen while preparing food. Findings include: 1. Review of the facility policy titled Food Storage, dated 2017, indicated: -All containers must be legible and accurately labeled and dated. -Food should be dated as it is placed on shelves if required by state regulation -Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2013 Federal Food Code. (Also see policy on Use of Leftovers later in this chapter.) Check state regulations as state regulations may allow shorter time frames for use of leftovers. -All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. During the initial tour of the facility kitchen on 6/8/25 at 7:10 A.M., the surveyor observed the following: In the stand-up refrigerator: -One plate of green peppers, covered not labeled and dated. -One plastic cup with dressing, covered not labeled and dated. -One metal container of tuna salad, covered not labeled and dated. -One metal container of ham salad, covered not labeled and dated. -One metal container of cooked meat, covered not labeled and dated -Two prepared salads, covered not labeled and dated. -Four fruit cups, covered not labeled and dated. In the walk-in refrigerator: - Seafood packaged in plastic and sealed, not labeled or dated. On the shelf below the food prep table: -Four sandwiches wrapped and labeled but not dated. During an interview on 6/8/25 at 7:35 A.M., Dietary Staff #1 said all the items in the refrigerators should have been labeled and dated. 2. Review of the facility's policy and procedure titled Food Safety and Sanitation (undated) indicated: -Beard nets are required when facial hair is visible During the initial tour of the facility kitchen on 6/8/25 at 7:10 A.M., the surveyor observed two of three dietary staff with beards preparing food and not wearing beard coverings. During an observation on 6/9/25 at 8:24 A.M., the surveyor observed a dietary aide with a full beard, covering his cheeks and neck, leave the dining room and enter the kitchen. The surveyor went into the kitchen and observed the dietary aide plating food from the food line with no beard covering in place. During an interview on 6/9/25 at 8:30 A.M., the Food Service Director (FSD), said the dietary aide should have been wearing a beard covering and was not. During an observation on 6/9/25 at 8:53 A.M., the surveyor observed the same dietary aide enter the dining area wearing a beard covering that was covering his cheeks but not pulled down over his chin and neck to cover his beard completely. He was observed handing food items to staff. During an observation on 6/11/25 at 11:16 A.M., surveyors observed three dietary staff members with beards preparing food. None of the three staff members observed were wearing beard coverings. During an interview on 6/11/25 at 11:20 A.M., the FSD said the staff members should have been a wearing beard covering while they were preparing the food.

Based on test log review, and interview, the facility failed to ensure that its staff tested residents for COVID-19 at the appropriate frequency, when the facility was experiencing an outbreak of COVID-19. Specifically, staff failed to conduct testing of residents every 48 hours as required, on a unit with COVID-19 outbreak to stop the spread of infection. Findings include: Review of the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Memorandum, dated 10/13/22, titled: Update to Caring For Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, indicated the following: -Once a new case is identified in the facility, following the requisite outbreak testing, the facility should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case then once per week until the facility goes 14 days without a new case. Review of the facility's Long Term Care Respiratory Surveillance Line List, indicated a Resident on the Laurel Unit tested positive for COVID-19 on 10/26/22. Review of the Resident Test Logs for October and November 2022, indicated all residents on the Laurel Unit were tested on [DATE], 10/30/22, and 11/2/22 (not the every 48 hours, as required). During an interview on 11/9/22 at 11:12 A.M., the Infection Preventionist (IP) said she thought they were supposed to test every three days and that is what they had been doing all along.

Based on record review, and interview the facility failed to ensure the opportunity to pay privately for a bed-hold was offered to one Resident/Resident Representative (#86), prior to a hospital transfer, out of 3 applicable sampled residents, resulting in termination of skilled rehabilitation services. Findings include: Resident #86 was admitted to the facility in August 2022. Review of a progress note, dated 9/5/22, indicated the Resident was sent to the emergency room for an evaluation. Review of a progress note, dated 9/6/22, indicated the Resident would not be on a bed-hold due to lack of a contract between the facility and the Resident's insurance company. The Resident was discharged from the facility on 9/5/22. During an interview on 11/09/22 at 1:51 P.M., Social Worker (SW) #1 said the Resident was admitted for short term rehabilitation only, due to the facility not having a contract with the Resident's insurance company. SW #1 said when the Resident was transferred to the hospital, the insurance company said they had only agreed to pay for the skilled care and would not offer a bed hold. The surveyor asked if the Resident or the Resident's Representative was given the opportunity to pay privately to hold the bed and SW#1 said that no one had that conversation with the Resident or Resident Representative. SW #1 said once they found out that the insurance company would not pay for the bed-hold, they discharged the Resident.

Based on record reviews, and interviews, the facility failed to ensure that its staff accurately executed the wishes for two Residents (#72 and #81), out of a total sample of 18 residents, and their designated Health Care Proxy (HCP-the legal document used to inform medical providers who should make decisions about care if an individual is not competent to do so) regarding advance directives (a written statement of an individual's wishes regarding medical treatment), resulting in no documented directions for an emergent status change. Specifically, 1) the facility failed to offer the opportunity to formulate an advance directive for one Resident (#72) after his/her HCP had been deactivated, and 2) failed to ensure that advance directive decisions were made by the activated HCP for one Resident (#81) who had been deemed as lacking the capacity for informed medical decision making. Review of the facility policy for Advance Directives, dated 3/25/18, included the following: -During the admission process and ongoing throughout a resident's stay, the facility would provide each resident with written information regarding his or her rights under Federal and State laws to formulate an advance directive. -Individuals have the right to make his or her own decisions about advance directives until they are deemed no longer capable of making these decisions. -Lack of capacity would be determined by a resident's Physician through activation of the HCP. Findings Include: 1) Resident #72 was admitted to the facility in November 2021. Review of Resident #72's Massachusetts Medical Order for Life-Sustaining Treatment (MOLST), dated 11/10/21, was signed by his/her HCP. Review of the clinical record indicated that on 1/10/22, the Physician had de-activated the HCP and deemed Resident #72 to have capacity to make medical decisions on his/her own behalf. Review of the clinical record indicated no evidence that Resident #72 had been provided with the opportunity to formulate an advance directive after his/her HCP had been de-activated by the Physician. During an interview on 11/9/22 at 1:30 P.M., Social Worker #1 said that Resident #72 had not been offered the opportunity to formulate an advance directive as required. 2) Resident #81 was admitted to the facility in January 2022. Review of the clinical record indicated a Documentation of Resident Incapacity form Pursuant to Massachusetts Health Care Proxy Act M.G.L.C201D for Resident #81 signed by the Physician on 1/5/22. Further review of the clinical record indicted that the MOLST form had been signed by Resident #81 on 1/27/22, after he/she had been deemed by the Physician to be incapable of making informed medical decisions. During an interview on 11/9/22 at 4:39 P.M., Social Worker #1 and Social Worker #2 said that the MOLST form in Resident #81's chart was not valid. No further information on correcting this issue had been provided by the Social Workers to this surveyor during the survey period.

Based on policy review, record review, and interview, the facility failed to ensure that one Resident (#9), out of three applicable sampled residents, was monitored for signs and symptoms of COVID-19 during an outbreak, to prevent the spread of infection. Findings include: Review of the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Memorandum, dated 10/13/22, titled: Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities indicated the following: -On unit(s) conducting outbreak testing, a long-term care facility should assess residents for signs and symptoms of COVID-19 during each shift. Review of the facility's Long-Term Care Respiratory Surveillance Line List, indicated a Resident on the Laurel Unit tested positive for COVID-19 on 10/26/22. Resident #9 was admitted to the facility in April 2018 and resided on the Laurel Unit. Review of Resident #9's October 2022 Medication and Treatment Administration Records (MAR/TAR) indicated no evidence that the Resident was monitored for signs and symptoms of COVID-19 as required, during the unit's outbreak period. During an interview on 11/9/22 at 11:12 A.M., the Infection Preventionist (IP) said the facility did not have orders in place to monitor for signs and symptoms of COVID-19 every shift during an outbreak.

Based on record review, and interview, the facility staff failed to ensure that one Resident (#19) was free from unnecessary doses of an opioid medication, out of a total sample of 18 residents. Findings include: Resident #19 was admitted to the facility in September 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the October 2022 and November 2022 Medication Administration Records (MAR) indicated the following Physician order: -[MEDICATION(S)] tablet 5 mg (milligrams) give 2.5 mg by mouth every 6 hours as needed (PRN) for moderate - severe pain (pain scale 4-10) Review of the October 2022 and November 2022 MARs for Resident #19 indicated the following: -[MEDICATION(S)] 2.5 mg was administered on 10/21/22 for a documented pain level of zero -[MEDICATION(S)] 2.5 mg was administered on 10/27/22 for a documented pain level of 3 -[MEDICATION(S)] 2.5 mg was administered on 10/29/22 for a documented pain level of zero -[MEDICATION(S)] 2.5 mg was administered on 11/3/22 for a documented pain level of 3 During an interview, and record review on 11/14/22 at 1:55 P.M., the Unit Manager (UM) for the Oak unit said that the Resident was administered the PRN [MEDICATION(S)] for documented pain levels less than 4 but that the resident should not have been administered the medication.

Based on observation, record review, and interview, the facility failed to ensure its staff provided appropriate care and services to one Resident (#52) with a Gastrostomy tube (G-tube - a tube that is placed directly into the stomach through an abdominal wall incision for enteral administration of food, fluids and medication), out of a total sample of 18 residents. Specifically, the facility failed to: 1) measure and document G-tube residual (the amount of stomach contents remaining in the stomach following administration of an enteral feed and used to monitor gastric emptying), and 2) provide appropriate treatment to the abdominal wall G-tube incision site. Findings include: Resident #52 was admitted to the facility in March 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/9/22 at 1:10 P.M., the surveyor observed the Resident asleep in bed with tube feeding, labeled [MEDICATION(S)] 1.5 and dated 11/9/22, infusing through his/her G-tube at 75 mililiters (ml) an hour via an electronic delivery device. 1. Review of the Facility Policy titled Tube Feedings, undated, indicated the following: - Tubing changes, tube placement and residual checks will be noted on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the November 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - Verify enteral tube placement and document residual every shift. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of the November 2022 Treatment Administration Record indicated no Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview and record review on 11/14/22 at 1:43 P.M., the Unit Manager (UM) for the Oak unit said that she could not find any documentation of G-tube residuals being recorded. She said staff should be documenting the amount of residual on the MAR. She also said that she could not find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on document review, record review, interview and observation, the facility A.) Failed to ensure staff properly monitored three residents (#1, #2, and #3) out of three applicable sampled residents, for fever based on the current threshold per the Centers for Disease Control and Prevention (CDC); B.) Failed to ensure staff properly removed Personal Protective Equipment (PPE), C.) Failed to ensure visitors were screened prior to entering the building, and D.) Failed to ensure staff wore face masks at all times, related to COVID-19. Findings include: A.) Review of the Centers for Disease Control and Prevention (CDC) guidance, considered a national standard by the Centers for Medicare and Medicaid Services (CMS), indicated the following on their website: Preparing for COVID-19 in Nursing Homes, updated 11/20/20, -Actively monitor all residents upon admission and at least daily for fever (T=100.0 Fahrenheit (F)) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions . 1. Review of Resident #1's January 2021 Physician's Orders indicated the following: -Temperature and oxygen saturation twice daily -Please notify physician/nurse practitioner for .temperature greater than 100.4 degrees F- (not 100.0 F, as required). 2. Review of Resident #2's January 2021 Physician's Orders indicated the following: -Temperature and oxygen saturation twice daily -Please notify physician/nurse practitioner for .temperature greater than 100.4 degrees F- (not 100.0 F, as required). 3. Review of Resident #3's January 2021 Physician's Orders indicated the following: -Respiratory assessment and vital signs (includes temperature) every four hours -Please notify physician/nurse practitioner for .temperature greater than 100.4 degrees F- (not 100.0 F, as required). During an interview on 1/14/21 at 10:45 A.M., the Unit Manager reviewed the Physician's orders and said the staff followed the order to notify the physician for temperature readings above 100.4. During an interview on 1/14/21 at 11:45 A.M., Nurse #2 reviewed the Physician's orders and said that all of the residents have the same order in place and the staff were to notify the physician for temperature readings above 100.4. B.) Review of the CDC website, Strategies for Optimizing the Supply of Eye Protection, dated 12/22/20, indicated: -Health Care Personnel (HCP) should leave the patient care area if they need to remove their eye protection. On 1/14/21 the surveyor observed the following on the(NAME)Unit: 1. At 9:25 A.M., Certified Nurse Aide (CNA) #1 and Nurse #1 came out of a resident room that had quarantine sign outside of the door. They took off their face shields at the medication cart, cleaned them, and put them back on. At 9:55 A.M., CNA #1 came to the doorway of a different resident room (quarantine), removed her face shield and cleaned it in the doorway of the resident's room. During an interview at 10:00 A.M., CNA #1 said she cleaned her face shield, both inside and out, after each resident she provided care for. During an interview at 10:06 A.M., Nurse #1 said she thought she was supposed to wipe the face shield between each resident and sometimes she took it off to clean it and other times she wiped only the outside of it to clean it. 2. On 1/14/21 the surveyor observed the following on the Oak Unit: At 11:25 A.M., the Housekeeper was observed coming out of a resident room she had just cleaned. She took her face shield off as she exited the room and put it on her cleaning supply cart. She then proceeded to the next resident room where she donned a gown and face shield prior to entering the room. Upon exiting the room she took the gown off, removed the face shield, and put it on her cleaning cart then walked down the hallway. During an interview at 11:43 A.M., the surveyor approached the housekeeper who picked the face shield up off her cleaning cart and put it on. She then gestured that she put on the face shield and gown to go into rooms. C.) Review of the facility policy, COVID-19 Pandemic Infection Control and Prevention Plan, dated 3/9/20, indicated the following: -All approved visitor/staff must do the following: *Complete questionnaire about symptoms, travel and direct exposure/contact with others who are infected of suspected to be infective. *Temperature is taken by facility staff (any temp above 100.0 degrees will prevent entry). Review of the CDC website, Preparing for COVID-19 in Nursing Homes, dated 11/20/20, indicated the following: -Screen all Health Care Personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. -Actively take their temperature and document absence of symptoms consistent with COVID-19. On 1/14/21 at 11:40 A.M., the surveyor observed Nurse #2 talking with a staff member. During an interview on 1/14/21 at 11:45 A.M., Nurse #2 said the person she was just talking with was the Nurse Practitioner (NP). Review of the Employee COVID-19 Screening log indicated the NP had not been screened since 1/13/21. During an interview on 1/14/21 at 11:59 A.M., the Receptionist said she did most of the screens and she had just returned from her break. She said she didn't know the NP was in the building, and that usually when she went to break someone in the administrative office would do the screens for people entering the building. D.) Review of the CDC website, Preparing for COVID-19 in Nursing Homes, dated 11/20/20, indicated the following: -Implement Source Control Measures: HCP should wear a facemask at all times while they are in the facility. On 1/14/21 at 2:00 P.M., the surveyor observed three staff CNAs in the warm zone (area between the negative unit and the COVID-19 positive unit, used for breaks and to put on PPE). One CNA was seated on a couch using her phone and the other two CNAs were seated across from each other and talking. None of them had masks on and none of them were eating. During an interview on 1/14/21 at 2:15 P.M., CNA #2 said that she could keep her mask off in the warm zone, even if other people are in there. During an interview on 1/14/21 at 2:20 P.M., CNA #3 said that she didn't think she needed to wear any PPE, including a mask, in the warm zone. During an interview at 3:15 P.M., the Director of Nurses said the staff should have known to keep masks on at all times, except when they are eating, as required.

Based on record review and interview, the facility failed to ensure that a [MEDICAL CONDITION] medication was limited to 14 days unless indicated otherwise by the physician in the medical record for one Resident (#39), in a total sample of 18 residents. Findings include: Resident #39 was admitted to the facility in January of 2019. Review of the physician's orders for January 2020, February 2020 and March 2020 indicated an order for [REDACTED]. Further review of the physician's orders did not indicate the duration for the administration of the PRN [MEDICATION NAME]. During an interview with Unit Manager stated that the PRN [MEDICATION NAME] order did not indicate a stop date. Refer to F756

Based on record review and interview, the facility failed to ensure pharmacy recommendations made for one resident (#39) were acted on by the physician, in a total sample of 18 residents. Findings include: Resident #39 was admitted to the facility in January of 2019. Review of the interdisciplinary progress notes indicated the pharmacist conducted a review and made recommendations for Resident #39 on the following dates: 1/8/2020, 2/9/2020 and 3/7/2020. Review of the physician's orders [REDACTED]. During an interview with Unit Manager (UM) #1 on 3/12/2020 at 9:21 A.M., he stated that the pharmacy recommendations were not located in the chart. During an interview with UM #1 on 3/12/2020 at 1:38 P.M., he provided a copy of the pharmacy recommendations made on 1/8/2020 and 3/7/2020. Both recommendations indicated the PRN [MEDICATION NAME] required a stop/evaluation date be added to the physician's orders [REDACTED]. Refer to F758

Based on observation and interview, the facility failed to account for one controlled (medication that can cause physical and mental dependence) medication on one of two units observed. Findings include: Review of the facility Disposal of Medications and Medication Related Supplies Policy, dated 2017, indicated when a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses and the disposal is documented on the accountability record book on the line representing the dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose [MEDICATION NAME] and doses of controlled substances wasted for any reason. During an observation on 3/11/20 at 3:10 P.M. of the(NAME)Unit Medication Cart A with Nurse #1, one [MEDICATION NAME] (an anti-anxiety) 0.5 milligram (mg) tablet was found loose in the narcotic drawer. During an interview on 3/11/20 at 3:12 P.M., Nurse #1 said she could not account for the [MEDICATION NAME] pill found in the narcotic drawer. During an interview on 3/11/20 at 3:15 P.M., Nurse #2 said there had not been any reports from the nursing staff concerning a missing controlled medication. During an interview on 3/11/20 at 3:31 P.M., Nurse #2 there was an entry in the narcotic book that indicated one [MEDICATION NAME] 0.5 mg tablet was popped in error and destroyed. During an interview on 3/11/20 at 3:40 P.M., Nurse #2 said she spoke to one nurse via telephone that had signed the entry in the narcotic book that indicated one [MEDICATION NAME] had been popped in error and destroyed. Nurse #2 said the nurse indicated an [MEDICATION NAME] had been popped, could not be found and 2 nurses made an entry in the narcotic book indicating the [MEDICATION NAME] was popped in error, destroyed and the lost [MEDICATION NAME] was not reported to management. Nurse #2 further said the nurses had falsely documented the missing [MEDICATION NAME] in the narcotic book and not reported it to a supervisor, as required.

Based on observation, record review and interview, the facility failed to ensure appropriate treatment and services were in place for a decrease in Range of Motion (ROM) for one Resident (#57), out of a total sample of 18 residents. Findings include: Resident #57 was admitted to the facility in March of 2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 2/6/20 indicated Resident #57 had severe cognitive impairment as evidenced by a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. The MDS further indicated the resident was dependent for dressing and bathing and had upper and lower extremity impairments on both sides. During an observation on 3/11/20 at 8:57 A.M., Resident #57 was resting in bed with eyes closed. The resident's hands were closed in tight fist positions and his/her arms were bent at the elbows and tightly pressed against his/her body. During an observation on 3/12/20 at 10:30 A.M., Resident #57 was resting in bed with eyes closed. The resident's hands were closed in tight fist positions and his/her arms were bent at the elbows and tightly pressed against his/her body. Review of an Occupational Therapy (OT) Progress & Discharge Summary, dated 9/3/19, indicated Resident #57 was treated from 8/12/19 to 9/3/19 for contractures of left and right hands. The summary indicated the resident had met his/her goal of tolerating bilateral palm guards for 8 plus hours per day. The discharge plan and instructions on the summary indicated the resident was discharged to long term care with use of palm guards and lamb's wool to prevent skin breakdown. Review of the Potential Risk for Alteration in Skin integrity Care Plan interventions included: - Left hand cone to be worn at all times as tolerated. Remove once a shift for Activities of Daily Living (ADL) care, skin checks and as needed (PRN) unless otherwise indicated on treatment sheets (initiated 12/31/18) -Nursing to monitor left hand skin integrity prior to applying splint and upon removing splint Review of the Certified Nursing Assistant (CNA) Care Card indicated for a left hand cone to be worn at all times as tolerated. Remove once a shift for Activities of Daily Living (ADL) care, skin checks and as needed (PRN) unless otherwise indicated on treatment sheets. Review of the March 2020 Monthly Physician Orders did not indicate any interventions in place for the bilateral hands. During an interview on 3/12/20 at 10:15 A.M., Unit Manager (UM) #2 said she assists the CNAs about three times a week with providing personal care to Resident #57. She said the resident's hands cannot be fully opened. UM #2 further said that Resident #57 did not have any interventions in place for his/her closed hands. During an interview on 3/12/20 at 12:47 P.M., Certified Occupational Therapy Assistant (COTA) said the discharge plan and instructions were in serviced to the unit manager and Resident #57 CNA upon discharge from OT. During an interview on 3/12/20 at 1:00 P.M., UM #2 said she could not recall any specific OT instructions for Resident #57.

Based on observation, record review and interview, the facility failed to 1.) Change the tube feeding tubing as per physician order, and 2.) Ensure care and services were maintained for a Low Air Loss (LAL) mattress for one Resident (#57), out of a total sample of 18 residents. Findings include: Resident #57 was admitted to the facility in March of 2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 2/6/20 indicated the resident had severe cognitive impairment as evidenced by a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. The MDS further indicated the resident was dependent for dressing and bathing and had upper and lower extremity impairments on both sides. 1. The facility failed to ensure an enteral tube feed (nutrition that is taken through a tube directly into the stomach) tubing was changed, as ordered. During an observation on 3/11/20 at 11:05 A.M., Resident #57 was resting in bed with eyes closed. The resident was receiving a tube feeding that was infusing at 65 cubic centimeters (cc) per hour. Review of the medical record indicated a Physician Order, dated 4/25/19, to change enteral tube feed tubing when bottle empties; not to exceed 48 hours. Review of the February 2020 Treatment Administration Record (TAR) indicated the tube feed tubing was changed 2/17/20 on the day shift and the next change occurred on 2/20/20 on the evening shift. This exceeded the 48 hours, as ordered. Further review of the February 2020 TAR indicated the tube feed tubing was changed on 2/26/20 during the day shift and the next change occurred on 2/28/20 on the evening shift. This exceeded the 48 hours, as ordered. Review of the March 2020 TAR indicated the tube feed tubing was changed on 3/4/20 on the evening shift and the next change occurred on 3/7/20 on the evening shift. This exceeded the 48 hours, as ordered. During an interview on 3/12/20 at 11:05 A.M., Unit Manager (UM) #2 said Resident #57's tube feed tubing was not changed 3 times within the ordered 48 hours; twice in February 2020 and once in March 2020, as required. 2. The facility failed to ensure settings of a LAL mattress were obtained and monitored. During an observation on 3/11/20 at 8:56 A.M., Resident #57 was resting in bed on an air mattress. The mattress setting was at 200 pounds. During an observation on 3/12/20 at 10:00 A.M., the resident was resting in bed on an air mattress. The mattress setting was at 200 pounds. Review of the medical record indicated no physician order or documentation of the LAL settings. The medical record further indicated the resident's weight was 135.6 in March 2020. During an interview on 3/12/20 at 12:10 P.M., UM #2 said the protocol for the use of an air mattress was to obtain a physician order and determine settings of the mattress by the resident's weight. She said there was no physician order in place and the LAL setting was incorrect and not set to the resident's weight.

Based on observation, interview and record review, facility staff failed to implement a comprehensive person-centered plan of care for 3 residents (#40, #45 and #76) in a total sample of 18 residents. Findings include: 1. For Resident #45, facility staff failed to implement a comprehensive person-centered care plan for falls resulting in a fall with fracture on 10/22/18. Resident #45 was admitted to the facility in 4/2018. [DIAGNOSES REDACTED]. The Plan of Care for injury/falls (initiated 4/26/18) related to a [DIAGNOSES REDACTED]. The goal was that the resident would be free from injury/falls through next review. Interventions included: Bed and Chair Alarm, proper nonskid footwear at all times. Resident to be attended by staff member at all times while toileting. Review of the 10/22/18 Incident Report, following a fall, indicated that Certified Nursing Assistant (CNA) #1 stated that he brought the resident to the bathroom and that he left the resident unattended to answer another call light. Another CNA (#4), heard the resident yelling, but when she got to the resident's bathroom, the resident was on the floor and incontinent of urine. When CNA #1 returned, the resident was on the floor writhing in pain. Resident #45 was admitted to the hospital with [REDACTED]. During interview on 4/3/19 at 12:05 P.M., CNA #1 said that Resident #45 was not his resident on 10/22/18. He said that he had to answer another call light and left the resident alone. He said that he was aware the resident should not have been left unattended if they have a chair and/bed alarm. During interview on 4/3/19 at 1:00 P.M., Unit Manager #1 told the Surveyor that Resident #45 had the alarms placed sometime in (MONTH) or (MONTH) of (YEAR), and that he/she should never have been left alone in the bathroom. During interview on 4/4/19 at 1:30 P.M., the Director of Nurses (DON) said that all residents are covered by all staff on the unit regardless of which residents are on a CNA's assignment, and that all the CNAs know that. The DON said that the intervention regarding residents who have chair and/or bed alarms include the Resident should never be left in the bathroom unattended, and the information should have been on the falls care plan. Please refer to F689. 2. For Resident #40, the facility staff failed to ensure fall prevention care plan interventions was maintained relative to transfers. Resident #40 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. Review of the resident's fall care plan, date initiated 6/26/15, indicated the following interventions: -Chair and bed alarm at all times. -Resident is an assist of one with a gait belt, stand and pivot. Review of the Quarterly MDS Assessment, dated 1/25/18, indicated the resident had severe cognitive impairment as evidenced by a score of 3 out of 15 on the BIMS Brief Interview for Mental Status), and required extensive assistance for transfers and toileting and used a bed and chair alarm daily. Review of the Fall Risk Assessment, dated 1/25/18, indicated the resident was scored at a moderate fall risk as evidenced by a score of 12. Further review of this same assessment indicated a gait analysis. The analysis indicated the resident exhibited loss of balance while standing and required hands on assistance to move from place to place. Review of the facility's Incident Report, dated 4/21/18, indicated the resident sustained [REDACTED].M. in the bathroom. A witness statement by the Certified Nursing Assistant (CNA) who placed the resident on the toilet, indicated she left the resident alone in the bathroom to go get towels and answer a call bell. The resident was found on the bathroom floor when the CNA returned. The new intervention added after the fall was to re-educate the staff that no resident with a bed or chair alarm was to be left alone in bathroom, and staff should call for needed supplies. Review of a nurse's notes, dated 4/27/18, indicated the resident complained of right ankle pain. The notes indicated an X-ray was ordered and he/she was found to have an acute ankle fracture involving the distal fibula with no displacement. During an interview on 4/3/19 at 12:22 P.M., Unit Manager #1 said the resident should not have been left alone in the bathroom when toileted as he/she required assistance with toileting and transfers. 3. For Resident #76 the facility staff failed to ensure a tab alarm was in place as care planned. Resident #76 was admitted to the facility in 6/2018 with a [DIAGNOSES REDACTED]. Review of the Falls care plan, revised on 6/15/18, indicated Resident #76 was at risk for injury from falls related to mobility and cognitive deficits. The following intervention was included: apply tab alarm at all times to the bed and chair, and check placement and function. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated 3/14/19, indicated Resident#76 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15 and utilized a chair alarm daily. Review of the current resident care card, indicated to apply a tab alarm at all times to the bed and chair. During observations on 4/03/19 at 3:10 P.M. and 3:47 P.M,. Resident #76 was seated in a wheelchair in the day room. The resident did not have a tab alarm applied, as care planned. During an interview on 4/03/19 at 3:47 P.M., CNA #2 said Resident #76 sometimes tries to stand without assistance and has fallen, so he/she needed to have alarms on while in bed and the chair. CNA #2 said the resident needs to be highly supervised. At this time, the surveyor and CNA #2 observed Resident #76. CNA #2 said the tab alarm was not on and should have been. During an interview on 4/3/19 at approximately 4:00 P.M., Unit Manager (UM) #2 said Resident #76 has fallen numerous times, and should have had the tab alarms in place as per his/her plan of care.

Based on observation, record review and interview, facility staff failed to ensure that supervision and assistive devices were in place to prevent accidents for 2 Residents (#40 and #45) in a total sample of 18 residents. Findings include: 1. For Resident #45, the facility failed to provide the resident with adequate supervision in the bathroom resulting in a fall with fracture. Resident #45 was admitted to the facility in 4/2018. [DIAGNOSES REDACTED]. The Plan of Care for injury/falls (initiated 4/26/18) related to a [DIAGNOSES REDACTED]. The goal was that the resident would be free from injury/falls through next review. Interventions included: bed and chair alarm, proper nonskid footwear at all times. Resident to be attended by staff member at all times while toileting. A quarterly Fall Risk assessment dated [DATE] indicated the resident scored 13 which is considered moderate risk with the following indicators: - receiving a diuretic and [MEDICAL CONDITION] medications - memory loss - frequent bowel and bladder incontinence - Unable to independently come to a standing position - exhibits loss of balance while standing - uses an assistive device - decrease in muscle coordination Review of the Quarterly MDS (Minimum Data Set) Assessment of 8/17/18 indicated the resident scored a 6/15 in the Brief Interview for Mental Status (BIMS) which indicates severe cognitive impairment; required extensive physical assistance of 2 staff for bed mobility; extensive physical assistance from 1 staff member for transfers, dressing, toilet use including transfers on and off the toilet, cleansing after toilet use, changing an incontinence pad and adjusting clothing after toilet use; personal hygiene; limited assistance from 1 staff for ambulation in the room and corridor. The section on balance indicated the resident was only able to move from a seated to a standing position; moving on and off the toilet and surface to surface transfers with staff assistance. The MDS also indicated the resident was frequently incontinent of bowel and bladder with no toileting program. The resident had no falls since admission; received an antidepressant, an anticoagulant, an antibiotic (urinary tract infection) and a diuretic. The resident was coded as having a bed and chair alarm that were used daily. Review of the 10/2018 Restorative Nursing/Rehab flowsheet, indicated the resident had been ambulating with staff 4 times weekly for 40-80 feet prior to the fall. Review of a nursing progress note and incident report of 10/22/19 indicated resident had an unwitnessed fall in the bathroom after being left unattended on the toilet at approximately 9:15 A.M. The resident was found on the bathroom floor and was incontinent of urine at the time. The resident was sent to the hospital and admitted with a displaced [MEDICAL CONDITION] hip which required surgical intervention. During further review of the 10/22/18 Incident Report Certified Nursing Assistant (CNA) #1 indicated that he brought the resident to the bathroom and that he left the resident unattended to answer another call light. Another CNA (#4), who was in the dining room, heard the resident yelling, but when she got to the resident's bathroom, the resident was on the floor and incontinent of urine. CNA #4 called for help. When CNA #1 returned, the resident was on the floor writhing in pain. the Resident was sent to the hospital for evaluation and was admitted with a [MEDICAL CONDITION]. During interview on 4/3/19 at 12:05 P.M., CNA #1 said that Resident #45 was not his resident on 10/22/18. He said that he had to answer another call light and left the resident alone. He said that he should not leave a resident alone if they have a chair and/bed alarm alone in the bathroom. During interview on 4/3/19 at 1:00 P.M., Unit Manager #1 told the Surveyor that Resident #45 had the alarms placed sometime in (MONTH) or (MONTH) of (YEAR), and that he/she should never have been left alone in the bathroom. During interview on 4/4/19 at 1:30 P.M., the Director of Nurses (DON) said that all residents are covered by all staff on the unit regardless which residents are on a CNA's assignment, and that all the CNAs know that. The DON said that the intervention regarding residents who have chair and/or bed alarms should never be left in the bathroom unattended, and should have been on the falls care plan. She said that all staff had been inserviced on this plan. 2) For Resident #40, the facility staff failed ensure the resident was adequately supervised when left on the toilet. Resident #40 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. Review of the resident's fall care plan, date initiated 6/26/15, indicated the following interventions: -Chair and bed alarm at all times. -Resident is an assist of one with a gait belt, stand and pivot. -Provide a well lit environment, free of clutter. Review of the Quarterly MDS Assessment, dated 1/25/18, indicated the resident had severe cognitive impairment as evidenced by a score of 3/15 on the BIMS, required extensive assistance for bed mobility, transfers, toilet use, dressing and hygiene, was totally dependent for bathing, did not ambulate, had no falls and used a bed and chair alarm daily. Review of the Fall Risk Assessment, dated 1/25/18, indicated the resident was scored at a moderate fall risk as evidenced by a score of 12. Further review of this same assessment indicated a gait analysis. The analysis indicated the resident exhibited loss of balance while standing and required hands on assistance to move from place to place. Review of the facility's Incident Report, dated 4/21/18, indicated the resident sustained [REDACTED].M. in the bathroom. The report indicated the resident had no bumps, bruises or complaints of pain immediately after the fall. A witness statement by the Certified Nursing Assistant (CNA) who placed the resident on the toilet indicated she left the resident alone in the bathroom to get towels and answer a call bell. The statement indicated the resident got him/herself off the toilet and fell . The resident was found on the bathroom floor when the CNA returned. The intervention added after the fall was to re-educate the staff that no resident with a bed or chair alarm was to be left alone in bathroom, and staff should call for needed supplies. The 4/21/18 in-service attendance log for staff education was provided and included the CNA involved in the incident. Review of a nurse's note, dated 4/17/18, indicated the resident was returned to the unit by rehabilitation therapy staff due complaints of right ankle pain. The note indicated that upon inspection by the nurse, the right ankle was bruised and [MEDICAL CONDITION]. The note also indicated the resident was in pain. The physician was notified and an X-ray was ordered. The X-ray result indicated an acute ankle fracture involving the distal fibula with no displacement. During an interview on 4/3/19 at 12:22 P.M., Unit Manager #1 said the resident should not have been left alone in the bathroom when toileted. She said the CNA that toileted the resident at the time of the fall no longer works at the facility. During an interview on 4/3/19 at 12:25 P.M. the Director of Nursing said the resident had impaired cognition and should not have been left alone in the bathroom at the time of his fall. She said staff should have stayed with him and not answered another call light leaving him unattended in the bathroom. She also said any resident that is alarmed and a fall risk should not be left alone in the bathroom.

Based on observation, record review, policy review and interview, facility staff failed to provide wound care consistent with professional standards of practice by ensuring adequate infection control practices during a pressure ulcer (PU) treatment for 1 of 1 applicable residents (#77) with pressure ulcers, in a total of 18 sampled residents. Findings include: Review of the facility's policy entitled: Pressure Ulcer - Stage III Identification, Intervention, Treatment (no date on this policy) indicated the following: - A treatment protocol will be established for pressure ulcers. The objectives will be to cover, protect, insulate, absorb, cleanse and prevent infections. For Resident #77, admitted to the facility in 3/2019 with [DIAGNOSES REDACTED].#3 failed to ensure proper infection control practices related to a treatment provided to the resident's right heel. Review of a skin assessment, dated 3/7/19, indicated the Resident had the following PU: -Right heel: Stage III (Stage 3), measuring 2.3 centimeters (cm) x 2 cm, with granulation, and small eschar (dead, non-viable tissue) area in the corner. (There was no depth measured). Review of the Admission Minimum Data Set (MDS) Assessment, dated 3/15/19, indicated Resident #77 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15/15; and indicated the resident was at risk for PUs, had an unhealed pressure ulcer; a Stage 4 PU (Stage 4, is described as a full-thickness skin and tissue loss. Slough and/or eschar may be visible on some parts of the wound bed. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI), although the skin assessment identified the resident had a Stage 3 PU (also can be described as full-thickness tissue loss, which may have slough/eschar). The most recent skin assessment was dated 3/29/19 and identified the right heel Stage 3 PU was measured as being approximately 2 cm x 2 cm, with a wound bed of 75% - 100% granulation, and small slough area noted to wound bed center. The surrounding tissue was dry, and intact. There was no depth measured. Record review indicated a physician's orders [REDACTED]. - Cleanse the right heel wound with normal saline, pat dry. - Apply Purogel (gel that softens wound debris and rinses off easily at dressing change) to wound bed, - Apply [MEDICATION NAME] (non-adhering fabric dressing, impregnated with a [MEDICATION NAME], which helps protect regenerating tissue, and can be cut to the size of the wound), followed by a Kling wrap. During a treatment observation on 4/3/19 at 10:35 A.M., the surveyor observed as Nurse #3 set up a bed side table with several clean and sterile supplies, with assist of the Unit Manager (UM) #2. The supplies included: an open bag of Q-tip applicators; a new bag containing 4 x 4 clean gauze pads; a 1.75-ounce jar of Purogel; a 3.4-ounce bottle of Sterile Saline; several packets of pre-moistened Skin Prep wipes (skin protectant); a clean Kling gauze wrap, a box of clean gloves, a sterile drape, a package containing a sterile [MEDICATION NAME] dressing, large container of hand sanitizing gel, large pair, black-colored bandage scissors and tape. UM #2 assisted and held up the resident's right leg, in order for Nurse #3 to provide the treatment to the posterior/lateral heel PU. Nurse #3 picked up the scissors and cut off the old soiled dressing from the Resident's right foot/heel, then set the now contaminated scissors back on the table with clean/sterile supplies. Nurse #3 inspected the area. The surveyor observed the PU to be a shallow crater, with raw edges. The area was approximately 1.5 cm x 0.6 cm x 0.2 cm depth. The wound base had approximately 95% of granulation tissue, with a few scattered areas of superficial slough, otherwise the wound base and inner margins were beefy red. The surrounding PU tissue was reddened, dry and scaly. After inspection, Nurse #3 removed his gloves, performed hand hygiene, donned clean gloves, picked up the bottle of sterile saline, removed the cap, set the cap on the drape under the resident's foot, then poured the solution over the wound located on the posterior/lateral heel. Nurse #3 then picked up a gauze pad and dabbed it over the PU, then surrounding tissue. He poured the saline over the area again, and using the same gauze, dabbed the surrounding tissue, all while holding the saline bottle. Nurse #3 then picked up the cover with the contaminated gloved hand, and placed the bottle back on the bedside table. Nurse #3 removed his gloves, performed hand hygiene, donned clean gloves, then picked up the jar of Purogel. He unscrewed the cap, setting it on the contaminated drape under the resident's feet, pulled a Q-tip out of the open wrapper, dipped the Q-tip applicator into the Purogel, removed a large dollop, wiped some of the gel against a 4 x 4 gauze, then coated the inside of the wound bed with the remaining gel. Nurse #3 then picked up the cover to the Purogel, from the contaminated drape (where Nurse #3 placed the used gauze pads), screwed the cap back onto the jar, and set it back on the bedside table, with contaminated gloved hands. Nurse #3 then removed his gloves, performed hand hygiene, donned clean gloves, picked up and opened the sterile [MEDICATION NAME] package. Nurse #3 peeled back the wrapper, set it down on the contaminated drape under the resident's heel, peeled away the [MEDICATION NAME] from the wrapper, picked up the contaminated scissors, and used them to cut a small piece of the [MEDICATION NAME], then placed this over the open PU. Nurse #3 then placed the contaminated scissors back on the bedside table. UM #2 then picked up saline bottle and jar of Purogel, and asked Nurse #3 if he were done with them. Nurse #3 said yes. UM #2 then walked out of resident's room, and the surveyor followed. UM #2 placed both containers on top of treatment cart, used to store multiple treatment supplies for residents on the(NAME)Unit, opened a drawer and was about to place them inside, when the surveyor intervened and informed UM #2 of potential cross-contamination during the PU treatment. UM #2 said she would clean the exterior of each container with bleach, and allow them to dry before placing them back into the cart. During interview on 4/3/19 at 11:00 A.M., both Nurse #3 and UM #2 were present. The surveyor reviewed the observations and cross-contamination with both the Sterile Saline, Purogel, and use of contaminated scissors to cut the sterile [MEDICATION NAME] to fit the PU wound, after cutting and removing the soiled old dressing. Nurse #3 said he should have either disinfected the scissors, after using them to cut off the old dressing, or he could have used a sterile pair of scissors, provided in suture removal kit to cut the sterile [MEDICATION NAME] to fit the PU. Nurse #3 said he should have opened each container, prior to using, to prevent cross-contamination.

Based on observation, record review and interview, the Facility failed to provide the necessary care and services for pain control for 1 resident (#13) in a total sample of 17. Findings include: For Resident #13, the Facility failed to provide any pre-medication and/or alternate therapeutic interventions prior to a treatment that caused discomfort and pain to his/her hands. Resident #13 was admitted to the Facility in 6/2011 with [DIAGNOSES REDACTED]. Review of the Occupational Therapist Progress Notes of 3/5/14 indicated the following: Resident continued to present with signs/symptoms of discomfort when ranging, requiring slow progressive stretch to inhibit further contractures and skin breakdown. Occupational Therapist Progress Note of 3/12/14 indicated that the resident's tolerance to range of motion of the left wrist fluctuated daily. Resident resisted all passive range of motion to the left hand since (3/6/14). The resident was discharged from therapy. Review of Nurses' Progress Notes indicated the following: 5/15/14 - The resident didn't have any pain until staff attempted to open his/her hand. 5/17/14 - The resident appeared to have pain when doing hand care. 5/28/14 - The resident complained of hand pain when staff attempted to open them. 5/29/14 - When staff attempted to open hands, the resident complained of pain. 5/31/14 - The resident complained of severe pain when staff attempted to open hands. 6/2/14 - The resident had no pain until staff attempted to open his/her hands. 6/15/14 - The resident complained of discomfort when staff attempted to open his/her fist for cleaning. 6/20/14 - The resident had intermittent discomfort when staff attempted to clean his/her hands. 6/25/14 - The resident never complained of pain until attempts were made to clean left hand. It was very difficult to clean the palm. The resident found this to be very painful. 6/26/14 - The resident refused hand care and was unable to open his/her hand. The resident complained of pain by facial grimacing. The quarterly Minimum Data Set assessment, (MDS) with an Assessment Reference Date (ARD) of 6/27/14, indicated that the resident had short and long term memory loss, was dependent for transfers, bathing, dressing, hygiene and eating, was non-ambulatory, had functional limitation to upper and lower extremities, and had no pain in the last 5 days. Review of Nurses' Progress Notes indicated the following: 7/8/14 - The resident only had pain when treatment to hands was done. 7/9/14 - The resident complained of pain when cleaning palm of hand. 7/10/14 - The resident complained of pain when doing care to hands. When attempting to put powder in resident's palms, he/she complained of pain. 7/12/14 - The resident only shows pain when doing hand care. The resident's fists were clenched tight. 7/13/14 - When trying to clean resident's hands, it was very uncomfortable. 7/14/14 - When attempting to clean resident's hands and position fingers, it caused discomfort and increased pain. 7/17/14 - Unable to clean palms. Resident called out with discomfort. 7/18/14 - Unable to clean hands because of contractures. This caused resident a great deal of pain. 7/20/14 - The resident winced when staff attempted to move his/her fingers. Tylenol 650 mg administered with effect. 7/23/14 (12:15 A.M.) - The resident exhibited severe pain with any motion or attempt from staff to move fingers. 7/23/14 (8:50 A.M.) - The resident was observed wincing when staff attempted to move his/her hand. Tylenol 650 mg administered with effect. 7/23/14 (10:11 P.M.) - The only time the resident complained of pain was during hand cleansing. 7/24/14 - The resident yelled how much his/her hands hurt, when attempting to cleanse them. 7/26/14 - When attempting to provide hand care, the resident became extremely anxious, pulled hands away and tried to cover his/her hands with shirt. The resident yelled when hand cleansing was attempted. 7/27/14 - The resident had hand pain with the least amount of movement. Unable to clean palm because of discomfort it caused. 7/28/14 - Staff made an attempt to cleanse resident's hands and met resistance. The resident stated it hurt to open his/her fingers. 7/31/14 - Resident exhibited pain during care to his/her hands. Review of Monthly physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of pain assessments of 7/2014 indicated that a pain assessment was conducted each shift and the pain level was always documented as "0", indicating the Resident was pain free. Review of Nurses' Progress Notes indicated the following: 8/5/14 - The resident did not appear to have any pain except when trying to clean his/her hands. 8/7/14 - Unable to clean the resident's hands for care without causing a great deal of discomfort. 8/8/14 - The resident had a lot of discomfort when trying to open his/her hand. 8/9/14 - The resident didn't complain of pain until hand care was attempted. It was very painful when his/her hand was cleansed because of contractures. 8/10/14 - The resident complained of pain when staff attempted to cleanse hands. 8/11/14 (2:21 P.M.) - The resident appeared to have a lot of discomfort when staff attempted to open hand. 8/11/14 (8:15 P.M.) - The only time the resident was in any discomfort was when hand care was attempted. 8/16/14 - The resident didn't exhibit any pain except when staff attempted to do hand care. It was very difficult to provide care because of contractures. The resident found this to be very painful. 8/19/14 - The resident exhibited pain only when staff attempted to do hand care. 8/20/14 - The resident only complained of pain when staff attempted to cleanse his/her hands. 8/21/14 - Unable to open the palm of his/her hand because of contracture. The resident became very upset because of discomfort. 8/23/14 - The resident had pain when staff attempted to cleanse his/her hands. 8/24/14 - The resident complained of pain when staff attempted to cleanse his/her hands. 8/25/14 -The resident had pain in his/her fingers during care. The resident was hollering and was very uncomfortable. 8/28/14 - The resident had no complaints of pain until hand care was provided, and the resident was very uncomfortable and complained of pain. 8/29/14 - The resident only complained of pain during hand care. Review of Monthly physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. Review of pain assessments of 8/2014 indicated that a pain assessment was conducted each shift and the pain level was always documented as "0", indicating the Resident was pain free. Review of Nurses' Progress Notes indicated the following: 9/2/14 - Staff attempted to cleanse his/her left hand and the resident became very upset. The resident did not exhibit any pain until hand care was provided. 9/3/14 - The resident only exhibited pain during hand care. Unable to do anything with resident's hands, because it caused discomfort. 9/7/14 - The resident only has pain when providing hand care. It was very difficult to open his/her hand today. 9/9/14 - The resident showed no signs of pain until hand care was attempted. The resident became very resistant and very upset. Review of Monthly physician's orders [REDACTED]. Review of the [DATE]/2014 indicated that Tylenol had not been administered from (9/1/14 to 9/9/14). Review of pain assessments of 9/2014, up until 9/9/2014, indicated that a pain assessment were conducted each shift and the pain level was always documented as "0", indicating the Resident was pain free. During an interview on 9/9/14 at 3:00 P.M., Unit Manager #1 said that Resident #13 did not receive any pain medication prior to providing treatment to his/her hands. After discussion with the Surveyor, Unit Manager #1 said she would contact the nurse practitioner for further orders. On 9/10/2014 at 9:00 A.M., Resident #13 was observed sitting in a wheelchair in the bedroom. Nurse #2 was observed providing treatment to Resident #13's hands. Nurse #2 said she pre-medicated Resident #13 with Tylenol. Nurse #2 attempted to open Resident #13's left hand. Resident #13 said, "Ouch." Nurse #2 said that she would not be able to provide treatment, because it caused the resident discomfort.