Every finding on record at Overlook Masonic Health Center

Based on observation, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to stop the spread of organisms and infections for one Resident (#9) out of a total sample of 19 residents. Specifically, for Resident #9, the facility failed to implement appropriate hand hygiene during wound care for Resident #9 who was on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) during high contact resident care). Findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, undated, included but was not limited to: -This facility considers hand hygiene the primary means to prevent the spread of infections. >Use of alcohol-based hand rub (ABHR) over soap and water is preferred in most clinical situations. -Use ABHR or soap and water for the following situations: >Before handling clean or soiled dressings, gauze pads, etc . >After contact with a resident's skin. >After removing gloves. -The use of gloves does not replace hand washing/hand hygiene. Resident #9 was admitted to the facility in May 2021 with diagnoses including Stage Two Pressure Injury to the left ischium (lower back of the hip bone also known as the sitting bone). Review of Resident #9's May 2025 Physician orders included: -Maintain EBP, effective 4/11/24. -Medihoney (Manuka antibacterial honey) Wound and Burn Dressing external paste (wound dressing). >Apply to left ischium topically as needed for stage two pressure injury. >Normal Saline wash, pat dry, apply Medihoney, followed by (f/b) bordered gauze dressing twice a day (BID) and as needed (PRN), effective 5/13/25. Review of Resident #9's Person-Centered Care Plan included but was not limited to: -Focus: The Resident has actual skin impairment: Stage Two Pressure Injury of the left ischium .on Enhanced Barrier Precautions, effective 4/11/25 with revision date 4/24/25. -Goal: The Resident's skin injury of left ischium will be healed in 12 weeks, initiated 4/11/25 with revision date 4/17/25. -Interventions: *Maintain EBP, effective 4/24/25. *Treatment to the area as ordered, effective 4/14/25. On 5/13/25 at 8:46 A.M., the surveyor observed Resident #9 seated in a wheelchair in his/her room and eating. The surveyor observed signage hanging on the Resident's doorway that indicated: -STOP ENHANCED BARRIER PRECAUTIONS STOP -EVERYONE MUST: *Clean their hands including before entering and when leaving the room. *Wear gloves and a gown for the following high contact resident care activities: >Wound Care: any skin opening requiring a dressing. During an interview on 5/14/25 at 4:29 P.M., Nurse #2 said she was the Nurse caring for Resident #9. Nurse #2 said that Resident #9 had a pressure ulcer to the left buttock area, was on EBP due to the wound and she would be doing the wound treatment today. Nurse #2 said that she was going to collect supplies and would meet the surveyor at the Resident's room. The surveyor observed wound care provided by Nurse #2 to Resident #9 who was lying in bed, as follows: -Nurse #2 cleansed her hands with ABHR and donned (put on) a gown and gloves. -Nurse #2 entered the Resident's room and explained the wound treatment to Resident #9. -Nurse #2 used a disinfectant wipe to clean the Resident's over the bed table for use as a work surface. -Nurse #2 doffed (removed) her gloves, donned new gloves and set out the dressing supplies on the cleaned work surface. Nurse #2 failed to perform hand hygiene between the glove change. -Nurse #2 positioned Resident #9 into a right-side lying position and removed the old dressing from the Resident's left ischium. -Nurse #2 discarded the old dressing into the trash can. -Nurse #2 then doffed the soiled gloves and discarded the gloves into the trash can. -Nurse #2 donned a new pair of gloves without performing hand hygiene between the glove change. -Nurse #2 cleansed the Resident's wound with Normal Saline Solution on a gauze pad. -Nurse #2 used a new gauze pad to pat the wound area dry. -Nurse #2 applied Medihoney Wound and Burn Dressing external paste with a tongue depressor to the wound bed and covered the wound area with a bordered gauze dressing. -Nurse #2 discarded the unused supplies and waste into the trash can. -Nurse #2 then positioned the Resident for comfort in his/her bed. -Nurse #2 doffed the soiled gloves, discarded them into the trash can and cleansed her hands with ABHR. During an interview immediately following the wound care observation, Nurse #2 said that she did not cleanse her hands between glove changes during the Resident's wound care that she had provided. Nurse #2 said that she should have washed her hands every time she changed her gloves because not washing her hands could cause the spread of germs to Resident #9. During an interview on 5/14/25 at 5:00 P.M., the Infection Preventionist (IP) said all staff were educated on hand hygiene and got checked for competency throughout the year. The IP said that Nurse #2 should have cleaned her hands between glove changes because germs could spread from Nurse #2 to the Resident when hands are not cleaned between glove use.

Based on record review, and interview, the facility failed to ensure one Resident (#86) out of a total sample of 19 residents, was free of a significant medication error. Specifically, for Resident #86, the facility failed to ensure that a daily PRN (as needed medication) Methocarbamol (central nervous system depressant - used to treat pain and muscle spasms while relaxing the brain and the spinal cord) medication was administered as ordered by the Physician. Findings include: Review of the facility's policy titled, Medication Orders, revised 2018, indicated the following: -Any dose or order that appears inappropriate considering the resident's age, condition, allergies to the medication, or diagnosis is verified by nursing and the attending physician. -Medication orders specify the following: >Time or frequency of administration. Resident #86 was admitted to the facility in December 2024 with diagnoses including hemiplegia and hemiparesis following Cerebral Infarction affecting the left non-dominant hand. Review of Resident #86's May 2025 Physician's orders indicated the following: -Methocarbamol Oral Tablet 500 milligram (mg). Give 500 mg by mouth as needed for muscle spasm once daily, ordered 3/31/25. -Methocarbamol Oral Tablet 500 mg. Give 500 mg by mouth two times a day for pain/spasm, ordered 3/31/25. Review of Resident #86's April 2025 Medication Administration Record (MAR) indicated that the Methocarbamol Oral Tablet 500 mg tablet, give 500 mg by mouth as needed (PRN) for muscle spasm once daily was administered on the following dates and times: -4/10/25: 2:54 A.M. and 1:34 P.M. -4/11/25: 12:40 A.M., and 6:02 A.M. -4/17/25: 3:00 A.M., and 3:21 P.M. -4/29/25: 6:33 A.M., and 1:28 P.M. Review of Resident #86's April 2025 MAR indicated that the Methocarbamol Oral Tablet 500 mg tablet, Give 500 mg by mouth two times a day for pain/spasm, was administered as ordered at 8:00 A.M. and 8:00 P.M. Review of Resident #86's May 2025 MAR indicated that the Methocarbamol Oral Tablet 500 mg tablet, give 500 mg by mouth as needed (PRN) for muscle spasm once daily, was administered on 5/12/25 at 5:36 A.M. and 2:39 P.M. Review of Resident #86's May 2025 MAR indicated that the Methocarbamol Oral Tablet 500 mg tablet, Give 500 mg by mouth two times a day for pain/spasm, was administered as ordered at 8:00 A.M. and 8:00 P.M. During an interview on 5/14/25 at 11:08 A.M., Unit Manager (UM) #1 said the Methocarbamol had been administered outside the parameters of the Physician orders. UM #1 said administering the medications too close to the Resident's scheduled doses could cause increase lethargy and sleepiness. UM #1 said the Methocarbamol was ordered as once daily PRN, but the Nurses had administered the medications as twice a day PRN on the identified dates. During a follow-up interview on 5/14/25 at 1:45 P.M., UM #1 said the PRN Methocarbamol for Resident #86 had been administered in error on the identified dates. UM #1 said the Physician would be notified. During an interview with the Director of Nursing (DON) on 5/14/25 at 3:06 P.M., the DON said the Methocarbamol for Resident #86 was administered twice a day in error on the identified dates and that the Physician had been notified about the significant medication error.

Based on record review and interview, the facility failed to monitor adverse consequences (side effects) of an antipsychotic (psychotropic medication capable of affecting the mind, emotions, and behaviors) medication in accordance with professional standards of practice for one Resident (#38) of five applicable residents, out a total sample of 19 residents. Specifically, for Resident #38, the facility failed to: -complete an Abnormal Involuntary Movement Scale (AIMS - an assessment used to identify the existence and severity of movement side effects associated with antipsychotic drugs) within the required time frame -act upon the Pharmacist Consultant's recommendation following the Resident's monthly medication regimen review indicating a need for AIMS when Resident #38 had been prescribed and administered Clozapine (antipsychotic medication). Findings include: Review of the facility policy titled Psychotropic Medications/Informed Consent, dated 7/16/93 with revision date 3/29/17 included but was not limited to: -Residents who use psychotropic drugs will be monitored for effectiveness of drug therapy and the presence of side effects. -Special considerations regarding the use of antipsychotic drugs: >The AIMS scale will be completed when the drug therapy is first started and at least every six months. >The pharmacy consultant will review the appropriateness of psychotropic therapy during the monthly medication review and the emergence of any adverse consequences. >Recommendations regarding psychotropic medication use by the pharmacist .will be communicated to nursing. Nursing will notify the provider, and the providers response and rationale will be documented. Review of the Increasing Abnormal Involuntary Movement Scale (AIMS) Screening for Tardive Dyskinesia in an Outpatient Psychiatry Clinic: A Resident-Led Outpatient Lean Six Sigma Initiative article at https://pmc.ncbi.nlm.nih.gov/articles/PMC10292174/ included but was not limited to: -The Abnormal Involuntary Movement Scale (AIMS) is used not only to detect tardive dyskinesia but also to follow the severity of a patient's TD over time. -AIMS is a valuable tool for clinicians who are monitoring the effects of long-term treatment with neuroleptic medications and for researchers studying the effects of these drugs. -The AIMS is administered every three to six months to monitor the patient for the development of TD. -The American Psychiatric Task Force report on tardive dyskinesia (TD) in its guidelines for the avoidance and management of TD, recommended: >regular examinations for early signs of choreoathetosis and oral-lingual dyskinesias. > .examinations that use instruments such as the AIMS should be done before the institution of neuroleptic drug therapy and then repeated on a regular basis. >American Psychiatric Association (APA) practice guidelines stated that patients receiving conventional antipsychotic medications should be monitored for TD every three to four months, and patients on newer atypical antipsychotics should be monitored for TD every five to six months. Resident #38 was admitted to the facility in March 2021 with diagnoses including unspecified psychosis and delusional disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #38: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of a total possible score of 15. -was receiving antipsychotic medication. Review of Resident #38's May 2025 Physician's orders included but was not limited to: -Clozapine 100 milligram (mg) tablet, one tab (tablet) by mouth once daily at 8:00 P.M., start date 11/4/24. -Clozapine 50 mg tablet 1.5 tablets (total dose 75 mg) by mouth daily at 6:00 A.M, start date 11/4/24. Review of the Residents person-centered Care Plan included but was not limited to: -Focus: Resident #38 was on Clozapine for Psychosis, initiated 1/16/25. -Goal: Resident #38 would remain free from Psychotropic drug related complications including movement disorder .through next review, revision date 3/19/25. -Interventions: Monitor/document/report adverse reactions to psychotropic mediations. Further Review of Resident #38's Medical Record included but was not limited to: -The Resident had his/her most recent AIMS completed on 7/9/24, with a score of zero out of a possible total score of 28. -The Resident was administered Clozapine as prescribed by the Physician from 7/10/24 through 5/14/25 (10 months since the initial AIMS). -The Resident had a Pharmacist Medication Regimen Review conducted and a Pharmisist Progress Note dated 12/16/24, which indicated recommendation for: AIMS now and every six months to monitor therapy. -No evidence that AIMS assessment had been conducted since the Pharmacist recommendation on 12/16/24 or the AIMS becoming due on 1/9/25 (6 months after the 7/9/24 initial AIMS). During an interview on 5/14/25 at 3:23 P.M., Unit Manager (UM) #1 said that Pharmacist recommendations come monthly via email to the Unit Managers. UM #1 said when the Pharmacy recommendations arrive, she would print them and address the recommendations with the Resident's Provider(s). The surveyor and UM #1 reviewed Resident #38's Pharmacy Progress Note dated 12/16/24 and UM #1 said that the recommendation indicated an AIMS was due at that time. UM #1 was unable to locate a completed AIMS in the Resident's record or the emailed Pharmacy Reccomendation Form. During a follow-up interview on 5/15/25 at 11:21 A.M., UM #1 said that an AIMS should have been completed every six months for Resident #38 but UM #1 was unable to locate a current AIMS in the Resident's medical record after 7/9/24. During an interview on 5/15/25 at 11:31 A.M., the Staff Development Coordinator (SDC) said that Nurses were educated about the AIMS policy upon hire and that the AIMS scale should be done every six months. The SDC said that each Unit Manager should be maintaining a list of residents that are on psychotropic medications as well. The SDC said that there was no current system for tracking AIMS testing within the facility to her knowledge. The SDC said that she would have concerns if the Resident's AIMS was not completed on time because Resident #38 could be at risk for unidentified side effects or may not supposed to still be taking an antipsychotic medication. During an interview on 5/15/25 at 1:09 P.M., the Director of Nursing (DON) said that Resident #38 was taking an antipsychotic medication and should have had an AIMS completed every six months for monitoring but had not.

Based on observations, interviews, and record reviews, the facility failed to ensure that respiratory care and services consistent with professional standards of practice pertaining to oxygen equipment maintenance was provided for two Residents (#9 and #23), out of a total sample of 19 residents. Specifically, for Resident #9 and Resident #23, the facility failed to maintain the Resident's oxygen concentrator (device used to deliver supplemental oxygen) air intake gross particle filter in accordance with Physician orders and manufacturer's guidelines, placing both Residents at risk for contamination, equipment malfunction, and impaired oxygen delivery. Findings include: Review of the facility policy titled Concentrator Maintenance, undated, included but was not limited to the following: -All oxygen concentrators should be wiped down to ensure cleanliness and filters should be cleaned at least weekly to prevent overheating. >Filter Cleaning: Cabinet filters should be pulled from the sides of the concentrator .can be cleaned by: *Manually removing dust by wiping with towel and/or shaking particles free, *Vacuuming the dust from the filter or, *Placing them in warm soapy water and allow to air dry. Once dry replace the filter by placing them back into the cabinet of the concentrator. Review of the New Life Elite Oxygen Concentrator Service Manual, undated, retrieved at https://files.caireinc.com/MN105-1-E.pdf indicated: -To ensure accurate output and efficient operation of the oxygen concentrator, the user must clean the gross particle filter weekly, as described below: >Remove the dirty air intake particle filter from the back of the unit, and install the clean filter stored in the pocket on the back of the unit. >Wash the dirty filter in warm soapy water and rinse. >Use a soft absorbent towel to remove excess water. >Place the clean air intake gross particle filter in the pocket on the back of the unit. 1. Resident #9 was admitted to the Facility in May 2021, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #9: -Resident #9 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a total score of 15. -was receiving oxygen therapy. Review of Resident #9's Person-Centered Care Plan, included but not limited to: -Focus- the Resident has COPD and was dependent on oxygen, initiated 1/24/25. -Goal- the Resident will display optimal breathing patterns daily through next review, initiated 4/17/25. -Interventions- Oxygen per orders, initiated 1/24/25 Review of Resident #9's May 2025 Physician's orders, included but was not limited to: -Oxygen at 3 Liters Per Minute (LPM) via nasal cannula (NC), start date 11/4/24. -Clean outside of oxygen concentrator with warm cloth, clean and rinse filter with warm water every evening shift (3:00 P.M.-11:00 P.M.), every Wednesday, start date 11/4/24. On 5/13/25 at 8:46 A.M., the surveyor observed Resident #9 seated at his/her bedside in a wheelchair with oxygen flowing at 3 LPM from the oxygen concentrator via NC to the Resident. The surveyor observed the oxygen concentrator filter was coated in thick gray dust. On 5/13/25 at 2:47 P.M., the surveyor observed Resident #9 lying in bed with oxygen being administered at 3 LPM via NC from the oxygen concentrator. The surveyor observed the oxygen concentrator filter remained coated in a thick film of gray dust. Review of Resident #9's May 2025 Medication Administration Record (MAR) included but not limited to: >The evening shift (3:00 P.M.-11:00 P.M.) Nurse signed off the completion of task for cleaning the outside of the Resident's oxygen concentrator and cleaning the filter on 5/14/25. On 5/15/25 at 9:19 A.M., the surveyor observed Resident #9 lying in bed with oxygen being administered at 3 LPM via NC from the oxygen concentrator. The surveyor observed that the oxygen concentrator filter was coated in a thick film of gray dust. During an interview at the time, Nurse #1 said that she was the Nurse caring for Resident #9. Nurse #1 said the oxygen equipment was supposed to be cleaned and changed by the evening shift Nurses on Wednesdays. The surveyor and Nurse #1 observed the Resident's oxygen concentrator and Nurse #1 said that the Resident was using a New Life Elite Airsep oxygen concentrator. Nurse #1 said that the concentrator filter was dirty and coated in dust. Nurse #1 said that the filter did not appear to have been cleaned on 5/14/25 evening shift as it should have been. Nurse #1 said she was unsure of why the oxygen concentrator filters needed to be cleaned. 2. Resident #23 was admitted to the Facility in July 2019, with diagnoses including COPD. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #23: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of a total score of 15. -was receiving oxygen therapy. Review of Resident #23's Person-Centered Care Plan included but was not limited to: -Focus- Resident has COPD, initiated 12/9/24. -Goal- Resident will display optimal breathing patterns daily through next review, revised 4/28/25. -Interventions- Oxygen as ordered, initiated 12/9/24 Review of Resident #23's May 2025 Physician's orders included but was not limited to: -Oxygen 2 LPM via NC at bedtime, effective 10/24/24. -Clean outside of oxygen concentrator with warm cloth, clean and rinse filter with warm water every evening shift (3:00 P.M.-11:00 P.M.), every Wednesday, start date 11/4/24. On 5/13/25 at 8:22 A.M., the surveyor observed Resident #23 lying in bed with oxygen flowing at 2 LPM via NC from the oxygen concentrator. The oxygen concentrator filter was observed to be coated in thick gray dust. Review of Resident #23's May 2025 MAR indicated but was not limited to: >The evening shift (3:00 P.M.-11:00 P.M.) Nurse had signed off completion of task for cleaning the outside of the Resident's oxygen concentrator and cleaning the filter on 5/14/25. On 5/15/25 at 9:23 A.M., the surveyor observed Resident #23 lying in bed with oxygen administered via NC at 2 LPM from the oxygen concentrator. The oxygen concentrator filter was observed coated in a thick film of gray dust. During an interview at the time, Nurse #1 said that she was the Nurse caring for Resident #23. Nurse #1 said that oxygen equipment was supposed to be cleaned and changed by the evening shift Nurses on Wednesdays. The surveyor and Nurse #1 observed the Resident's oxygen concentrator and Nurse #1 said that the Resident was using a New Life Elite Airsep oxygen concentrator. Nurse #1 said that the concentrator filter was dirty and coated in dust. Nurse #1 said that the filter did not appear to have been cleaned on the 5/14/25 evening shift as it should have been. Nurse #1 said she did not know anything about cleaning the oxygen concentrator filters. During an interview on 5/15/25 at 9:55 A.M., Unit Manager (UM) #2 said that the evening shift Nurses should be cleaning the concentrator filters weekly on Wednesday. UM #2 said filter cleaning was indicated in the Resident Physician orders and on the Resident MAR.The surveyor and UM #2 observed Resident #9's and Resident #23's oxygen concentrators and UM #2 said both Resident's oxygen concentrator filters were dirty, and the filter cleaning had not been done last night (5/14/25) but should have been. UM #2 said that a dirty concentrator filter could affect the function of the concentrator and oxygen flow to the Resident. During an interview on 5/15/25 at 12:15 P.M., the Infection Preventionist (IP) said that Nurses should be cleaning the oxygen concentrator filters weekly per Physician's orders. The IP said that failure to clean the oxygen concentrator filters could result in Resident nasal irritation as well as causing the oxygen concentrator to overheat and affect the oxygen concentrator's function.

Based on observation, interview and policy review, the facility failed to store food in accordance with professional standards for food service safety in the main kitchen and maintain a refrigerator temperature log for one out of four kitchenettes in the facility. Specifically, the facility staff failed to ensure the following: -in the main kitchen: >that expired food items were discarded. >that food items were labeled, dated, and included an expiration date after being opened. -in the Post Acute Unit ([NAME]) kitchenette: >that temperature logs were maintained for the kitchenette refrigerator. >expired food was discarded from the refrigerator by the discard date. Findings include: Review of the facility's policy titled Dining Services, dated [DATE], indicated: -Food will be properly stored to preserve flavor, nutrition, and appearance. -Dry bulk foods are to be stored in plastic containers with tight covers, or bins that are easily sanitized. The container should be clearly labeled. -Refrigerated storage temperatures should be 40 degrees or below. -Thermometers placed so as to be easily visible for checking and in the upper third of storage unit [of the refrigerator]. Temperatures will be recorded on the Freezer/Cooler Temperature Record [log] on a regular basis. -Food should be covered, dated and stored loosely to permit air circulation. -All foods in the freezer are to be wrapped in moisture-proof wrapping or placed in a suitable container, to prevent freezer burn. They are to be labeled and dated. On [DATE] at 7:19 A.M., during an observation of the main kitchen, the surveyor observed in the walk-in freezer that eight (8) pies were on cookie sheets, and placed on a rack. The surveyor further observed that the 8 pies were not covered and had no identifying labels, use by dates or expiration dates. On [DATE] at 11:15 AM., during an inspection of the main kitchen with the Food Service Director (FSD), the following was observed: -in the walk-in feezer: >4 cream pies with no covers, dates, or labels. >A large tray of breadsticks that was not labeled and not dated. -in the walk-in refrigerator: >A box of tortillas with a manufacturer date of [DATE], but no expiration date, the box was opened and the tortillas partially removed and re-wrapped with no date indicating when the box had been opened. >A large tray of fish with a sticker indicating it was taken out of the freezer on [DATE], to be discarded [DATE]. -in the kitchen area: -An open box of wine with no date indicating when it was opened. During an interview on [DATE] at 12:15 P.M., the FSD said the 4 cream pies and breadsticks should have been dated, labeled, and covered but they were not. The FSD said the fish in the walk-in refrigerator should have been discarded on [DATE] but it was not. The FSD further said the box of wine should have been dated with a date opened sticker, but it was not. On [DATE] at 4:29 P.M., during an inspection of the [NAME] kitchenette with Unit Manager (UM) #1, the following was observed in the refridgerator: -a Styrofoam cup with a lid labeled maple syrup, dated [DATE] -8 cans of pomegranate juice -6 cans of vegetable juice -5 bottles of nutritional health shakes -the refrigerator felt warm to touch. During an interview at the time, UM #1 said the kitchenette refrigerator was used to store food for the unit residents. UM #1 also said that the refrigerator temperature log was managed by the Dietary Department but was unable to locate the thermometer in the refrigerator or provide evidence of a temperature log. UM #1 further said that the refrigerator felt warm to touch. During an observation and interview on [DATE] at 4:50 P.M., in the [NAME] kitchenette with the FSD, the FSD said the refrigerator was managed by the nursing staff. The FSD further said there was no thermometer in the refrigerator or temperature log (with the refrigerator temperatures). The FSD also said that the refrigerator felt warm to touch. During a follow-up observation and interview on [DATE] at 1:49 P.M., in the walk-in refrigerator of the main kitchen, the FSD said the box of tortillas had expired on [DATE] and should have been discarded but they were not. On [DATE] at 7:56 A.M., the surveyor observed that there was a thermometer in the kitchenette refrigerator on the [NAME], and the temperature on the thermometer read 46 degrees. The surveyor also observed a temperature log that was initiated on [DATE] with a documented temperature reading of 42 degrees. The surveyor further observed a refrigerator temperature reading documented on [DATE] of 46 degrees. During an interview on [DATE] at 8:58 A.M., the Director of Nurses (DON) said the dietary department was responsible for managing the refrigerator temperature logs and that there should have been a thermometer and a temperature log record but there had not been. The DON further said that the refrigerator temperature should have been 40 degrees or below, but it was not.

Based on observation, interview, policy and record review, the facility failed to adhere to infection control practices and standards to mitigate the spread of infection during a COVID-19 outbreak and for two Residents (#70 and #102). Specifically, the facility staff failed to: 1. Implement timely outbreak testing for COVID-19 when the facility experienced an outbreak of COVID-19. 2. Adhere to infection control practices during wound dressing changes and implement Contact Precautions (gown and gloves for all interactions that may involve contact with the patient or the patient's environment) for one Resident (#70) when the Resident required wound dressing changes to his/her bilateral lower extremities and required Contact Precautions due to the presence of a wound infection. 3. Implement timely Droplet Precautions (precautions used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking) on the Post Acute Unit ([NAME]) when one Resident (#102) presented with symptoms of respiratory infection, then tested positive for Influenza. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, indicated: -Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. -This will typically be at Day 1 (where day of exposure is day 0), Day 3, and Day 5. Review of the Massachusetts (MA) Department of Public Health (DPH) memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated: -Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -If the long-term care facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago, then they should wait to test until 24 hours after any exposure, if known. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities 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 unless a DPH epidemiologist directs otherwise. Review of the facility's policy titled COVID-19 - Infection Prevention and Control Measures, undated, indicated the facility follows infection prevention and control practices recommended by the CDC to prevent the transmission of COVID-19 within the facility. Review of the facility's as-worked Nursing Daily Schedule Report, dated 2/14/24, indicated Nurse #5 worked the 7:00 A.M. through 3:00 P.M. (Day) shift that day on the [NAME]. Review of the facility's document titled 2024 Staff Positives, undated, indicated Nurse #5 tested positive for COVID-19 on 2/15/24. During an interview on 2/16/24 at 12:55 P.M., the Infection Preventionist (IP) said Nurse #5 tested positive for COVID-19 on 2/15/24 and had last worked at the facility on 2/14/24. The IP said Nurse #5 was assigned to care for six residents on the [NAME], so those residents were being tested and monitored for signs and symptoms of COVID-19, and staff who had worked on the [NAME] with Nurse #5 on 2/14/24 were also being tested for COVID-19. The IP further said outbreak testing was scheduled to start for those residents and staff members on 2/17/24 and would continue every 48 hours until the facility identified no new positive COVID-19 cases for a period of seven days. During an interview on 2/20/24 at 11:45 A.M., the IP said outbreak testing for COVID-19 was conducted on 2/17/24 and 2/19/24 for residents and staff identified as having been exposed to Nurse #5 on 2/14/24. The IP said she was not aware of any staff or residents with COVID-19 symptoms. The IP said she was not sure if any testing had resulted in any new positive COVID-19 cases at that time, but the Director of Nurses (DON) would know. At this time, the Director of Nurses (DON) joined the interview and said when an outbreak of COVID-19 was isolated to one unit, outbreak testing for residents and staff on that unit would be implemented and that the facility had 48 hours to initiate this testing. The DON said the facility would then continue testing affected residents and staff every 48 hours until no new cases of COVID-19 were identified over a period of seven days. The DON said outbreak testing began for residents and staff on 2/17/24 and more testing was conducted on 2/19/24, and that no new cases of COVID-19 had been identified. During a follow-up interview on 2/20/24 at 1:53 P.M., the DON said the facility adhered to CDC and MA DPH guidance relative to guidelines for COVID-19 testing. The surveyor reviewed the CDC and MA DPH guidelines for COVID-19 outbreak testing with the DON and the DON said she thought she had 48 hours to initiate outbreak testing after a positive case of COVID-19 was identified. The DON further said the facility had no contact with their Epidemiologist for guidance during this outbreak and that initiating outbreak testing timely was important to help mitigate transmission of COVID-19 in the facility. 2. Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease). Review of the facility policy titled Infection Control, dated 2001 and revised July 2014, indicated the following: -The facility's infection control . practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. -Objectives of the infection control practices included establishing guidelines for implementing . Standard (used for all resident care) and Transmission-Based (used to reduce the risk for spread of infection) Precautions. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/22, indicated the following: -Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered. -Provide job-specific, infection prevention education and training to all healthcare personnel for all tasks. -Require training before individuals are allowed to perform their duties and at least annually as a refresher. -Require healthcare personnel to perform hand hygiene for the following clinical indications: >Immediately before touching a patient >Before moving from work on a soiled body site to a clean body site on the same patient >After touching a patient or the patient's immediate environment >After contact with blood, body fluids or contaminated surfaces >Immediately after glove removal -Remove and discard personal protective equipment (PPE) . upon completing a task before leaving the patient's room or care area. Review of Resident #70's Wound Care Plan, dated 9/12/23, indicated the Resident had venous wounds (wounds that develop due to poor blood supply) to his/her bilateral lower extremities. Review of Resident #70's Wound Infection Care Plan, dated 2/13/23, indicated: -The Resident had a current infection of Pseudomonas (environmental bacteria) in his/her bilateral lower extremities. -Staff were to maintain Enhanced Precautions (infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that involve gown and glove use during high-contact resident care activities). Review of Resident #70's February 2024 Physician orders indicated an order, initiated 1/5/24, as follows: -Cleanse bilateral lower extremities with wound cleanser, apply Triad cream to periwound (area of skin surrounding a wound that is affected by the wound), apply Calcium Alginate (highly absorbent dressing) followed by Optilock (highly absorbent dressing which locks in drainage under compression) dressing. -Wrap with cling (gauze wrap) daily and PRN (as the situation demands). On 2/15/24 between 1:26 P.M. and 2:00 P.M., the surveyor observed the following during a wound dressing change: -Nurse #3 put on a disposable gown, gloves, and a mask while outside of Resident #70's room. -Resident #70 was seated in a recliner chair in his/her room, with both legs elevated on the chair's footrest. -The Resident's legs were wrapped with gauze and the front of the gauze was stained with yellow and brown colored substance. -Nurse #3 retrieved a towel from Resident #70's closet, used her gloved hands to lift the Resident's legs, and placed the towel on the footrest of the recliner, under the Resident's legs. -Nurse #3 then used the same gloved hands to reach under her gown and into her pant pocket, removed a pair of scissors, and began cutting the gauze off of the Resident's lower extremities. -Nurse #3 removed the gauze, then removed the Optilock dressings which were thick and wet, placed the Resident's lower extremities back onto the towel, and dropped the dressings into the trash can. -Nurse #3 removed her gloves, performed hand hygiene, and donned a new pair of gloves. -Nurse #3 proceeded to cleanse Resident #70's lower extremities with wound cleanser and completed the dressing change but did not change the soiled towel under the Resident's legs to a clean towel. -Nurse #3 removed her gloves, completed hand hygiene and donned a new pair of gloves, then pushed the dirty dressings down into the trash can using her right hand. -Nurse #3 then used the same gloved right hand to reach into her pant pocket. -Nurse #3 said she was looking for a Sharpie marker but did not have one with her. -Nurse #3 then removed her gloves and left the room, entering the hallway wearing the same gown she wore during the dressing change. -Nurse #3 returned with a Sharpie marker, initialed, and dated the dressings on the Resident's legs, placed the Sharpie marker into her pocket, donned a new pair of gloves, and removed the trash bag containing the soiled dressings from the trash can. -Nurse #3 then entered the hallway wearing the same gown she wore during the dressing change and walked toward the trash bin that was positioned down the hallway away from the Resident's room to discard the trash bag. -Nurse #3 then removed her gown and placed it in the trash bin in the hallway, and then performed hand hygiene. During an interview on 2/15/24 at 2:06 P.M., Nurse #3 said that Resident #70 required Enhanced Precautions but had been changed to Contact Precautions due to Pseudomonas in his/her lower extremity wounds and that the signage for Contact Precautions had just not been posted as yet. Nurse #3 said Resident #70 had been experiencing a large amount of drainage from his/her lower extremity wounds and that the Optilock dressings were saturated with drainage and were heavy when she removed them from the Resident's legs. Nurse #3 said she would typically have replaced the soiled towel under the Resident's legs after removing the soiled dressings and cleaning the Resident's wounds, but that residents were only allotted two bath towels per shift, so she did not replace it during the dressing change. When the surveyor asked if there was a shortage of towels, the Nurse said there was not, and when asked if residents could have more than two towels per shift, the Nurse said she imagined they could. Nurse #3 also said she should have removed her gown after completing the dressing change, prior to entering the hallway, but she did not. During an interview on 2/15/24 at 3:23 P.M., with the Infection Preventionist (IP) and Unit Manager (UM) #2, the UM said Resident #70 had been placed on Enhanced Precautions after a recent return from the hospital. UM #2 said that Contact Precautions had been initiated for the Resident on 2/15/24 due to the Resident having Pseudomonas in his/her lower extremity wounds. UM #2 said she was not aware of any limitation on how many bath towels were allowed for residents and that Nurse #3 should have removed and replaced the towel used during the wound dressing change. The IP said she had done more research on Pseudomonas and due to a concern for multi-drug resistant organisms (MDROs), it was determined that Contact Precautions should be implemented in order to help reduce the risk of spreading infection. The IP further said whether a Resident required Enhanced or Contact Precautions, all staff were required to remove their gowns and gloves prior to leaving a Resident's room, contain the gown and gloves in a bag, then transport it to the trash bin in the hall if there was no trash bin located in the room. The IP said Nurse #3 should have followed this procedure. The IP also said Nurse #3 should have removed her gloves and performed hand hygiene after touching the soiled dressings in the trash can and before reaching into her pant pocket. On 2/15/24 at 4:40 P.M., the surveyor observed that a Contact Precaution sign was placed outside of Resident #70's room. The surveyor also observed a three-drawer bin located outside the room, under the Contact Precaution sign, which contained disposable gowns, gloves, and masks. The surveyor observed CNA #2 enter Resident #70's room without donning a gown and gloves. CNA #2 was observed assisting the Resident to drink from a cup, talked with the Resident, then moved the call bell from the bed to the chair where the Resident was seated. CNA #2 then exited the room and did not perform hand hygiene. During an interview at the time, CNA #2 said Resident #70 had been on Enhanced Precautions and was now on Contact Precautions, but that there was no change in what staff were required to use for PPE. CNA #2 said Contact Precautions meant staff had to put on a gown and gloves only when they performed high contact care and that neither a gown nor gloves were required upon room entry or to handle items within the Resident's environment. During an interview on 2/15/24 at 4:45 P.M., UM #2 said Resident #70 was on Contact Precautions and that staff were required to don a gown and gloves for high contact care only. The surveyor reviewed the Contact Precaution sign outside of Resident #70's room with UM #2. UM #2 read the sign, then said since the sign indicated a gown and gloves were required for room entry, that was what needed to be done and she would need to educate staff. 47901 3. Review of the facility's policy titled, Transmission-based (Isolation) Precautions, dated 2023, indicated: -Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. -Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission-based precautions/isolation empirically while awaiting confirmation. -An order for transmission-based precautions/isolations will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. -Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room. -Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles or face shield should be worn. Resident #102 was admitted to the facility in January 2024 with diagnoses including Periprosthetic fracture (a broken bone that occurs around an orthopedic implant) with wound infection, Vancomycin Resistance Enterococcus (VRE: a serious infection caused by bacteria that are resistant to the antibiotic Vancomycin) in the wound and Cough. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #102 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of Resident #102's Physician's orders dated 2/13/24, indicated Influenza A/B swab (a laboratory test) with diagnosis of Acute Cough. On 2/14/24 at 9:15 A.M., the surveyor observed a Contact Precaution sign outside the resident's room. The Contact Precaution sign indicated: -Clean hands, including before entering and when leaving the room. -Providers and staff must also put on gloves before room entry, discard gloves before room exit. -Put on gown before room entry, discard gown before room exit. During an observation at the time, the surveyor observed several staff members entering and exiting Resident #102's room without wearing gowns. During an interview on 2/14/24 at 11:00 A.M., Resident #102 said that he/she had been coughing and the facility staff had obtained a sputum sample and sent it to the lab as they were questioning whether he/she had Influenza. Resident #102 said he/she had a fever and was being treated for an infection to his/her right hip with intravenous (IV - medications through the vein) antibiotics. Review of the Physician's orders for February 2024 indicated an order for Droplet Precautions for Influenza A had been added on 2/14/24. On 2/15/24 at 7:24 A.M., the surveyor observed that a Droplet Precautions sign, in addition to a Contact Precautions sign were posted outside Resident #102's bedroom door. The Droplet Precaution sign indicated: -Everyone must clean hands before and after entering the room. -Make sure their eyes, nose and mouth are fully covered before room entry, remove face protection before the room exit. On 2/15/24 at 9:07 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 entering Resident #102's room wearing a face mask but no gloves or eye protection. CNA #1 was observed to exit the room with the Resident's breakfast tray and placed the tray in the unit kitchenette. During an interview at the time, CNA #1 said that all new residents are placed on precautions for five days when they are newly admitted , and she was not aware of any additional precautions that needed to be taken. During an interview on 2/15/24 at 9:16 A.M., Nurse #1 said that Resident #102 had tested positive for the Influenza A virus and had been placed on Droplet Precautions. Nurse #1 further said Resident #102 was started on Droplet Precaution after the results for Influenza A had been obtained the evening of 2/14/24. During an interview on 2/15/24 at 9:25 A.M., UM #1 said Droplet Precautions were initiated after the lab results for Influenza had been obtained on 2/14/24 and that CNA #1 should have worn gloves and face shield before entering the Resident's room. During an interview on 2/15/24 at 9:52 A.M., the IP said Droplet Precautions were initiated for Resident #102 after the positive result for Influenza had been obtained and that the Droplet Precautions should have been initiated when the Resident became symptomatic and an order was obtained for the Influenza swab, but was not done as required. During a follow-up interview on 2/15/24 at 2:16 P.M., the IP said CNA #1 should have worn eye protection and gloves (as indicated on the Contact Precautions and Droplet Precautions signs) when she entered Resident #102's room.

Based on observation, interview, policy and record review, the facility failed to administer parenteral fluids (delivery of fluid or medication through an intravenous [IV: within a vein] . route) according to professional standards of practice and in accordance with the Physician's order for one Resident (#70) out of a total sample of 22 residents. Specifically, the facility staff failed to verify patency (openness of an IV line, allowing medication to flow directly into one's vein) of Resident #70's midline catheter (small tube inserted into a vein in one's arm used to deliver medication and take blood samples), prior to administering an IV antibiotic (medication used to treat infection), as required per the Physician's order, increasing the Resident's risk for complications during antibiotic treatment. Findings include: Review of the facility's policy, titled Administration of IV Fluids and Medications: Setting Up a Primary Infusion (Hydration or Medication), dated 2011, indicated the following: -Scrub needleless connector (device which connects to the end of the midline catheter and enables access for infusion [slow injection of medication into a vein] and aspiration [drawing out by suction]) on resident's catheter with antiseptic (substance used to prevent infection) wipe. -Attach flush syringe (medical device used to ensure IV lines stay clean and prevent blockages), aspirate for a blood return to determine patency and then flush resident's IV catheter with appropriate flush solution as ordered . -Scrub needleless connector on resident's catheter with antiseptic wipe. -Attach . IV tubing to the needleless connector. - . begin infusion. Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease). Review of Resident #70's February 2024 Physician's orders indicated: -IV Midline - Insertion site: Right upper arm, . dated 2/12/24. -Cefepime (antibiotic medication used to treat bacterial infections) 2 Gram (gm) Solution for injection: Infuse 2 gm by injection route two times per day for five days, dated 2/12/24 and discontinued 2/16/24. -Verify patency: Attach flush syringe, aspirate for a blood return to determine patency prior to administration of medications and solutions ., dated 2/12/24. -Cefepime 2 gm Solution for injection: Infuse 2 gm in 100 milliliters (ml) in 0.9 percent (%) Normal Saline (NS) over 30 minutes intravenously every 12 hours, dated 2/16/24. Review of Resident #70's IV Therapy Care Plan, dated 2/13/24, indicated: -The Resident required IV antibiotic therapy due to Pseudomonas (environmental bacteria) in his/her bilateral lower extremity wounds. -The IV site would remain free from signs of infiltration (dislodgement), . extravasation (leakage of medication into the tissue rather than remaining in the vein), . until the course of IV therapy was completed. Review of Resident #70's Medical Progress Note, dated 2/14/24, indicated the Resident was transferred to the hospital from the facility on 2/7/24, and: -admitted with diagnosis of bilateral lower extremity Cellulitis (serious bacterial infection of the skin) in the setting of Chronic Venous Stasis Ulcers (sores that develop due to poor blood circulation). -Lower extremity wound cultures grew Pseudomonas. -The Resident was treated with Cefepime. -The Resident returned to the facility on [DATE]. -The plan was to continue IV Cefepime twice daily to complete a seven-day course. On 2/14/24 at 9:31 A.M., the surveyor observed Resident #70 seated in a recliner chair with both lower extremities wrapped in gauze and elevated on the chair's footrest. An IV pole was positioned to the right side of the Resident's chair. On 2/16/24 at 9:45 A.M., the surveyor observed the following in Resident #70's room: -Resident #70 was seated in a recliner chair in his/her room, with both lower extremities wrapped in gauze and elevated on the chair footrest. -The resident had a midline catheter in place in his/her right upper extremity. -An IV pole was positioned to the right of the Resident. -Nurse #4 hung one bag of Cefepime 2 gm Solution on the IV pole and programmed the IV pump. -Nurse #4 scrubbed the needleless connector of Resident #70's midline catheter with an antiseptic wipe and flushed the midline catheter with 10 ml of NS. -Nurse #4 did not aspirate for a blood return to determine patency. -Nurse #4 scrubbed the needleless connector with an antiseptic wipe a second time, attached the IV tubing to the needleless connector of Resident #70's midline catheter and began the antibiotic infusion. During an interview on 2/16/24 at 1:39 P.M., Nurse #4 said Nurses were required to flush the residents' IV catheters prior to administering medications through an IV but Nurse #4 did not state how to verify patency of the line. When the surveyor asked whether there was a process in place to verify patency, Nurse #4 said yes, that she should have aspirated for a blood return to verify patency of Resident #70's midline catheter before administering the antibiotic, but she skipped that step. During an interview on 2/20/24 at 4:23 P.M., the Director of Nurses (DON) said Nurses administering medications to residents via midline catheters were required to verify patency prior to medication administration by aspirating for a blood return. The DON said this was important to ensure that the line was open and working properly. The DON also said Nurse #4 should have aspirated for a blood return prior to administering Resident #70's antibiotic infusion on 2/16/24. Please refer to F726.

Based on record and policy review, and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Infection Preventionist (IP) attended three out of the four quarterly QAPI meetings, as required. Findings include: Review of the facility policy for Quality Assessment and Assurance Committee, last revised 11/28/18, indicated that the Quality Assessment and Assurance (QAA) Committee will consist of the following individuals: -Director of Nursing -Medical Director or his/her designee -At least three other members of the facility's staff, one of whom must be the Administrator, Owner. A board member or other individual in a leadership role, and -Infection Preventionist (effective 11/28/19). During a meeting on 2/20/24 at 3:37 P.M., the surveyor reviewed the quarterly QAA Committee sign in sheets provided by the facility with the Administrator, and the Director of Nurses (DON). The quarterly QAA Committee sign in sheets did not indicate any evidence that the IP had attended the quarterly QAPI meetings as required, that were held on 7/27/23, 10/26/23 and 1/25/24. During an interview on 2/20/23 at 3:54P.M., the DON said that the IP was a required member of the QAA Committee and should have attended the quarterly QAPI meetings but did not. The DON further said that there had been no other team member certified as an IP or assigned to present on the IP's behalf during the quarterly QAPI meetings held on 7/27/23, 10/26/23 and 1/25/24.

Based on observation, interview, record and policy review, the facility failed to ensure that medications and biologicals for two Resident's (#61 and #70) were appropriately managed by staff in a safe and secure manner. Specifically, the facility staff failed to: 1. For Resident #61, store and/or dispose of medications after Resident refusal. 2. For Resident #70, ensure that medications and biologicals left at the Resident's bedside were stored and secured in locked compartments and not accessible to unauthorized individuals. Findings include: 1.Review of the facility policy titled Storage of Medications, Destruction and Disposal of Medication, revised 11/20, indicated: -drugs and biologicals are stored in the packaging containers or other dispensing systems in which they are received. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner. Resident #61 was admitted to the facility in January 2024 with the following diagnoses: Depression (a mood disorder where the patient experiences persistent symptoms of depressed mood, sadness, and a loss of interest in daily activities to the point where it affects their normal function such as their appetite, energy levels, concentration levels and sleep) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of the Minimum Data Set (MDS) assessment, dated 1/21/24, indicated Resident #61 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #61's Physicians orders, dated 1/16/24, indicated the following medications to be administered by oral (mouth) route at 8:00 A.M. daily: -Atenolol (Beta-blocker, used to treat high blood pressure) 25 milligram (mg) tablet -Bupropion HCL (antidepressant, used to treat depression) 75 mg tablet -Finasteride (alpha-reductase inhibitor, used to shrink an enlarged gland) 5 mg tablet -Folic acid (Vitamin B-complex, used for folic acid deficiency) 1mg tablet -Lisinopril (ace inhibitor, used to treat high blood pressure) 5 mg tablet -Flomax (used to treat BPH) 0.4 mg tablet -Thiamine HCL (vitamin, needed by the body to turn food into energy) 100 mg -Aspirin (nonsteroidal anti-inflammatory drug [NSAID] used to reduce pain, fever, and/or inflammation) 81 mg tablet During an observation and interview on 2/20/24 at 2:29 P.M. with Nurse #3 on the third floor unit, Nurse #3 unlocked medication cart two (2) and the surveyor observed a medication cup filled with several prepared medications in the top drawer of the medication cart. Nurse #3 said the prepared medications belonged to Resident #61. Nurse #3 further said that Resident #61 had refused the medications in the morning and that the medications should have been disposed of [wasted] when he/she refused them in the morning and not left in the medication cart. Review of the February 2024 MAR (Medication Administration Record) indicated that the 8:00 A.M. medications that were dispensed on 2/20/24 for the Resident and documented as refused by the Resident, was signed off on the MAR as 'refused' by the Nurse. Nurse #3 kept the medications that were refused by Resident #61 stored in the medication cart from the time of the morning medication pass to 2:29 P.M. 42761 2. Review of the facility's policy titled Storage of Medications, dated 2001 and revised November 2020, indicated: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals used in the facility are stored in locked compartments . -Only persons authorized to prepare and administer medications have access to locked medications. Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease) and Dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of a Minimum Data Set (MDS) Assessment, dated 11/22/23, indicated Resident #70 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status Score (BIMS) of three out of 15 total possible points. Review of Resident #70's February 2024 Physician orders indicated: -Nystatin (antifungal antibiotic used to treat skin infections caused by yeast) Powder: Apply by topical (pertaining to a specific part of the body) to ABD (abdominal) fold and groin after incontinent care every day at 7:00 A.M. - 3:00 P.M.[day shift]; 3:00 P.M. - 11:00 P.M.[evening shift] for 14 days, dated 2/7/24. -Hydrocerin with Petrolatum (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations) Topical Cream: Apply one applicatorful [sic] by topical route two times per day to the affected areas, dated 2/12/24. On 2/14/24 at 9:31 A.M., the surveyor observed the following in Resident #70's room: -Resident #70 was seated in his/her recliner chair. -One 30 milliliter (ml) bottle of Saline Spray Maximum Strength Oxymetaloine HCl 0.05% (decongestant that shrinks blood vessels in the nasal passages) Nasal Decongestant on the nightstand. -One container of Nystop (Nystatin) Topical (applied directly to a part of the body) Powder 100,000 units (u)/gram (gm) on the nightstand. -One 106 gm jar of Hydrocerin with Petrolatum Topical Cream on the nightstand. On 2/15/24 from 11:08 A.M. through 12:00 P.M., the surveyor observed the following in Resident #70's room: -The Resident was seated in his/her recliner in the room and had a visitor. -The Resident's visitor periodically walked around the room. -One 30 milliliter (ml) bottle of Saline Spray Maximum Strength Oxymetaloine HCl 0.05% Nasal Decongestant remained on the nightstand. -One container of Nystop Topical Powder 100,000 units (u)/gram (gm) remained on the nightstand. -One 106 gm jar of Hydrocerin with Petrolatum Topical Cream remained on the nightstand. During an interview on 2/15/24 at 2:06 P.M., Nurse #3 said all medications and biologicals were to be stored in locked compartments and should not be left in any resident rooms. Nurse #3 said all medications and biologicals should be stored properly to ensure that only the staff with the authority to administer the medications and biologicals to residents had access. Nurse #3 said the Saline Spray, Nystop Topical Powder, and Hydrocerin with Petrolatum should have been stored in a secure manner and not left on the Resident's nightstand.

Based on observation, interview, and record review, the facility failed to ensure that nursing competencies (measurable patterns of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) were assessed, according to the Facility Assessment and care needed by the resident population for two Nurses (#3 and #4) out of four Nurses reviewed. Specifically, the facility failed to: 1. Assess any skill competencies for Nurse #3 since May 2022, including clean dressing (use of a clean procedure field, clean gloves, and with avoidance of direct contamination of materials and supplies) technique, when the Nurse was assigned to care for one Resident (#70) who required daily dressing changes to his/her lower extremities. 2. Assess annual competency for Nurse #4 relative to care of intravenous (IV: within a vein) catheters when Nurse #4 was assigned to care for one Resident (#70) who required IV antibiotic administration through a midline catheter (small tube inserted into a vein in one's arm used to deliver medication and take blood samples). Findings include: Review of the Facility Assessment, updated January 2024, indicated the following: -Staff assigned to care for residents were assigned with the objective of ensuring that there were staff with appropriate training, experience, and expertise to meet the needs of the residents on each unit, as best as possible. -Competencies were determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population. -Competencies were to be verified upon orientation, at least annually, and as needed. Review of the facility's Annual Nursing Skills Competency Checklist, undated, indicated competencies to be assessed included, but were not limited to: -Clean Dressing Technique -IV (intravenous) Basic and Pump -Precaution Policy Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease). 1. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/22, indicated the following: -Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered. -Require training before individuals are allowed to perform their duties and at least annually as a refresher. Review of the facility policy titled Infection Control, dated 2001 and revised July 2014, indicated the following: -The facility's infection control . practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. -Objectives of the infection control practices included establishing guidelines for implementing . Standard (minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient) and Transmission-Based (second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected . with certain infectious agents for which additional precautions are needed to prevent infection transmission) Precautions. Review of Resident #70's Wound Care Plan dated 9/12/23, indicated the Resident had venous wounds (wounds that develop due to poor blood flow) to his/her bilateral lower extremities. Review of Resident #70's Wound Infection Care Plan, dated 2/13/23, indicated: -The Resident had a current infection of Pseudomonas (environmental bacteria) in his/her bilateral lower extremities. -Staff were to maintain Enhanced Precautions (infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) and involve gown and glove use during high-contact resident care activities). Review of Resident #70's February 2024 Physician orders indicated an order, initiated 1/5/24, as follows: -Cleanse bilateral lower extremities with wound cleanser, apply Triad (sterile coating that can be applied directly onto the skin) cream to periwound (skin around a wound that has been affected by the wound), apply Calcium Alginate (absorbent wound dressing) followed by Optilock (super absorbent dressing which locks in drainage under compression) dressing. -Wrap with Cling (gauze wrap) daily and PRN (as the situation demands). On 2/15/24 between 1:26 P.M. and 2:00 P.M., the surveyor observed an Enhanced Barrier Precaution (targeted glove and gown use during high contact resident care) sign posted outside of Resident #70's room. The surveyor observed Nurse #3 donning (putting on) a disposable gown, gloves, and a mask and then entered the Resident's room. Resident #70 was observed seated in a recliner chair in his/her room, both legs wrapped in gauze (which was stained with a yellow and brown substance) and elevated on the chair footrest. The surveyor observed the following care and services being provided: -Nurse #3 used her gloved hands to lift the Resident's legs and place a towel under both legs, on the footrest of the recliner. -Nurse #3 then used the same gloved hands to reach under her gown and into her pant pocket, removed a pair of scissors, and cut and removed the dressings from the Resident's lower extremities. -The surveyor observed the dressings to be thick, wet and soiled. -Nurse #3 placed the Resident's lower extremities back onto the towel, and dropped the soiled dressings into the trash can. -Nurse #3 was observed to remove her gloves, performed hand hygiene, and don a new pair of gloves. -Nurse #3 then cleansed Resident #70's lower extremities with wound cleanser and completed the dressing change but did not change the towel under the Resident's legs from a soiled towel to a clean towel. -Nurse #3 was observed to remove her gloves, performed hand hygiene, and don a new pair of gloves. -Nurse #3 then pushed the dirty dressings down into the trash can using her right hand, and used the same gloved right hand to reach into her pant pocket. Nurse #3 said she was looking for a Sharpie marker but did not have one with her. -Nurse #3 then removed her gloves, left the room, and entered the hallway still wearing the same gown she wore during the dressing change. -Nurse #3 returned with a Sharpie marker, initialed and dated the dressings on the Resident's legs, placed the Sharpie marker into her pocket, put on a new pair of gloves, and removed the trash bag containing the soiled dressings from the trash can. -The surveyor observed Nurse #3 enter the hallway wearing the same gown she wore during the dressing change and walked toward the trash bin that was positioned down the hallway from the Resident's room to discard the trash bag. -Nurse #3 then removed her gown while in the hallway and placed it in the trash bin located in the hallway. Review of Nurse #3's Skills Competency record indicated annual competencies had not been assessed for the Nurse since June 2020. Further review of Nurse #3's Skills Competency record indicated facility identified periodic skill competencies had not been assessed since May 2022, including: -Hand Washing Competency -Sterile and Clean Dressing Competency Please refer to F880. 2. Review of the facility's policy, titled Administration of IV (intravenous: directly into a vein) Fluids and Medications: Setting Up a Primary Infusion (Hydration or Medication), dated 2011, indicated the following: -Scrub needless connector (device which connects to the end of the midline catheter and enables access for infusion [slow injection of medication into a vein] and aspiration [drawing out by suction] on resident's catheter with antiseptic (substance used to prevent infection) wipe. -Attach flush syringe (medical device used to ensure IV lines stay clean and prevent blockages), aspirate for a blood return to determine patency (openness) and then flush resident's IV catheter with appropriate flush solution as ordered . -Scrub needless connector on resident's catheter with antiseptic wipe. -Attach IV tubing to the needleless connector. - . begin infusion. Review of Resident #70's February 2024 Physician orders indicated: -IV Midline - Insertion site: Right upper arm, . dated 2/12/24. -Cefepime (antibiotic medication) 2 Gram (gm) Solution for injection: Infuse 2 gm by injection route two times per day for five days, dated 2/12/24 and discontinued 2/16/24. -Verify patency: Attach flush syringe, aspirate for a blood return to determine patency prior to administration of medications and solutions ., dated 2/12/24. -Cefepime 2 gm Solution for injection: Infuse 2 gm in 100 milliliters (ml) in 0.9 percent (%) Normal Saline (NS) over 30 minutes intravenously every 12 hours, dated 2/16/24. On 2/16/24 at 9:45 A.M., the surveyor observed Resident #70 was seated in a recliner chair in his/her room, with both lower extremities wrapped in gauze and elevated on the chair footrest. The surveyor observed that the Resident had a midline catheter in place in his/her right upper extremity and an IV pole/pump was positioned to the right of the Resident. The surveyor observed Nurse #4 hanging one bag of Cefepime 2 gm Solution on the IV pole and programming the IV pump. Nurse #4 was observed to scrub the needleless connector of Resident #70's midline catheter with an antiseptic wipe and flush the midline catheter with 10 ml of NS. The surveyor did not observe Nurse #4 performing an aspiration procedure for a blood return to determine patency. Nurse #4 was observed to scrub the needleless connector again with an antiseptic wipe, attach the IV tubing to the needleless connector of Resident #70's midline catheter and start the antibiotic infusion. During an interview on 2/16/24 at 1:39 P.M., Nurse #4 said Nurses were required to flush the residents' IV catheters prior to administering medications through an IV. Nurse #4 did not state how to verify patency of the IV line. When the surveyor asked whether there was a requirement to verify patency, Nurse #4 said there was, but she skipped that step. Nurse #4 then said she should have aspirated for a blood return to verify patency of Resident #70's midline catheter before administering the antibiotic, but she did not. Review of Nurse #4's Skills Competency Record indicated competency assessment relative to care of IV catheters had not been completed since July 2022. During an interview on 2/20/24 at 4:50 P.M., the Staff Development Coordinator (SDC) said nursing competencies were to be assessed on hire and annually, but there were no skill competency assessments on file for Nurse #3 since May 2022. The SDC also said there was no annual or periodic skill competency assessment on file for Nurse #4 relative to the care of IV catheters.

Based on record and policy review, and interview, the facility failed to perform a trauma assessment on admission to the facility for one Resident (#61) out of a total sample of 22 residents. Specifically, the facility failed to assess whether Resident #61 had a past history of trauma, and/or any triggers which may cause re-traumatization. Findings include: Review of the facility's policy titled Trauma Policy, undated, indicated but was not limited to: -Residents will be assessed by social services upon admission for mental, psychosocial adjustment difficulty, with a history of trauma and or Post-Traumatic Stress Disorder (PTSD: a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). -Interviews with the resident, resident's family, or representatives, will be conducted as able, to determine: a. Their awareness of the current condition(s) or history of the condition(s) or diagnosis/diagnoses. b. To have their participation in the development of a person-centered care plan. c. To ensure Resident choices are considered. Resident #61 was admitted to the facility in January 2024 with the following diagnoses: Depression ( a mood disorder where the patient experiences persistent symptoms of depressed mood, sadness, and a loss of interest in daily activities to the point where it affects their normal function such as their appetite, energy levels, concentration levels and sleep) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #61 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #61's medical record did not include any documentation that an assessment for Trauma and the prevention of potential re-traumatization had been initiated. During an interview on 2/20/24 at 11:44 A.M., Social Worker (SW) #2 said that when a new resident is admitted to the facility, Social Services would ask them about a history of trauma. SW #2 further said that if the resident answered that they have had trauma then the staff are prompted to ask additional questions to avoid re-traumatization of the residents and that Social Services would develop a plan of care. During an interview on 2/20/24 at 5:02 P.M., the surveyor and SW #2 reviewed the medical record for Resident #61 and SW #2 said that the Resident was not asked about a trauma history on admission to the facility and that he/she should have been asked about previous trauma.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff for care, the Facility failed to ensure staff implemented and followed their Abuse Prohibition Policy, when on 10/05/23 Certified Nurse Aide (CNA) #2 witnessed an alleged incident of potential physical abuse involving CNA #1 and Resident #1, but did not immediately report the incident per facility policy, and waited until the following day to report it, therefore placing other residents at risk for potential abuse. Findings include: Review of the Facility's Policy, dated as effective 09/20/18, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property indicated that all staff who suspect abuse, neglect, mistreatment and or misappropriation must immediately make an oral report to his or her supervisor. The Policy indicated the alleged perpetrator will be immediately removed and the resident will be protected. The Policy indicated the employees accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation. Resident #1 was admitted to the Facility in October 2022, diagnoses included vascular dementia, anxiety disorder and aphasia (a disorder that causes a person to have trouble expressing their thoughts with spoken and/or written language.) Review of Resident #1's most recent Annual Minimum Data Set (MDS) Assessment, dated 09/05/23, indicated that Resident #1's cognitive patterns were severely impaired and that he/she was dependent on two staff members for mobility and Activities of Daily Living (ADLs). Review of the Facility's Incident Report, dated 10/06/23, indicated the facility was made aware (on the afternoon of 10/06/23) of an allegation of possible physical abuse, involving CNA #1 and Resident #1, that had occurred at approximately 8:30 P.M. on 10/05/23. The Report indicated that CNA #2 alleged that CNA #1 put a shirt on Resident #1's face to stop him/her from spitting. Review of the Facility's Nursing Schedule, dated 10/05/23, indicated CNA #1 and CNA #2 worked from 3:00 P.M. to 11:00 P.M. (for the entire shift). During an interview on 11/01/23 at 2:58 P.M. with Certified Nurse Aide (CNA) #2 (which also included a review of her written witness statement dated 10/10/23), CNA #2 said that sometime between 7:00 P.M. and 8:00 P.M. on 10/05/23, she observed CNA #1 put a shirt over Resident #1's face to prevent him/her from spitting during care. CNA #2 said that CNA #1 held the shirt firmly in place over Resident #1's face, with one hand, for approximately 8-10 seconds. CNA #2 said that she told CNA #1 that holding a shirt over Resident #1's face was not okay. CNA #2 said she reported the alleged incident to someone in the Human Resources (HR) Department on 10/06/23 at approximately 3:00 P.M., (the following day), and they immediately notified Unit Manager #1. CNA #2 said she had not immediately reported the incident on 10/05/23, because she had not known the proper procedure for reporting suspected abuse. During an interview on 11/01/23 at 4:38 P.M., Nurse #1 said he worked the evening shift on 10/05/23. Nurse #1 said that at the time of the alleged incident, CNA #2 was on orientation and she was shadowing CNA #1. Nurse #1 said no one reported any incidents to him on 10/05/23, and he did not recall if anything unusual happened that evening. During an interview on 11/01/23 at 3:25 P.M., Unit Manager #1 said that around 3:00 P.M. on 10/06/23, someone from HR notified her that CNA #2 had just reported an allegation of abuse. Unit Manager #2 said she immediately went to the HR Department to meet up with CNA #2. The Unit Manager said that CNA #2 accompanied her to the Administrator's office where she (CNA #2) reported an incident of potential physical abuse that occurred on 10/05/23, involving CNA #1 and Resident #1. During an interview on 11/01/23 at 4:00 P.M., the Administrator said CNA #2 should have immediately reported the incident involving potential physical abuse to a supervisor on 10/05/23, but she had not reported the incident until 10/06/23. The Administrator said CNA #1 worked the remainder of her shift (approximately 2.5 hours) on 10/05/23 and was not suspended until 10/06/23 when the incident was reported, therefore the residents were not immediately protected from potential abuse.

Based on observation, policy review and interview the facility failed to ensure that its staff stored, prepared, distributed, and served food in accordance with professional standards for food service safety. Specifically: 1) The staff failed to monitor and record food temperatures, and 2) Date refrigerated food items. Findings include: Review of the facility policy titled Temperature Monitoring, revised 9/2009, included: The objective was to reduce the risk of food borne illness. Food temperatures will be monitored and recorded before serving. Review of the facility policy titled Handling Leftover Food, revised 9/2009, included: Leftover foods will be handled in an appropriate food safe manner to minimize risk of food borne illness. Refrigerated items should be dated and used within seventy-two hours after opening. 1. The facility failed to ensure that its staff monitored and recorded food temperatures. On 8/23/22 at 7:30 A.M., during the initial tour of the kitchen, the surveyor observed the breakfast line was in process. The surveyor asked Dietary Staff #2 if he had taken the temperatures of the breakfast foods before he started to serve. Dietary Staff #2 said he did but did not write the temperatures down and did not know where the food temperature logbook was located. During an interview on 8/23/22 at 7:40 A.M., Dietary Staff #1 said the food temperature log was in her office. The surveyor and Dietary Staff #1 entered her office, she opened the temperature logbook and attempted to find temperatures for breakfast, lunch, and dinner. Dietary Staff #1 said there were no documented temperatures for any meals during the past two months. The surveyor asked when the last time food temperatures were taken, and she said she did not know. Dietary Staff #1 said temperatures should be taken and documented for all meals. 2. The facility failed to ensure that its staff dated refrigerated items in a) the kitchen and b) on one out of four Resident units. a) On 8/23/22 at 7:50 A.M., during a follow-up tour of the kitchen, the surveyor observed five plated salads and three sandwiches that were not dated, in the condiment refrigerator. Dietary Staff #1 said all plated items should be dated and thrown away if not used within three days, and all refrigerated items should be dated when opened. The surveyor observed the following in the walk-in refrigerator: -an undated plastic container of whip cream -one block of blue cheese, not dated when opened -one bag of shredded parmesan cheese, not dated when opened -one bag of shredded cheddar cheese, not dated when opened b) On 8/24/22 at 9:10 A.M., during an inspection of the refrigerator located on Unit 3 between Pods #1 and #2, the surveyor observed the following: - three plates covered with plastic wrap not labeled with contents or dated - an unsealed box containing a partial cake that was not labeled or dated During an interview on 8/24/22 at 9:10 A.M., Dietary staff #3 said that the three plates contained brownies and that they should have a label and date on the outer plastic wrap. She also said that the unsealed cake box should have a label and date on it to indicate which Resident the cake belonged to and the date it was brought into the facility. Dietary staff #3 said that any unlabeled food items should have been discarded.

Based on observation, record review and interview the facility failed to ensure that its staff assessed two Residents (#407 and #66), out of a total sample of 23 residents for self-administration of medication, while medication was not stored safely and securely at the bedside. Specifically, the facility staff failed to determine if self-administration of medications was clinically appropriate for Residents #407 and #66. Findings include: Review of an undated facility policy, titled Self-Administration of Medications, included but was not limited the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. - If a resident expresses their wishes to self-administer medication, the interdisciplinary team (IDT) assesses the resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. -Residents who are identified as being able to self-administer medications must sign the consent form. -For self-administering residents, the nursing staff is responsible for documenting that medications are taken. -Self-administered medications are stored in a safe and secure place, which is not accessible by other residents 1. Resident #407 was admitted to the facility in August 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #407 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. On 8/23/22 at 8:28 A.M., the surveyor observed two bottles of eye drops located on the bedside table while the Resident was lying in the bed. Resident #407 said that he/she used the eye drops as needed for extreme dry eyes, and he/she was currently using them without staff assistance. The two bottles were labeled as Anti-Microbial Lid and Lash Solution and [MEDICATION(S)] eye drops. Review of the August 2022 Physician's orders indicated an order, initiated on 8/12/22, for [MEDICATION(S)] ([MEDICATION(S)] [MEDICATION(S)]) 0.4%-0.3% eye drops (a solution specially formulated to moisten the eyes) instill 1 drop by ophthalmic (eye) route in each eye every 4 hours as needed. Review of the Self-Administration of Medication Consent and Assessment, signed 8/12/22, indicated the determination of the Resident's ability to self-medicate was not assessed and Resident #407 indicated that they wished to have a Nurse administer medications. During an interview on 8/23/22 at 9:35 A.M.with Nurse #1, the two bottles of eye medications were observed at the bedside of Resident #407 and Nurse #1 said she didn't know why they were left there. She further said the policy was to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/23/22 at 9:40 A.M., Nurse #1 reviewed the medical record with the surveyor and said there was no evidence that a self-administration form for the eye drops was completed. 2. Resident #66 was admitted to the facility in January 2021. Review of a MDS assessment, dated 7/12/22, indicated Resident #66 was cognitively intact as evidenced by a BIMS score of 15 out of 15. On 8/23/22 at 9:09 A.M., the surveyor observed Resident #66 eating breakfast in his/her room. There was a cup on the bedside table containing several pills. The surveyor asked about the medications in the cup and Resident #66 said that Nurse #2 left them for him/her because he/she preferred to take them after breakfast. Review of a facility Clinical Self-Administration of Medication Informed Consent and Assessment form, signed by Resident #66 on 1/2/21, indicated that the Resident wished to have the Nurse administer his/her medications. The back of the form, titled Assessment of Resident's Cognitive, Physical and Visual Ability to Self-Administer Medications, was left blank. Review of the August 2022 Physician's orders indicated there was no order to self-administer medications. During an interview on 8/23/22 at 9:15 A.M., Nurse #2 said that he left Resident #66's 8:00 A.M. medications on the bedside table because Resident #66 liked to take them after eating breakfast. He further said that he administered the eye drops and hearing aids and left the remaining medications in the cup for the Resident to self-administer. Review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M.: -Metamucil 3.4 grams/5.4 gram oral powder (fiber supplement) -Artifical tears, (eye drops) -[MEDICATION(S)] extended release 150 milligrams (mg), (beta blocker) -Vitamin D3 50,000 International Units (IU), (vitamin D supplement) -[MEDICATION(S)] 5 mg, (blood pressure medication) -Tylenol extra strength 1000 mg, (pain reliever) -[MEDICATION(S)] 40 mg, (decreases uric acid in body) -[MEDICATION(S)] delayed release 20 mg, (treats acid reflux) -[MEDICATION(S)] [MEDICATION(S)] 325 mg, (iron supplement) During an interview on 8/24/22 at 10:46 A.M., the Infection Preventionist (IP) reviewed Resident #66's medical record with the surveyor and said there was no evidence that the Resident had been assessed to safely self-administer medications and there was no Physician's order for self-administration. The IP reviewed the Clinical Self-Administration of Medication Informed Consent and Assessment form, signed by the Resident on 1/2/21, and said the Resident indicated on the form that he/she wanted the Nurse to administer medications therefore, an assessment was not completed. She said an assessment must be completed when a Resident indicates that they wish to self-administer medications to determine if it would be clinically appropriate. The IP said that Nurse #2 should not have left the medications at the Resident's bedside for self-administration when there was no Physician's order and an assessment had not been completed.

Based on interviews and record review the facility failed to ensure staff assessed residents for signs and symptoms of COVID-19 every shift during an outbreak of COVID-19 within the facility, for two Residents (#1 and #2) out of a total of three sampled residents. Findings Include: Review of the facility policy titled Infection Control Guidelines for All Nursing Procedures, revised 4/16/22, indicated the following: -In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted. This may include organism specific guidelines for care and monitoring of Residents from The Centers for Disease Control (CDC), Massachusetts Department of Public Health (DPH), and or other authoritative entities. Review of the DPH memo titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated June 10, 2022 indicated the following: -Residents should be asked about COVID-19 symptoms and must have their temperatures checked a minimum of one time per day. On unit(s) conducting outbreak testing, a long-term care facility should assess residents for symptoms of COVID-19 during each shift. During an interview on 7/6/22 at 11:50 A.M., the Infection Preventionist (IP) said residents on both Unit 3 and Unit 4 were being tested on outbreak testing (testing for COVID-19 of all residents who are on a unit where a positive COVID-19 case has been identified to monitor for new cases). She further stated Unit 3's outbreak testing began 6/23/22. 1. Resident #1 was admitted to the facility 12/17/19. Review of the Resident's current Physician's Orders indicated the following order: -Monitor: Temperature Only, cough, shortness of breath, New or Worsening malaise, New dizziness, sore throat, loose stools, headache, or loss of taste or smell . -Protocol: Document absence or presence of symptoms in the comment section -Start Date/Time: 9/30/2020 . Review of the June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #2 was admitted to the facility 11/19/21. Review of the Resident's current Physician's Orders indicated the following order: -Monitor: Temperature, for cough, shortness of breath, New or Worsening malaise, New dizziness, sore throat, loose stools, headache, or loss of taste or smell daily . -Protocol: Document absence or presence of symptoms in the comment section. -Start Date/Time: 1/24/2022 . Review of the June MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/6/22 at 1:00 P.M., Nurse #1 said residents who are not positive for COVID-19 should be monitored every shift for signs and symptoms of COVID-19 when there are active COVID-19 cases on the unit. He further said Resident #1 and Resident #2 should have been being monitored every shift during the dates in question and they were not. During an interview on 7/6/22 at 4:40 P.M., the Director of Nursing said the facility follows DPH guidance related to COVID-19 monitoring for signs and symptoms and the guidance to monitor every shift was not followed for the Residents in question.

Based on observation, policy review and interview, the facility failed to maintain infection control precautions related to proper hand hygiene on one of four units observed. Findings include: On 12/29/21 at 12:30 P.M., the surveyor observed a Certified Nursing Assistant (CNA) propelling a resident seated in a wheelchair out of his/her room. The CNA was wearing gloves while holding a plastic bag containing soiled items and pushing the wheelchair. The CNA parked the wheelchair and disposed the plastic bag into a trash receptacle located in the hallway. The CNA then removed her soiled gloves, readjusted her mask and reentered the resident's room and was observed readjusting her goggles, mask before donning (put on) a new pair of gloves. She did not sanitize or wash her hands after doffing (removing) her soiled gloves or before adjusting her goggles, mask or donning new gloves. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 8/2015, indicated but is not limited to: Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing non-surgical invasive procedures; e. Before and after handling an invasive device ( example: urinary catheters, intravenous access sites); f. Before donning sterile gloves; g. Before handling clean or soiled dressing dressings, gauze pads, etcetera (etc); h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc; l. After contact with objects (example: medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; o. Before and after eating or handling food; p. Before and after assisting a resident with meals; and q. After personal use of the toilet or conducting your personal hygiene. During an interview on 12/29/21 at 12:35 P.M., the CNA said she did not wash or sanitize her hands after doffing the soiled gloves or before adjusting her mask, goggles and donning new gloves, as required. During an interview on 12/29/21 at 3:00 P.M., the Infection Preventionist said the CNA should not have propelled the resident's wheelchair while wearing soiled gloves and carrying a bag containing soiled items. She further said the CNA should have removed her gown and gloves in the resident's room and sanitized her hands prior to exiting the room.

Based on interviews and records reviewed, for one of six sampled residents (Resident #6), the Facility failed to ensure they reported an allegation of misappropriation, when in May 2021, nursing staff were made aware of an allegation the Certified Nurse Aide (CNA) # misappropriated a stuffed animal from Resident #6, however this was not reported to the Administrator and to the Massachusetts Department of Public Health within twenty four hours, as required. Findings include: Review of the Facility Policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 9/20/18, indicated that the Facility would ensure all allegations of abuse, neglect, exploitation or mistreatment, are reported immediately but not later than twenty four hours after the allegation is made if the allegation does not involve abuse and did not result in serious bodily injury, to the Administrator and to other officials, including the State Survey Agency (Massachusetts Department of Public Health). Review of Resident #6's Minimum Data Set Assessment, dated 10/05/21, indicated that his/her long, short memory skills, and his/her decision making skills were severely impaired. During an interview on 12/14/21 at 10:40 A.M., Nurse #4 said that she recalled an incident in which she reported that Resident #6's stuffed animal was missing. Nurse #4 said that Resident #6's family member brought in a stuffed animal for Resident #6 during a time when visits were restricted. Nurse #4 said that she brought the stuffed animal to Resident #6's room and said she gave it to him/her. Nurse #4 said that Resident #6 enjoyed carrying dolls or toys. Nurse #4 said a few days later, when she noticed that Resident #6 was not carrying the stuffed animal, she searched Resident #6's room and was not able to locate it. Nurse #4 said that she reported Resident #6's missing stuffed animal to Nurse #5. During an interview on 12/21/21 at 12:23 P.M., Nurse #5 said that Nurse #4 spoke to her about Resident #6's missing stuffed animal. Nurse #5 said that at the time Nurse #4 made the report, she (Nurse #5) was the Nurse Manager for Resident #6's unit. Nurse #5 said that she completed an incident report and said she provided the incident report to the Director of Nurses. Review of the Record of Resident and Family Concerns (grievance) Form, dated 5/21/21, indicated that Resident #6 was missing a Squishmallow Seal (stuffed animal) which Resident #6 received (as a gift from a family member) about two weeks prior. Nurse #4 said that a short time later she saw a photograph on CNA #1's social media account which showed CNA #1's family member holding a Squishmallow Seal. Nurse #4 said that she showed the photograph to Nurse #5 and said she told Nurse #5 that she thought CNA #1 had taken the Squishmallow Seal from Resident #6. Nurse #5 said that Nurse #4 showed her a photograph of a child holding a Squishmallow Seal and said that Nurse #4 told her the image came from CNA #1 social media account. Nurse #5 said that Nurse #4 told her that she thought CNA #1 misappropriated the stuffed animal from Resident #6. Nurse #5 said that she showed the Director of Nurses the social media image that Nurse #4 gave her and said she told the Director of Nursing that Nurse #4 thought CNA #1 misappropriated the stuffed animal from Resident #6. During an interview on 12/14/21 at 10:00 A.M., the Director of Nurses said that she did not recall Nurse #5 reporting that Resident #6's stuffed animal (Squishmallow Seal) was missing or that Nurse #4 thought CNA #1 misappropriated the stuffed animal from Resident #6. Review of the reports submitted by the Facility via the Health Care Facility Reporting System (HCFRS) indicated that there was no documentation to support the Facility ever having submitted a report of the allegation that CNA #1 misappropriated a stuffed animal from Resident #6 during May 2021 to the Department of Public Health. The Director of Nursing said there was no documentation to support that the allegation had been reported to the Administrator or the Department of Public Health, as required.

Based on observation, policy review and interview, the facility failed to ensure staff adhered to proper use of Personal Protective Equipment (PPE) related to COVID-19, on three out of three applicable units. Findings include: During an interview on 8/19/21 at 8:10 A.M., the Infection Preventionist (IP) said there were three staff members that had recently tested positive for COVID-19. The dates of positive results were 8/6/21, 8/10/21 and 8/13/21. The IP said that due to the staff positive results, the facility had implemented the following PPE protocols: -Units three, four, and post-acute: masks and eye protection for all resident contact; gown and gloves for high contact care. Review of the facility's policy for PPE, dated 8/16/21, indicated the following: -Our goal is to follow current guidelines set forth by the Department of Public Health (DPH), Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) for PPE use. -If any residents admitted for longer than 14 days or staff are confirmed to be COVID-19 positive within the past 14 days, healthcare personnel should wear additional PPE for the care of all residents on affected units . -Appendix A provides PPE guidance, based upon the resident's COVID-19 status. Review of Appendix A indicated for COVID-19 negative residents and COVID-19 recovered residents (>3 months from infection): When there are resident or staff case (s) identified within the last 14 days on the unit the recommended PPE includes face mask, face shield/goggles, gown and gloves. Gown use can be prioritized for high-contact resident care activities. Gown and gloves must be changed between residents. Review of the CDC website, Using PPE, dated 8/19/20, indicated the following: How to Take Off (Doff) PPE Gear: Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique . Remove gown. Untie all ties . Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. Healthcare personnel may now exit patient room. Perform hand hygiene On 8/19/21 the surveyor observed the following on Unit 2: -Upon entering the unit there were signs that indicated staff must wear mask, eye protection for all patient care and gowns and gloves during high contact care. -At 10:10 A.M., a disposable blue gown was clipped to the back of a resident room's door. -Several resident rooms had hooks on the wall, most were labeled nurse or CNA, several had either a disposable gown or a washable gown hanging on them. During an interview on 8/19/21 at 10:02 A.M., CNA #1 said she used washable gowns to care for the residents. She said she put it on the designated hook in each resident room and used it the entire shift. She said at the end of the shift the gowns were put in the dirty linen bin. During an interview on 8/19/21 at 10:13 A.M., Nurse #1 said they used the blue disposable gowns for the entire shift then they threw them away at the end of the shift. Nurse #1 accompanied the surveyor into a resident room and the surveyor observed a hook labeled CNA that held a disposable gown, and a hook labeled nurse that also held a disposable gown. The surveyor asked Nurse #1 if the disposable gown on the nurse hook was hers and she said it wasn't and that it was probably left there from the nurse that worked the prior shift. She said it should have been thrown out at the end of the shift. On 8/19/21 the surveyor observed the following on Unit 3: -Upon entering the unit there were signs that indicated staff must wear mask, eye protection for all patient care and gowns and gloves during high contact care. -Several resident rooms had hooks on the wall or behind the doors, most were labeled nurse or CNA, several had disposable gowns hanging on them. During an interview on 8/19/21 at 10:50 A.M., Nurse #2 said they got a disposable gown in the hallway prior to entering a resident room to provide direct care. She said the disposable gowns were then left in each resident room to be used for the whole shift. She said at the end of the shift they got thrown out. On 8/19/21 the surveyor observed the following on the Post-Acute Unit: -Upon entering the unit there were signs that indicated staff must wear mask, eye protection for all patient care and gowns and gloves during high contact care. -Several of the resident room doors were closed. During an interview on 8/19/21 at 11:10 A.M., CNA #2 said they get the washable gowns at the start of their shift, they kept the gowns on hooks inside the resident rooms and they remove them at the end of the shift to be cleaned. During an interview on 8/19/21 at 11:25 A.M., CNA #3 said he brought a gown into the resident's rooms when he first provided care and hung the gown on the hook in their rooms to be used the whole shift. During an interview on 8/19/21 at 12:50 P.M., the IP said the staff should not have been using the hooks at all. She said all gowns (disposable or washable) were for one-use only and should not have been put on hooks for re-use. She said they did not have a gown shortage and were in conventional capacity (no change to daily practice of infection control).

Based on interview and license review, the facility failed to ensure the Administrator was licensed in Massachusetts, as required. Findings include: During an interview on 8/19/21 at 8:40 A.M., the Administrator said she was the President and CEO of the facility and was the interim Administrator until they found a new one. She said the last Administrator left about two weeks prior and they were in the process of hiring a new one. During an interview on 8/19/21 at 12:10 P.M., the Administrator said she had Nursing Home (NH) Administrator Licenses in several states with the most current one being in Washington. She provided the license number to the surveyor. She said she didn't have a NH Administrator license for Massachusetts.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was at increased risk for falls, required the use of a gait belt and the assistance of one staff member for ambulation, the Facility failed to ensure his/her safety was maintained during mobility to prevent a fall resulting in injury. On 6/03/21, while assisting Resident #1 with ambulation, Certified Nurse Aide (CNA) #1 turned away from Resident #1 to get a wheelchair, briefly let go of the gait belt, Resident #1 fell backwards, and hit his/her head on the floor. Resident #1 was transferred to the Hospital Emergency Department for an evaluation and was diagnosed with a Subarachnoid (space between the brain and the tissues covering the brain) Bleed and a Sacral (triangular bone at the end of the spine) fracture. Findings include: Resident #1 was admitted to the Facility in August 2018, diagnosis included Dementia, [CONDITION(S)], Mood Disorder, Major Depressive Disorder, Chronic Kidney Disease and [CONDITION(S)]. Review of Resident #1's Care Plan Activity Report, dated 12/07/20, indicated that he/she required a gait belt for all transfers and during ambulation. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she required the assistance of one staff member for ambulation. Review of Resident #1's Nursing Falls Comprehensive Assessment, dated 4/26/21, indicated that he/she is a high risk for falls. Review of Resident #1's Nursing Summary, dated 5/31/21, indicated Resident #1 required the assistance of one staff member for ambulation, and he/she had functional limitations that included the following; unsteady gait, generalized weakness, no sense of direction/destination and unaware of his/her surroundings/environment. Review of the Facility's Investigation, dated 6/07/21, indicated that on 6/03/21, Certified Nurse Aide (CNA) #1, while assisting Resident #1 with ambulation in his/her room, CNA #1 briefly let go of Resident #1's gait belt to turn around to grab his/her wheelchair to follow behind resident, at which time Resident #1 fell backwards, hitting his/her head on the floor and was transferred to the hospital. The Investigation indicated that Resident #1 required the assistance of one staff member for ambulation, with gait belt, and a wheelchair for long distances. The Investigation indicated that Resident #1 returned to the Facility with a diagnosis of a Subarachnoid (space between the brain and the tissues covering the brain) Bleed and Sacral (triangular bone at the end of the spine) Fracture. Review of the Facility's Competency titled, Resident Assist Transfer Using Gait Belt, undated, indicated staff are required to hold the gait belt (a safety assistive device placed on a resident and used to transfer residents from one location to another) throughout the resident's transfer. During an interview on 7/07/21 at 12:48 P.M., the Physical Therapist (PT) said Resident #1 required the assistance of one staff member for ambulation with a gait belt prior to his/her fall on 6/03/21. The PT said nursing staff, including Certified Nurse Aides, were educated to hold onto the resident's gait belt the entire time during the task, when transferring and ambulating a resident, until the resident is safely sitting or lying down. The PT said when Resident #1 returned back to the Facility after the fall, Resident #1 required the assistance of two staff members for transfers and ambulation with a gait belt. The PT said Resident #1 had poor mobility and was observed to be in pain from the fracture, which resulted in Resident #1 having limited movement. During an interview on 7/07/21 at 1:43 P.M., CNA #1 said on 6/03/21, she assisted Resident #1 with ambulation, that she was going to assist him/her to ambulate to one of the Facility's common areas. CNA #1 said while ambulating Resident #1 that day, he/she fell , hit his/her head and was sent to the hospital. CNA #1 said at the time of the incident, Resident #1 was standing up in front of her, and her left hand was holding onto Resident #1's gait belt, in the back of the resident. CNA #1 said, with her right hand she reached behind herself to grab Resident #1's wheelchair. CNA #1 said that the wheelchair was out of her reach and said she briefly let go of Resident #1's gait belt to grab the wheelchair. CNA #1 said that was when Resident #1 fell backwards hitting his/her head on the floor. CNA #1 said Resident #1 required the assistance of one staff member for ambulation, with gait belt, and said staff needed to bring the wheelchair when assisting him/her to walk for long distances. CNA #1 said she is aware that it is Facility's policy for staff to hold onto the gait belt at all times during a resident transfer and while ambulating, and said she knows staff are not to let go of the gait belt until the resident is safe. During an interview on 7/14/21 at 8:30 A.M., Nurse #1 said on 6/03/21, she heard CNA #1 yelling and calling for help. Nurse #1 said upon arrival to Resident #1's room, Resident #1 was lying on the floor, and said she observed bleeding coming from behind his/her head. Nurse #1 said she immediately applied pressure to Resident #1's head to stop the bleeding and said Resident #1 was yelling in pain when even just lightly touched, while she attempted to assess him/her. Nurse #1 said she called for additional help and called Emergency Medical Services (EMS) to transfer Resident #1 to the hospital. Nurse #1 said CNA #1 told her she was assisting Resident #1 with ambulation to the common area, and that CNA #1 said she had let go of Resident #1's gait belt to reach for his/her wheelchair, and that Resident #1 fell backwards and hit his/her head. Nurse #1 said when ambulating with a resident it is important at all times to keep your hands on his/her gait belt until the resident is safe. During an interview on 7/07/21 at 4:54 P.M., the Director of Nurses (DON) said CNA #1 reenacted what had happened on 6/03/21 when assisting Resident #1 with ambulation in his/her room. The DON said CNA #1 said she had taken her hands off of Resident #1's gait belt to grab his/her wheelchair, and that was when Resident #1 fell backwards and hit his/her head. DON said it is best practice to follow the residents Plan of Care and for staff to keep their hands on residents gait belt at all times during a transfer and/or ambulation, until the resident safe. On 7/07/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. Resident #1 returned to the facility on [DATE]. B. Resident #1's Plan of Care was reviewed and updated, as needed to indicated he/she required two staff member assistance for transfers and ambulation, with a wheeled walker and gait belt. C. Nursing staff were in-serviced (from 5/27/21 to 6/10/21) with mandatory education for all nurses and CNA's provided by staff Development Coordinator. D. The Unit Manager, on 6/04/21, provided CNA #1 one to one education, which included following residents Plan of Care and gait belt use during resident transfers and or ambulation. E. CNA Meeting conducted April, May and June 2021 and concern areas discussed with CNA's and will continue. F. Nurse Meeting conducted April, May and June 2021 and concern areas discussed with Nurses and will continue. G. Nurse Management Meeting conducted 5/05/21, 5/26/21 and 5/09/21 and concern areas discussed with Unit Managers and will continue. H. Risk Project Summary conducted on 5/27/21 and concerns with Falls, Care Plan Compliance, Gait Belt Use and Transfer Training with staff will remain ongoing. I. The DON and his/her designee is responsible for overall compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who required the assistance of two staff members for transfers, the Facility failed to ensure that he/she was provided with adequate assistance to prevent accidents or injury, when on 7/9/20, Certified Nurse Aide (CNA) #1 transferred Resident #1 alone and he/she sustained a laceration to his/her leg which required seven sutures to close. Findings include: The Facility's Investigation, dated 7/9/20, indicated that, Certified Nurse Aide (CNA) #1 transferred Resident #1, who's Comprehensive Plan of Care indicated two staff members were needed when assisting him/her with a transfer, from his/her wheelchair into his/her bed. The Investigation indicated that Resident #1's leg caught on the bed rail and caused a skin laceration which required seven sutures to close. Resident #1 was admitted to the Facility in December 2019, [DIAGNOSES REDACTED]. The Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 6/19/20, indicated that Resident #1 began OT on 6/18/20, due to difficulty with functional transfers and history of falls on 6/6/20 and 6/14/20. Resident #1's Quarterly Minimum Data Set, dated dated [DATE], indicated that he/she required limited assistance from two staff members during a transfer. Resident #1's Plan of Care, dated 6/25/20, indicated he/she required two staff members to assist with ambulation, transfers, and bed mobility. During an interview on 8/10/20 at 3:45 P.M., the Charge Nurse said that on 7/9/20, Resident #1 was in the dining room and he/she was yelling and uncontrollably crying, and said CNA #1 assisted Resident #1, who was in a wheelchair, out of the dining room and transported him/her back into his/her room. The Charge Nurse said that a staff member notified her that Resident #1 was hurt and bleeding, and CNA #1 needed help. The Charge Nurse said Resident #1 was transferred to the hospital following the incident. The Hospital Record, dated 7/9/20, indicated that Resident #1 presented to the Emergency Department with a skin tear which was dressed and his/her laceration was repaired with sutures. During an interview on 8/11/20, at 5:20 P.M., CNA #1 said that Resident #1 was not typically on his/her care assignment but he helps him/her with care as needed. CNA #1 said that on 7/9/20, he assisted Resident #1 with a transfer which resulted in an injury. CNA #1 said that after the incident, he looked at the Resident #1's medical record and saw that he/she required two staff members to assist him/her during a transfer.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who required the assistance of two staff members for transfers, the Facility failed to ensure that interventions identified in his/her Comprehensive Plan of Care related to transfers were implemented and followed. On 7/9/20, Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her wheelchair into his/her bed and his/her leg scraped the bedside which caused a laceration that required seven sutures to close. Findings include: The Facility's Investigation, dated 7/9/20, indicated that Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her wheelchair into his/her bed. The Investigation indicated that Resident #1's leg caught on the bed rail and caused a skin laceration which required seven sutures to close. The Resident Incident Investigation Report, dated 7/9/20, indicated that staff members were re-educated that Resident #1 required two staff members to assist him/her with all Activities of Daily Living (ADL) and transfers. Resident #1 was admitted to the Facility in December 2019, [DIAGNOSES REDACTED]. The Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 6/19/20, indicated that Resident #1 began OT on 6/18/20, due to difficulty with functional transfers and history of falls on 6/6/20 and 6/14/20. Resident #1's Quarterly Minimum Data Set, dated dated [DATE], indicated that he/she required limited assistance from two staff members during a transfer. Resident #1's Plan of Care, dated 6/25/20, indicated he/she required two staff members to assist with ambulation, transfers, and bed mobility. During an interview on 8/10/20, at 3:45 P.M., the Charge Nurse said that Resident #1's Plan of Care was updated with new interventions that indicated he/she required two staff members with transfers due to his/her behaviors such as increased anxiety, weakness and a tendency to buckled his/her knees. During an interview on 8/11/20, at 5:20 P.M., CNA #1 said that Resident #1 was not typically on his/her care assignment but he helps him/her with care as needed. CNA #1 said that on 7/9/20, he assisted Resident #1 with a transfer which resulted in an injury. CNA #1 said that after the incident, he looked at the Resident #1's medical record and saw that he/she required two staff members to assist him/her during a transfer.

Based on record review and staff interview, the facility staff failed to ensure that the 1 resident (#126) received adequate supervision and assistance devices to prevent falls, out of 11 applicable residents, in a total sample of 26 residents. Findings include: For Resident #126, the facility staff failed to prevent the resident from falling and sustaining 2 fractures. The resident was observed on the floor next to his/her bed and the bed alarm did not sound. The resident sustained [REDACTED]. Resident #126, was admitted to the facility in 4/2018, with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 4/20/18, indicated that the resident had a history of [REDACTED]. The falls care plan included the following interventions: - Anticipate the resident's needs with regards to activities of daily living. - Ensure that the call bell is kept within reach. - Pressure (bed pad) alarm in bed. Review of the Admission Minimum Data Set (MDS) Assessment, dated 4/26/18, indicated that the resident's short and long term memory was impaired, the Resident required extensive assistance with transfers and ambulation, and had sustained falls prior to his/her admission to the facility. Review of the Significant Change MDS Assessment, dated 7/10/18, indicated that the resident was severely cognitively impaired as evidenced by a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS), required limited assistance with transfers, extensive assistance with ambulation, and had not sustained any falls since admission to the facility. Review of the Nurse's Note, dated 7/24/18, indicated that the resident experienced a witnessed fall. The resident leaned forward and fell out of his/her wheelchair, hitting his/her head on the closet door. The resident did not sustain an injury. Review of the Quarterly MDS Assessment, dated 10/2/18, indicated that the resident's short and long term memory was impaired, the resident required extensive assistance with transfers and ambulation and sustained 1 fall with injury (except major) since the last MDS Assessment. Review of the Nurse's Note, dated 12/7/18, indicated that at 9:00 P.M., the resident was observed in bed calling out dad. Further review of the Nurse's Note indicated that the resident was observed on the floor between 9:15 and 9:30 P.M., the bed alarm did not sound, and the resident was placed onto the bed, utilizing a Hoyer (mechanical) lift, for assessment. The Nurse's Note further indicated that the resident was difficult to assess, guarding and striking out at the staff. Upon standing the resident was holding up his/her left leg and would not put pressure on the leg. The physician ordered x-rays. Review of the Immediate Post Fall Investigation, dated 12/7/18, indicated that the resident's bed alarm did not sound. The investigation further indicated that the alarm was working at 3:00 P.M., the resident was assisted to bed at 7:30 P.M., the alarm broke during care, and the alarm did not sound when the resident fell . The investigation further indicated that an immediate intervention to prevent recurrence was to always check alarms and replace any broken alarms. Review of the Nurse's Note, dated 12/8/18, indicated that the resident cried out in pain with care. Further review of the Nurse's Note, indicated that the resident had a reddish, purple bruise on the left forehead, at the hairline with swelling. The Nurse's Note further indicated that the x-ray results showed a left distal clavicle fracture. The resident was sent to the hospital for an evaluation at 11:10 A.M. and returned at 2:55 P.M. Review of the Nurse's Note, dated 12/10/18, indicated that while the resident was at the hospital, additional x-rays were performed. The Nurse's Note further indicated that the clavicle fracture was confirmed, a Computed Tomography (CT) scan of the head was completed with negative results, and an x-ray of the resident's left hip was suspicious for an impacted [MEDICAL CONDITION] femoral neck. The Nurse's Note further indicated that the resident's Health Care Proxy (HCP) chose not to treat the resident surgically and the resident returned to the facility on comfort measures. During an interview with CNA (Certified Nursing Assistant) #1 on 1/7/19 at 1:55 P.M., she said that the resident tried to get up independently. CNA #1 said that the resident's alarm would sound, so she would run into the resident's room to assist the resident. She further stated that the resident had a bed pad alarm and that alarms were checked to ensure that they are working at the beginning of each shift. During an interview with Unit Manager (UM) #1 on 1/7/19 at 2:10 P.M., she said that the assumption was that the resident's bed pad alarm broke during care. The clip was in the alarm box so the alarm did not sound. During an interview with the Director of Nursing (DON) on 1/7/19 at 2:39 P.M., she said that she received a call from UM #1 stating the resident fell and they were awaiting x-rays of the left hip. The DON said that UM #1 told her that the resident was found on the floor during rounds. The DON said that UM #1 told her that when they lowered the bed during care, the alarm broke and did not sound when the resident fell . The DON further said that the staff were unaware that the alarm was broken until the fall and that the alarm should have been checked after care was performed.

Based on record review and interviews, the Facility failed to ensure that a system was established for developing and implementing effective plans of care for preventing falls or elopement and for a structure to identify when the plan of care was not followed. The Facility failed to ensure that Residents had a safe and secure environment with functional and effective fire door alarms and accurate emergency alert panels to notify the staff to the location of emergencies related to the Fire Door on 2 of 4 Units (Units 3 and 4). Findings include: On 4/26/16 at 4:00 P.M., in the presence of the Administrator, the Surveyor reviewed the Facility's Quality Assurance and Performance Improvement Records for falls, dated October 2015 through January 2016, including signature sign in sheets, and the trending of falls reviewed. Although they were tracking and monitoring falls and accidents, the facility had not ensured within the Quality Assurance and Performance Improvement Records that effective interventions were in place when the care plans were reviewed and revised. The Quality Assurance Committee had not ensured the environment was safe and secure on 2 of 4 units (units 3 and 4) with accurate emergency alert panels and a system to monitor the alarms prior to Resident #1's injuries on 3/10/16. The Administrator Chair Person of the Quality Assurance Committee said he was unaware of any concerns related to residents with repeated falls whose care plan with interventions that were not followed or that were ineffective for keeping residents safe. The Quality Assurance Committee received information regarding environmental rounds for safety for the 4 Units. But there were no preventive maintenance or quality indicators for monitoring the emergency alarm panels, the tab alarms put on exit doors, or the fire door alarms which had been identified during survey. The environment on Unit 3 and Unit 4 had not been adequately assessed to protect the residents at risk for elopement. The nursing staff did not have a method (prior to 3/10/16) to accurately detect and identify the emergency alarm sound and intervene immediately. The facility did not assess and educate the staff regarding the fire door alarms in differentiating them from the multiple other alarms on units 3 and 4. The Surveyor interviewed the Director of Maintenance on 4/19/16 at 10:35 A.M. and on 4/20/16 at 10:15 A.M. The Director of Maintenance said he did not check the battery in the tab alarm that was attached to the fire doors, and he did not have safety checks of the fire doors or the emergency alert panels in the resident care areas. The Administrator on 4/20/16 said that he only recently was made aware that the emergency alert panel on Units 3 and Units 4 were not installed correctly. The fire door alarms for Unit 3 and Unit 4 (on the Dementia Unit) are in Pod 1, but they incorrectly notified the nursing staff to the wrong location on Pod 2. So when the fire door located in Pod 1 was opened, it notified the staff in the 2 Certified Nursing Aide Stations that the alarm was in Pod 2. The Surveyor interviewed Unit Manager #1 on 4/19/16 at 2:45 P.M. Unit Manager #1 said that prior to Resident #1 breeching the fire door, she had not been aware that the battery for the tab alarm on the Fire door for Unit 4 (the Dementia Unit) was not being checked by anyone. Unit Manger #1 said the fire door alarm sounded like the call bell alarms in the Resident rooms, and therefore it could be difficult to differentiate. The emergency alert panels incorrectly notified the staff as to the correct location of Resident #1, who was in the stairwell on the other side of the fire door. The Surveyor interviewed Unit Manager #1 at 2:17 P.M. on 4/20/16. Unit Manager #1 said that the falls care plan was not followed for the falls that occurred on 11/22/15, 12/30/15, 1/2/16, and 3/10/16, because Resident #1 was left unsupervised in the common area. The Surveyor interviewed Unit Manager #2 at 9 A.M. on 4/26/16. Unit Manager #2 said prior to Resident #1 breeching the fire door on 3/10/16, the fire door alarms did not have a sound distinct from the other multiple alarms on the unit. The fire door alarm did not sound loud enough, and the incorrect emergency alert panel lit up for Pod 1 and Pod 2 on Unit 3. During a tour on 4/26/16 at 12:15 P.M. with Unit Manager #3, it was observed that the tab alarm on the egress door to the large Activity Room to the outside had been shut off. This large Activity Room is utilized for 11 to 15 Dementia Residents on Unit 4 (the secured unit) every Tuesday. Unit Manager #3 said this alarm should never have been shut off. During a tour at 9:45 A.M. on 4/26/16 with Unit Manager #3, on Unit 2, the label above the emergency alert panel which was used to identify the correct location of a Resident needing assistance, had numbers hand written over the previous numbers, which could potentially create a delay in identifying the location of the alarm. Prior to Resident #1's fall down the stair well on 3/10/16, 13 of 19 Residents on Unit 4 who were identified as being elopement risks and 5 of 33 Residents on Unit 3 were at risk requiring a safe environment. The Pod alarms for Pod 1 and Pod 2 incorrectly identified the location of the emergency. These alarm panels were incorrectly installed approximately [AGE] years ago and this problem was not identified unit Resident #1 sustained a significant injury and death.

Based on records reviewed, interviews and observations, for 1 of 3 sampled residents (Resident #1), the Facility failed to provide an environment free of accidental hazards and failed to provide adequate supervision. Resident #1, whose Falls Prevention plan of care indicated he/she was at risk high risk for falls and elopement/exit seeking. The care plan of [DATE] indicated Resident #1 was to be in the common area with staff or activities when out of bed. On [DATE], [DATE], and [DATE], Resident #1 fell while unsupervised in common areas, but no corrective action was taken in response on [DATE],. Resident #1 was not being supervised in the common area as care planned. On [DATE], Resident #1 fell down nine stairs in a wheelchair and sustained a subdural hematoma (an abnormal collection of blood in the skull, usually due to trauma and lacerations to the forehead and arm. Resident #1 subsequently died 3 days after that fall. Findings include: The Lost Resident Elopement Plan, dated [DATE], stated that it is the policy of the facility to ensure all residents are safe from inadvertent elopement. An eloped resident will be termed as a resident /patient who had intentionally/unintentionally exited this facility without notifying staff, or a resident who is exit seeking and has left their unit/area last seen. Resident #1 was admitted to the Facility in ,[DATE]. Resident #1's [DIAGNOSES REDACTED]. The Facility's fall Risk Reduction Program, dated [DATE] stated that the goal of the falls risk reduction program was to evaluate the resident's risk for falls, take action to reduce the risk of falling and reduce the risk of injury should a fall occur. The fall team will review each resident falls and will include circumstances surrounding the fall and the development of a plan to prevent further falls. The Fall Risk Assessment, dated [DATE], indicated Resident #1 was a high risk for falls. The Elopement Prevention care plan of [DATE], indicated Resident #1 was at risk for elopement. He/she self propels in a wheelchair on the Unit and seeks family members and his car to go home. Interventions included to redirect Resident #1 and encourage him/her to engage in activities. The Rehabilitation Evaluation, dated [DATE] to [DATE], indicated that Resident #1 was unable to recall information in regards to new environment, and recommended having assistance for standing and transferring at this time and had poor safety awareness and poor judgment. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 was severely cognitively impaired, required extensive assistance of 2 persons for transfers, ambulation and toilet use. This Resident had wandering behavior (defined as seemingly oblivious to needs or safety) in the previous 4 to 6 days, but less than daily. The Nurse's Note, dated [DATE], indicated that Resident #1 was confused, a wanderguard was placed on Resident #1's ankle, chair and bed alarms were initiated. The care plan interventions were updated on [DATE] to include that Resident #1's room will be free of clutter. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had a witnessed fall in the hallway on [DATE] at 7:55 P.M. The chair alarm sounded when Resident #1 stood up from the wheelchair and lost his/her balance. Staff members were unable to intervene to prevent the fall and Resident #1 sustained a reddened area to the forehead, which measured 1.5 centimeters (cm) by 1.2 cm. The falls care plan was updated on [DATE] to include a one assist for transfers, and ambulate with a rolling walker and gait belt. The Psychosocial wellbeing care plan, dated [DATE], indicated that Resident #1 was exit seeking with efforts to go home and was at risk for elopement. The falls care plan was updated on [DATE] to include a bathroom door alarm. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had an unwitnessed fall on [DATE] at 9:30 A.M. Resident #1 had unlatched the bathroom door alarm, and the chair alarm sounded, and he/she was found sitting on the bathroom floor. The falls care plan was updated on [DATE] to include a bedroom and bathroom door alarm. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had an unwitnessed fall on [DATE] at 1:20 A.M. Resident #1's bed and tab alarm sounded, and he/she was found on the floor at the foot of his/her bed. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had a fall witnessed by the Housekeeper on [DATE] at 8:10 A.M. Resident #1's chair alarm sounded and the Housekeeper was unable to reach Resident #1 in time to prevent his/her fall. The falls care plan was updated on [DATE] to include that Resident #1 was to be in common area with staff, or engage in activities (programs), when he/she was out of bed. The Nurse's Note and the falls investigation, both dated [DATE], the documentation indicated that Resident #1 was in bed and had an unwitnessed fall on [DATE] at 1:20 A.M. Resident #1's bed alarm sounded and he/she was found sitting on the floor in his/her room. Resident #1 sustained abrasions to both elbows and right ear. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had a unsupervised fall on [DATE] at 9:30 P.M. in the Dining Room (a common area). The chair alarm sounded, Resident #1 was unsupervised standing up from his/her wheelchair and holding the handrail along the wall, and missed the wheelchair while trying to sit back down. Staff members were unable to intervene in time. No injuries were sustained. The post fall review indicated that education was done with the staff, not to leave Resident unsupervised in the common area. The Quarterly MDS assessment, dated [DATE], indicated Resident #1 had disorganized thinking and wandering behavior in the past 1 to 3 days, was a two person physical assist with transfers, locomotion on unit is an extensive assist of one person and had falls without injury. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had an unwitnessed fall on [DATE] at 1:15 P.M. in the Kitchenette Area (a common area). There were no staff members present during this incident. This was not consistent with Resident #1's plan of care. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had an unwitnessed fall on [DATE] at 9:55 A.M. in the Kitchenette Area (a common area) there were no staff present during this incident. The chair alarm did not sound (there was a question if the Resident had removed it) and it was found not to be attached. No injuries were sustained. There was no indication the facility identified that the [DATE] Fall Prevention care plan was not being followed at the times of [DATE] and [DATE] falls. For the fall of [DATE] inservice education was provide to the staff, not to leave Resident #1 unsupervised in the common areas. The post fall investigation of [DATE] indicated Resident #1 would have 15 minute visual checks. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had an unwitnessed fall on [DATE] at 7:00 A.M. in the Resident's bathroom, the bed alarm was going off. The witness statements indicated Resident #1 was impulsive and had urinary urgency. Resident #1 sustained sustained a skin tear to the right arm and steri strips were applied. The falls care plan was updated for a Rehabilitation evaluation and 15 minute visual checks. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had an unwitnessed fall on [DATE] at approximately 6:36 P.M. and was found by Dietary Aide #1 face down in the stair well with his/her wheelchair strapped on to him (he/she fell down 9 steps). Resident #1 was last seen by the staff when he/she was sitting in the main dinning area (a common area) in the witness statement, dated [DATE]. Resident #1 was not being supervised, which was not consistent with the plan of care. There were no staff present during this incident. They were in other Resident rooms. Resident #1 was last seen at 6:15 P.M., sitting in the main Dining Area (common area) propelling him/herself in a wheelchair. The Surveyor interviewed Dietary Aide #1 at 10:25 A.M. Dietary Aide #1 said that on [DATE] at 6:33 P.M., she finished cleaning the dishes in Pods 5 and 6 (which is the Unit on the opposite of the floor from Pod 1 and Pod 2). Dietary Aide #1 then walked to Pod 1 and Pod 2. Dietary Aide #1 said she was in the Kitchen area of Pod 1 and Pod 2, and she turned on the sink faucet in the Kitchenette area, and then she heard Resident #1 yelling for help from behind the fire door in Pod 1. Dietary Aide #1 entered the push button code and opened the fire door. Dietary Aide #1 said she found Resident #1 on the bottom of the first group of stairs lying face down, still strapped to his/her wheelchair, and there was blood everywhere, and she called for help. Nurse #1's witness statement indicated the tab alarm on the fire door did not sound and the emergency alert panel notified the staff to an emergency in Pod 2 the incorrect location, the fire door which alarmed is located in Pod 1. The Surveyor interviewed Unit Manager #1 at 2:17 P.M. on [DATE]. Unit Manager #1 said that the falls care plan was not followed for the falls that occurred on [DATE], [DATE], [DATE], and [DATE], because Resident #1 was left unsupervised in the common area. Unit Manager #1 said that Resident #1 was exiting seeking on admission in April of 2015. The Surveyor interviewed Nurse #1 at 3:40 P.M. on [DATE]. Nurse #1 said that she left Resident #1 unsupervised in the common area prior to the fall on [DATE] at approximately 6:36 P.M. to perform a treatment in another resident's room. Nurse #1 said she did not assign another staff member to supervise Resident #1 in the common area prior to leaving the area prior to leaving the area. Tour of Unit 4 on Pod 1 and Pod 2, with the Maintenance Director at 10:35 A.M. on [DATE]. The Maintenance Director identified the stairwell fire door as the one the Resident used to exit Pod 1 and go down a flight of stairs. The fire door was in close proximity to the Resident dinning area. The Surveyor interviewed Maintenance Director on [DATE] at 10:35 A.M. The Maintenance Director said that the fire door in Pod 1 had a 15 second delayed release door with a crash bar to open the door. This fire door had an automatic door closed on it; once it was opened, it then closes in seconds and the alarm sounded until the push button code was entered. The Surveyor interviewed Certified Nursing Assistant (CNA) #1 at 12:10 P.M. on [DATE]. CNA #1 said that for the fall of [DATE] at approximately 6:30 P.M., Resident #1 was left unsupervised on [DATE] because the staff members were in Resident Rooms providing care. CNA #1 said that one staff member was always supposed to be in the common area supervising the Residents and on [DATE], but no one was supervising the Residents. CNA #1 said on [DATE], she heard an alarm sound which indicated a emergency light was activated in Pod 2. CNA #1 said it was later determined that the emergency light and alarm was a fire door in Pod 1. The emergency alert panel had incorrectly identified the location of the activated door alarms Pod 2 when the fire door was located in Pod 1 and it created confusion as staff could not find where the alarm was coming from. The Surveyor interviewed CNA #2 at 1:50 P.M. on [DATE]. CNA #2 said that on [DATE] at approximately 6:36 P.M. emergency alarm panels (in Pod 1 and Pod) indicated the wrong location of the emergency. CNA #2 said in response to the alarm, the alarm panel indicated that the alarm was sounding in Pod 2 when it was in Pod 1. CNA #2 said and thought it was a Resident's call bell. The staff checked Pod 2, but it was later determined Resident #1 opened and passed through a door at the top of a flight of stairs in Pod #1. The staff could not find where the alarm was sounding, nor were the staff familiar with fire door alarm sound the staff was looking for a Resident call light. CNA #2 said there was a second alarm on the Pod 1 exit fire door, but this did not sound to alert staff when Resident #1 opened the door on [DATE], prior to falling down the stairs. Review of the physician's orders [REDACTED].M. indicated an order to transfer Resident #1 to the Hospital. The Surveyor interviewed Unit Manager #1 at 2:17 P.M. on [DATE]. Unit Manager #1 said that the falls care plan was not followed for the falls that occurred on [DATE], [DATE], [DATE], and [DATE], because Resident #1 was left unsupervised in the common area. The Emergency Department Record, dated [DATE], indicated Resident #1 had sustained a fall on a secured unit, was found to have an acute large left subdural hematoma and facial trauma, and was in significant pain. The emergency room Physical Examination, dated [DATE], indicated blood in Resident #1's mouth, an avulsed tooth, the left eye swollen shut, a laceration on the left side of the nose, and abrasions and contusions to the face, upper and lower extremities. Emergency Department Physician discussed treatment options with Resident #1's family, and it was decided not to have aggressive treatment. Resident #1 was transferred back to the Facility and received comfort and hospice care. Resident #1 died at 12:00 A.M. on [DATE]

Based on records reviewed and interviews, the Facility failed to ensure for 1 of 3 residents (Resident #1), that the Plan of Care for Falls and elopement prevention was followed. Resident #1, who's fall prevention care plan indicated he/she was to be supervised in common area on [DATE], [DATE] and [DATE]. Resident #1 experienced an unwitnessed fall on [DATE], he/she fell down a flight of stairs in a wheelchair, sustained a subdural hematoma and died 3 days later. Findings include: Resident #1 was admitted to the Facility in ,[DATE]. Resident #1's [DIAGNOSES REDACTED]. The Fall Risk Assessment, dated [DATE], indicated Resident #1 was a high risk for falls. The Psychosocial wellbeing care plan, dated [DATE], indicated Resident #1 was exit seeking in efforts to go home and was at risk for elopement. The Quarterly MDS assessment, dated [DATE] indicated Resident #1 was severely cognitively impaired, had disorganized thinking and wandering behavior (defined as seemingly oblivious to needs and safety) in the past 1 to 3 days, required a two person physical assistance with transfers and had falls without injury. The Falls Prevention care plan, dated [DATE] indicated that Resident #1 was to be in the Common Area with staff, or engage in activities (programs), when he/she was out of bed. The Elopement Prevention care plan of [DATE], indicated Resident #1 was at risk for elopement. He/she self propelled in a wheelchair on the Unit and seeks family members and his car to go home. Interventions included to redirect Resident #1 and encourage him/her to engage in activities. The Nurse's Note and the falls investigation, both dated [DATE], indicated that Resident #1 had an unsupervised fall on [DATE] at 9:30 P.M. in the Dining Room (a common area). The documentation indicated that a chair alarm sounded, Resident #1 was unsupervised standing up from his/her wheelchair and holding the handrail along the wall, and missed the wheelchair while trying to sit back down. Staff were in area, but not close enough to allow members to intervene in time. The post fall review indicated that education was done with the staff, not to leave Resident unsupervised in the common area. The Nurse's Note and the falls investigation both, dated [DATE], indicated Resident #1 had an unwitnessed fall on [DATE] at 1:15 P.M. in the Kitchenette Area (a common area). There were no staff present during this incident. This was not consistent with the plan of care. The Nurse's Note dated and the falls investigation, both dated [DATE] indicated Resident #1 had an unwitnessed fall on [DATE] at 9:55 A.M. in the Kitchenette Area (a common area) there were no staff present during this incident. For the fall of [DATE] inservice education was provide to the staff, not to leave Resident #1 unsupervised in the common areas. There was no documentation to indicate the facility identified that the [DATE] care plan was not being followed at the time of [DATE], [DATE] and [DATE] falls. The care plan was updated with 15 minute checks after the falls of [DATE]. The care plan was updated for a chair sensor alarm after the fall of [DATE]. The Nurse's Note and the falls investigation, both dated [DATE] indicated Resident #1 had an unwitnessed fall on [DATE] at approximately 6:36 P.M. and was found by Dietary Aide #1 face down at bottom of the stairs well platform with his/her wheelchair strapped on to him (he/she fell down 9 steps). Resident #1 sustained a subdural hematoma (an abnormal collection of blood in the skull, usually due to trauma) and lacerations to the left arm and face. The note indicated Resident #1 was last seen by the staff when he/she was sitting in the main dinning area (a common area). There were no staff present during this incident. This was not consistent with Resident #1's fall prevention plan of care. The Surveyor interviewed Unit Manager #1 on [DATE]. Unit Manager #1 said that the falls care plan was not followed for the falls that occurred on [DATE], [DATE], and [DATE] because Resident #1 was left unsupervised in the common area. Unit Manager #1 said that Resident #1 was exiting seeking on admission in April of 2015. The Surveyor interviewed Nurse #1 at 3:40 P.M. on [DATE]. Nurse #1 said that she left Resident #1 unsupervised in the common area prior to the fall on [DATE] at approximately 6:36 A.M. to perform a treatment in another resident's room and did not assign a staff member to supervise Resident #1.

Based on Observation, interview and record review, the facility failed to implement the plan of care for falls for 2 residents (#5 and #6) in a total sample of 24 residents. Findings include: 1. For resident # 5 the facility failed to implement the care planned intervention of alarms resulting in falls with injury. Resident # 5 was admitted to the facility in 8/2013 with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 11/1/14, included the following interventions: · Encourage remaining in a supervised setting while not in bed. · Sensor and Tab alarms in chair/wheelchair. · 1 assist with transfers and ambulation with rolling walker and gait belt. · Bathroom door alarm. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE] assessed the resident with moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) assessment with a score of 10 of a total possible 15 points. The MDs also assessed the resident as requiring limited assistance with transfers and ambulation. Required extensive assistance with toilet use and had no falls since the prior assessment. Review of the 11/2014 CNA documentation, Record Safety Section, indicated that on 11/5/14 during the first and second shifts, the resident had a functional bed alarm, chair alarm, and clip (TAB) alarm. There was no indication that the resident had a bathroom door alarm per the plan of care. Review of the nurse's notes indicated that on 11/5/14 at 8:40 P.M., the Resident was found on the floor in the doorway of his/her room bathroom, facing his/her wheelchair and the fall was unwitnessed. The nurse's note further indicated that the Resident was noted to have a 2.5 cm (centimeter) by 1.6 cm dark purple bruise near the resident's left middle finger during evening care. The resident was placed on 15 minute checks for safety. Review of the Facility's internal investigation for the 11/5/14 fall indicated that the CNA heard a chair alarm sounding and observed the resident sitting on the toilet. The TAB alarm was unclipped and the Bathroom Door alarm did not sound as per the plan of care. The CNA shut off the chair alarm, left the Resident sitting on the toilet and left the bathroom to assist another resident (The care plan encouraged the resident to remain in a supervised setting when not in bed). The resident had an unwitnessed fall. Review of the 1/2015 CNA Documentation Record, Safety Section, indicated that on 1/7/15 during the 1st and 2nd shifts, the Resident had a functional bed alarm, chair alarm and clip (TAB) alarm. There was no indication as to the presence of a bathroom door alarm per the plan of care. Review of the nurse's notes of 1/7/15 at 10:40 P.M. indicated that the resident quietly called for help. The Resident was found sitting on the floor of his/her bedroom, bleeding from the back of the head, and no alarms sounded. The resident sustained [REDACTED]. The Nurse's note further indicated that the resident was sent to the hospital for evaluation and returned with 4 staples to the right scalp. Review of the Facility's internal investigation for the 1/7/15 fall indicated that the resident sustained [REDACTED]. The resident had removed the TAB alarm and had turned off the chair alarm. During observation of the resident on 5/19/15 at 9:50 A.M., the Resident was sitting in the unit activity room, in his/her wheelchair, watching television. The Resident had shoes on his/her feet and the TAB and chair alarms were on the wheel chair as care planned. During interview with Unit Manager # 2 (UM) on 5/20/15 at 8:20 A.M., she said, regarding the fall of 11/5/14 that Resident # 5 should not have been left alone in the bathroom and she was unsure why the Resident's bathroom door alarm did not sound. She further said, regarding the fall of 1/7/15, that the documentation stated that Resident #5 had turned off the chair alarm. She said that she had only observed the resident turn off the chair alarm on one occasion, but the Resident had to stand up to turn off the alarm, causing the alarm to sound. UM # 2 further said that the Resident's chair alarm should have sounded and she was concerned that even though the documentation indicated that the safety checks were documented as complete, the alarms may not have been in place and functioning. 2. For Resident # 6 the Facility failed to implement the plan of care to prevent falls. Resident # 6 was admitted to the facility in 2/2014 with [DIAGNOSES REDACTED]. The plan of care for Falls, dated 2/13/14 noted that the Resident was at high risk for falls due to a history of falls with [MEDICAL CONDITION], use of psychiatric medications, impulsiveness and poor safety awareness. Interventions include: · Monitor for medication side effects, · Anticipate needs, ensure proper footwear, · Maintain clutter free floor, · Call bell in reach, · Remind resident to call for assist, · Pressure alarm to bed, chair and wheelchair · Do not leave unattended in the bathroom, · Bathroom door alarm, · Wheelchair with tilt feature and head rest, · TABS alarm in chair, · Hand bell when in recliner. Review of the Progress Notes and Fall investigation of 11/24/14 indicated that at 3:45 A.M., the resident sustained [REDACTED]. The bed alarm did not sound, the bathroom door alarm did not sound and the resident had unclipped the chair alarm. The resident sustained [REDACTED]. During interview on 5/20/15 at 2:30 P.M., the Director of Nurses said that Resident #6 was a challenge, very impulsive and preferred independent activities.

Based on observation, record review and interview, the Facility failed to ensure that 2 of 15 residents with falls (#5 and #6) received adequate supervision, in a total sample of 24 residents. Findings include: 1. For Resident #5 the Facility failed to provide adequate supervision and ensure that the resident's alarms were on and functioning. The resident sustained [REDACTED]. Resident #5 was admitted to the Facility in 8/2013 with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 11/1/14, included the following interventions: - Encourage remaining in supervised setting while not in bed. - Sensor and Tab alarms in chair/wheelchair. - 1 assist with transfers and ambulation with rolling walker and gait belt. - Bathroom door alarm. Review of the quarterly MDS assessment, dated 11/4/14, indicated that the resident had moderate cognitive impairment, as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, required limited assistance with transfers and ambulation, required extensive assistance with toilet use and had no falls since the previous assessment. Review of the 11/2014 CNA Documentation Record Safety Section indicated that on 11/5/14, during the 1st and 2nd shifts, the resident had a functional bed alarm, chair alarm and clip alarm (Tab alarm). There was no indication as to whether the resident had a bathroom door alarm. Review of the nurse's note indicated that on 11/5/14 at 8:40 P.M., the resident was found on the floor in the doorway of the resident's bathroom, facing his/her wheelchair and the fall was unwitnessed. The nurse's note further indicated that during evening care, a dark, purple bruise, measuring 2.5 cm. by 1.6 cm, was observed near the base of the resident's left middle finger. The resident was placed on 15 minute checks for safety. Review of the Facility's internal investigation, for the fall of 11/5/15, indicated that a CNA heard a chair alarm sounding, and observed the resident sitting on the toilet. The Tab alarm was unclipped and the bathroom door alarm did not sound. The CNA shut off the chair alarm, left the resident sitting on the toilet, and left the room to assist another resident. The resident sustained [REDACTED]. Review of the 1/2015 CNA Documentation Record Safety Section indicated that on 1/7/15, during the 1st and 2nd shifts, the resident had a functional bed alarm, chair alarm and clip alarm (Tab alarm). There was no indication as to whether the resident had a bathroom door alarm. Review of the nurse's note indicated that on 1/7/15 at 10:40 P.M., the resident quietly called for help. The resident was found sitting on the floor in his/her bedroom, bleeding from the back of the head and no alarms sounded. The resident sustained [REDACTED]. The nurse's note further indicated that the resident was sent to the hospital for an evaluation and returned with 4 staples to the right scalp. Review of the Facility's internal investigation for the fall of 1/7/15, indicated that the resident sustained [REDACTED]. The resident had removed the Tab alarm and had turned off the chair alarm. The Surveyor observed Resident #5 on 5/19/15 at 9:50 A.M. Resident #5 was sitting in the unit activity room, in his/her wheelchair, watching the television. The resident had shoes on his/her feet and the Tab and chair alarms were on the wheelchair. During interview with Unit Manager #2 on 5/20/15 at 8:20 A.M., she said that regarding the fall of 11/5/14, Resident #5 should not have been left alone in the bathroom and that she was unsure as to why the resident's bathroom door alarm did not sound. She further said that regarding the fall of 1/7/15, the documentation stated that the resident had turned off the chair alarm. She said that she had only observed the resident turn off the chair alarm on one occasion, but the resident had to stand up to turn off the alarm, causing the alarm to sound. Unit Manger #2 further said that the resident's chair alarm should have sounded and she was concerned that even though the documentation indicated that the safety checks were documented as complete, the alarms may not have been in place and functioning. 2. For Resident #6, the Facility failed to provide adequate supervision and assistance devices to prevent 7 of 12 falls which occurred in the resident's unit dining room. Findings include: Resident #6 was admitted to the Facility in 2/2014 with [DIAGNOSES REDACTED]. The Plan of Care for Falls, dated 2/13/14, indicated that the resident was at high risk due to history of falls with hip fracture, use of psychiatric medications, impulsive and poor safety awareness. Interventions included: *monitor for medication side effects; *anticipate needs; *ensure proper footwear; *maintain clutter free floor; *call bell in reach; remind resident to call for assist; *pressure alarm to bed, chair and wheelchair; *do not leave unattended in bathroom; *bathroom door alarm; *wheelchair with tilt feature and head rest; *Tabs alarm in chair; *and hand bell when in recliner. Review of Progress Notes and Fall Investigation of 6/2/14 indicated that at 7:30 P.M., the resident sustained [REDACTED]. The chair alarm sounded, and the resident was found on the Dining Room/Day Room floor. The resident hit his/her head on the coffee table and sustained a laceration to the right side of his/her head. The resident was transferred to the emergency room and received 3 sutures. New interventions included: Tabs alarm when sitting in recliner. Remove the coffee table. Review of Progress Notes and Fall Investigation of 7/25/14 indicated that at 9:00 P.M., the resident was in the Dining Room/Day Room, the second fall in the Dining Room. The wheelchair alarm sounded, and staff observed the resident attempting to kneel on the floor to pick up a puzzle piece. Staff could not reach him/her in time, and the resident landed on the floor on one knee. New interventions included: obtain a larger table to hold jigsaw puzzle pieces. The Fall Assessment of 8/5/14 indicated that the resident was at risk to fall. The quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/5/14 indicated that the resident scored 9 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated a moderately impaired mental status. The resident required assist with transfer, ambulation, toilet use, bathing, dressing, hygiene, was incontinent of bladder, had sustained 2 or more falls with no injury and 2 or more falls with injury. Review of Progress Notes and Fall Investigation of 9/14/14 indicated that at 8:10 P.M., the resident sustained [REDACTED]. This was the third fall in the Dining Room. The chair alarm sounded, and the resident was found on the Dining Room/Day Room floor. The resident sustained [REDACTED]. New interventions included: move wheelchair out of line of vision when sitting in recliner. Review of Progress Notes and Fall Investigation of 9/22/14 indicated that at 7:15 P.M., the resident sustained [REDACTED]. The Tabs alarm and chair alarm sounded, and the resident was found on the Dining Room/Day Room floor. The resident sustained [REDACTED]. New interventions included: relocate puzzles for easier reach and hand bell at puzzle table. Review of Progress Notes and Fall Investigation of 11/22/14 indicated that at 2:40 P.M., the resident sustained [REDACTED]. The alarms sounded, and the resident was found on the Dining Room/Day Room floor. The resident sustained [REDACTED]. This was the fifth fall in the dining Room. New interventions included: occupational therapy evaluation of wheelchair positioning. Review of Progress Notes and Fall Investigation of 1/19/15 indicated that at 6:25 P.M., the resident sustained [REDACTED]. The alarms sounded, and the resident was observed bending forward and falling to his/her knees on the Dining Room/Day Room floor, the sixth fall in the Dining Room. New interventions included: 15 minute checks for the remainder of the evening, rehab to assess and remind to use the hand bell to call for help (resident has cognitive loss) Review of Progress Notes and Fall Investigation of 3/16/15 indicated that at 11:35 A.M., the resident sustained [REDACTED]. The alarms sounded, and the resident was found on the Dining Room/Day Room floor. This was the seventh fall in the Dining Room. New interventions included: new custom wheelchair provided on 3/18/15. Observation on 5/18/15 at 3:00 P.M., found Resident #6 sitting in a wheelchair up to a table in the Dining Room/Day Room working on a jigsaw puzzle. The Tabs and chair alarms were in place. There were no staff present. Observation on 5/19/15 at 1:40 P.M. and 2:45 P.M., found Resident #6 sitting in a wheelchair in the Dining Room/Day Room reading a book. The Tabs and chair alarms were in place. There were no staff present despite the resident having had 7 falls in this location. During interview on 5/20/15 at 2:30 P.M., the Director of Nurses said that Resident #6 was a challenge, very impulsive and preferred independent activities.

Based on interviews and record review for one of three sampled residents (Resident #1), the Facility failed to prevent a second degree burn. On 2/6/14, Nurse #1 initiated a hot pack treatment for [REDACTED]. Nurse #1 assigned Certified Nurse Aide (CNA) #1 to apply the hot pack to Resident #1's right shoulder. Nurse #1 did not monitor Resident #1's skin or inform the oncoming nurse of the hot pack and as a result, Resident #1 sustained a second degree burn on his/her right scapula (shoulder blade). Findings include: The Resident Face Sheet indicated the Facility admitted Resident #1 in December 2014 with a [DIAGNOSES REDACTED]. The admission History and Physical, dated 12/26/14, indicated the Facility admitted Resident #1 after a fall with trauma to his/her right shoulder. The admission Minimum Data Set (MDS) assessment, dated 12/20/14, indicated Resident #1 was alert and oriented to person, time and place, and experienced occasional shoulder pain rated by Resident #1 as 4/10 (0 representing no pain and 10 representing the worse possible pain). The Physician Orders, dated 1/23/15, did not include an order for [REDACTED]. The Surveyor interviewed Resident #1 at 11:45 A.M. on 3/5/15. Resident #1 said on 2/6/15 she experienced right shoulder pain not relieved by Acetaminophen and a female staff member offered him/her a hot pack. Resident #1 said he/she was in bed with a Johnnie on when a female staff member came in and placed a hot pack on his/her right scapula. Resident #1 said the heat felt good and he/she fell asleep. Resident #1 could not recall the exact positron of the hot pack. The Surveyor interviewed Nurse #1 at 12:35 P.M. on 3/5/15. Nurse #1 said on 2/6/15 she was assigned to Resident #1 during the evening shift. Nurse #1 said during shift report with Nurse #2, CNA #1 told her Resident #1 requested heat for his/her shoulder. Nurse #1 said she thought she did not need a physician order [REDACTED]. Nurse #1 said about 11:15 P.M., she got an Accu-Therm hot pack, activated it, placed it in a sleeve, and handed it to CNA #1 to place on Resident #1's right shoulder. Nurse #1 said Nurse #2 knew she had CNA #1 apply the hot pack. Nurse #1 said she finished giving report then left the Facility without checking Resident #1. Nurse #1 did not place the hot pack in a towel which was not consistent with Facility policy, did not ensure proper placement of the hot pack, and did not assess the condition of Resident #1's skin prior to leaving the Facility. The Surveyor interviewed CNA #1 at 2:50 P.M. on 3/5/15. CNA #1 said on 2/6/15 she was assigned to Resident #1 during the evening shift. CNA #1 said during orientation the Staff Development Educator informed her that she could not do treatments. CNA #1 said around 11:00 P.M., Resident #1 complained of right shoulder pain and requested a hot pack. CNA #1 said she reported Resident #1's request to Nurse #1. CNA #1 said Nurse #1 took a hot pack from the medication room, activated it, and placed it in a protective sleeve. CNA #1 said Nurse #1 handed the hot pack to her to apply to Resident #1's right shoulder. CNA #1 said she did not remember any other staff present when Nurse #1 handed her the hot pack. CNA #1 said she did not question whether she could place the hot pack because in other facilities she was allowed to place cool packs and did not think of it as a treatment. CNA #1 said she placed the hot pack on Resident #1's right shoulder with the johnnie, sheet and protective sleeve between Resident #1's skin and hot pack. CNA #1 said she told CNA #2 about the hot pack being used then left the Facility. The Surveyor interviewed CNA #2 at 2:20 P.M. on 3/6/15. CNA #2 said she was assigned to Resident #1 on the night shift from 2/6/15 to 2/7/15. CNA #2 said when she came on duty, CNA #1 told her Resident #1 had a hot pack on his/her right scapula. CNA #2 said on first rounds, between 11:30 P.M. and 1:00 A.M., Resident #1 told her that Resident #1 had right shoulder pain. CNA #2 said she removed the hot pack located under Resident #1's right scapula, and disposed of the hot pack. CNA #2 said she did not inspect Resident #1's skin and when she reported Resident #1's pain to Nurse #2, she did not inform Nurse #2 about removing the hot pack. The Surveyor interviewed Nurse #2 at 5:00 P.M. on 3/5/15. Nurse #2 said she was assigned to Resident #1 on the night shift from 2/6/15 to 2/7/15. Nurse #2 said when she got shift report from Nurse #1, she did not observe Nurse #1 give a hot pack to CNA #1. Nurse #2 said if she had seen Nurse #1 give the hot pack to CNA #1 she would have intervened because the CNAs were not supposed to apply hot packs. Nurse #2 said Nurse #1 did not tell her in report about applying a hot pack to Resident #1's right shoulder and CNA #2 did not report to her when CNA #2 removed Resident #1's hot pack. The Progress Note, dated 2/7/15, indicated CNA #3 reported to Nurse #3 that Resident #1 had a blister on his/her back. The Progress Note indicated Nurse #3 examined Resident #1 and determined Resident #1 had a fluid filled blister on the right scapula with reddened tissue surrounding the blister as well as another area of faint redness near the blister. The Progress Note indicated Nurse #3 outlined the reddened tissue to monitor for migration. Nurse #3 said Resident #1's blister measured 4 centimeters by 2 centimeters. The Surveyor interviewed CNA #3 at 10:15 A.M. on 3/5/15. CNA #3 said she was Resident #1's consistent caregiver during the day shift and on 2/6/15, Resident #1 did not have a blister on his/her back. CNA #3 said on 2/7/15, Resident #1 reported his her right shoulder was uncomfortable. CNA #3 said when she took Resident #1 into the bathroom to get washed and dressed, she removed Resident #1's johnnie. CNA #3 said Resident #1 had a quarter-sized blister on his/her right scapula and the surrounding tissue was red and warm to touch. CNA #3 said she notified Nurse #3. The Surveyor interviewed Nurse #3 at 11:00 A.M. on 3/5/15. Nurse #3 said when she examined Resident #1's back, Resident #1 had an intact fluid filled blister surrounded by a faint square reddened area. Nurse #3 said she marked the reddened area to monitor for migration, notified the covering clinician and Unit Manager #1, and added to the Treatment Record as a nursing measure to monitor the site every shift. Nurse #3 said the blister self absorbed and healed without additional treatment.

Based on interviews and record review for one of three sampled residents (Resident #1), the Facility failed to ensure Nurse #1 acted within his/her scope of practice. On 2/6/15, Nurse #1 initiated a hot pack treatment without a physician order [REDACTED]. Nurse #1 failed to follow acceptable standards of practice when she 1) failed to properly delegate to CNA #1 and 2) failed to contact a physician and obtain an order to use a hot pack to treat Resident #1's pain. Findings include: According to 244 CMR 3.05: (3) (5) Nursing Activities That May Not Be Delegated, "by way of example, and not in limitation the following are nursing activities that are not within the scope of sound nursing judgment to delegate: (a) Nursing activities which require nursing assessment and judgment during implementation; (b) Physical, psychological, and social assessment which requires nursing judgment, intervention, referral or follow-up; (c) Formulation of the plan of nursing care and evaluation of the patient's/client's response to the care provided." The Policy/procedure titled Accu-Therm Hot Pack 9 a disposable hot pack), effective 12/17/12, indicated use of the hot pack required a physician order, should be placed on a towel and secured with tape, should be placed on the resident as to avoid direct pressure on the hot pack, and the nurse should check the skin under the hot pack every 4-5 minutes for redness and to check skin temperature. Nurse #1's Personnel File indicated the Facility hired Nurse #1 in April 2012. On 7/12/13, Nurse #1 signed a copy of 244 CMR: Board of Registration in Nursing, definition, responsibilities and function of the registered nurse. On 9/19/14, Nurse #1 attended an education on review of the Accu-Therm Policy/Procedure. The Surveyor interviewed the Staff Development Coordinator (SDC) at 10:45 A.M. on 3/5/15. The SDC said the Facility developed an order set for the nurse to use when obtaining an order for [REDACTED]. The SDC said the 2014 Annual Competencies included the hot pack policy/procedure. The Surveyor interviewed Nurse #1 at 12:35 P.M. on 3/5/15. Nurse #1 said on 2/6/15 she was assigned to care for Resident #1 during the evening shift. Nurse #1 said during shift report with Nurse #2, CNA #1 told her Resident #1 requested heat for his/her shoulder. Nurse #1 said she thought she did not need a physician order [REDACTED].#1 said about 11:15 P.M., she got an Accu-Therm hot pack, activated it, placed it in a sleeve, and handed it to CNA #1 to place on Resident #1's right shoulder. Nurse #1 said Nurse #2 knew she had CNA #1 apply the hot pack. Nurse #1 said she finished giving report then left the Facility without checking Resident #1. Nurse #1 did not ensure proper placement of the hot pack and did not assess the condition of Resident #1's skin prior to leaving the Facility. The Surveyor interviewed Nurse #3 at 11:00 A.M. on 3/5/15. Nurse #3 said when she examined Resident #1's back, Resident #1 had an intact fluid filled blister surrounded by a faint square reddened area. Nurse #3 said she marked the reddened area to monitor for migration, notified the covering clinician and Unit Manager #1, and added to the Treatment Record as a nursing measure to monitor the site every shift. Nurse #3 said the blister self absorbed and healed without additional treatment. The February 2015 Treatment Record regarding the burn indicated the nurses monitored Resident #1's burn every shift and the area healed without complication. .

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that the nurse followed the Accu-Therm Hot Pack protocol. On 12/7/12, at approximately 11:50 P.M., Nurse #1 placed a hot pack on Resident #1's right hip for pain relief without a physician order. Nurse #1 asked Resident #1 if his/her pain was improved after 30 minutes and Resident #1 said, yes. Nurse #1 failed to assess Resident #1's skin during the 11:00 P.M. to 7:00 A.M. shift, failed to document the heat application in the nurse's note, and failed to notify the oncoming nurse regarding the heat application. On 12/8/12, at 11:00 A.M., Resident #1 asked Nurse #2 to assess his/her right hip. Resident #1 had a fluid filled blister on the right hip. Findings include: The Admission record indicated that the staff admitted Resident #1 to the Facility in September, 2012. The plan of care, dated 9/13/12, related to Resident #1's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, completed on, 10/6/12, indicated that Resident #1 understand others and made himself/herself understood. The December, 2012, physician orders indicated that Resident #1's [DIAGNOSES REDACTED]. The physician orders did not include a warm/hot pack treatment. There was no nursing documentation regarding a hot pack treatment to Resident #1's right hip during the night shift between 12/7/12 and 12/8/12. The day shift nurse's note, dated 12/8/12, indicated that Resident #1 had a 3 centimeter (cm) by 2 cm raised, fluid filled, blister on the right hip. Nurse # 1's written statement, dated 12/12/12 indicated that on 12/7/12, at 11:50 P.M., Resident #1 complained that his/her right hip was sore. Nurse #1's statement indicated that she administered Tylenol to Resident #1. Nurse #1's statement indicated that Resident #1 asked if he/she could have a heating pad. Nurse #1's statement indicated that she told Resident #1 not to lie directly on the hot pack as the hot pack was hot. Nurse #1's statement indicated that at 12:20 A.M., Resident #1 was asleep, awoke easily, and said his/her right hip felt O.K. Nurse #1's statement indicated that Resident #1 had no further complaints during the night. The Surveyor interviewed Nurse #1 on 1/22/13, at 8:00 A.M. Nurse #1 said on 12/7/12, she did not check Resident #1's physician orders to determine if Resident #1 had an order for [REDACTED]. Nurse #1 said she taped the hot pack closed and placed the hot pack over Resident #1's night gown on his/her right hip. Nurse #1 said at 12:20 A.M., she removed the hot pack and Resident #1 had no issues. Nurse #1 said she did not assess Resident #1's right hip while Resident #1 used the hot pack and did not assess his/her skin when she removed the hot pack. Nurse #1 said Resident #1 had no further complaints during the night and she did not assess Resident #1's right hip during the night. The Nurse's Notes Notebook Policy indicated that nurse's notes were maintained for each resident and were used to record personal services rendered and observations, which may be of importance to the attending physician or to nursing personnel. The Policy indicated that such notes were made in writing and recorded with the time the service was rendered or observations were made. Nurse #1 said in error, she did not document Resident #1's right hip hot pack application in Resident #1's clinical record. The Change of Shift Handoff Report Policy indicated that the nurse was to enter throughout the shift in the 24 hour report book any and all noted change in resident condition. Nurse #1 said in error, she did not notify the day nurse that Resident #1 used a hot pack during the night shift and did not record the information in the 24 hour report book. Nurse #2's written statement, indicated that on 12/8/12, Resident #1 asked her to assess his/her right hip. Nurse #2 said Resident #1 had a raised, fluid filled blister on the right hip. Nurse #2's written statement indicated that Resident #1 said someone may have placed something cold or hot on his/her hip during the night shift. The instructions on the Hot Pack package indicated that the patency of the hot pack was to be checked regularly during the product use. The Surveyor interviewed the Director of Nurses (DON) on 1/6/13, at 9:00 A.M. The DON said she investigated the incident. The DON said Nurse #1 did not obtain a physician order for [REDACTED]. The DON said Nurse #1 did not assess Resident #1's right hip during the hot pack application per the Facility Policy. The DON said Nurse #1 did not document her findings regarding the effectiveness of the hot pack in Resident #1's clinical record per the Facility Policy. The DON said Nurse #1 did not report to the oncoming nurse that she applied a hot pack to Resident #1's right hip.

Based on record review, observation and interviews, the facility failed to ensure the provision of necessary care and services related to pressure sores for 1 (#15) of 2 applicable sampled residents with pressure sores, from a total sample of 24. Findings included: For Resident #15, the facility failed to ensure necessary care and services for the prevention of a pressure ulcer that developed on the resident's right lateral foot. Resident #15 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. (Within 14 day admission assessment time frame. No Minimum Data Set information available.) Review of the "Initial Wound Assessment sheet (no date identified) indicated the resident had a new surgical wound to the right hip with staples. Review of the Admission Evaluation and Interim Care Plan, dated 4/1/11 at 2:30 P.M., revealed that the Norton Plus Skin Assessment section was blank and never completed (This section is part of the four page admission evaluation). A front and back anatomical diagram was to the right of the blank Norton Plus Skin Assessment. A line was drawn, then circled on the front, right lateral hip area of the anatomical diagram. There was a brief description documented in the section below the diagram that identified the resident as having 23 staples with sero/sang (serous/sanguineous) drainage. The 4/1/11 Pressure sore/skin care Admission care plan indicated that the goal was to prevent pressure sores and skin breakdown. However, the only intervention checked off on the pre-printed care plan identified preventative care to hips, coccyx and ischium. There was no care plan intervention to address prevention of pressure sores to the resident's feet/heels, for this resident with a recent right [MEDICAL CONDITION]. The nursing note of 4/5/11 indicated that the resident is alert and oriented x 3 (person, place and time); [MEDICAL CONDITION] persists to the right lower extremity, and the resident was encouraged to elevate when resting. During the initial tour of the Resident's unit on 4/5/11 at approximately 2:45 P.M. with UM (Unit Manager) #1, UM #1 told the surveyor that Resident #15 had a recent [MEDICAL CONDITION] with a total hip replacement; had pain; was in a weakened condition, and was recovering from a recent gastrointestinal illness; and had no skin issues other than an incision to the right hip and scar to the right knee. The surveyor observed Resident #15 sitting up in bed to the left of the room with eyes closed. The resident's right foot rested directly on the mattress and was slightly externally rotated. The left foot also rested directly on the mattress. The surveyor observed Resident #15 sitting up in bed with O2 (Oxygen) running on 4/6/11 from 8:50 A.M. to 9:18 A.M. during a medication pass observation for this resident. The resident's right foot was slightly externally rotated, and pressed directly on the mattress. The resident told the surveyor that he/she was sick with nausea and vomiting since before being admitted to the facility 4/1/11, and stayed in bed, for the most part, while recovering. Review of a "Weekly Skin Assessment" sheet, dated 4/8/11, revealed "No new skin issues." However, the licensed nurse documented that the resident had a blister on the right lateral foot. There were no treatments identified for pressure relief relative to this new blister. Instructions on the form directed nursing staff to "Use diagram provided, indicate all present marks such as bruises, discolorations, abrasions, skin tears and wounds." There were no areas identified on the diagram for 4/8/11, despite the facility identified there was a blister on the right lateral foot. There were no measurements of this new blister. The 4/11 TAR (Treatment Administration Record) revealed an entry to "Monitor blister rt (right) lateral foot daily until resolved,"and indicated that this was initiated on 4/8/11 for the 7:00 A.M. to 3:00 P.M. shift. The 4/8/11 (7:00 A.M. to 3:00 P.M. shift) nursing note indicated that the resident is alert and oriented x 3; received one assist for transfers and ambulation with the rolling walker, and has slight [MEDICAL CONDITION] in the right foot. There was no mention of the new blister that was identified on both the "Weekly Skin Assessment" sheet and TAR for 4/8/11. In fact there was no mention of the new blister in any of the subsequent nursing notes (from 4/8/11 to 4/10/11) to identify that treatment or preventative measures were provided to the resident's feet. The surveyor observed Resident #15 sitting up in a stationary chair on the Rehabilitation Unit Dining Room on 4/11/11 from 8:50 .M. to 9:00 A.M.. The Resident had [MEDICAL CONDITION] to the right foot and ankle, and was wearing open toe slip-on slippers. The Surveyor observed a dark colored, irregular shaped area on the lateral aspect of the right foot, partially covered by the snugly fitted slipper. There were no areas observed on the left foot. Resident #15 told the surveyor that he/she was not aware how the area came about; that although the area was tender, it was not painful. Resident #15 identified he/she had been in bed a lot due to being very sick with nausea and vomiting from a stomach virus; and that this was the first day he/she felt like getting up out of bed to eat. The surveyor met with UM #1 directly following this observation on 4/11/11 at 9:02 A.M.. UM #1 stated that he/she was not aware the resident had any areas. The surveyor accompanied UM #1 to the Unit's Dining Room where Resident #15 was still sitting. UM #1 confirmed that Resident #15 was at risk for developing pressure ulcers due to a weakened condition and having a right [MEDICAL CONDITION]. UM #1 confirmed that Resident #15 developed a new pressure ulcer on the right lateral foot; the pressure area was never measured; pressure relief had not been provided in order to prevent the development of new pressure ulcers, and treatment options had not been discussed with the resident's physician when the ulcer was identified on 4/8/11. On 4/12/11 at 8:10 A.M., UM #1 provided a copy of a Norton Plus Skin Assessment, completed on 4/11/11, and identified that the resident scored a 14 (Moderate Risk for pressure ulcer development 11- 15). UM #1 identified that the pressure ulcer to the resident's right lateral foot was a Stage 2, which measured 2 cm x 1 cm. Please refer to F157, Example #1.

Based on record review, observation and interview, the facility failed to ensure that 1 sampled resident (#8) from a total sample of 24, received necessary care and services in order to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. Findings included: For Resident #8, the facility failed to ensure the resident received necessary care and services related to an open area on the resident's left buttock. Additionally, 4 new areas were identified on the resident's right buttock during the treatment observation. Resident #8 was admitted to the facility in 2/09. The resident's [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) assessment of 11/2/10 identified the resident had both short and long term memory problems; moderately impaired cognitive and decision-making abilities; required extensive assist for bed mobility, transfer, ambulation, dressing, toilet use; was always incontinent of bladder, and frequently incontinent of bowel; had no pressure or vascular ulcers; non-surgical dressings, creams and ointments were applied, other than to feet. The Quarterly MDS assessment of 1/25/11, was essentially unchanged. However, the resident was now identified as always incontinent of bowels. During the initial tour of the resident's unit on 4/5/11 at 1:30 P.M. with UM (Unit Manager) #3, UM #3 told the surveyor that Resident #8 did not have any skin issues/problems. According to an Initial Wound Assessment form (of 3/19/11) it was revealed that the resident had a wound on the left inner buttock. The Weekly Wound Assessment sheet indicated on (3/2211) that the left buttock wound was 1.8 cm (centimeters) x 0.2 cm; and on 4/5/11 had improved to 0.8 cm x 0.6 cm; was a superficial, red, firm wound with no drainage. The Weekly Skin Assessment sheet of 4/5/11 identified to "see treatment sheet." Instructions on this sheet included: "Use diagram provided, indicate all present marks such as bruises, discolorations, abrasions, skin tears and wounds." There were no areas identified on the Weekly Skin Assessment sheet for 4/5/11 (despite that the facility identified there was a wound on the left buttock). Review of the April, 2011 TAR (Treatment Administration Record) indicated to wash the resident's left buttock open area with Normal Saline; apply Hydrogel, then a dry clean dressing every shift, and as needed until healed. Initials were documented on 4/7/11 for the 11:00 P.M. to 7:00 A.M. shift, indicating the treatment was provided. However, there was no documentation on the reverse side of the treatment sheet to describe the integrity of the open area on the left buttock for this shift. The TAR included that [MEDICATION NAME] Protectant Paste was to be applied to buttocks every shift, as needed. The surveyor observed Resident #8 (on 4/7/11 at 7:25 A.M.) sitting up in a recliner in the resident's room. The resident was restless and attempted to shift weight from the right side to the left buttock, then leaned forward, peered around the half open door, and reached out with the left hand. The resident leaned back then forward still reaching out with the left hand. During interview with UM (Unit Manager) #3 on 4/7/11 at 7:38 A.M., UM #3 told the surveyor that Resident #8 had a treatment to the left buttock that would be done by Nurse #3 after breakfast, and when the medication pass was completed. The surveyor observed the treatment to the resident's left buttock on 4/7/11 at 10:00 A.M. with Nurse #3. Nurse #3 told the surveyor that the resident prefers the treatment to be done in the bathroom, while holding onto the W/C arms, in front of the toilet. Nurse #3 secured a gait belt around the resident's abdomen; assisted the resident to stand (with some difficulty), then pivot the resident to stand, and face toward the seat of the W/C (located in front of the toilet). Nurse #3 instructed and cued Resident #8 to hold onto the W/C armrests while Nurse #3 pulled the resident's pants down; then peeled the left and right tabbed sides of the incontinent brief, and lowered the brief, as well. The surveyor observed smeared feces inside the brief. There was no dressing on the resident's left buttock wound or in the soiled brief. Resident #8 sat back onto the toilet for a few moments. The surveyor inquired as to why there was no dressing on the left buttock wound, and Nurse #3 replied that the dressing must have fallen off earlier during toileting. Nurse #3 assisted the resident to stand from the toilet, and cued the resident where to hold the w/c armrests. Nurse #3 stood to the resident's right. The surveyor stood to the Resident's left. The left buttock wound revealed a moist, shallow crater with a red wound base. The bordering wound margin of the shallow crater had pale, white macerated tissue. There were also 4 areas observed on the resident's medial right buttock. The distal open area (larger of the 4 areas) had a slightly tannish wound bed surrounded by reddened tissue. This area was approximately 1.5 cm x 1 cm. The 3 proximal open areas were linear, superficial, with shiny, raw wound beds (approximately 1 cm long x 0.1 cm wide). Nurse #3 identified that the resident had a small bowel movement in the toilet, then proceeded to wipe the resident's rectal area and gluteal fold with a pre-moistened wipe. Nurse #3 washed her/his hands, applied gloves and proceeded to cleanse the left buttock wound with a gauze, moistened with Normal Saline. Nurse #3 patted the left buttock wound dry, then squeezed a large mound of Hydrogel from the tube onto a 2 x 2 gauze dressing and applied it to the left buttock open area. The surveyor pointed out the 4 new open areas, located on the resident's right buttock. Nurse #3 asked "Where?" The surveyor pointed to the 3 linear areas, then the lower, tannish colored open area. Nurse #3 leaned forward, then separated the resident's left and right buttocks, and confirmed the open areas were new. Nurse #3 applied the same treatment, and Hydrogel dressing to these areas (without measuring or consulting the physician for treatment options first). Nurse #3 then proceeded to lift and apply the same soiled brief back on the resident. The surveyor pointed out that the brief had smeared feces in it. Nurse #3 examined, then confirmed that the brief was soiled, and proceeded to change it. Directly following the treatment observation, the surveyor inquired to Nurse #3 which CNA (Certified Nursing Assistant) was assigned to take care of the resident today. Nurse #3 stated that he/she did not know; consulted the assignment sheet, and identified that it was CNA #5. During interview with CNA #5 on 4/7/11 at 10:25 A.M., CNA #5 stated that he/she was assigned to the resident, but did not dress or bathe the resident today, as the 11:00 P.M. to 7:00 A.M. shift completed care on that shift. CNA #5 stated that he/she did toilet the resident after breakfast, saw the dressing was off and decided to "let the wounds breathe." CNA #5 stated that no barrier creams were used after toileting the resident because the resident was not wet. " The surveyor met directly with UM #3 on 4/7/11 at 10:28 A.M., who acknowledged that a CNA does not possess the qualification to determine wound treatments, and that the Nurse should have been notified immediately when the dressing was found off. UM #3 acknowledged that he/she was not aware the resident had any new open areas; agreed that any new areas identified should have been measured when discovered, and the physician should have been consulted regarding treatment options. UM #3 indicated that the Hydrogel treatment was the appropriate treatment to the new areas, but would contact the Physician for an order. UM #3 provided a copy of the "Initial Wound Assessment sheet, dated 4/7/11 (at 4/12/11 at 9:45 A.M.). The "Wound Type" section documented the 4 new open areas as "Excoriations." "Location of Wound" identified 'right' inner buttock with "multiple red excoriated areas." "Appearance" identified the 4 wounds, each being 1 cm long, with "Granulation tissue (red)."

Based on record review and interview, the facility failed to ensure the physician was promptly notified/consulted regarding treatment options and/or changes in residents' condition for 3 sampled residents (#13, #15, and #20), from a total sample of 24. Findings included: 1. For Resident #15, the facility failed to notify/consult the Physician for treatment options when a new blister was identified on the resident's right lateral foot. (No Minimum Data Set Assessment information available, as still in 14 day assessment period/time frame.) Resident #15 was admitted to the facility on [DATE]. The 4/1/11 admission nursing note, skin assessment, and initial wound sheet indicated that the resident had an incision on the right hip with staples and a dressing. The 4/8/11 "Weekly Skin Assessment" sheet revealed the resident now had a blister on the right lateral foot. The 4/8/11 nursing notes, and subsequent nursing notes for 4/9 through 4/10/11 did not identify this new blistered area on the right lateral foot. There was no evidence that the MD was ever notified/consulted for treatment options of the new blister (pressure ulcer); and this was confirmed by both UM (Unit Manager) #1 and Resident #15's Physician on 4/11/11 at 9:05 A.M.. Please refer to F314. 2. For Resident #20, the facility failed to ensure the Physician was promptly notified/consulted for treatment orders relative to slits under the resident's breasts. Resident #20 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. (No Minimum Data Set Assessment information available, as still in 14 day assessment period/time frame) The 4/2/11 admission nursing note revealed that the resident had a slit under the right breast. The nurse documented, "will clean '+' apply powder '+' 4 x 4 qd (every day) until healed." The nurse then documented that the covering Physician verified all medications and treatments. Review of the 4/2/11 admission physician's orders [REDACTED]. Review of the 4/11 TAR (Treatment Administration Record) revealed an entry which read: "Powder under 'right' breast 'with' 4 x 4 until healed on the 3:00 P.M. to 11:00 P.M. shift. The reverse side of the TAR revealed the following on 4/3/11 at 9:00 P.M.; "Unclear as to which powder to use." The nurse documented that a 4 x 4 dressing was placed on the slit. There was no evidence that the Physician was consulted in order to clarify what treatment powder should have been applied (medicated, talcum, anti-fungal etc.), when the nurse identified that the treatment was "unclear." The reverse side of the TAR for 4/5/11 revealed "Left (not right)" breast slit persists, Anti-fungal powder provided (no order for this medication). The 4/6/11 entry identified under bilateral breasts pink with small slit and "Powder" provided. There was no evidence that the Physician was notified/consulted for treatment options related to slits under the left and/or right breasts, as identified in the clinical record; and this was confirmed by UM #1 on 4/11/11 at 1:50 P.M.. Please refer to F514, Example #6. 3. For Resident #13, the facility failed to notify/consult the physician after a prescribed 1 week regimen of [MEDICATION NAME] (an anti-depressant medication) was administered. Resident #13 was admitted to the facility in 12/10 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment (MDS) of 3/8/11 indicated the resident had signs and symptoms of depression, and received an anti-depressant medication. A 3/25/11 Physician's Telephone Order indicated to increase [MEDICATION NAME] to 50 mg (milligrams) by mouth daily for one week. Review of the 3/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 4/11 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an interview with UM #3 on 4/6/11 at 10:00 A.M., it was confirmed that the Physician should have been notified/consulted after the resident received the 1 week regimen of [MEDICATION NAME] 50 mg, in order to determine what course of treatment would be prescribed thereafter. Please refer to F 329 and F 514, Example #2.