Every finding on record at Seven Hills Pediatric Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who required the use of a mechanical ceiling lift for all transfers, the Facility failed to ensure that his/her safety was adequately maintained a during a transfer, when on 04/22/26, prior to moving Resident #1 from his/her wheelchair to his/her bed, Certified Nurse Aide (CNA) #1 did not completely secure all the loops (straps) of the lift pad to the overhead mechanical lift, and when she elevated Resident #1 in the lift, one of the straps (loops) became detached and his/her right side started to slip out of the lift pad, CNA #1 lowered him/her to the floor and Resident #1 hit his/her head on the floor.Findings include:Review of the Facility's policy, titled, Falls and Fall Risk, Managing, dated 2001, indicated that a fall is defined as unintentionally coming to rest on the ground, floor, or lower level.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/29/26, indicated that on 04/22/26 at around 4:30 P.M., CNA #1 was transferring Resident #1 from his/her wheelchair to his/her bed with the overhead mechanical lift when Resident #1 started to slip out of the lift pad. The Report indicated that CNA #1 immediately lowered Resident #1 to the floor and called for a nurse. The Report indicated that Resident #1 was observed to be lying on the floor on his/her right side with the lift sling (pad) still underneath him/her. The Report indicated that Resident #1 had a small area of swelling on his/her right eyebrow, and a small amount of bleeding from his/her lip, but no other injuries noted.Review of the Facility's Post Fall Investigation Report, dated 04/29/26, indicated that CNA #1 was in the process of transferring Resident #1 with the overhead mechanical lift, and thought she had fully attached all of the lift pad (sling) loops (straps) to the lift before she began to lift him/her up from the wheelchair. The Report indicated that when CNA #1 moved Resident #1's wheelchair out of the way, she noticed that the top right loop (strap) of the pad had not been completely attached to the mechanical lift and that Resident #1 was slipping out of the lift pad while in the elevated position. The Report indicated that CNA #1 immediately lowered Resident #1 to the floor with the mechanical lift. The Report indicated that Resident #1 did not sustain any injuries except for a small amount of bleeding from his/her lip, and small area of swelling on his/her right eyebrow. The Report indicated that CNA #1 did not ensure that the top loop (strap) of the mechanical lift pad (sling) had been completely attached to the lift, and when she (CNA #1) raised Resident #1 with the lift, he/she began to slip out of the lift pad.Resident #1 was admitted to the Facility in May 1973, diagnoses included cerebral palsy (neurological disorder that affects movement, muscle tone, posture, and balance) and a seizure disorder.Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 04/17/26, indicated he/she was dependent on staff for all care.Review of Resident #1's Physical Therapy (support needed) Care Plan, reviewed and renewed with the Quarterly Minimum Data Set Assessment, dated 04/17/26, indicated that he/she required assist of one staff person for transfers with the overhead (ceiling) mechanical lift.Review of a Nurse Practitioner's Note, dated 04/22/26, indicated that Resident #1 had a fall from the overhead mechanical lift and was noted to have a small amount of lip bleeding and a small bump above his/her right eyebrow.During a telephone interview on 05/27/27at 2:07 P.M., (which included a review of her written witness statement, dated 04/22/26), CNA #1 said that on 04/22/26, while she was transferring Resident #1 from his/her wheelchair to his/her bed, the upper right side loop (strap) of the lift pad became detached from the mechanical lift when she lifted Resident #1 up out of his/her wheelchair, and moved it (wheelchair) out from underneath Resident #1. CNA #1 said she immediately lowered Resident to the floor with the mechanical lift. CNA #1 said she was unable to catch Resident #1 before he/she hit his/her head on the floor. CNA #1 said she thought she had fully secured all loops (straps) to the overhead lift before she lifted him/her up out of the wheelchair, but she must not have since the right upper loop (strap) came undone during the transfer.During a telephone interview on 05/27/26 at 1:28 P.M., Nurse #1 said that on 04/22/26, after CNA #1 called him into Resident #1's room, he saw him/her lying on the floor with the mechanical lift sling pad underneath him/her. Nurse #1 said Resident #1 had a small area of swelling over his/her right eyebrow, and a little blood on his/her lip, but no other injuries.During an interview on 05/27/26 at 2:25 P.M., the Assistant Director of Nurses (ADON) said she had CNA #1 reenact the incident with the overhead mechanical lift and determined that CNA #1 had not fully secured the upper right loop (strap) of the mechanical lift pad to the lift which caused Resident #1 to begin slipping out of the top right corner of the lift pad once CNA #1 lifted him/her from the wheelchair. The ADON said CNA #1 had moved the wheelchair out of the way once she had lifted Resident #1 from it (wheelchair), and that is when Resident #1 began to slip out of the mechanical lift pad causing him/her to hit his/her head on the floor as (CNA #1) lowered him/her to the floor. The ADON said that other than a small area of swelling on Resident #1's right eyebrow area and a little blood on his/her lip, he/she did not sustain any injuries. The ADON said this incident was a result of user error, and that CNA #1 should have double-checked to make sure she had fully attached all mechanical lift pad loops (straps) to the lift, but she had not.During an interview on 05/27/27 at 2:47 P.M., the Director of Nurses (DON) said that after she completed their investigation, she determined that CNA #1 had not fully secured the mechanical lift pad loops (straps) to the lift, which caused the right side loop (strap) of the lift pad to come loose (detached) from the lift once CNA #1 had raised Resident #1 up from the wheelchair. The DON said they revised the Facility's Mechanical Lift Policy to include annual reeducation for all nursing staff.On 04/27/26, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction, with an effective date of 05/07/26, which addressed the area(s) of concern as evidenced by:A. On 04/22/26, Resident #1 was immediately evaluated, found to have no significant injuries, and remained at the Facility. Resident #1's overhead mechanical lift and lift sling were inspected by the Therapy Department and found to have no issues.B. On 04/22/26, CNA #1 reenacted the transfer incident with Resident #1 for the DON and/or designee, and it was determined that CNA #1 had not fully attached all of the mechanical lift pad loops (straps) to the lift, which caused Resident #1's right upper body to slip out from the pad during the transfer.C. On 04/23/26, the Therapy Department reeducated and completed a mechanical lift competency skills check for CNA #1.D. On 4/23/26, the Therapy Department audited all mechanical lift slings for integrity and correct size.E. On 04/23/26, the DON revised the mechanical lift policy to include yearly reeducation for all nursing staff.F. On 04/23/26 through 04/28/26, the Therapy Department educated all nursing staff on the revised mechanical lift policy.G. On 04/23/26 through 05/01/26, the Therapy Department completed mechanical lift competencies with all nursing staff.H. On 04/23/26, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to develop and institute a corrective action plan, and results will be reviewed at monthly QAPI meetings to determine compliance.I. On 05/06/26, the DON and/or designee began observational audits of mechanical lift use by nursing staff which will continue weekly for four weeks, bi-weekly for two weeks, and then monthly for three weeks or until substantial compliance is met.J. The DON and/or Designee are responsible for overall compliance.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), who had a known history of placing toys in his/her mouth, and required direct supervision by staff while in his/her wheelchair, the facility failed to ensure he/she was provided with the necessary level of staff supervision to prevent him/her from ingesting an object not made for consumption. On 01/20/26, Resident #1 was able to access, remove and swallow a battery from a musical toy. Resident #1 was transferred to the Hospital, testing confirmed he/she had a battery in his/her abdomen, and he/she underwent an endoscopy (a procedure that uses a scope to examine the digestive tract) to remove the battery. Findings include:Review of the facility's policy titled Incidents, with a review date of 05/2025, indicated the purpose of the policy was to ensure prompt and appropriate treatment to any resident sustaining and incident or accident and to prevent a recurrence.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/21/26, indicated Resident #1 was seated in a Common Room on 01/20/26 playing with a battery powered doll when facility staff requested emergent assessment from the resident's Nurse Practitioner for concerns of choking/gagging and possible AA battery ingestion. The toy's rear Velcro pouch was opened, the back cap of the battery pack was off, and one of the two AA batteries was missing.The Report indicated a search of Resident #1's person and environment were conducted, and the missing battery was not located. Resident #1 was transferred to the Hospital Emergency Department (ED) for an evaluation and treatment.Review of Resident #1's Hospital Records indicated a battery was in his/her abdomen and was removed via endoscopy.Review of the Facility's Investigation and Fact-Finding Review Report, dated 01/21/26, indicated the following conclusions from Resident #1's incident on 01/20/26:-The toy in question was not safe. The screw to the battery compartment was either missing or failed.-There was documentation to support that he/she required direct supervision while in his/her wheelchair and on that day [01/20/26] it appeared direct supervision was not provided.-Resident #1 had a history of mouthing toys and while some of his/her toys were sewn shut by his/her parents/guardians, this specific toy relied on a screw and Velcro, and the screw was either missing or failed.Resident #1 was admitted to the facility in January 2016, diagnoses included mitochondrial disorder resulting in developmental and intellectual delay and hypotonia (decreased muscle tone).On 02/17/26 at 9:28 A.M., the Surveyor observed Resident #1 in his/her classroom, seated on a therapeutic ball, with a toy rubber ring in his/her mouth.Review of Resident #1's Bedside Bulletin (instructions for direct care staff), dated as initiated 03/07/24, indicated he/she required direct supervision when he/she was in his/her wheelchair.During an interview on 02/17/26 at 3:32 P.M., Nursing Supervisor (NS) #1 said Resident #1 was well known to her and he/she often put things in his/her mouth. NS #1 said following Resident #1's incident, she [along with other staff] conducted an audit of his/her toys and found that about half of the toys were sewn shut on the back [if battery powered] and half of the toys were not. NS #1 said there was no clear process in place to determine if the facility staff or Resident #1's parents and/or guardians were responsible for sewing his/her toys shut prior to bringing them into the facility. NS #1 said that any toys Resident #1's parents and/or guardians allowed him/her to have, the facility did as well.NS #1 said that at the time of Resident #1's incident on 01/20/26, he/she required direct staff supervision when he/she was in his/her wheelchair, but said it was not clear if that meant 1:1 supervision or if someone could be in his/her vicinity to keep an eye on him/her.During an interview on 02/17/26 at 2:52 P.M., Certified Nurse Aide (CNA) #2 said Resident #1 was well known to him and often placed his/her toys in his/her mouth. CNA #2 said that at the time of Resident #1's incident on 01/20/26, he was assigned to provide 1:1 supervision for Resident #2, and that Resident #1 was assigned to CNA #1. CNA #2 said when providing 1:1 supervision to Resident #2, staff cannot take their eyes off him/her, so although he could see Resident #1, he was not supervising him/her.CNA #2 said he was in the Community Room with Resident #2 and other residents (including Resident #1) were also in the Room. CNA #2 said Resident #1 was seated in his/her wheelchair and playing with a battery-operated doll that he/she had played with in the past. CNA #2 said Resident #1 gagged/coughed and looked like he/she may be choking, CNA #2 called for the nursing staff.CNA #2 said Resident #1 stopped coughing and he noticed that the door to the battery compartment on the doll was open and one of the two AA batteries was missing. CNA #2 said that some of Resident #1's toys were designed for a toddler's strength and dexterity, and that Resident #1 was quick and strong.CNA #2 said the nursing staff attempted to find the battery on Resident #1's person and environment but were unable to locate it and Resident #1 was transferred to the Hospital ED.CNA #2 said direct supervision could be defined as 1:1 supervision or it could mean a staff member would need to be arm's length away from the resident.Review of Certified Nurse Aide #1's witness statement, dated 01/21/26, indicated Resident #1 was on her assignment on 01/20/26 and she observed Resident #1 playing with his/her musical doll in the Community Room and left him/her there to attend to her other assigned residents. The Surveyor was unable to interview CNA #1 as she did not respond to the Department of Public Health's telephone or letter requests for an interview.During an interview on 02/17/26 at 1:39 P.M, Nurse Practitioner (NP) #1 said Resident #1 was well known to her and he/she put items in his/her mouth all the time and she believed it was part of his/her disease.Nurse Practitioner #1 said she was on duty at the time of Resident #1's incident on 01/20/26 and that nursing staff called for her to assess Resident #1 due to fear that he/she may have swallowed a battery. Nurse Practitioner #1 said she immediately went to the Common Room and Resident #1 did not appear to be in acute distress but because she and the nursing staff could not locate the missing AA battery, Resident #1 was transferred to the Hospital ED for evaluation.Nurse Practitioner #1 said the screw on the toy doll's battery pack should have kept the battery pack closed but that Resident #1 was very strong.During an in-person interview on 02/17/26 at 11:36 A.M., and a telephone interview on 02/18/26 at 11:47 A.M., the Assistant Director of Nursing (ADON) said that Resident #1 has always required direct supervision when he/she was in his/her wheelchair. The ADON said they are in the process of clarifying the definitions of different levels of supervision but said direct supervision for Resident #1 meant he/she required a staff member's supervision [present with him/her] when he/she was in his/her wheelchair.The ADON said that Resident #1's family brings toys in for him/her and that unless the toy is electronic, they are not inspected by the nursing staff.During a telephone interview on 02/18/26 at 1:49 P.M., the Administrator said that Resident #1 should have had direct supervision by a staff member when he/she was in his/her wheelchair and that the facility's investigation of Resident #1's incident on 01/20/26 indicated there had been a lapse in his/her required level of direct staff supervision. The Administrator said the facility did not have a policy to define different levels of staff supervision at the time of Resident #1's incident.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), who was developmentally delayed and had a known history of placing toys in his/her mouth, the facility failed to ensure they developed and implemented a comprehensive individualized care plan specific to his/her oral fixations, associated risks and need for supervision, that included interventions, goals and outcomes. Findings include:Review of the Facility's policy, titled admission Assessment, with a review date of 05/2025, indicated the following:-An initial assessment of all new residents will be conducted by each discipline and re-assessments will be conducted when a change occurs and at specified intervals during the resident's stay.-The purpose is to obtain the necessary information to develop and maintain an individualized interdisciplinary plan of care with appropriate education and training about his or her illness and care needs.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/21/26, indicated Resident #1 was seated in a Common Room on 01/20/26 playing with a battery powered doll when facility staff requested emergent assessment from the resident's Nurse Practitioner for concerns of choking/gagging and possible AA battery ingestion. The Report indicated that the toy's rear Velcro pouch was opened, the back cap of the battery pack was off, and one of the two AA batteries was missing.The Report indicated a search of Resident #1's person and environment were conducted, and the missing battery was not located. Resident #1 was transferred to the Hospital Emergency Department (ED) for an evaluation and treatment.Review of Resident #1's Hospital Records indicated a battery was in his/her abdomen and was removed via endoscopy (a procedure that uses a scope to examine the digestive tract).Resident #1 was admitted to the facility in January 2016, diagnoses included mitochondrial disorder resulting in developmental and intellectual delay and hypotonia (decreased muscle tone).Review of Resident #1's Comprehensive Care Plans, indicated there was no documentation to support that he/she had an individualized plan of care that included or addressed the following:-Behavior of placing items in his/her mouth.-Risk of choking due to behaviors associated with oral seeking tendencies.-Specific level of staff supervision required to maintain his/her safety.On 02/17/26 at 9:28 A.M., the Surveyor observed Resident #1 in his/her classroom, seated on a therapeutic ball, with a toy rubber ring in his/her mouth.During an interview on 02/17/26 at 1:00 P.M., the Minimum Data Set (MDS) Nurse #1 said Resident #1 was well known to him/her, that he/she was very sensory seeking and often had a toy that he/she could gum.During an interview on 02/17/26 at 1:39 P.M, Nurse Practitioner (NP) #1 said Resident #1 was well known to her, that he/she put items in his/her mouth all the time and she believed it was part of his/her disease.During an interview on 02/17/26 at 2:52 P.M., Certified Nurse Aide (CNA) #2 said Resident #1 was well known to him/her and that he/she was always putting things including toys or his/her fingers in his/her mouth.On 02/17/26 at 4:00 P.M., the Surveyor observed Resident #1 in the Common Room, seated in his/her wheelchair, with a toy rubber carrot in his/her mouth.During a telephone interview on 02/18/26 at 1:42 P.M., MDS Nurse #1 said it was the MDS department who generated and updated the residents' care plans. MDS Nurse #1 said that they do not typically include a resident's level of supervision or specific behaviors in the comprehensive care plan.During an in-person interview on 02/17/26 at 11:36 A.M., and a telephone interview on 02/18/26 at 11:47 A.M., the Assistant Director of Nursing (ADON) said that Resident #1 has always required direct supervision when he/she was in his/her wheelchair. The ADON said the MDS Department creates the residents' care plans and that the goal is to have the nursing staff play a role in creating and updating the care plans moving forward.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 3 2025 (April 1 - June 30), in accordance with the schedule specified by CMS.Findings include:Review of the facility's policy titled Payroll Based Journal (PBJ) Reporting, dated as revised February 2025, indicated but was not limited to:Policy: -The facility will submit complete and accurate PBJ staffing data to CMS no later than 11:59 PM ET on the 45th day following the end of each fiscal quarter, as required by CMS. All staffing data must be audible, standardized, and validated prior to submission. The facility will maintain all related records in accordance with CMS and MA DPH requirements and will make them available upon request during surveys or audits.During an interview on 11/24/2025 at 8:11 A.M., the Administrator said the business office completes the quarterly PBJ report and that he was unaware that the report had not been submitted for the third quarter as required by CMS. During a phone interview on 11/24/25 at 12:01 P.M., the Business Office Manager said she completes and submits the quarterly PBJ report and per her notes she submitted it on 8/11/25. She said she logged into the system the next day to get the report number but was unable to obtain it and then was on vacation. She said she did not check to see if it was successfully submitted upon her return from vacation and was unaware it was not submitted until it was brought to her attention by the Administrator following the discussion with the surveyor. The facility failed to provide evidence of submission by the conclusion of the survey.

Based on record review and interview, the facility failed to ensure a physician's order for a phenobarbital (anti-seizure medication) level lab draw was implemented for 1 Resident (#4) of 24 sampled residents. Findings include:Resident #4 was admitted to the facility in March 2019 and has diagnoses which include cerebral palsy and seizure disorder. Review of Resident #4's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition (a Brief Interview for Mental Status examination was not performed), and that the Resident was prescribed an anti-convulsant medication. Review of Resident #4's care plan dated 6/25/25 indicated:- Maintain physical health related to seizure activity. Care plan interventions included, but were not limited to, Anticonvulsant levels as ordered by MD/NP. Review of Resident #4's physician orders indicated:- Phenobarbital oral tablet 100 mg (milligrams). Give 50 mg via g-tube in the afternoon for seizure. Give one half tab with 60 mg daily for a total dose:110 mg.- Phenobarbital oral tablet 60 mg. Give 60 mg via g-tube in the afternoon for seizures. Give one tab (60 mg) with 50 mg for total dose 110 mg/day.- Obtain routine labs at Children's Hospital Boston with appointments or any outside facilities. Yearly labs in August: phenobarbital.Phenobarbital is a narcotic and sedative barbiturate drug used chiefly to treat epilepsy.According to the National Institute for Health the risk of not obtaining a phenobarbital trough concentration may result in suboptimal or toxic levels of the drug. Trough concentrations too low could result in lack of seizure control, and too high may lead to toxicity. Review of Resident #4's pharmacy Monthly Medication Review (MMR) dated 7/31/25 indicated [Resident] receives phenobarbital but does not have a trough concentration documented in the medical record within the previous 6 months. The MMR indicated a recommendation to obtain a trough concentration level at the next lab day, every 6 months, and as clinically indicated. The MMR was signed as reviewed by Physician #1 and the Director of Nurses on 11/25/25, approximately four months after the Pharmacist's recommendation.Review of Resident #4's clinical record from January 2025 to 11/25/25 indicated documentation of a phenobarbital trough concentration level had not occurred. Review of the physician, nurse practitioner and nursing progress notes since January 2025 indicated there was no mention of attempting to obtain phenobarbital trough concentration levels. During an interview with the Director of Nurses (DON) on 11/25/2025 at 11:20 A.M., she said it was not clear why the Pharmacist's recommendation for Resident #4 to have a phenobarbital lab draw was not reviewed earlier by Physician #1 or nursing staff, or why the order for a phenobarbital lab draw was not implemented. The DON said a lab draw for a trough concentration level should be taken every 6 months, per the physician's order. The DON said the last lab draw for phenobarbital appeared to be over 10 months ago. The DON said that in August 2025 the facility requested that staff at Children's Hospital Boston obtain a phenobarbital trough concentration, but it was not completed. The DON said facility staff did not attempt to obtain a level after this date. The DON said a lab draw for a phenobarbital trough concentration could be obtained at the facility.The surveyor telephoned and left a voice mail message for Physician #1 on 11/25/25 at 11:10 A.M., but there was no response.

Based on record review and interview, the facility failed to obtain consent for the use of psychotropic medications as required for three Residents (#57, #73 and #80) out five residents reviewed, in a total sample of 19 residents. Findings include: Review of the facility's policy, Department of Nursing, Concern: Informed Consent for use Topic: Psychotropic medications, dated 5/22/19 indicated the following: -Prior to administering psychotropic medication listed on the schedule under subsection (b) the facility shall obtain written consent of the resident, the resident's health care proxy or the resident's guardian as required by M.G.L.c.111, Section 72BB. Attached Circular Letter 17-2699. Review of the Circular letter 17-2699, issued by: The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Bureau of Health Care Safety and Quality, dated February 1, 2017 indicated the following: -While prescribers are not required to complete this process each and every time a resident is administered a dose of psychotropic medication, written informed consent must be obtained each time a new or renewed prescription falls outside the dosage to which the resident or the resident's legal representative previously consented, or once a year, whichever is shorter. -In the event that the medication will continue to be administered in the following year without a change in dosage, the facility may re-use the form so long as the prescriber explains again the risks and benefits to the resident or his or her legal representative, and the facility representative updates the signatures and dates, the date of discussion with the prescriber, and facility representative information. -If all relevant information is identical, written informed consent may be renewed using the previously signed form by attaching a notice of renewal to the updated form. The notice and any additional attachments must include all necessary attestations and signatures that are on the original form, updated discussion dates, and updated names of prescriber and facility representative, as necessary. Each page of the notice and any additional attachments must be re-initialed, dated and numbered to precisely indicate the relative page number (e.g., 2 of 4, etc.) 1. Resident #57 was admitted to the facility in September 2018 with diagnoses including Epileptic Encephalopathy, developmental delay and intellectual delay. Review of Resident #57's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #57 was cognitively impaired and dependent on staff for activities of daily living (ADLs). Review of Resident #57's Physician's orders indicated the following PRN (as needed) medications: Lorazepam (an anti-anxiety medication): 1 milligram (mg) every 8 hours for agitation, initiated 5/23/23. Lorazepam: 1 mg every 4 hours for seizure activity PRN, initiated 2/4/22. Diazepam (a controlled substance used to treat anxiety and seizures): 10 mg Nasal, as directed for seizure activity, initiated 2/18/22. Resident #57's consents for the use of the psychotropic medications were dated June 2022, and failed to indicate the use of the Lorazepam for agitation. During an interview on 8/16/23 at approximately 11:15 A.M., Social Worker (SW) #1 said that staff were in the process of obtaining updated consents. During an interview on 8/16/23 at 3:11 P.M., the Director of Nursing (DON) and the Administrator said that it was facility policy for consents to be completed annually. 36431 2. Resident #73 was admitted to the facility in September 2020 with diagnoses including Chronic Respiratory Failure, Cerebral Palsy and seizure disorder. Review of Resident #73's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #73 was cognitively impaired and dependent on staff for activities of daily living (ADLs). Review of Resident #73's Physician's orders indicated the following psychotropic medications: Diazepam (a medication used to treat anxiety and seizures) 10 milligrams(mg) as directed, seizure activity, PRN (as needed) for seizure activity greater than 3 minutes, dated 8/25/20. Diazepam 4 mg, every 8 hours, PRN. Dystonia. Dated 8/27/23. Diazepam, 2 mg TID (three times a day), dated 8/24/21. Diazepam, 3 mg give ml at 1800, dated 8/24/21. Lorazepam (an anti-anxiety medication) 1 mg, every 4 hours PRN, dated 2/7/22. Lorazepam, 1 mg TID, dated 2/14/22. Review of Resident #73's medical record indicated consents for the use of psychotropic medication administered to Resident #73, were dated 6/26/22. During an interview on 8/15/23 at 3:36 P.M., Social Worker #1 said consents for psychotropic medications were obtained verbally by the Minimum Data Set (MDS) Nurse, then the Social Worker would get the written consents for psychotropic medications. Social Worker #1 said the written consents for Resident #73 had not been obtained and should be obtained at least annually. 3. Resident #80 was admitted to the facility in April 2022 with diagnoses including Cerebral Palsy and seizure disorder. Review of Resident #80's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #80 was cognitively impaired and dependent on staff for activities of daily living (ADLs). Review of Resident #80's physician's orders indicated the following psychotropic medications: Clonzepam, 0.5 mg form, tab q 6 hours, PRN, dated 3/30/22. Diazepam 10 mg, daily PRN, indication seizures, dated 3/30/22. Clobazam (a sedative medication, used for seizures), 5 mg, dated 4/14/22. Clobazam, 7.5 mg, dated 4/14/22. Review of Resident #80's medical record indicated consents for the use of psychotropic medication administered to Resident #80, were dated 6/16/22. During an interview on 8/16/23 at 9:51 A.M., Social Worker #1 said consents for psychotropic medications were completed annually around this time of year.

Based on observation, record review and interview, the facility failed to identify and assess the use of a Sleep Safe Bed (also known as institutional beds, adaptive beds, enclosed canopy beds, special needs beds, and child-safe beds) as a restraint for one Resident (#57) out of a total sample of 19 residents. Specifically, the facility failed to conduct individualized and ongoing assessments on the use of the Sleep Safe Bed for Resident #57. Findings include: Review of the facility's Physical Restraint Policy, dated April 2018 indicated: *A restraint is defined as any manual method or any physical or mechanical device, material, or equipment attached to or adjacent to the body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body and environment. *Physical Restraints may be used: If the resident is at significant risk of self-injury or injury to others and no safer alternative or setting can be found. *The assessment process for the use of physical restraints/enablers is ongoing and individualized. The assessment identifies the cause of the problem utilizing the pre-restraint assessment form. *If a restraint or enabler is utilized, the documentation in the medical record will include verification that: -The resident has medical symptoms for which the restraint has been determined to be achieved or maintain the highest level of mental, physical and psycho-social well-being. -A pre-restraining assessment has been conducted by the interdisciplinary team to ascertain the feasibility of less restrictive devices. -There has been consultation with appropriate health professionals such as occupational and/or physical therapists and their recommendations have been evaluated and implemented. -A care plan has been established that identifies the least restrictive restraint necessary for specified periods. Resident #57 was admitted to the facility in September 2018 with diagnoses including Epileptic Encephalopathy, developmental delay and intellectual delay. Review of Resident #57's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #57 was cognitively impaired and dependent on staff for activities of daily living (ADLs). On 8/15/23 at 7:51 A.M., the surveyor observed Resident #57 lying in bed. The bed was fully enclosed with panels and mesh on all sides which would prevent the Resident from getting out of bed. Resident #57 was moving around and put himself/herself into a position with his/her buttocks in the air and his/her head on the mattress. During an interview on 8/16/23 at 9:44 A.M., Physical Therapist (PT) #1 said that Resident #57 was currently on service with rehabilitation and able to kneel and crawl independently. PT #1 said that Resident #57 would not move on command, but has the ability to move. PT #1 said that Resident #57 utilizes the Sleep Safer Bed to prevent him/her from falling out of bed or getting out of bed due to safety concerns. PT #1 said that she was not aware if any assessments had taken place to determine the use of the Sleep Safe Bed as a restraint. Review of Resident #57's clinical record indicated: *An Interdisciplinary Team Quarterly Review note dated 6/13/23: The Sleep Safer Bed is on order and will ensure Resident will be able to safely remain in his/her bed without risk of injury as he/she is able to roll, transition into and out of sitting, kneeling and is able to crawl. *A Physical Therapy Note dated 6/26/23: Resident received a Sleep Safer Bed to prevent injury secondary to involuntary movements and ability to crawl, kneel, roll and transition into and out of sitting. Lower bed to lowest position when Resident is in bed for safety. *A Physician's order dated 9/21/18: Sleep Safer Bed to prevent injury secondary to involuntary movements. Lower bed to lowest position when resident in bed for safety. No restraints used. *A care plan titled Use of Adaptive Equipment dated 9/20/22: Posey bed with sides zipped and locked; Resident will be able to safely remain in his/her bed without risk of injury, as he/she is able to roll, transition into and out of sitting, kneeling and is able to crawl. Given his/her size, he/she requires the Sleep Safer Bed. Resident #57's clinical record failed to identifiy and assess the use of the Sleep Safer Bed as a restraint despite Resident #57's capability of crawling and purposeful movement. During an interview on 8/16/23 at 10:36 A.M., Nurse Supervisor #1 said that Resident #57's previous bed was not safe for him/her and that he/she uses the Sleep Safer Bed for safety. Nurse Supervisor #1 said that she was not aware if Resident #57's Sleep Safer Bed was assessed as a restraint. During an interview on 8/16/23 at 1:03 P.M., the Rehabilitation Director said Resident #57 has some purposeful movement as he/she was able to crawl, which is motivated by something he/she sees, like a toy. She said that Resident #57 has the Sleep Safer Bed for safety concerns and because it was for safety, the facility did not consider it to be a restraint.

Based on observation, record review and interview, the facility failed to implement the medical plan of care for one Resident (#72), out of a total sample of 19 residents. Specifically, the facility failed to ensure Resident #72 had both his/her glasses and hearing device applied, to assist in his/her ability to hear and see. Findings include: Resident #72 was admitted to the facility in March 2022 with diagnoses that include Respiratory Failure, seizure disorder, and congenital glaucoma. Review of Resident #72's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #72 had severe cognitive impairment, was dependent on staff for daily care, had moderate difficulty to hear, a hearing appliance was used, had highly impaired vision and used corrective lenses. Review of Resident #72's care plan with a start date of 1/20/23, focus of care and plan/services/approach: Resident will respond to multi-sensory cues during ADL, classroom and play experiences with changes in facial expressions, turning toward and/or visual attention to caregivers and objects of interest and maintain a relaxed muscle tone. Resident has glasses and bilateral hearing aids worn per nursing. On 8/15/23 at 11:14 A.M., Resident #72 was observed lying in bed as a Nurse was providing care and talking to him/her. Resident #72 did not have a hearing device or glasses on. On 8/16/23 at 11:41 A.M., Resident #72 was in his/her room sitting in his/her wheelchair and was observed not wearing his/her glasses or hearing device. He/she was looking in the direction of the television and he/she did not respond to the surveyor. On 8/16/23 at 12:55 P.M., Resident #72 was in his/her wheelchair and was observed not wearing his/her glasses or hearing device. During an interview with Certified Nursing Assistant (CNA) #1 who was with Resident #72, CNA #1 said Resident #72 did not have on his/her hearing aids or glasses, and that the Nurses put them on and kept the items in the medication cart. During an interview on 8/16/23 at 12:59 P.M., with Nurse #1 and Nurse #2, Nurse #2 said Resident #72 had a medical order to wear glasses and a hearing device. Nurse #1 said they were not provided or placed on Resident #72 that day. Nurse #1 located the Resident's glasses in the medication cart but was unable to find the hearing device. Nurse #2 and the surveyor went to Resident #72's room, where she located the hearing device in a bag on the back of Resident #72's chair. Nurse #2 placed both the glasses and hearing device on Resident #72 and right after, Resident #72 looked in the direction of Nurse #2 and the surveyor who was talking to him/her and he/she smiled.

Based on record review and interview, the facility failed to ensure Physician orders for as needed (PRN) psychotropic medications that surpassed 14 days had a duration for continued use, as required for three Residents (#57, #73 and #80) out of a total sample of 19 residents. Findings include: 1. Resident #57 was admitted to the facility in September 2018 with diagnoses including Epileptic Encephalopathy, developmental delay and intellectual delay. Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #57 was cognitively impaired and dependent on staff for activities of daily living (ADLs). Review of Resident #57's Physician's orders indicated the following PRN (as needed) medications: Lorazepam (an anti-anxiety medication): 1 milligram (mg) every 8 hours for agitation, initiated 5/23/23. Lorazepam: 1 mg every 4 hours for seizure activity PRN, initiated 2/4/22. The Physician orders failed to include a stop date or review date as required. The clinical record indicated Resident #57's consent for the use of the PRN psychotropic medications were dated June 2022, and failed to indicate the use of the Lorazepam for agitation. During an interview on 8/16/23 at 1:32 P.M., the Director of Nursing (DON) said that residents with orders for PRN psychotropic medications should have a documented rationale for the use of the medication. The DON was not aware of the requirement for a stop date or review date for PRN medications. 36431 2. Resident #73 was admitted to the facility in September 2020 with diagnoses including Chronic Respiratory Failure, Cerebral Palsy and seizure disorder. Review of Resident #73's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #73 was cognitively impaired and dependent on staff for activities of daily living (ADLs). Review of Resident #73's Physician's orders indicated the following PRN psychotropic medications: Diazepam (a medication used to treat anxiety and seizures) 10 milligrams (mg) as directed, PRN for seizure activity greater than 3 minutes, dated 8/25/20. Diazepam 4 mg, every 8 hours, PRN. Dystonia. Dated 8/27/23. Lorazepam (an anti-anxiety medication) 1 mg, every 4 hours PRN, dated 2/7/22. The PRN psychotropic medication orders failed to have a stop and duration date as required. During an interview on 8/15/23 at 3:55 P.M., Nurse Practitioner (NP) #1 said residents are reviewed every 60 days, including the use of PRN medications. NP #1 said the PRN medications do not have a stop date due to the needs of the residents with autonomic symptoms. 3. Resident #80 was admitted to the facility in April 2022 with diagnoses including Cerebral Palsy and seizure disorder. Review of Resident #80's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #80 was cognitively impaired and dependent on staff for activities of daily living (ADLs). Review of Resident #80's physician's orders indicated the following psychotropic medications: Clonzepam, 0.5 mg form, tab q 6 hours, PRN, dated 3/30/22. Diazepam 10 mg, daily PRN, indication seizures, dated 3/30/22. The PRN psychotropic medication orders failed to have a stop and duration date as required. During an interview on 8/16/23 at 1:32 P.M., the Director of Nursing (DON) said that residents with orders for PRN psychotropic medications should have a documented rationale for the use of the medication. The DON was not aware of the requirement for a stop date or the review date for PRN medications.

Based on observation, policy review and interview, the facility failed to ensure that food was stored in accordance with standards of practice for food safety. The facility also failed to ensure that the kitchen was maintained in a clean, sanitary manner. Findings include: Review of the facility's policy, entitled Food Storage Policy, not dated, included the following: -All food must be labeled and dated. -All leftovers must be labeled and dated. -All food must be discarded after three days. -Any food item not dated will be discarded immediately. On 8/15/23 at 7:21 A.M., during a tour of the facility kitchen with the Food Service Director (FSD) present the following observations were made: *Reach in refrigerator #1: -A thermometer had an internal buildup of black substance, was dirty and unable to read. -A lunch in a bag, not dated or labeled that the FSD said belonged to staff, and removed it from the refrigerator. *Reach in refrigerator #2: -A large bag of dairy free yogurt, with a use by date of 8/5/23. -An individual cup of salsa, with a use by date 8/12/23 -The bottom shelf of the refrigerator had a thermometer stuck under a sheet pan, along with food grime, and a stained paper towel with food stains. *The walk-in refrigerator: -A plastic bag containing sliced tomatoes, dated 7/27/23. *Walk-in freezer: -The door to enter the walk-in freezer had a buildup of ice on the outside threshold and inside threshold, and ice and frost debris on the floor. -The ceiling had hanging ice and buildup of frost and water was dripping above the doorway, while the surveyor and FSD were in the freezer. -A bag of bread closed with a clip, not labeled, or dated. -A bag of frozen chicken patties, opened, not labeled or dated. -A bag of cooked ground beef, opened, not labeled or dated. -17 individual cups of prepared food, not labeled or dated. -An open bag of frozen pizza, that the FSD said was for the staff, not labeled or dated. Further observation of the kitchen with the FSD the following was observed: -Five ventilator grates in the hood vent above the stove area were laden with dust and a buildup of greasy grime. -The baseboard and windowsill near the hand sink had a buildup of dust and grime. During an interview at the time, the FSD said the hood ventilator grates have not been cleaned by kitchen or maintenance staff. Review of the sticker on the hood provided by the company indicated the last date of service was December 2022. The FSD said she would expect the kitchen to be clean. During a follow-up visit to the kitchen on 8/16/23 at 9:00 A.M., the ventilator grates in the hood vent were observed to still be laden with dust and greasy grime. The freezer door was observed with less frost and ice around the door. During an interview with the Maintenance Director and Administrator on 8/16/23 at 9:10 A.M., the Maintenance Director said the grates are not on a routine cleaning schedule. Regarding the walk-in freezer the Administrator said they have another reach-in freezer available for food requiring freezer storage (that was inaccessible at the time due to maintenance work).

Based on interview, observations and policy review the facility failed to adhering to infection control practices during medication pass. Specifically, the facility staff failed to: 1) perform adequate hand hygiene throughout a medication pass. 2) adequately clean a mortar and pestle used for multiple residents. Findings include: Review of facility policy titled, Hand Hygiene revision date 8/2023 indicated the following: Indications for hand hygiene -Before touching a resident -Before clean or aseptic procedure -After body fluid exposure risk -After touching a resident -After touching a resident's surroundings -Before and after removing gloves Review of the facility policy titled, Medication Administration, revision date 8/2023, indicated the following: -Wipe clean mortar and pestle with gauze and alcohol in between residents. 1a. On 8/16/23 at 8:27 A.M., the surveyor observed Nurse #4 administering medications through a Gastrostomy/gastric tube (G-tube). Nurse #4 then doffed (removed) her gloves without performing hand hygiene, prepared the medication and began giving a Resident a nebulizer treatment with contaminated hands. Nurse #4 then donned (put on) gloves with contaminated hands and removed the nebulizer treatment when it was completed without performing hand hygiene. During an interview on 8/16/23 at 11:54 A.M., Nurse #4 said hand hygiene should be performed before donning gloves and after doffing gloves. 1b. On 8/16/23 from 8:17 A.M. to 8:47 A.M., and 8:55 A.M. to 9:31 A.M., the surveyor observed Nurse #4 during two medication administration passes. Nurse #4 was observed to wipe out the mortar bowl with only a gauze pad after crushing medications for each resident. Nurse #4 said the expectation for cleaning the mortar and pestle was wiping the bowl out with a gauze pad. During an interview on 8/16/23 at 1:38 P.M., the Director of Nurses (DON) said that she expects the Nurses to clean the mortar bowl and pestle with alcohol as well as gauze after each use. 43846 2. On 8/16/23 from 7:14 A.M. to 7:54 A.M., the surveyor observed Nurse #1 during medication administration pass. Nurse #1 was observed to wipe out the mortar bowl she had crushed medications in for each resident with a gauze pad in between each resident's medication. Nurse #1 said that is normal practice to wipe the bowl out with the gauze pad. During an interview on 8/16/23 at 1:38 P.M., the Director of Nurses (DON) said that she expects the Nurses to clean the mortar bowl and pestle with alcohol, then clean with a gauze pad after medications are crushed.

Based on observation, interview, and record review the facility failed to ensure staff followed the plan of care for four Residents (#31, #75, # 72 and #52). Specifically, the facility staff failed to: - ensure Resident #31 was administered the correct medication and wore a palm guard per the plan of care, - ensure Resident #75 utilized a pressure relieving device for his/her ear, - failed to ensure Resident #72 had padded side rails per the plan of care and, - failed to ensure Resident #52 utilized hand splints per the plan of care, in a total sample of 18 residents. Findings include: 1. Resident #31 was admitted to the facility in January 2008. A. Review of the facility policy for Medication Administration: Incident, reviewed 6/1/2018, indicated that it was the responsibility of the nurse who discovers a medication incident to initiate a Quality Assurance Performance Improvement (QAPI) tool. Medication related incidents that warrant immediate medical attention or direction include: -Omitted dose -Wrong dose -Wrong medication -Wrong time -Wrong resident Review of a QAPI Form, dated 2/3/22, indicated Resident #31 had been administered the wrong medication, wrong dose, at the wrong time. The Resident had received [MEDICATION(S)] (an anti-convulsant medication) 194.4 milligrams (mg.), instead of [MEDICATION(S)] (a benzodiazepine) 4 mg. The medications were in the wrong slots in the medication cart, and the nurse did not double check the medication, dose, and time against the medication administration record. During an interview on 5/25/22 at 1:13 P.M., Nurse #1 said she had made a medication error and self reported it as soon as she realized it. The QAPI report was reviewed with Nurse #1 and she said the report was accurate. B. Review of the Care Card in Resident #31's room indicated the use of a right palm guard from the morning until evening. On 5/24/22 at 9:25 A.M., the surveyor observed Resident #31 in bed, without the palm guard on his/her right hand. The palm guard was observed on the bedside table. On 5/24/22 at 4:27 P.M., the surveyor observed Resident #31 in bed, without the palm guard on his/her right hand. The palm guard was observed in the same place as it had been during the previous surveyor observation. At this time, Nurse #3 told the surveyor the resident was not wearing the palm guard, but maybe the staff had removed it when they put the resident back to bed. On 5/25/22 at 9:08 A.M., Resident #31 was observed in a wheelchair, not wearing the right palm guard. During an interview with Certified Nurses' Aide (CNA) #2 at this time, she said she had just finished caring for Resident #31 and did not put the right palm guard on because she had forgotten. 2. Resident #75 was admitted to the facility in June 2003. On 5/24/22 at 8:54 A.M., the surveyor observed Resident #75 lying in bed with eyes closed. Review of the care card, located in the room, indicated the use of a gel ear donut. No such device was observed to be in use at that time. On 5/25/22 at 8:16 A.M., the surveyor observed Resident #75 lying in bed with eyes closed. No gel donut was observed. At this time, during an interview with CNA #2, she said the gel donut had been missing for some time and that she would call the rehabilitation department to find out what was going on, or had one been re-ordered. CNA #2 said the resident sometimes gets skin breakdown and that's what the donut was for. Review of the resident's care plan for functional needs, start date 10/27/21, indicated the resident was to use comfort foam to the right ear. There was no intervention for a gel donut for the resident's ear in the care plan. On 5/25/22 at 8:38 A.M. during an interview with the Rehabilitation Director, she said the gel donut was discontinued a while ago and the care card in the resident's room was incorrect. The decision had been made to use comfort foam to the resident's right ear. The Rehabilitation Director had a square piece of comfort foam with her which she said was to be used for Resident #75. She could not say how long the resident had gone without the comfort foam, but thought they had been using it. 3. For Resident #72, the facility failed to ensure staff implemented the Resident's care plan relative to the use of protective padding to the side rails while the Resident was in bed, which resulted in a bruise. Resident #72 was admitted to the facility in October 2014 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physical Health Care Plan, initiated 10/18/21, indicated that Resident #72 required the use of adaptive equipment for safety, including padding for both side rails when the Resident was in bed. Review of a Nurse's Note, dated 5/18/22, indicated that a red and black egg-sized bruise was identified on Resident #72's left knee on 5/17/22 when he/she was in bed. Further review of the note indicated that the Resident's bumper pads were not in use at the time that the bruise was identified. Review of the facility's investigation, dated 5/20/22, included that staff identified a red and black egg-sized bruise on Resident #72's left knee while he/she was in bed on 5/17/22 and that the bumper pads were not in use in the bed, as required. Further review of the investigation included that the determined cause of the Resident's bruise was that the padding was not in place. On 5/24/22 at 10:22 A.M., the surveyor observed Resident #72 while he/she was in bed with both lower extremities exposed. The surveyor observed a large, dark purple bruise on the Resident's left knee. During an interview on 5/25/22 at 1:00 P.M., the Director of Nursing (DON) said that Resident #72 had sustained a bruise to his/her left knee while in bed on 5/17/22, and that the cause of the bruise was that staff failed to provide the required padding. The DON further said that the padding should have been provided, as required by the Resident's care plan. 4. For Resident #52, the facility failed to ensure its staff implemented the Resident's care plan relative to the application of a hand splint. Resident #52 was admitted to the facility in April 2011 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physical Health Care Plan, initiated 12/29/21, indicated that the Resident's functional needs included maintaining upper extremity flexibility and range of motion, and that the Resident required the use of a splint to the left wrist/hand when out of bed. Further review of the care plan indicated it was reviewed on 3/30/22 and that the Resident tolerated wearing the splint well. On 5/24/22 at 8:53 A.M., the surveyor observed Resident #52 out of bed, seated in his/her wheelchair. The wrist/hand splint was not on the Resident's left hand but was resting on the Resident's lap. On 5/25/22 at 8:30 A.M., the surveyor observed Resident #52 out of bed, seated in his/her wheelchair in his/her room. The wrist/hand splint was not on the Resident but was resting on a counter in the room. On 5/25/22 at 9:25 A.M., the surveyor observed Resident #52 out of bed, seated in his/her wheelchair in his/her room. The wrist/hand splint was not on the Resident and was still resting on a counter in the room. During an interview on 5/25/22 at 9:31 A.M., CNA #4 said that staff were to apply a splint to Resident #52's left wrist/hand when out of bed and that the Resident had been tolerating the splint without any complications. CNA #4 observed Resident #52 during the interview and said that the splint had not been applied as required, but it should have been.

Based on observation, document review and interview, the facility failed to ensure staff: - maintained safe sanitation practices relative to monitoring food temperatures, - monitored the low temperature dish machine temperatures and checked the chemical solution to ensure correct concentration and, - dated refrigerated food items once opened to help minimize and prevent the risk of food borne illnesses. Findings include: During the initial tour of the kitchen on 5/24/22 at 7:54 A.M., the surveyor observed in the refrigerator, the following items that were not dated when opened: - Three blocks of cheese, - Four sandwiches wrapped with plastic wrap, - One jar of minced garlic, - One jar of crushed peppers, - One bagel with cream cheese wrapped in plastic, - Three opened low fat Dannon yogurts, - Two bags of green lettuce, left open to air, - One bag of shredded carrots, and - One box of artisan rolls left open to air. Review of the Dish Machine Temperature Log, dated May 2022, indicated the dish machine temperatures and the chemical solution were not checked 30 out of the 46 times required. Review of the Daily Food Temperature log, dated May 2022, indicated the food temperatures were not checked for 22 out of 69 meals served. During an interview on 5/24/22 at 8:17 A.M., the surveyor reviewed the concerns with the Food Service Director (FSD). She said that the refrigerated items needed to be dated once opened and were not. The FSD said that the dish machine temperature and chemical solution were not checked as required and the food temperature were not taken with each meal.

Based on observations, interviews, and record review, the facility failed to ensure its staff implemented infection prevention and control requirements according to standards of practice and proper mask use as personal protective equipment (PPE) for protection from exposure to respiratory secretions while performing aerosol-generating procedures (AGPs; procedures that stimulate coughing and promote generation of droplets in the air) for one Resident (#281) on Droplet Precautions whose COVID-19 Status was unknown, and relative to proper mask use as source control to reduce the risk of COVID-19 transmission for one Resident (#72) out of a total sample of 18 residents. Findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled Strategies for Optimizing the Supply of Facemasks, dated 11/23/20, indicated that healthcare personnel were to use facemasks according to .Local, State, and Federal requirements and included the following: - When facemasks are used as PPE to protect one's nose and mouth from exposure to splashes, sprays, splatter, and respiratory secretions (e.g. for patients on Droplet Precautions), the facemask should be removed and discarded after each patient encounter. - When facemasks are used for source control while in the healthcare facility, they are to cover one's mouth and nose to prevent spread of respiratory secretions when talking, sneezing, or coughing. Review of the Centers for Disease Control and Prevention (CDC) document titled How to Use Your N95 Respirator, dated 3/16/22, included the following: -Wear your N95 properly so that it is effective. - N95s must form a seal to the face to work properly. Review of the facility's policy titled Infection Control: Standard/Transmission-Based Precautions, dated May 2022, included that the facility followed CDC and Massachusetts Department of Public Health (DPH) guidance for COVID-19 and that staff would follow signs posted outside of resident doors for which PPE to utilize. 1. For Resident #281, the facility failed to ensure its staff implemented proper use of a N95 mask as PPE while providing AGPs for the Resident who was on Droplet Precautions and whose status for COVID-19 was unknown. On 5/24/22 at 9:00 A.M., the surveyor observed signage outside of Resident #281's room that indicated Isolation Precautions and included the following: - A N95 respirator was required. - A facemask was acceptable only if a N95 was not available. - A fit tested N95 or higher was required for AGPs. - Picture images on the sign indicated that one mask was to be worn. On 5/24/22 at 9:42 A.M., the surveyor observed Nurse #3 enter Resident #281's room wearing a N95 mask positioned over a surgical style facemask and close the door. On 5/24/22 at 10:14 A.M., the surveyor observed Nurse #3 exit Resident #281's room wearing a surgical style facemask. During an interview on 5/24/22 at 10:14 A.M., Nurse #3 said that Resident #281 had a fever and increased respiratory secretions and was placed on Droplet Precautions. Nurse #3 said that she had just completed providing suction and cough assist procedures to the Resident when she exited the room at 10:14 A.M. Nurse #3 said that she wanted to be sure she was well protected when providing these procedures to residents and that when she was required to use a N95 mask, she always placed it over her surgical mask. She said that she removed the N95 after she completed care to Resident #281, but she did not change her surgical style facemask as it was covered by the N95 when she was in the room. Review of a Nursing Note, dated 5/24/22, included the following: - Resident #281 was noted to have increased copious secretions. - AGPs provided included suctioning, cough assist, and nebulizer treatment. - A COVID-19 test was obtained. During an interview on 5/25/22 at 1:23 P.M., Staff Development Coordinator (SDC) #2 said that she provided education to staff relative to proper use of PPE which included masks. SDC #2 said that wearing a N95 mask over a surgical mask should never happen, that it did not provide increased protection to the user, and that Nurse #3 should not have positioned a N95 over her surgical style facemask. She further said that Nurse #3 should have removed the surgical style facemask and applied a N95 directly over her mouth and nose to enter Resident #281's room. SDC #2 also said that Nurse #3 should not have worn the same surgical mask after exiting Resident #281's room, and that she should have discarded it and applied a new mask. 2. For Resident #72, the facility failed to ensure its staff implemented proper use of a facemask for source control by wearing the mask positioned so that the staff member's nose was exposed while interacting with and providing assistance to the Resident. During an observation on 5/24/22 at 9:43 A.M., the surveyor observed Certified Nurse Aide (CNA) #5 assist Resident #72 to his/her room by pushing him/her in a wheelchair. CNA #5 wore a surgical style facemask that was positioned so that his nose was exposed. CNA #5 moved between the Resident and the sink that was located by the door twice, his mask still positioned so that his nose was exposed. CNA #5 exited the room at 9:56 A.M., his mask still positioned under his nose. At no time during the observation did the surveyor observe CNA #5 to reposition his mask so that it covered his mouth and nose. During an interview on 5/24/22 at 9:59 A.M., CNA #5 said that staff were required to wear facemasks in the facility and when providing care to residents and that the facility provided the masks to staff. He said that sometimes the masks did not fit well, that they would fall under his nose and he needed to readjust them. During an interview on 5/25/22 at 1:23 P.M., SDC #2 said that all staff were required to wear facemasks that covered their mouths and noses when interacting with and providing care to residents in the facility. She also said that if staff had masks that did not fit properly, they should notify her as different sizes of masks were available. SDC #2 said that CNA #5 should have worn a proper fitting mask that covered his mouth and nose while he interacted with and provided care to Resident #72.

Based on record review and interview the facility failed to ensure staff issued the transfer/discharge notice for five Residents (#35, #51, #52, #56 and #78) out of a total sample of 18 residents. Findings include: Review of Residents' #35, #51, #52, #56 and #78 records, indicated all of the these Residents were transferred to the hospital with return expected. Continued review of the Residents' records indicated a transfer/discharge notice was not issued for these transfers. During an interview on 5/25/22 at 9:04 A.M., Social Worker (SW) #1 said that she was not aware that a transfer/discharge notice needed to be issued. SW #1 said that she did not know what a transfer/discharge notice was. During an interview on 5/25/22 at 9:30 A.M., the Director of Social Services said that she had worked at the facility for nine years and had never issued a transfer/discharge notice. The Director of Social Services said that the facility was not aware that it was a requirement.

Based on interview, record review and observation, the facility 1. failed to ensure it followed Center for Disease Control (CDC) requirements for assessing in-person visitation for signs and symptoms of COVID-19 and exposure to others with suspected or confirmed [CONDITION(S)]-CoV-2 infection and 2. failed to provide a private setting for COVID-19 testing to reduce the risk of spread of infection. Findings include: 1. The Centers for Disease Control (CDC) guidance for Nursing Home Visitation - Covid-19 (revised 11/12/2021), indicated: Visitors who have a positive [CONDITION(S)] test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, should not enter the facility. Facilities should screen all who enter for these visitation exclusions. The surveyors entered the Facility on 12/30/2021 at approximately 8:30 A.M. and observed a table with a sign-in sheet in the lobby. A staff person greeted the surveyors and asked that each surveyor print their name and enter the date and time of the visitation. The staff person did not ask the surveyors if they had tested positive for COVID-19 or met criteria for quarantine. The staff person did not ask the surveyors if they had symptoms of the illness (such as coughing, headache, myalgia, fever, or difficulty breathing), or were exposed to COVID-19. The surveyors observed that there was no screening form or other means of obtaining or documenting this information from the surveyors. During an interview with the Director of Nursing (DON) and Infection Control Nurse on 12/30/2021 at 9:00 A.M., they said it was the Facility's policy and CDC requirement for all visitors to be screened for signs and symptoms of COVID-19. The DON and Infection Control Nurse said that the staff person in the lobby was required to verbally screen visitors prior to entering further into the building. The DON said that the Facility did not use a paper questionnaire for the screening of visitors for COVID-19. 2. The facility failed to ensure staff performed Binax testing (rapid testing for Covid-19 virus) in a private setting to reduce the potential spread of infection. During an observation on 12/30/21 at 8:35 A.M., the receptionist in the lobby was seated at a table, right in front of the entrance, and provide Binax testing to all staff that walked in the door. There was no privacy screen and the testing samples were sitting on the table in the open. The staff members being tested waited approximately 15 minutes in the lobby for their test results. During an interview on 12/30/21 at 12:14 P.M., the Director of Nursing said that there used to be a private space where Binax tests were performed, but that it had changed to the lobby. The Director of Nursing said she would check with her epidemiologist regarding Binax testing.

Based on record review and interview the facility failed to adhere to testing requirements put forth by the Centers for Medicare and Medicaid Services (CMS), for two residents who presented with symptoms consistent with Covid-19, out of total sample of five residents. Findings include: Review of the CMS QSO-20-38-NH dated August 26, 2020, with the subject; Interim Final Rule, CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing requirements and Revised COVID-19 Focused Survey Tool, indicated: COVID-19 testing. The LTC facility must test resident and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all resident and facility staff, including individuals providing services under arrangement and volunteers, the LTC facility must: (1) Conduct testing based on parameters set forth by the Secretary, including and not limited to: (iii) The identification of any individual specified in this paragraph with symptoms consistent with COVID-19 or with known or suspected exposure to COVID-19. Review of the Centers of Disease Control and Prevention document dated as updated February 22, 2021, indicated the following: Symptoms of COVID-19 Watch for Symptoms People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. On 9/9/21 at 9:02 A.M., the Director of Nursing (DON) said the facility had three residents on Covid watch. The DON said the three residents are on full infection control precautions, that one resident was swabbed for Covid-19 and the other two were on Covid watch and did not have a Covid 19 test. The DON said residents under care of the facility (admitted as pediatric care) will run fevers related to temperature dysregulation. The DON said a Covid watch protocol was developed to account for their specialized residents and that the Department of Public Health epidemiologist was consulted. The surveyor requested supporting documentation regarding the consult. Review of the Facility's document titled COVID-19 Testing Guidelines, dated as developed and revised by the medical director,10/23/20 indicated the following: 1. Temp 100.4 or greater AND no other COVID-19 or other [CONDITION(S)] symptoms a. resident to be placed on COVID-19 precautions with full COVID-19 Personal Protection Equipment (PPE) and monitored for a minimum of 24 hours for any further temps or symptoms. b. Obtain temperature every two hours until the temp is below 100.4. c. Avoid Tylenol/[MEDICATION(S)] until temp is less than 100.4 so as not to mask the fever, use if needed for discomfort. d. Do not count as second fever if temperature continue to decrease following firs fever. e. Nursing may discontinue precautions of no further temps or new symptoms after 24 hours. f. Obtain COVID-19 test and place on COVID-19 precautions if second fever or other symptoms occur within 24 hours. g. Note: obtain COVID test with first fever if concern in someone with no history of temperature dysregulation and no environmental factor to explain fever. h. Do not consider a fever if the elevated temp:1) occurs within 15 minutes of an observed [CONDITION(S)], 2) occurs when t-pump used for low temperature. The Facility's COVID Testing Guidelines are not in alignment with the CMS regulatory guidance. Review of Resident #4's medical record indicated in a progress note dated 9/8/21, resident on COVID watch, temperature at 1300 hours (1:00 P.M.) as 101[degrees]. Review of Resident #5's medical record indicated in a progress note dated 9/8/21, resident on COVID watch temperature 100.8 [degrees]. During an interview on 9/9/21 at approximately 3:30 P.M., the DON said the Residents were not tested for COVID-19 as per their facility Covid testing guidelines. The DON was unable to provide the surveyor with documentation from the consulting epidemiologist.

Based on observation, interview and record review the facility failed to maintain infection control standards to prevent the further spread of COVID-19 in the facility. Findings include: During inspection of the facility on 7/1/20, at 9:36 A.M., the surveyor observed Certified Nurse's Aide (CNA) #1 in a resident's room and pull down her mask off of her nose and mouth, contaminating her hands, and then lean down to speak to a resident. The surveyor also observed CNA #1 then touch items in the resident's room without performing hand hygiene (HH), contaminating the items in the resident's environment. At 9:39 A.M., the surveyor observed CNA #1 exit room [ROOM NUMBER] wearing contaminated gloves and not performing HH before walking down the hallway and enter room [ROOM NUMBER]. CNA #1 then obtained a scale from room [ROOM NUMBER], exited the room without changing her gloves or performing HH and enter room [ROOM NUMBER] wearing her contaminated gloves. CNA #1 then provided direct care to the resident in room [ROOM NUMBER]. During an interview on 7/1/20, at 10:35 A.M., the Director of Nursing said that HH is to be performed each time you leave a room. Review of the facility policy titled Infection Control Hand Hygiene and dated revised 2/2015, indicated that hand hygiene is to be performed after touching a resident, touching a resident's surroundings and before donning and after removing gloves.

Based on record review and interview, the facility failed to complete a performance review at least every 12 months for 3 out of 3 sampled Certified Nursing Assistants. Findings include: Review of 3 out of 3 Certified Nursing Assistants education files failed to include an annual performance review. -Certified Nursing Assistant #1 was hired on 3/7/16 -Certified Nursing Assistant #2 was hired on 4/17/12 -Certified Nursing Assistant #3 was hired on 10/22/18 During an interview with the Administrator and Director of Nurses on 10/22/19 at 10:03 [NAME]M., they said that the facility has been completing annual education and training with all staff, but that they have not been completing annual performance reviews. They said that as they identify areas for improvement they will complete education with each staff member on an ongoing basis. They have not been completing formal performance reviews with the Certified Nursing Assistants on an annual basis.

Based on observation and interview, the facility failed to ensure that foods were stored in accordance with professional standards for food safety. Findings include: During tour of the kitchen on 10/20/19 at 7:27 [NAME]M., the surveyor observed the following items in the walk-in refrigerator and small refrigerator units: - 15 individual serving bowls of an unknown pureed substance labeled with a resident name but no date as to when they had been prepared or an expiration date. - Multiple containers of an unknown pureed substance in small portion cups, undated. - a stack of what appeared to be approximately 1.5 lbs (pounds) of white American cheese, loosely wrapped in plastic wrap, unlabeled and undated. - An open container of feta cheese, undated. During an interview with Dietary Staff #1, she said all the prepped foods are done during the week by the full time staff. She said that she was uncertain the date that the foods were prepped but said that typically the full time staff set it up and she assumes that they throw away what is not used on Monday. She said that usually all of the prepped foods are labeled and dated. She acknowledged that the foods were not labeled. During observation of the kitchen walk in refrigerator and smaller refrigerator unit on 10/21/19 at 8:12 [NAME]M., the surveyor observed the following: -11 containers of pureed foods, undated. - 3 individual portion cups with an unknown pureed substance, unlabeled and undated. - a stack of what appeared to be approximately 1.5 lbs of white American cheese, loosely wrapped in plastic wrap, unlabeled and undated. - An open container of feta cheese, undated. During an interview with Dietary Staff #2 on 10/21/19 at 8:15 [NAME]M., she said she was unsure when the 11 containers of pureed food with the name of the resident on it were prepped but said that she believed it occurred on Saturday (10/19/19). With regard to the small portion cups in the small refrigerator units she said she was unsure what date they were prepared and that they should be dated. She said the facility policy is for all foods to be dated.

Based on record review, observations and staff interviews, the facility staff failed to ensure that the resident's environment was free from accident hazards and also failed to provide adequate supervision to prevent accidents for 1 resident (#60), out of a total sample of 18 residents. Findings include: Resident #60, with [DIAGNOSES REDACTED]. Review of the 5/24/18 quarterly MDS (Minimum Data Set) Assessment indicated the resident exhibited no speech, rarely/never was able to express his/her ideas and wants, rarely/never understood others; exhibited short and long term memory deficits, severely impaired decision making ability; totally dependent on staff for bed mobility, transfers, dressing, eating, personal hygiene and bathing and non ambulatory; exhibited Range of Motion impairment of the upper and lower extremities; requires Oxygen (O 2), has a [MEDICAL CONDITION] and is Ventilator dependent. Review of the Progress Notes of 6/13/18 indicated that his/her portable liquid 02 canister was found in the bed next to him/her and that the resident's left arm was [MEDICAL CONDITION] with dark pigmentation of 14 cm. (centimeters) x 13 cm., was warm to touch and taut. There were 2 fluid blisters near the outer elbow. The one closer to the elbow measured 2.2 cm. x 1 cm. and the other blister measured 0.6 cm. x 0.3 cm. The note further indicated the resident was exhibiting discomfort from [MEDICAL CONDITION] The resident was transferred to the ER (emergency room ) for an evaluation of a left arm burn. The resident required hospital admission and Plastic Surgery was consulted to evaluate the wound and to provide recommendations on debridement/management. Review of the CNA's (Certified Nursing Assistant's) written statement of 6/13/18 indicated that the CNA had assisted the Nurse with transferring the resident into the bed and that once the resident was in bed, the Nurse was called out of the resident's room. The statement further indicated that the CNA positioned the resident in the bed and placed the portable liquid Oxygen canister on the counter/shelf behind the head of the bed. Review of the Nurse's written statement (who was assigned to the resident, at the time of the incident) of 6/14/18 indicated that when the Nurse returned to the resident's room he found the portable liquid Oxygen canister next to the resident and removed it immediately, then he noticed a blister on the resident's left arm. Review of the Progress Note of 6/15/18 indicated the resident was readmitted to the facility. Review of the Progress Note of 6/19/18 indicated the resident was transferred again to the ER for an evaluation of the left arm wound/burn. The arm was [MEDICAL CONDITION] and blistering on the outer aspect mid left bicep to below the elbow. Review of the Hospital Discharge Summary of 6/25/18 indicated the resident underwent [REDACTED]. Review of the 6/27/18 Progress Notes indicated the resident was readmitted to the facility. Further documentation relative to the resident's left arm burn indicated the following: a. the arm area presented with an irregular border, tissue pink in color, intact, ranging from approximately 0.3 cm. to 4.4 cm. in width.; b. intact dark pigmented area distal to the elbow with areas of pink tissue throughout measuring approximately 3.5 cm. in length and 7 cm. in width.; c. open areas within borders of pink tissue appeared moist, with small amounts of light purulent drainage, sanguineous drainage and weeping-inclusive of areas of granulation tissue and black spotting throughout; area measured approximately 10.5 cm. in length by 12 cm in width; d. entire affected area measured approximately 14.5 cm. in length by 12.5 cm. in width; e. arm circumference just above the wound measured 23 cm. and the arm circumference just below the wound measured 16 cm. and f. follow up with Plastic Surgeon would be necessary. Review of the 7/10/18 Progress Note indicated the resident was admitted to the Hospital for a skin graft (due to the resident's burn). Review of the 7/23/18 Progress Note indicated the resident was readmitted to the facility. Review of the 8/25/18 quarterly MDS Assessment indicated the resident remained unchanged. On 10/09/18 at 10:10 AM, the surveyor was informed by Nurse # 1 that the resident experienced a burn to (his/her) arm due to a portable liquid O 2 canister leaking onto his/her arm, when he/she was in bed. On 10/11/18 at 12:18 P.M., the surveyor observed the resident sitting in a wheelchair, with his/her eyes closed and the portable liquid O 2 canister was strapped to the wheelchair handle. On 10/15/18 at 9:02 AM, the surveyor observed the resident's entire body lying in the upper head/shoulder area of the bed, with his/her eyes closed while on a Ventilator. The portable liquid O 2 canister was observed strapped to the resident's wheelchair handle. During an interview with the Director of Nursing (DON) on 10/15/18 at 1:39 PM, she said that once the resident was transferred into the bed, the Nurse would usually take the resident off of the portable liquid O 2 canister (leave the O 2 canister on the wheelchair) and place the resident on the room O 2. She said the Nurse was called out of the room to attend to another matter before the resident was placed on the room O 2. The DON said that when she spoke with the CNA (who was involved in the incident), the CNA said that she had placed the portable liquid O 2 canister on the shelf (above the resident's headboard) because the O 2 canister was in her way when she went to reposition the resident and change him/her and that she had done this in the past. The DON said she was unaware of the CNA's practice of placing the O 2 canister on the shelf. The DON said that the portable liquid O 2 canister should have stayed on the resident's wheelchair and not have been taken off. The DON further said that the shelf was not a safe place to put the O 2 canister on. The DON said that she believed what may have happened was that the resident was known to move his/her arms around in the air and that one of his/her arms may have caught the O 2 tubing which then pulled the O 2 canister into the resident's bed. Further review of the facility investigation indicated that after the incident, the facility completed house wide education regarding the safe delivery and handling of liquid oxygen via a portable canister to the staff. The facility's corrective measures included: 1. Canisters can only be in an upright position. 2. When transferring a resident who is utilizing an oxygen canister, the canister must remain on the wheelchair. 3. Only an RN (Registered Nurse) or LPN (Licensed Practical Nurse) can transfer oxygen delivery to an oxygen flow meter or concentrator. 4. Canisters are not to be placed on the bedside table, on the shelf at the head of the bed, or on the floor. 5. Once filled with liquid oxygen, canisters should be secured to the wheelchairs by the supporting strap. Training was completed with all staff by 6/21/18 and is ongoing. The Quality Assessment and Performance Improvement process is ongoing. The Director of Nursing is responsible to ensure compliance.