Every finding on record at Shrewsbury Rehabilitation and Nursing at Southgate

Based on observation, and interview, the facility failed to ensure that the facility dumpster area was maintained in a clean and sanitary manner to mitigate the harborage and feeding of pests. Specifically, the facility failed to ensure trash, garbage, and refuse were appropriately disposed of and properly contained within a trash receptable and not thrown on the ground around two dumpsters in a fenced-in dumpster area that was located in proximity to the main facility kitchen. Findings include: Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA); retrieved from < FDA Food Code 2022: Full Document> indicated: -Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. -Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. -Create a system of prevention and overlapping safeguards designed to minimize foodborne illness, and acceptable levels of sanitation on food establishment premises. -Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. -Soiled receptacles and waste handling units for Refuse, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. On 3/11/26 at 1:45 P.M., the surveyor and the Food Service Director (FSD) observed the following at the trash receptacles located outside of the facility main kitchen: *Inside the fenced-in dumpster area: -Two dumpsters in the wooden fence area: one on the left for general refuse and another on the right for recyclable cardboard. -within the fenced area on the ground scattered around the two dumpsters, there were 10 -15 cardboard boxes, four old worn mattresses, disposable gloves in multiple colors, worn coca cola box, multiple disposable clear cups, clear trash bags and various other trash debris. During an interview on 3/11/26 at 2:07 P.M., the FSD said she was not aware there was so much trash on the ground around the dumpsters. During an interview on 3/11/26 at 3:03 P.M., the Maintenance Director said this amount of trash and debris could breed insects and rodents. During an interview on 3/12/26 at 10:49 A.M., the Infection Preventionist (IP) said she observed the dumpster area, and it is a breeding ground for infestation. The IP also said that there should not have been any trash on the ground outside the dumpsters and that all trash should have been contained inside the dumpsters.

Based on observations, policy review and interviews, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacturing, possession, and use, that are classified into schedules based on their potential for abuse) for one Control Medication Log (Unit One Side A) out of three Control Medication Logs reviewed. Specifically, for the Unit One Side A Control Medication Log, the facility failed to ensure accurate documentation was maintained relative to the reconciliation of the controlled medication count, when the Control Medication Log was missing licensed nursing documentation that controlled medication reconciliation was completed as required. Findings include:Review of the facility policy titled Controlled Substances, revised November 2022, included but was not limited to:-The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II - V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).-Handling Controlled Substances.Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises.-Dispensing and Recording Controlled Substances.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: records of personnel access and usage;-Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.-The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. On 3/11/26 at 8:10 A.M., during an observation and review of the Control Medication Log on the Unit One Side A medication cart with Unit Manager (UM) #1 and Nurse #1, the surveyor observed in the back of the Control Medication Log there were no signatures or evidence that a count of the controlled medication had taken place on 3/10/26 at 11:00 P.M., and on 3/11/26 at 7:00 A.M. During an interview at the time, Nurse #1 said she did count the controlled medication on 3/11/26 at 7:00 A.M. with Nurse #2 who had control of the medications from 3/10/26 at 11:00 P.M. until 3/11/26 at 7:00 A.M. Nurse #1 further said that the controlled medication count was correct when she counted the controlled medication with Nurse #2 on 3/11/26 at 7:00 A.M. but she must have forgotten to sign the back of the Control Medication Log. During an interview on 3/11/26 at 8:15 A.M., with Nurse #1 and UM #1, Nurse #1 said she should have signed the back of the Control Medication Log once she had counted the controlled medications on 3/11/26 at 7:00 A.M. with Nurse #2, but she had not done so. UM #1 said that it was expected that two Nurses count the controlled medication at every change of shift including 7:00 A.M., 3:00 P.M., and 11:00 P.M. The surveyor and UM #1 reviewed the Control Medication Log and UM #1 said there were no entries for 3/10/26 at 11:00 P.M. or 3/11/26 at 7:00 A.M. During an interview on 3/11/26 at 8:32 A.M., Nurse #2 said she had counted the controlled medications on 3/10/26 at 11:00 P.M. with Nurse #3, and on 3/11/26 at 7:00 A.M. with Nurse #1, and on both occasions the controlled medication count was correct. Nurse #2 said she had forgotten to sign the back of the Control Medication Log after both counts, but she should have done so. During an interview on 3/11/26 at 10:52 A.M., the Director of Nursing (DON) said the expectation was that two Nurses would count the controlled medications at every change of shift and then both Nurses would sign the Control Medication Log together. The DON said she believed two Nurses had counted the medications at each change of shift but had not signed the back of the Control Medication Log as they should have. During an interview on 3/11/26 at 11:55 A.M., Nurse #3 said she did count the controlled medication on the Unit One Side A medication cart on 3/10/26 at 11:00 P.M. with Nurse #2. Nurse #3 said the count of the controlled medication was accurate, but she must have forgotten to sign the back of the Control Medication Log once the count was complete. Nurse #3 said she knew that the expectation was for two Nurses to count the controlled medication together and then sign the back of the Control Medication Log together indicating that the count was accurate, but she must have forgotten to do so.

Based on observation, record review, and interviews, the facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal laws for one (Unit One) of two medication storage rooms reviewed. Specifically, the facility failed to ensure a multi-dose vial of medication was discarded upon the expiration date according to manufacturer's guidelines in the Unit One medication storage room. Findings include:Review of the facility policy titled Medication Labeling and Storage, revised February 2023, included but was not limited to:-If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.-Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.-the medication label includes, at a minimum:.expiration date, when applicable,-Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer supplies a shorter or longer date for the open vial. On 3/11/26 at 8:49 A.M., during an observation and review of the Unit One medication storage room, the surveyor observed an open multi-dose vial of Tuberculin, Purified Protein in the refrigerator. The box containing the open vial was labeled as opened on 1/24/26. The box contained instructions on the side which indicated that once opened, the multi-dose vial should be discarded after 30 days. During an interview at the time, Nurse #1 said the Tuberculin, Purified Protein open multi-dose vial should have been discarded last month (February 2026) but it had not been discarded. Review of the Tuberculin, Purified Protein Derivative outer box containing the open multi-dose vial indicated:-Tuberculin, Purified Protein Derivative Diluted/Aplisol 5TU (Tuberculin Units) for intradermal test, 1 ML (milliliter) (10 tests), once entered [opened], vial should be discarded after 30 days. Review of the Tuberculin, Purified Protein Derivative Diluted/Aplisol package insert indicated that the multi-dose vial should be dated when opened and discarded after 30 days. During an interview on 3/11/26 at 10:00 A.M., the Staff Development Coordinator (SDC) said the Nurses were expected to discard multi-dose vials of Tuberculin, Purified Protein, 30 days after opening, but they had not done so. During an interview on 3/11/26 at 10:52 A.M., the Director of Nursing (DON) said the expectation was that multi-dose vials of Tuberculin, Purified Protein, should be labeled when opened, and discarded per the instructions after 30 days.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of urinary retention (bladder does not empty completely or at all), the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when he/she did not receive a physician ordered treatment for the monitoring and treatment of his/her urinary retention, placing him/her at risk for the development of complications associated with this condition.Findings include:Review of the Facility's policy, titled Charting and Documentation, with a revision date of 07/2017, indicated the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, or functional condition, shall be documented in the resident's medical record.-The following information is to be documented in the resident medical record: treatments and services as performed.Resident #1 was admitted to the facility in October 2025, diagnoses included obstructive and reflux uropathy (a blockage in the urinary system that prevents normal urine flow, while reflux uropathy involves urine flowing backward from the bladder to the kidneys).Review of Resident #1's Nursing Progress Note, dated 10/19/25, indicated Resident #1 removed his/her indwelling urinary catheter (a tube placed in the bladder to allow the flow of urine) and the Physician was notified.Review of Resident #1's Physician's Orders for the month of October 2025 indicated he/she had an order, dated 10/19/25, for a post void residual (PVR- a bladder scan that determines the amount of urine left in the bladder after urinating voluntarily) every shift and if the residual is greater than 500 milliliters (ml), to [use a] straight catheterization (an intermittent flexible tube used to drain urine from the bladder).Review of Resident #1's Medication Administration Record (MAR) for the month of October 2025, related to nursing documentation for his/her PVR indicated the following:-On 10/20/25 day shift (7:00 A.M. to 3:00 P.M.) Resident #1's PVR was 100 ml.-On 10/20/25 evening shift (3:00 P.M. to 11:00 P.M.) Resident #1's PVR was 200 ml.-On 10/20/25 night shift (11:00 P.M. to 7:00 A.M.) the boxes for nursing to sign off that his/her PVR was done and also the amount of urine that was retained in Resident #1's bladder, were left blank.Review of Resident #1's medical record indicated there was no documentation to support that his/her PVR was checked by nursing on the 10/20/25 night shift, as ordered by the physician.-On 10/21/25 day shift (7:00 A.M. to 3:00 P.M.) Resident #1's PVR was 605 ml, and he/she was catheterized for 1000 ml of urine output.During a telephone interview on 11/04/25 at 2:10 P.M., Nurse #1 said she was on duty for the 10/20/25 night shift. Nurse #1 said she was supervising Nurse #2 who was on orientation. Nurse #1 said at the end of their shift, Nurse #2 asked her if they could do Resident #1's PVR. Nurse #1 said she asked Nurse #2 if Resident #1 had voided. Nurse #1 said she did not know if Nurse #2 ever provided her the answer and that she did not do Resident #1's PVR with Nurse #2.Nurse #1 said if the PVR had been completed, it would have been signed off on Resident #1's MAR as being completed and would also have included the amount of urine retained in his/her bladder.The Surveyor was unable to interview Nurse #2, as she did not respond to the Department of Public Health's telephone or letter requests for an interview.During a telephone interview on 11/05/25 at 11:09 A.M., the Staff Development Coordinator (SDC) said when a nurse is on orientation she should stay side by side with her preceptor. The SDC said Nurse #2 was a recent graduate of nursing school. The SDC said that the preceptor should have ensured that all the treatments and medications were done as ordered and that the documentation was complete and accurate. The SDC said Nurse #1 should have known what her role was as a preceptor because she had been working at the facility for a long time.During a telephone interview on 11/05/25 at 3:33 P.M., the Director of Nurses (DON) said that if Resident #1's PVR was done as ordered on the night shift of 10/20/25, nursing would have signed it off as being completed on Resident #1's MAR or would have written a nursing progress note.

Based on record review and interview, the facility failed to maintain an accurate medical record for one Resident (#34) out of a total sample of 18 residents. Specifically, the facility failed to accurately document a behavioral incident by Resident #34 putting his/her roommate at risk for potential abuse. Findings include: Review of the facility policy titled Documentation in Medical Record, initiated 5/1/24, indicated: - Each residents' medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. - Principles of documentation include, but are not limited to: > Documentation shall be factual, objective, and resident centered. > False information shall not be documented > Record descriptive and objective information based on first hand knowledge of the assessment, observation or service provided. > Documentation shall be accurate, relevant, complete, and containing sufficient details about the resident's care and/or responses to care. Resident #34 was admitted to the facility in August 2017 with diagnoses including Dementia (progressive disease with impairment in memory and functioning), Expressive Aphasia (an acquired language disorder caused by damage to the brain's language centers, characterized by partial loss of the ability to produce language [spoken, manual, or written], although comprehension generally remains intact), Generalized Anxiety Disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life [work, social relationships, financial matters, etc.]). Review of the Minimum Data Set (MDS) assessment, dated 11/1/24, indicated: - Resident #34 had clear speech - Resident #34 was usually able to understand others and usually able to make themselves understood - Resident #34 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a total possible of 15. - Resident #34 did not exhibit any behaviors. During an interview on 11/21/24 at 12:09 P.M., Family Member #1 said that Resident #34 had an incident with his/her roommate over the past weekend and Resident #34 got mad at her roommate. Review of the Nurses Note dated 11/17/24 at 23:02 indicated: - Resident #34 had two episodes of behavior Issues. - Resident #34 became very mean and angry. - Yelling at roommate, - Pointing finger in [roommate's] face and - Attempted to strike roommate with his/her wheelchair. - While cursing at roommate and calling him/her fowl (sic) names. - Redirected with poor effect. Review of the Witness Statement by Nurse #1, dated 11/21/24, indicated that Nurse #1 was called to the room as Resident #34 was yelling out from his/her bed. The statement indicated Resident #34 was unable to say why he/she was upset and had used foul language. The statement further indicated that Resident #34 and their roommate did not touch each other, did not make contact, and both calmed down when staff intervened. During an interview on 11/21/24 at 4:49 P.M. the Director of Nurses (DON) said that she would have expected more accurate documentation and the nursing note to reflect that the incident did not rise to the level of abuse at that time. During an interview on 11/22/24 at 9:20 A.M. Nurse #1 said that she recalled Resident #34's behavioral incident on 11/17/24. She said that she observed Resident #34, and his/her roommate seated in their beds at opposite ends of the room and that Resident #34 was calling the staff foul names, not his/her roommate, and pointing his/her finger at the staff and anyone in the room. Nurse #1 said that she did not observe any action relative to Resident #34 using his/her wheelchair to strike at his/her roommate. Nurse #1 said that when Resident #34 becomes upset, he/she will swear and use foul language. During a second interview on 11/22/24 at 1:34 P.M., the DON said that the Nurse's Progress Note about the incident on 11/17/24 was inaccurate based on the witness statement provided by Nurse #1 and that the progress note would be corrected.

Based on record review and interview, the facility failed to complete an accurate comprehensive assessment, according to the required Resident Assessment Instrument (RAI) process in the Minimum Data Set Assessment (MDS), for one Resident (#6) out of a total sample of 18 residents. Specifically, the facility staff failed to assess Resident #6's cognitive and mood status through the required Resident interview process when the Resident had adequate hearing, clear speech, and sometimes made him/herself understood and sometimes understood others. Findings include: Review of the Centers for Medicare and Medicare Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11, dated October 2023, included the following: -Assessment Reference Date (ARD) refers to the specific endpoint for the observation (or look-back) periods in the comprehensive Minimum Data Set (MDS) assessment process. - The standard look-back period for the MDS 3.0 is 7 days, unless otherwise stated. - The interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. - Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. - If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard no information code (a dash -) entered in the resident interview items. - Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted but was not done. Resident #6 was admitted to the facility in October 2024, with diagnoses including Dementia (progressive disease with impairment in memory and functioning) with Agitation (a condition in which a person is unable to relax and be still. The person may be very tense and irritable, and become easily annoyed by small things), Anxiety Disorder (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), and Hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). Review of the Resident #6 Admission Nursing Progress Note dated 10/8/24, indicated the following: - Resident was cooperative - BIMS interview Score 0 out of a total possible 15 - BIMS interview category: severe impairment Review of Resident #6's comprehensive Minimum Data Set (MDS) Assessment, dated 10/14/24, indicated the following: - The Resident had adequate hearing. - The Resident had clear speech. - The Resident could sometimes make him/herself understood. - The Resident could sometimes understand others. - The Brief Interview for Mental Status (BIMS) should be attempted with all residents. - The BIMS was not assessed. - The Mood interview should be attempted with all residents. - The Resident's mood was not assessed. During an interview on 11/27/24 at 7:51 A.M., the MDS Nurse said that nursing staff on the floor are not trained to assess BIMS upon admission for Residents and said that the Social Worker was responsible for assessing Residents' BIMS upon admission. The MDS Nurse also said that if BIMS assessment were not completed within the time frame allowed during the assessment reference period which is 14 calendar days by CMS, then he had to indicate that the BIMS was not assessed. The MDS Nurse said that BIMS should have been assessed when Resident #6 was admitted to the facility in October 2024 and on the comprehensive MDS assessment. During an interview on 11/27/24 at 9:05 A.M., Nurse #3 said that Nurses on the floor are not trained to assess a Resident's BIMS. Nurse # 3 also said that BIMS assessment opened as part of the Nursing Admission Assessment in Point Click Care (PCC, a cloud based healthcare software platform that offers electronic health records and other solutions for a variety of healthcare settings) but the Nurses were not trained to complete the BIMS with residents and that the Social Workers was responsible for the BIMS. Nurse #3 further said that Social Workers are responsible for assessing Resident's BIMS the following day after Resident's are admitted to the facility. Nurse #3 reviewed the clinical records with the surveyor which indicated Resident #6's BIMS was not assessed in October 2024, when the Resident was admitted . During an interview on 11/27/24 at 11:30 A.M., the Director of Nursing (DON) said that BIMS and Mood assessments were completed for Resident #6 after the comprehensive assessment ARD date, so the BIMS and Mood scores were not included on the comprehensive assessment.

Based on observation, record review, and interviews, the facility failed to ensure professional standards of practice for medication administration for one Resident (#15) out of a total of 18 residents sampled. Specifically, the facility staff failed to administer Ativan (a medication used to treat anxiety [persistent worry and fear about everyday situations]) in accordance with the physician order. Findings include: Review of facility policy titled Medication orders, dated 5/1/2024, indicated the following: -Elements of medication order: > Date and time of the order written > The resident's full name > Name of the medication > Dosage (strength) of the medication > Frequency (how often) of the administration (provided) > Duration, if applicable. > Route (location) of administration > Type/formulation (if applicable). > Hour of administration (if applicable). > Diagnosis or indication for use. > PRN (pro re nata [as needed]) orders should also specify the condition for which they are being administered (e.g. [exempli gratia (for example)] as needed for sleep). - Documentation of medication orders: > Each medication order should be documented with the date, time and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). > Clarify the order. > If using electronic medication records, input the medication order according to the electronic health record (EHR) instructions and per facility policy. > Transcribe (to put data into written or printed form) newly prescribed medications on the MAR or treatment record or ensure the order is in the electronic MAR. Review of the facility policy titled Medication Administration, dated 5/1/24 indicated: - Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. > Ensure that the six rights of medication administration are followed: 1. Right resident 2. Right medication 3. Right dosage 4. Right route 5. Right time 6. Right documentation > Review the MAR to identify medication to be administered. > Administer medication as ordered. > Correct any discrepancies and report to nurse manager. Review of Nursing2024 Drug Handbook, Edition 44 [NAME] &Wilkins, indicated the following professional standard of practice: -The rights of medication administration include the five well known rights: 1. Right patient: ensuring the medication is given to the correct patient. 2. Right drug: ensuring the medication matches the prescribed drug. 3. Right dose: administer the correct dose. 4. Right route: administer the medication through the appropriate route. 5. Right time: administer the medication at the scheduled time or frequency. Resident #15 was admitted to the facility in September 2023 with diagnoses including Dementia (a group of symptoms affecting memory, thinking and social abilities which interferes with daily life) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #15 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of a total possible score of 15. Review of Resident #15 ' s comprehensive medical record indicted the following: -Activation of Health Care Proxy (HCP- a legally authorized person to make medical decisions on behalf of another person), effective 9/28/2023. -A comprehensive, person-centered care plan for Anxiety which indicated interventions for administering anti-anxiety medication (like Ativan) as ordered by physician, effective 10/9/24. -Physician order for Ativan 0.5 mg (mg-milligrams) by mouth every morning and bedtime for anxiety, initiated 7/29/2024. -Physician order for Ativan 0.5 mg PO (per os [by mouth]) daily (once a day) PRN as needed anxiety/agitation, initiated 11/18/24. Review of Resident #15 ' s November 2024 MAR indicated the following: -An order for Ativan oral tablet 0.5 mg - give 0.5 mg by mouth as needed for anxiety/agitation for 14 days with start date of 11/19/2024. -Documented administration of Ativan 0.5 mg PO twice a day PRN on 11/20/24 at 1:44 A.M. and 5:51 A.M. During an interview on 11/26/24 at 10:17 A.M., the Unit Manager #1 (UM#1) said Resident #15 was unaware of his/her prescribed medications due to his/her dementia. The UM#1 said that Resident #15 had increased episodes of anxiety and the physician recently ordered a daily PRN dose of Ativan, as a result. The UM said Resident #15 was given PRN Ativan twice on 11/20/24 at 1:44 A.M. and 5:51 A.M. and should not have been, because the PRN Ativan was ordered for once a day. The UM then said the PRN Ativan had been transcribed incorrectly to the MAR and did not include a frequency. The UM said medication frequency was part of the five rights of medication administration and should be included on the transcribed order. The UM said Resident #15 was high risk due to his/her dementia and too much Ativan could increase his/her confusion. During an interview on 11/27/24 at 10:45 A.M., the Director of Nursing (DON) said that orders for medication should be transcribed to the MAR by the unit nurse and include the five rights of administration which were the right resident, medication, dose, route, and frequency. The DON said that the five rights should be followed for all residents as a professional standard of practice. The DON said that all nurses are educated on transcription of orders upon hire. The DON said that the 11:00 P.M. to 7:00 A.M. shift nurses also completed a chart check to ensure that the order for Ativan was transcribed correctly but the order for Ativan had not been transcribed correctly for Resident #15 as the frequency had been omitted. The DON said that the PRN Ativan had not been administered in accordance to the Physicians order.

Based on observation, record review, and interviews, the facility failed to ensure its staff maintained professional standards of practice to prevent the development and promote healing of pressure ulcers/skin injuries for one Resident (#55) out of a total sample of 18 residents. Specifically, for Resident #55, the facility staff failed to perform a wound treatment as ordered by the physician, placing the Resident at risk for delayed wound healing. Findings include: Review of the facility policy titled Wound Treatment Management, last revised 5/1/24, indicated: -To promote healing of various types of wounds, it is the policy of this facility to provide evidence based treatments in accordance with current standards of practice and physician orders. -Wound treatments will be provided in accordance with physician orders, including; the cleansing method, type of dressing, and frequency of dressing change. -Dressings will be applied in accordance with manufacturers recommendations. Resident #55 was admitted to the facility in July 2024 with diagnoses including paraplegia (a condition that causes paralysis of the lower half of the body, including the legs, hips, stomach, and chest) and a Deep Tissue Injury (DTI: damage to tissues beneath the skin that occurs due to pressure or shear forces that can progress into large deep wounds). Review of a Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. Review of the clinical record indicated Resident #55 had been transferred to the hospital 8/16/24 and returned to the facility 8/27/24. Further review of the clinical record indicated a Physician progress note dated 8/27/24 that indicated Resident #55 had developed a Stage IV pressure ulcer (a deep wound that extends beyond the skin layers reaching muscles, tendons, or bone). Review of the Active Physician orders dated 11/26/24 indicated the following: - Sacral ulcer: Wash with antibacterial soap and irrigate with saline, pat dry, apply Santyl (a prescription medicine that removes dead tissue from wounds so that they can start to heal properly) to wound base (the open area of the wound also known as the wound bed) followed by a damp to dry dressing, cover with border foam dressing every day and evening shift for wound healing, initiated on 10/24/24. On 11/25/24 at 11:27 A.M., the surveyor observed Nurse #2 and Unit Manager #2 (UM #2) perform a wound care treatment to Resident #55's Stage IV sacral wound. The surveyor observed UM #2 positioned on one side of Resident #55's bed, and Nurse #2 positioned on the opposite side of the bed with Resident #55 positioned on his/her side facing UM #2. The surveyor observed Nurse #2 perform hand hygiene, don clean gloves, remove the old dressing from the wound, discard the dressing, remove gloves, and perform hand hygiene. Nurse #2 then put on clean gloves, cleansed the wound as ordered and placed a clean damp gauze into the wound covering the wound base. The surveyor then observed Nurse #2 to apply Santyl around the outside of the wound with a cotton tipped applicator and place a border foam dressing over the wound. At no time did the surveyor observe Nurse #2 apply Santyl to the wound base of Resident #55's sacral wound. During an interview on 11/25/24 at 11:57 A.M., UM #2 said that she could not see what Nurse #2 did with the Santyl because she was on the opposite side of the bed. UM #2 said that the Physician's order for the wound care to Resident #55's sacral wound indicated to apply the Santyl to the wound bed and not around the wound. During an interview on 11/25/24 at 12:02 P.M., Nurse #2 said that the Physician's order for the wound care for Resident #55's sacral wound said to apply the Santyl to the wound bed. Nurse #2 said she applied the Santyl around the wound but did not apply the Santyl to the wound bed as ordered.

Based on observation, interviews, and records reviewed, the facility failed to adequately assess wandering and elopement risk for one Resident (#83) out 18 total sampled residents which increased the Resident's risk for unsafe wandering and elopement. Specifically, facility staff failed to: - Accurately complete Resident #83's Admission Assessment for Wandering according to the instructions provided in the facility's Admission Wandering Assessment for the Resident. - Assess Resident #83's wandering risk, when the Resident exhibited changes in behavior and demonstrated exit seeking behaviors that were not present when the Resident was admitted to the facility. - Establish a resident-centered plan of care relative to wandering when Resident #83 began exhibiting wandering behaviors and seeking exit from the facility. Findings include: Review of the facility's policy titled Elopements and Wandering Residents, dated 5/1/24, indicated the following: - This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement . receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. - Wandering is random or repetitive locomotion that may be goal directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed and aimless. - The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, . - Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. - The interdisciplinary team will evaluate the unique factors contributing to risk on order to develop a person-centered care plan. - Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Resident #83 was admitted to the facility in June 2024 with diagnoses including Parkinson's Disease (movement disorder of the nervous system that worsens over time), Dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) with Behavioral Disturbance, and Right Femur (thigh bone) Fracture. Review of Resident #83's Wandering Risk Scale Assessment, dated 6/13/24, indicated instructions for staff to complete the assessment on admission/readmission, at 72 hours, and one month later, with any change of condition, and annually for all residents. Further review of the Assessment indicated: - The Resident could follow instructions. - The Resident could move without assistance while in his/her wheelchair. - The Resident could communicate. - The Resident had no history of wandering. - The Resident had no diagnosis of Dementia/cognitive impairment; diagnosis impacting gait/mobility or strength. - The Assessment sections G (complete 72 hours post admission), H (complete at one month, ., and adhoc [when needed] screening) were not completed. - The Resident's Wandering Risk Scale Score was two (low risk). Review of Resident #83's Minimum Data Set (MDS) Assessment, dated 6/20/24, indicated the following: - The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out 15 total possible points. - The Resident exhibited no wandering behaviors. - The Resident reported no mood problems. Review of Resident #83's Nurses Note, dated 7/25/24, indicated the following: - The Resident was non-compliant with safety measures. - The Resident transferred him/herself to the bathroom and bed. Review of Resident #83's Behavior Note, dated 7/25/24, indicated the following: - The Resident attended activities in the Main Dining Room. - During transport back to the Unit, the Resident refused to come back and attempted to exit. - Facility staff had difficulty redirecting the Resident. - The Resident eventually agreed to return to the Unit. - The Resident transferred him/herself and ambulated without the use of an assistive device or staff member. Review of Resident #83's clinical record did not include any evidence that: - The Resident's wandering or elopement risk was assessed when the Resident exhibited refusal to return to the Unit from the Main Dining Room. - A care plan relative to risk for wandering and elopement had been initiated for the Resident. Review of Resident #83's clinical record indicated the Resident was transferred to the hospital related to a medical change in condition on 7/28/24 and returned to the facility on [DATE]. Further review of the clinical record did not include any evidence Resident #83's risk for wandering and elopement was assessed upon readmission to the facility on [DATE]. Review of Resident #83's clinical record indicated the Resident was transferred to the hospital after sustaining a fall on 8/18/24 and returned to the facility on [DATE]. Review of Resident #83's Nursing Readmission Evaluation, dated 8/19/24 and completed 8/20/24, indicated the following relative to elopement risk: - The Resident was confined to chair/bed. - The Resident was unable to walk. - The Resident was not an elopement risk. Review of Resident #83's Physician Progress Note, dated 8/22/24, indicated the following: - The Resident was seen due to increasing paranoia, delusions, possible hallucinations observed by staff. - The Resident was wheeling him/herself into other residents' rooms and was intrusive. - The Resident had Parkinson's Disease and cognitive impairment. Review of Resident #83's clinical record did not include any evidence that: - The Resident had been assessed for wandering and elopement risk when the Resident exhibited wandering into other residents' rooms. - A care plan relative to wandering and elopement had been initiated for the Resident. Review of a Nurses Progress Note, dated 8/28/24, indicated the following: - The Resident exhibited delusions, hallucinations, and paranoia. - The Resident was difficult to redirect during the shift. - The Resident wanted to call 911 and stated that he/she was being held at the facility against his/her will. - The Resident stood to grab the phone. - The Resident was seeking exit. Review of a Nurses Progress Note, dated 8/29/24 at 9:13 A.M., indicated the Resident was redirected that same morning for exit seeking. Review of Resident #83's Nurses Progress Note, dated 8/29/24 at 1:45 P.M., indicated the following: - The Resident was reviewed at Risk Meeting. - The Resident had delusional, paranoid, and exit seeking behaviors. - Will assess for elopement risk. Review of Resident #83's Skilled Progress Note, dated 8/29/24, indicated the Resident wandered, sought exit, and was difficult to redirect at times. Review of Resident #83's clinical record did not include any evidence facility staff assessed the Resident's risk for elopement when the Resident exhibited exit seeking behaviors on 8/28/24 and 8/29/24, and per the recommendation of the facility's Risk Meeting held on 8/29/24. Further review of the Resident's clinical record did not include any evidence a care plan relative to the Resident's risk for wandering and elopement had been initiated. Review of Resident #83's Nurses Progress Note, dated 9/2/24, indicated the following: - The Resident was alert and confused. - Facility staff found the Resident in another resident room in the evening. - The Resident was sitting behind the closed door to the other resident room, staring at both residents in that room. Review of Resident #83's Nurses Progress Note, dated 9/17/24, indicated the following: - The Resident continually sought out staff to report that he/she did not belong among residents with Dementia. - The Resident requested to see the Social Worker to get out of here. - The Resident was redirected with little effect. Review of Resident #83's MDS Assessment, dated 9/18/24, indicated the following - The Resident was moderately cognitively impaired as evidenced by a BIMS score of 12 out of 15 total possible points. - The Resident reported feeling down, hopeless, or depressed several days during the assessment reference period for the MDS Assessment. - The Resident exhibited wandering behavior one to three days during the assessment reference period for the MDS Assessment. Review of Resident #83's Quarterly Elopement Risk Evaluation, dated 9/18/24, indicated the following: - The Resident was ambulatory or used a wheelchair. - The Resident had one or more of the following predisposing conditions: Dementia, Organic Brain Syndrome, Alzheimer's Disease, Mental Illness, Traumatic Brain Injury. - The Resident had intermittent confusion. - The Resident had poor safety/environment awareness. - The Resident's elopement risk score was 14 (10 or higher indicates high risk). - The Resident resided on the locked unit and had made no attempts to elope from the Unit. Further review of the Elopement Risk Evaluation indicated instructions as follows: If the total score is 10 or greater, the resident should be considered at high risk for elopement. A prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #83's Nurses Progress Note, dated 9/30/24, indicated the following: - Facility staff observed the Resident pushing on the door from the Unit that led to the stairwell. - The Resident said that he/she had been kidnapped and was being held against his/her will. - The Resident said that he/she was going to go down the stairs or go through the door to jump out the window to leave. - The Resident was pushing aggressively on the door, setting off the door alarm. - Facility staff offered the Resident a drink and snack and offered to assist the Resident back to his/her room with no effect. - The Physician was in the facility and attempted to talk with the Resident. - The Nurse placed a wander guard (device used to alert caregivers when a Resident gets close to an exit door) on the Resident's wheelchair. Review of Resident #83's Physician Progress Note, dated 9/30/24, indicated the following: - The Resident was seen urgently by the Physician due to paranoia and agitation. - The Resident appeared very aggravated and paranoid, and not reasonable. - The Resident was transferred to the hospital for management of psychotic episode. Review of Resident #83's Nursing Elopement Risk Evaluation, dated 9/30/24, indicated the following: - The Resident was ambulatory with assistive devices. - The Resident was disoriented at all times. - The Resident exhibited purposeful exit seeking. - The Resident exhibited one elopement episode in the past three months. - A wander guard was placed on the Resident's wheelchair that same day. - The Resident's elopement risk score was 20 (high risk). Review of Resident #83's active care plan indicated the following: - The Resident was at risk for elopement related to elopement attempt, delusions. - The elopement care plan was not initiated until 9/30/24. - The Resident's Behavior Care Plan was not revised to include exit seeking behaviors until 10/8/24. On 11/21/24 at 7:59 A.M., the surveyor observed Resident #83 self mobilizing in his/her wheelchair in the hallway on the Unit. The surveyor observed Resident #83 using his/her feet and using the handrail while mobilizing in the wheelchair. The surveyor observed Resident #83 mobilize to the end of the hallway, facing the door that led to the stairwell outside of the Unit. The surveyor observed Resident #83 sit and face the door for approximately four minutes, then the Resident began to push on the door handle until the door alarm sounded. During an interview on 11/22/24, the Assistant Director of Nursing (ADON) said that she was the Nurse who responded to Resident #83's attempt to exit the Unit on 9/30/24. The ADON said that Resident #83 did not exit through the door into the stairwell, but that the Resident was pushing on the door and was threatening to leave. The ADON said that she was eventually able to redirect Resident #83 away from the door, but the Resident's behaviors continued, the Resident could not be reasoned with and required transfer to the hospital. The ADON said that she was not working at the facility when the Resident was admitted in June 2024, so she could not speak to the Resident's presentation at the time of admission. The ADON said she would have to review the Resident's clinical record to determine when the Resident should have been assessed for wandering and elopement and for when individualized interventions for wandering and elopement should have been added into the Resident's care plan. During an interview on 11/26/24 at 8:00 A.M., Unit Manager (UM) #1 said Residents were assessed for wandering and elopement risk upon admission/readmission, quarterly, annually, and if a status change occurred where a resident attempted to leave or voiced wanting to leave the facility. UM #1 said she completed an elopement assessment for Resident #83 on 8/19/24, when the Resident returned to the facility from the hospital after having had a fall. UM #1 said that at the time she completed the assessment, Resident #83 was lethargic, sleepy and bedbound, and the Resident was assessed to be not at risk for elopement. UM #1 further said that the Resident needed to gain some strength before becoming mobile again. The surveyor inquired whether Resident #83's risk for wandering and elopement should have been reassessed when the Resident exhibited exit seeking behaviors on 8/28/24, UM #1 said that she did not think the Resident had been exit seeking at that time. During an interview on 11/26/24 at 11:35 A.M., the Director of Nursing (DON) said assessments for wandering and elopement risk were to be completed for residents upon admission/readmission to the facility, quarterly, annually, and with a change in condition where exit seeking behaviors are increased from the resident's baseline exit seeking behavior. The DON said that she completed an elopement assessment and revised Resident #83's plan of care on 9/30/24 when the Resident attempted to exit the Unit and was transferred to the hospital. The DON said she would need to review Resident #83's clinical record to determine whether the Resident's wandering and elopement risk should have been assessed and a care plan relative to wandering and elopement developed prior to 9/30/24. During a follow-up interview on 11/26/24 at 4:05 P.M., the DON said she reviewed Resident #83's clinical record and that the Resident's initial Wandering Risk Scale Assessment, dated 6/13/24, should have been completed to indicate that the Resident had a diagnosis of Dementia/cognitive impairment and diagnosis impacting gait/mobility or strength since the Resident was admitted with a diagnosis of Dementia and a hip fracture. The DON also said staff should have reassessed the Resident's wandering and elopement risk when the Resident began exit seeking and again when the IDT recommended an elopement assessment be completed on 8/29/24. The DON also said that staff should have developed a plan of care with individualized interventions relative to Resident #83's wandering and exit seeking behaviors prior to 9/30/24 when the Resident required hospital transfer relative to exit seeking behaviors.

Based on observation and interview, the facility failed to remove expired medications from one medication cart, out of a sample of three medication carts. Specifically, the facility failed to remove and dispose two bottles of expired Ferrous Gluconate liquid (Iron Supplement), increasing the risk of non-therapeutic benefit when the medication is administered. Findings include: Review of the facility policy titled Medication Storage, revised 5/1/24, indicated: -All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . -The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. Review of the facility policy titled Medication Administration, revised 5/1/24, indicated: -Identify expiration date. If expired, notify nurse manager. On 11/26/24 at 10:33 A.M., the surveyor and Nurse #2 observed the medication cart on the Station 3 nursing unit to contain two bottles of Ferrous Gluconate liquid with labels that indicated expiration dates of 5/2024 and 10/2024. During an interview at the same time, Nurse #2 said the expired Ferrous Gluconate liquid medications should not have been administered to residents and should have been removed from the medication cart when they expired. Nurse #2 said she would notify the Unit Manager and have the expired medications removed from the medication cart.

Based on interviews and records reviewed, the facility failed to notify the State mental health authority promptly after a significant change in the mental condition for resident review for one Resident (#83) out of 18 total sampled residents which increased the Resident's risk for not receiving specialized services in a timely manner. Specifically, facility staff failed to notify the State mental health authority of the need for resident review when: - Resident #83 exhibited a new onset of paranoia (unwarranted or delusional belief that one is being persecuted, harassed, or betrayed by others, occurring as part of a mental condition), delusions (unshakable belief in something that is untrue; type of psychotic disorder [collection of symptoms that affect the mind, where there has been some loss of contact with reality]), and visual hallucinations (experience involving the apparent perception of something not present). - Resident #83 had newly added diagnoses of: Delusional Disorders, Paranoid Personality Disorder, and Psychotic Disorder with Delusions. - Resident #83 required treatment with an antipsychotic medication, when the Resident had not previously required antipsychotic medications use. Findings include: Resident #83 was admitted to the facility in June 2024 with a diagnosis of Dementia with Behavioral Disturbance. Review of Resident #83's Preadmission Screening and Resident Review (PASRR) Level One Screening, dated 6/13/24, indicated the following: - The Resident had not been diagnosed with Delusional Disorder, Paranoia, or Other Psychotic Disorder. - The Resident's screen for Serious Mental Illness (SMI) was negative. - A Level Two PASRR Evaluation was not indicated. Review of Resident #83's Minimum Data Set (MDS) Assessment, dated 6/20/24, indicated the Resident did not exhibit any hallucinations or delusions. Review of Resident #83's Initial Psychiatric Diagnostic Evaluation, dated 7/9/24, indicated the following: - The resident was referred for psychiatric evaluation due to concerns for adjustment, motivation, and depression. - The Resident had no known previous psychiatric history. - No psychotropic medications were in use for the Resident. - The Resident had Adjustment Disorder with Depressed Mood. Review of Resident #83's Nursing Progress Note, dated 8/28/24 and written at 2:49 P.M., indicated the Resident was alert with delusions and hallucinations. Review of Resident #83's Nursing Progress Note, dated 8/28/24 and written at 9:10 P.M., indicated the following: - The Resident was difficult to redirect during the shift. - The Resident wanted to call 911 and was seeking exit. - The Resident spoke with his/her healthcare proxy (HCP: individual designated to make healthcare decisions for one determined incapacitated) over the phone, requested the HCP contact 911, and stated that his/her phone conversation was being recorded by the FBI. - Facility staff contacted the Physician and the Physician ordered a one-time dose of Seroquel (antipsychotic medication) to be administered to the Resident. - The Physician gave approval for a repeat dose of Seroquel to be administered that same night if needed. - The Seroquel was effective for the Resident. Review of Resident #83's Skilled Progress Note, dated 8/29/24, indicated the following: - The Resident was alert and oriented, with confusion and delusions. - The Resident wandered and sought exit. - The Resident was difficult to redirect at times. Review of Resident #83's Psychiatric Nurse Practitioner Visit Note, dated 8/29/24, indicated the following: - The reasons for the Visit were paranoia, aggression, and exit seeking. - The Resident had received a one-time dose of Seroquel on 8/28/24 with good effect. - The Resident had no psychotropic medications ordered for use. - Consider starting Seroquel 12.5 mg BID (two times per day) for aggressive behaviors and distressing delusions. Further review of the Psychiatric Nurse Practitioner Visit Note indicated the recommendation for starting Seroquel was reviewed with the Physician and approved to start on 9/3/24. Review of Resident #83's Order Recap Report indicated the following: - Seroquel Oral Tablet, give 12.5 mg by mouth two times a day for Anxiety, dated 9/4/24 and discontinued 9/13/24. - Seroquel Oral Tablet, give 12.5 mg by mouth two times a day for hallucinations/delusions, dated 9/13/24 and discontinued 10/3/24. - Seroquel Oral Tablet, give 25 mg by mouth two times a day for hallucinations/delusions, dated 10/3/24 with no stop date. Review of Resident #83's September 2024 Medication Administration Record indicated Seroquel was administered to the Resident, as ordered, while the Resident was in the facility. Review of Resident #83's Diagnosis Listing Report indicated new diagnoses were added as follows: - Paranoid Personality Disorder on 9/5/24. - Delusional Disorders on 9/5/24. - Psychotic Disorder with Delusions due to Known Physiological Condition on 9/27/24. Review of Resident #83's clinical record did not indicate any evidence facility staff notified the State mental health authority of the Resident's newly indicated serious mental illness (SMI) and decline in condition. Review of Resident #83's Nurses Progress Note, dated 9/30/24, indicated the following: - Facility staff observed the Resident pushing on the door from the Unit that led to the stairwell. - The Resident said that he/she had been kidnapped and was being held against his/her will. - The Resident said that he/she was going to go down the stairs or go through the door to jump out the window to leave. - The Resident was pushing aggressively on the door, setting off the door alarm. - Facility staff offered the Resident a drink and snack and offered to assist the Resident back to his/her room with no effect. - The Physician was in the facility and attempted to talk with the Resident. - The Nurse placed a wander guard (device used to alert caregivers when a Resident gets close to an exit door) on the Resident's wheelchair. Review of Resident #83's Physician Progress Note, dated 9/30/24, indicated the following: - The Resident was seen urgently by the Physician due to paranoia and agitation. - The Resident appeared very aggravated and paranoid, and not reasonable. - The Resident was transferred to the hospital for management of psychotic episode. Review of Resident #83's clinical record indicated the following: - The Resident returned to the facility from the hospital on 10/3/24. - The State mental health authority was not notified of the Resident's need for Resident Review until 10/7/24. During an interview on 11/21/24 at 3:45 P.M., Unit Manager (UM) #2 said that she had been assisting the facility with completing PASRR screenings and submissions to the State mental health authority for resident reviews during the time that Resident #83's mental condition changed, requiring the use of Seroquel for new diagnoses of Paranoid Personality Disorder and Delusional Disorders. UM #2 said that she had not been made aware of the Resident's newly added diagnoses and use of antipsychotic medication until a Consultant Social Worker alerted her of the diagnoses and use of Seroquel when the Resident returned from the hospital on 10/3/24. UM #2 said that she did not complete the request for resident review through the State mental health authority until 10/7/24. During an interview on 11/22/24 at 10:42 A.M., the Consultant Social Worker (SW) said that when a resident had a change in mental condition with a newly added diagnosis of Paranoid Personality Disorder, Delusional Disorder, or Psychotic Disorder and required a change in treatment for antipsychotic use when psychotropic medications were not previously prescribed, the facility was required to promptly submit a resident review to the State mental health authorities for a Level Two PASRR Evaluation to be completed. The Consultant SW said that facility staff's submission for a resident review on 10/7/24 was not completed promptly and should have been completed when the Resident's change in condition occurred.

Based on interview and records reviewed, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for one Resident (#83) out of a total sample of 18 residents. Specifically, facility staff failed to accurately code the use of antianxiety (used to treat symptoms of anxiety [feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome] medication on one MDS Assessment for Resident #83. Findings include: Resident #83 was admitted to the facility in June 2024 with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). Review of Resident #83's active Physician Orders indicated the following order dated 11/12/24: - Ativan (antianxiety medication) oral tablet 0.5 milligrams (mg). - Give 0.5 mg by mouth every eight hours as needed for Anxiety/Agitation for 180 days. Review of Resident #83's MDS Assessment, dated 11/8/24, indicated the Resident received antianxiety medication during the MDS Assessment observation period (11/2/24-11/8/24). Review of Resident #83's November 2024 Medication Administration Record did not indicate any Ativan was administered to resident #83 during the observation period for the Resident's MDS assessment dated [DATE]. During an interview on 11/22/24 at 2:20 P.M., the MDS Nurse said that Resident #83 did not receive any antianxiety medication during the observation period for the MDS assessment dated [DATE] and that antianxiety medication should not have been coded on the MDS Assessment as having been taken during the observation period. The MDS Nurse further said that coding use of antianxiety medication on Resident #83's MDS Assessment, dated 11/8/24, was a coding error.

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for two Residents (#1 and #3) out of a total sample of three residents and one unit (Station 1) out of three units observed. Specifically, the facility failed to: 1. Ensure the appropriate personal protective equipment (PPE - protective devices, garments, or coverings such as eye protection, gloves, and gowns, that are worn to minimize exposure to hazards that may cause injury or illness) was utilized by staff during an active Covid-19 (a disease caused by the SARS-CoV-2 virus which can be very contagious and spreads quickly) outbreak. 2. Monitor Resident's #1 and #3 for signs and symptoms of Covid-19 during an active outbreak. Findings include: Review of the facility's policy titled, Coronavirus Disease (Covid-19) - Using Personal Protective Equipment, revised September 2022 indicated but was not limited to: When caring for a resident with confirmed or suspected SARS-CoV-2 infection: - Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to standard precautions and use a NIOSH-approved N-95 (a type of mask that protects the wearer from particles or from liquid contaminating the face) or equivalent or higher-level respirator, gown, gloves, and eye protection. - Disposable respirators are doffed (removed) and discarded after exiting the resident's room or care area and closing the door. - Hand hygiene is performed after removing the respirator. - Eye protection (goggles or face shield) is applied prior to entry to the resident room or care area. - Eye protection is removed after leaving the resident room or care area. - Gloves are applied upon entry to the resident room or care area. - Gloves are removed and discarded before leaving the resident room or care area, and hand hygiene performed immediately. - A clean isolation gown is donned (applied) before entry to the resident room or care area. - The gown is removed and discarded in a dedicated container for waste or linen before leaving the resident room or care area. 1. During an interview on 12/6/23 at 8:05 A.M., the Director of Nurses (DON) said the facility was currently in a Covid-19 outbreak and the staff were required to wear N-95 respirators throughout all the resident care areas. In addition, staff were required to wear full PPE (N-95 respirator, eye protection (goggles), gown and gloves) in rooms where residents were on isolation precautions for Covid-19. The DON further said that upon exiting an isolation room, staff were required to sanitize their eye protection for re-use, discard their contaminated N-95 respirator and don a new N-95 respirator upon exiting the isolation room. During an observation on the Station 1 Unit on 12/6/23 at 8:20 A.M.- 8:30 A.M., the surveyor observed CNA #1 inside a resident room which was designated an isolation room as evidenced by signs hanging outside the door. The sign read: Clean hands when entering and exiting, wear a gown, wear an N-95 respirator, wear eye protection and wear gloves. There was also a sign outside of the room with detailed steps on the proper way to don and doff PPE. The surveyor observed CNA #1 in the room assisting in setting up the resident's breakfast tray wearing an N-95 respirator and goggles, but she was not wearing a gown or gloves. The surveyor then observed CNA #1 exit the resident's room, without sanitizing her hands, changing her N-95 mask, or sanitizing her goggles. The surveyor observed CNA #1 go into the unit kitchen, using her hands which were contaminated to punch in the key code on the locked door. The CNA came out of the kitchen with a styrofoam cup with a straw, re-entered the same resident's room, delivered the drink to the resident, exited the room without sanitizing her goggles, changing her N-95 respirator, or sanitizing her hands a second time. She then immediately went into the meal cart to remove another breakfast tray, carry it down the hall and into another isolation room without stopping to sanitize her hands or put on a gown or gloves (which were all available hanging outside the resident's door) while wearing the original N-95 mask that should have been discarded and goggles that should have been sanitized. CNA #1 was observed to place the breakfast tray on the resident's overbed table, open the containers for the resident, adjust the bed height and positioned the resident to an upright position by adjusting his/her shoulders, without donning gloves or washing her hands. The surveyor observed CNA #1 sanitizing her hands and exiting the resident's room, but she did not change her N-95 mask or sanitize her goggles. During an interview on 12/6/23 at 8:26 A.M., Nurse #1 said the resident in the room where CNA #1 was assisting was on isolation precautions because he/she was infected with Covid-19 and all staff who entered the room should be wearing eye protection, N-95 respirator, gown and gloves and were required to remove their PPE upon exiting the room, discard the N-95 mask and apply a new mask and sanitize the eye protection. During an interview on 12/6/23 at 8:30 A.M., CNA #1 said she should have been wearing a gown and gloves in addition to the N-95 respirator and goggles, but she had nowhere to place the breakfast tray outside of the resident's room to put on the gown and gloves. CNA #1 said that she did not need to wear a gown and gloves if she was not performing personal care. When the surveyor relayed observations of CNA #1 going from an isolation room to the kitchen, back to the isolation room, then to the breakfast cart and into another isolation room without utilizing the appropriate PPE or sanitizing her hands between patients and locations, CNA #1 refused to answer any more questions. During an interview on 12/6/23 at 8:55 A.M., Unit Manager (UM) #1 said the two rooms that CNA #1 entered were both under isolation precautions for Covid-19 and full PPE was required including an N-95 respirator, eye protection, gown, and gloves without exception. She further said that all staff were instructed to follow the instructions on the isolation signs that were posted outside of the resident rooms. UM #1 said CNA #1 should not have entered any isolation rooms without the required PPE. 2. Review of the facility's policy titled, Coronavirus Disease (Covid-19) - Infection Prevention and Control Measures, revised September 2022 indicated but was not limited to: - This facility follows infection prevention and control practices recommended by the Centers for Disease Control and Prevention (CDC) to prevent the transmission of Covid-19 within the facility. - Facility follows Massachusetts Department of Public Health (DPH) guidelines and/or local recommendations from epidemiology. Review of the Massachusetts 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 May 10, 2023, indicated but was not limited to: - Residents included in outbreak testing or who are being tested following an exposure should be assessed for symptoms of Covid-19 during each shift. During an interview on 12/6/23 at 8:05 A.M., the DON said that all residents were currently being monitored every shift for signs and symptoms of Covid-19. During an interview on 12/6/23 at 11:20 A.M., the Infection Preventionist (IP) Nurse said Station 1 began outbreak testing on 11/26/23 and the facility followed current Massachusetts DPH guidelines regarding outbreak testing and resident monitoring. The IP further said that monitoring of residents during an outbreak included blood pressure, temperature, pulse, oxygen saturation (the amount of oxygen circulating in the blood), heart rate, respiratory rate and all other signs and symptoms of possible Covid-19 infection every shift and this was documented in the medical record. 2a. Resident #1 was admitted to the facility in February 2020 with a diagnosis of Colon Cancer and resided on Station 1. Review of the Resident's record did not indicate the Resident was monitored every shift for signs and symptoms of Covid-19 during the outbreak beginning on 11/26/23. Review of the facility line listing of Covid positive residents provided by the IP indicated that Resident #1 tested positive for Covid-19 on 12/3/23. 2b. Resident #3 was admitted to the facility in July 2023 with a diagnosis of Alzheimer's Disease and resided on Station 1. Review of the Resident's record did not indicate the Resident was monitored every shift for signs and symptoms of Covid-19 during the outbreak beginning on 11/26/23. Review of the facility line listing of Covid positive residents provided by the IP indicated the resident tested positive for Covid-19 on 12/2/23. During an interview on 12/6/23 at 11:59 A.M., the IP said Resident #1 and Resident #3 were included in the outbreak testing on Station 1 and should have been monitored for signs and symptoms of Covid-19 every shift, but they were not as required.

Based on observation, records reviewed and staff interviews, the facility failed to provide an adequate level of assistance to prevent an avoidable accident for one Resident (#49), out of a total sample of 18 residents. Specifically, the facility staff failed to implement a necessary two-person transfer, resulting in the Resident sustaining a laceration (a deep cut or tear in skin or flesh) requiring hospital transfer and eight sutures (row of stitches holding together the edges of a wound or surgical incision) to the injury. Findings Include: Resident #49 was admitted to the facility in May 2019 with diagnoses including: Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), personal history of (healed) traumatic fracture, presence of right artificial hip joint, and history of falling. Review of the facility policy titled Care Planning: Interdisciplinary Team, revised March 2022, indicated the following: -Comprehensive person-centered care plans are based on resident assessment and developed by an interdisciplinary team (IDT). Review of the facility Unusual Event Report, dated 9/2/23, indicated the following: -On 9/2/23 at 9:15 P.M., Resident #49 sustained a laceration to his/her outer right lower extremity during transfer from his/her wheelchair into the bed. The Resident was immediately evaluated by the Nurse who updated the facility Physician and Resident's legal guardian. Resident #49 was sent to the hospital for evaluation on 9/2/23. -The skin tear to the Resident's outer right lower extremity measured 12 centimeters (cm) x 7 cm x 1 cm. -The attached written witness statement from Certified Nurses Aide (CNA) #2 indicated that the CNA transferred the Resident with assist of one when the laceration occurred. Review of the facility Incident Report Form dated 9/8/23 indicated the following: -Resident #49 returned to the facility on [DATE] with eight sutures to his/her right lower extremity laceration. Review of the Resident's Activities of Daily Living (ADLs) Care Plan, initiated 4/28/21 and last revised 1/27/23, indicated that the Resident had a self-care performance deficit with an inability to follow through with tasks due to confusion and Dementia. Further review of the Care Plan indicated: -the Resident needed the assistance of two staff for stand-pivot transfers. -for staff to use a gait belt (a safety device positioned around an individual's waist, used to help them move, such as from a bed to a chair) for support. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #49 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) assessment and had severe cognitive impairments. The MDS further indicated that: -Resident #49 required extensive assist of two staff members for bed mobility and transfers. -the Resident's balance during transitions, walking, and surface to surface transfers were not steady. -the Resident was only able to stabilize with staff assistance. Review of the September 2023 Physician's orders for Resident #49 indicated the following: -Dressing on right lower leg laceration: wash with Normal Saline (NS: a sterile salt solution), apply Xeroform (a medicated mesh gauze), cover with non-adherent pad then wrap with Kling (absorbent gauze roll). Every day shift, initiated 9/2/23. -Maintain sutures to right lower extremity until steri-strips (wound closure tape put across an incision or cut) fall off. Every shift, initiated 9/11/23. During an interview on 9/15/23 at 11:43 A.M, CNA #2 said that on 9/2/23 she was assisting Resident #49 back to bed. CNA #2 said that she pushed the footrests on the Resident's wheelchair out of the way, and in the middle of the transfer, Resident #49 began pulling on his/her wheelchair, and then CNA sat him/her in bed. The Resident stated to CNA #2 that his/her leg hurt and that was when CNA #2 noticed the skin tear. The CNA stated that she was the only staff member in the room when the incident occurred. The CNA further stated that all residents' transfer status is documented in the Care Kardex. The CNA said that the Care Kardex outlines how much assistance a resident would need with transferring and mobility. During an interview on 9/15/23 at 12:05 P.M., Nurse #3 said that CNA #2 immediately notified Nurse #3 of the skin tear, that the Nurse assessed the Resident, and determined that the skin tear could not be steri-stripped (wound closure tape put across a minor incision or cut). Nurse #3 contacted emergency medical services due to the extent of the skin tear injury and the Resident was transported to the emergency room . Nurse #3 stated that documentation of the Resident's transfer status was noted in the Care Kardex. Nurse #3 showed the surveyor Resident #49's Care Kardex in the electronic medical record, which indicated that the Resident required transfer with two staff for a stand-pivot transfer. Review of the current Care Kardex (plan of care summary utilized by staff) indicated Resident #49 required assist of two staff during stand-pivot transfer for all functional transfers using a gait belt. On 9/19/23 at 8:17 A.M., the surveyor observed Nurse #1 perform a wound dressing treatment to Resident #49's injury site on the right lower extremity. When Nurse #1 removed the old dressing, the surveyor observed the lacerated area which was covered by several steri-strips. During an interview on 9/19/23 at 10:09 A.M., the Director of Nursing (DON) said that staff were trained upon hire to reference the Care Kardex which documents a resident's transfer status. The DON said that at the time of the incident, CNA #2 had referenced a CNA assignment sheet which incorrectly documented Resident #49's transfer status as an assist of one staff member. The DON stated that the expectation was that staff follow the Care Kardex when providing care for Resident #49. Please refer to F880

Based on observation, record review and interview, the facility failed to ensure one Resident (#10), out of a total sample of 18 residents, who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition. Specifically, the facility failed to provide Resident #10 with interventions to engage in eating, when he/she was identified to have impaired cognition, terminal prognosis and an eating deficit, in addition to requiring assistance from staff to eat. Findings include: Review of the facility policy, titled Activities of Daily Living, Supporting, dated 2001 and revised March 2018, indicated: - Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition . Review of the facility policy, titled Assistance with Meals, dated 2001 and revised March 2022, indicated: - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. - Facility staff will help residents who require assistance with eating according to plan of care. Resident #10 was admitted to the facility in November 2021 with diagnoses including Alzheimer's Disease and encounter for Palliative Care (patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering). Review of Resident #10's active Comprehensive Care Plan, revised 7/9/23, indicated the Resident had impaired cognitive function, terminal prognosis (medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course), and an eating deficit. Further review of the Care Plan indicated: - Resident #10 had a poor appetite and caregivers were to feed the Resident as needed. - Resident #10 required assist to dependence on staff for eating. - Staff were to identify themselves with each interaction. - Staff were to face the Resident when speaking and make eye contact. - Staff were to provide the Resident with necessary cues. - Staff were to adjust provision of activities of daily living to compensate for Resident #10's changing abilities. - Staff were to encourage participation to the extent the Resident wished to participate. Review of the September 2023 Certified Nurses Aide (CNA) Flow Sheet indicated: - Resident #10 was dependent on one staff member for breakfast on 9/13/23 and that the Resident's food consumption was 0%. - Resident #10 required limited assistance from one staff member for breakfast on 9/14/23 and that the Resident's food consumption was 0-25%. On 9/13/23, between 9:01 A.M. and 9:22 A.M., the surveyor observed the following in the Station One supervised dining room: - Resident #10 was seated in his/her wheelchair, at a table, with his/her eyes closed. - Resident #10's breakfast tray was positioned on the table in front of him/her. The breakfast tray contained one cup of juice, one cup of milk, one covered mug, one piece of toast that was cut in half, and one bowl of oatmeal. All items were uncovered with exception of the mug. - There were three staff members in the dining room assisting other residents to eat, but no staff were observed to approach Resident #10 until 9:19 A.M. at which time a staff member woke the Resident and placed the cup of milk into the Resident's hand. -At 9:22 A.M., the surveyor observed Resident #10, still seated at the table in the Station One supervised dining room. The Resident's eyes were closed, his/her head was down with his/her chin positioned near his/her chest, and he/she continued to hold the cup of milk in his/her hand. Resident #10's food items, juice, and covered mug were still on the Resident's breakfast tray and no staff were observed assisting the Resident to eat. The Resident was not assisted timely or adequately during the breakfast meal, during which time not all food items provided on the tray were offered to the Resident for consumption. On 9/14/23 between 8:31 A.M. and 9:16 A.M., the surveyor observed the following in the Station One supervised dining room: - Resident #10 was seated in his/her wheelchair at the same table where he/she was observed by the surveyor the previous day. A staff member set the Resident's breakfast meal up in front of him/her, then asked the Resident if he/she was going to eat breakfast. The staff member did not make eye contact with the Resident and the Resident did not respond. - The breakfast meal provided for Resident #10 included a cup of milk, a cup of juice, a piece of coffee cake, and scrambled eggs. The staff member placed a portion of the piece of coffee cake in Resident #10's hand, and the Resident began to eat the coffee cake. The Resident finished the portion of coffee cake at 8:38 A.M. He/she did not initiate drinking or eating anything further at this time. - At 8:44 A.M., the surveyor observed Resident #10 with his/her eyes closed and head down. No staff were observed to provide cues or assistance to eat to Resident #10. - At 8:55 A.M., one staff member approached Resident #10 and attempted to provide one spoonful of oatmeal, but the Resident's eyes were closed and when the spoon touched his/her lips, the Resident automatically withdrew from it. At this time, the staff member said the Resident's name, then told the Resident it was time for breakfast. The Resident did not respond and the staff member left to assist another resident in the dining room. - At 8:57 A.M., another staff member approached and engaged with Resident #10, made eye contact with the Resident, placed the cup of milk in the Resident's hand while she said, drink your milk. Resident #10 then said, Oh and began to drink the milk. The staff member then walked away to assist another resident. The Resident did not initiate any further eating or drinking. The staff member did not re-approach Resident #10 until 9:10 A.M. at which time she removed the milk from the Resident's hand, and provided the Resident with another portion of coffee cake to hold. Once the Resident had the coffee cake in his/her hand, he/she began to eat it. - At 9:16 A.M., the surveyor observed a staff member remove Resident #10's tray which included the bowl of oatmeal, a portion of coffee cake, and the scrambled eggs (which had not been offered to the Resident). The Resident was not assisted timely or adequately during the breakfast meal, all food items provided on the tray were not offered to the Resident for consumption. During an interview on 9/14/23 at 2:00 P.M., CNA #1 said she had worked at the facility since January 2022 and that she worked regularly on Station One. CNA #1 said she knew who to assist with meals by looking around the dining room to see if anyone wasn't eating. She said if she saw that, then she knew to go sit with that resident, offer them each food item from their tray, and help them eat. CNA #1 also said she knew Resident #10 well and that the Resident did not understand verbal prompts alone due to his/her cognitive status and that he/she required physical assistance and cues along with verbal prompts to encourage eating. CNA #1 further said all residents should be offered each food item from their tray, even if they chose not to eat it, and that staff should have offered each food item to Resident #10 over the last two breakfast meals. During an interview on 9/15/23 at 9:03 A.M., the MMQ (Management Minutes Questionnaire) Nurse said that if a resident is coded on the CNA flow sheet as dependent, this meant that that the resident was fully dependent on staff and could not do the task for themselves. She said that Resident #10 was dependent on staff for ADLs and someone should have been with him/her throughout meals because the Resident was unable to feed him/her self without assistance. She also said staff should always offer all foods provided for residents, even if a resident was known to not eat well as they should still be given the opportunity to eat. During an interview on 9/15/23 at 10:48 A.M., the Speech Therapist (ST) said she had completed providing treatment to Resident #10 in May 2023 and that she also screened the Resident for current level of assistance while eating after the surveyor's inquiry to staff. The ST said Resident #10 required supervision and assistance as needed for eating and that this had not changed since she last treated the Resident. The ST said Resident #10 was a slow eater, but if the Resident did not maintain a continued pace while eating, was not engaged in the meal, and/or was not picking items up and bringing them to his/her mouth, staff were expected to intervene and provide assistance to the Resident. The ST also said staff were expected to offer all food items to the Resident that were provided on his/her tray. During an interview on 9/15/23 at 11:03 A.M., the Staff Development Coordinator (SDC) said part of her job was to educate staff on caring for residents. She said that all residents should be offered each food item from their trays and that residents who required assistance to eat were to be provided with that assistance. The SDC said staff should have offered assistance and all food items to Resident #10 during breakfast on 9/13/23 and 9/14/23, even if the Resident was known to not eat much. The SDC also said staff should have offered to assist Resident #10 with breakfast more promptly on 9/13/23 and that he/she should not have had to wait almost 20 minutes for staff intervention to offer food.

Based on policy review, record review, observation and interviews, the facility failed to follow infection control guidelines relative to hand hygiene during a wound dressing change treatment for one Resident (#49), in an applicable sample of four residents, and a total sample of 18 residents. Specifically, the facility staff failed to complete required hand hygiene between glove changes during a wound dressing change to Resident #49's right lower leg laceration (a deep cut or tear in skin or flesh), increasing the Resident's risk for wound infection. Findings include: Review of the facility policy titled Wound Care last revised October 2010, indicated the following procedure: -Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. -Wash and dry your hands thoroughly -Position resident properly -Put on exam gloves. Loosen tape and remove dressing. -Remove gloves and used dressing. Dispose. Wash and dry your hands thoroughly. -Put on gloves . -Clean wound per MD order -Apply treatments as indicated. [NAME] tape with initials and date and apply to dressing. Be certain all clean items are on clean field. -Discard disposable items into the designated container .Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Review of the September 2023 Physician's orders for Resident #49 indicated the following: -Dressing on right lower leg laceration: wash with Normal Saline (NS: a sterile salt solution), apply Xeroform (a medicated mesh gauze), cover with non-adherent pad then wrap with Kling (absorbent gauze roll). Every day shift, initiated 9/2/23. -Maintain sutures to right lower extremity until steri-strips (wound closure tape put across an incision or cut) fall off. Every shift, initiated 9/11/23. During an observation on 9/19/23 at 8:17 A.M., the surveyor observed a wound dressing treatment performed by Nurse #1 with Nurse #2 assisting, to Resident #49's right lower leg as follows: -Nurse #1 utilized hand sanitizing gel before entering the room. Nurse #1 donned gloves while Nurse #2 wore gloves and held the Resident's leg in elevation for the dressing change. -Nurse #1 removed the Kling from the Resident's leg, discarded it, and removed her gloves. The old dressing did not have visible exudate (fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) and the wound bed was dry, red, with sutures on the incision site. -Nurse #1 donned new gloves (without conducting hand hygiene between glove change as required) and wet the Resident's wound with NS to remove the Xeroform which was adhered to the Resident's wound. The Nurse then removed her gloves and donned new gloves (without conducting hand hygiene) and wiped the wound bed with gauze. Nurse #1 applied Xeroform to the wound bed, followed with one non-adherent pad, and determined additional non-adherent pads were needed. Nurse #1 removed her gloves (without conducting hand hygiene) and exited the room to obtain additional supplies. -Nurse #1 re-entered the Resident's room and performed hand hygiene, donned new gloves, applied the additional non-adherent pads, and wrapped the site with Kling. Nurse #1 removed her gloves (without preforming hand hygiene) and applied tape to secure the wound dressing without donning new gloves. During an interview on 9/19/23 at approximately 8:27 A.M., Nurse #1 said that she should change her gloves between each step of the wound care procedure. She further said that she would have completed hand hygiene, but there was no hand sanitizer located near her when the Resident's wound dressing was changed. Nurse #1 said she did not perform hand hygiene after removing her gloves and before donning new gloves, as required. During an interview on 9/19/23 at 10:09 A.M., the Director of Nursing (DON) said the expectation is that staff perform hand hygiene between all glove changes when performing a wound dressing change as required in the facility wound care policy.

Based on interview and records reviews, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccination for three residents (Residents #1, #3, and #4) out of a total sample of five residents. Findings include: Review of the facility policy titled Pneumococcal Vaccine, revised March 2022, indicated the following: -Prior to or upon admission, residents are assessed for eligibility to receive the Pneumococcal Vaccine series, and when indicated, are offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessments of Pneumococcal Vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. -Before receiving a Pneumococcal Vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the Pneumococcal Vaccine. (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.htlm for educational materials). Provision of such education is documented in the resident's medical record. -Administration of the Pneumococcal Vaccines are made in accordance with current CDC recommendations at the time of vaccination. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/15/23 indicated the following: -For adults 65 and over who have had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been five years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20) . 1. Resident #1 was admitted to the facility in December 2019 and was over the age of 65. Review of the Resident's immunizations indicated the Resident had received the PPSV23 on 7/16/12 and the PCV13 on 6/12/15. Further review of the Resident's medical record indicated no documentation the Resident and/or Resident's Representative had been offered, educated on, received or declined the CDC's recommended dose of PCV20. 2. Resident #3 was admitted to the facility in June 2023 and was over the age of 65. Review of the Resident's immunizations indicated the Resident had received the PPSV23 on 10/10/16 and the PCV13 on 8/5/15. Further review of the Resident's medical record indicated no documentation the Resident and/or Resident's Representative had been offered, educated on, received or declined the CDC's recommended dose of PCV20. 3. Resident #4 was admitted to the facility in October 2022 and was over the age of 65. Review of the Resident's immunizations indicated the Resident had received the PPSV23 on 10/5/13 and the PCV13 on 4/20/15. Further review of the Resident's medical record indicated no documentation the Resident and/or Resident's Representative had been offered, educated on, received or declined the CDC's recommended dose of PCV20. During an interview on 8/3/23 at 11:04 A.M., with the Infection Preventionist (IP) and Director of Nursing (DON), the IP said the facility had not begun implementation of the CDC's recommendation to offer the new Pneumococcal Vaccination (PCV20). The IP further said she was not aware of when the CDC had first recommended the new Pneumococcal Vaccination and had only recently spoken with the facility's Medical Director regarding implementation of the new Pneumococcal Vaccination.

Based on observation, interview and record review, the facility failed to ensure its staff adhered to professional standards and their policies/procedures relative to Personal Protective Equipment (PPE) to reduce the spread of infection, such as COVID-19, during an outbreak. Specifically, the facility staff failed to don (put on) and/or doff (remove) PPE when caring for 1.) five Residents (#4, #5, #8, #9, and #10), on two out of three Units, who had confirmed COVID-19 infections requiring Isolation/Droplet Precautions (strategies implemented to reduce the spread of infection caused through speaking, sneezing, and/or coughing), and 2.) one Resident (#2) who was negative for COVID-19 and required Enhanced PPE Precautions (an approach of targeted gown and glove use during high contact resident care activities) on one of three Units observed. Findings include: Review of the facility's Infection Control Policy and Procedure Manual, dated August 2019, included that the facility was required to be in compliance with Federal, State, and Local Laws and Professional Standards, including those from the CDC, relative to infection control practices. Review of the facility policy titled Isolation -Initiating Transmission Based Precautions, revised August 2019, indicated Transmission Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of infection; or has a laboratory confirmed infection; and is at risk for transmitting the infection to other residents. The policy also included the following: -when Transmission Based Precautions are implemented, the Infection Preventionist (IP) or designee: --clearly identifies the type of precautions, the anticipated duration, and the PPE that must be used --determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. --the signage informs staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see the nurse before entering the room --ensures that PPE (i.e gloves, gowns, masks, eye protection, etc) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment --ensures that PPE and supplies needed to maintain precautions during care are in the resident's room, and --ensures that an appropriate linen barrel/hamper and waste container, with appropriate lining, are placed in or near the resident's room -Transmission Based Precautions remain in effect until the Attending Physician or the IP discontinues them, which occurs after criteria for discontinuation are met Review of the CDC document, titled Selected Options for Reprocessing Eye Protection, updated 9/30/21, included the following relative to the disinfection of eye protection: - While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. - Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution. - Wipe the outside of face shield or goggles with clean water or alcohol to remove residue. - Fully dry (air dry or use clean absorbent towels). - Remove gloves and perform hand hygiene. Review of the CDC document, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 9/23/22, included the following: - Healthcare personnel who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions. - Care for a resident for which a NIOSH approved .facemask is indicated for PPE (for example, during the care of a resident with COVID-19 infection), the facemask should be removed and discarded after the resident care encounter and a new one should be donned. During an interview on 11/10/22 at 8:30 A.M., the IP said that the facility was experiencing an active outbreak of COVID-19 on Units One and Two. She said that the facility's process for all residents who had tested positive for COVID-19 was to place them under Isolation Precautions for 10 days following their positive test and to discontinue the precautions on the eleventh day, as long as residents met clinical criteria to discontinue the precautions. The IP also said that no residents in the facility required Isolation Precautions for anything other than COVID-19. 1. For Resident #8, the facility failed to ensure its staff removed and/or disinfected PPE as required upon exiting an Isolation Precaution room. Resident #8 was admitted to the facility in March 2020. Review of the clinical record indicated Resident #8 was placed on Isolation/Droplet Precautions on 11/3/22 for ten days due to COVID-19 infection. On 11/10/22 at 8:52 A.M., the surveyor observed Unit Manager (UM) #1 enter the Resident's room with an N95 mask, a face shield, gown and gloves donned to deliver his/her meal. Signage was posted outside of the Resident's room which indicated that Resident #8 required Isolation Precautions for COVID-19. Resident #8 was seated in a wheel chair beside the bed, was not wearing a facemask, and was observed to converse with UM #1 for a short period of time. After setting up the Resident's meal tray, UM #1 exited the Resident's room, removed her gown and gloves and discarded them in a designated receptacle outside of the room. She then performed hand hygiene, reached her hand into her pocket, retrieved a small packet from her pocket, removed the contents, and proceed to wipe the outside of her face shield. She then continued to walk down the Unit hallway, without discarding the N95 mask she wore to enter the Resident's room or disinfecting the inside of the face shield. 2. For Residents #9 and #10, the facility failed to ensure its staff removed and/or disinfected PPE as required upon exiting an Isolation Precaution room. Resident #9 was admitted to the facility in September 2018. Resident #10 was admitted to the facility in December 2018. Review of the clinical records indicated Resident #9 and Resident #10 were placed on Isolation/Droplet Precautions on 11/2/22 due to COVID-19 infections. On 11/10/22 at 8:57 A.M. through 9:05 A.M., the surveyor observed UM #1 don a gown and gloves (she already had an N95 mask and face shield in place) and enter Resident #9 and #10's room to deliver a meal tray. Signage was posted outside of the Residents' room which indicated that Resident #9 and Resident #10 required Isolation Precautions for COVID-19. At 9:05 A.M., UM #1 exited the room and discarded her gown and gloves in the designated receptacle outside of the room. She did not discard the N95 mask she was wearing or immediately disinfect the face shield that was worn within the Isolation Room. The surveyor observed UM #1 enter into the dirty utility room which was down the hallway. She opened the door shortly after entering and was observed wiping the outside of her faceshield with a wipe while standing in the doorway to the dirty utility room, and proceed down the unit hallway. During an interview on 11/10/22 at 9:05 A.M., Nurse #1 said that full PPE, which included a gown, gloves, N95 mask and eye protection, were required prior to entering a room with COVID-19 positive residents who required Isolation Precautions. She said the gloves, gown, and N95 mask would need to be discarded and the eye protection would either be discarded or disinfected with the specific disinfectant wipes which were located in the PPE bins outside of the Isolation rooms. During an interview on 11/10/22 at 9:30 A.M., UM #1 said that prior to entering a resident room with Isolation/Droplet Precautions, staff were to don full PPE which included a gown, gloves, N95 mask, and eye protection (face shield or goggles). She said upon exiting the room, facility staff were to remove their gloves, perform hand hygiene, remove their gown, then wipe their eye protection with alcohol wipes (not the approved disinfectant wipes), and then perform hand hygiene. When the surveyor asked UM #1 about when she would discard the N95 mask, she said the N95 mask would only need to be discarded if she was providing direct care to the residents who were on Isolation Precautions. When the surveyor asked UM #1 to explain what direct care was, she said direct care included activities such as washing, dressing, bathing or other tasks that would require being near the resident for an extended length of time. UM #1 said that if she was briefly entering an Isolation room to deliver a tray, she would not need to discard her N95 mask upon exiting the room. During an interview on 11/10/22 at 9:50 A.M., the IP said that there was no shortage of PPE at the facility and that staff were required to remove their gown and gloves, perform hand hygiene, and change their mask when leaving an Isolation Precaution resident room. The IP said that UM #1 should have discarded the N95 mask upon exiting the Isolation room and should not have used alcohol wipes, but should have disinfected the inside and outside of her face shield with the designated disinfectant wipes which were located at the PPE stations. 4. The facility failed to ensure that its staff implemented standards of practice relative to PPE and hand hygiene for two Residents (#4 and #5) who resided together in the same room, according to CDC guidelines, when both residents were identified as requiring Isolation Precautions for COVID-19. Specifically, the facility failed to ensure that one staff member: a.) removed her gown and gloves, and b.) performed hand hygiene, after coming in contact with the Residents' environment and before exiting the Residents' room, where Isolation Precautions were required. Review of the CDC document, titled Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings -Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC), dated 12/27/18, included the following for Standard Precautions: Remove and discard PPE, .upon completing a task, before leaving a patient's room or care area. Review of the facility policy titled Handwashing/Hand Hygiene, revised August 2019, included that staff were required to perform hand hygiene after contact with objects in a resident's environment and before/after entering Isolation Precaution settings. Review of the CDC document, titled Hand Hygiene in Healthcare Settings, dated 1/8/21, included that hand hygiene should be performed after contact with contaminated surfaces. Resident #5 and Resident #4 were admitted to the facility in June 2022. Review of the facility's COVID-19 tracking document included that Resident #5 tested positive for COVID-19 on 10/31/22 and that Resident #4 tested positive for COVID-19 on 11/2/22. Review of Resident #5's November 2022 Physician Orders included: Droplet Precautions, dated 10/31/22. Review of Resident #4's November 2022 Physician Orders included: Maintain Isolation Droplet/Contact Precautions every shift due to COVID-19, dated 11/2/22. On 11/10/22, between 8:50 A.M. and 9:25 A.M., the surveyor observed the following on Unit One: - Signage outside of the Residents' room which indicated that Resident #4 and Resident #5 required Isolation Precautions for COVID-19. - Certified Nurse Aide (CNA) #1 wore an N95 mask and eye protection and donned a gown and gloves, then entered the Residents' room. - Resident #4 was seated by the doorway, inside the room, and was not wearing a face mask. - CNA #1 stopped and spoke with Resident #4, then proceeded to Resident #5's side of the room and picked up the Resident's meal tray. - CNA #1 then walked through the room and exited the room into the hallway. She did not remove her gown or gloves, and she did not perform hand hygiene. - CNA #1 walked down the hall to the meal cart and placed the meal tray inside. - CNA #1 then walked from the meal cart, through the hallway where staff were present, to the hallway bathroom across from the Nurses' Station. - CNA #1 used her gloved hand to open the bathroom door, entered the bathroom,where Resident #5 and another staff member were located, and closed the door. - CNA #1 exited the bathroom and walked back toward the Residents' room, removed her gown and gloves in the hallway, placed the gown in the designated receptacle located outside of the Residents' room, and discarded her gloves. During an interview on 11/10/22 at 9:26 A.M., CNA #1 said that staff were required to wear gowns, gloves, an N95 mask, and eye protection when they entered a resident room that was marked for Isolation Precautions, and that after interacting with that environment, staff were required to remove their gowns and gloves and perform hand hygiene upon exiting the room. CNA #1 said that it was important to remove a gown and gloves after they were worn while coming in contact with a resident and/or his/her environment where Isolation Precautions were required because the gown and gloves would be considered contaminated once used. CNA #1 said that she did not remove her gown or gloves after she interacted with the Residents' environment because she was holding Resident #5's meal tray and had no place to put it down so that she could remove her PPE. CNA #1 also said that she wore the same PPE out of the Residents' room, through the hallway, and into the hallway bathroom because Resident #5 was in there, and it was Resident #5's room that she had just exited. During an interview on 11/10/22 at 9:50 A.M., the IP said that staff leaving a resident room where Isolation Precautions were implemented were required to remove their gown and gloves and perform hand hygiene when leaving the room. The IP said that CNA #1 should not have worn her gown and gloves into the hallway, to the meal cart and then into the hallway bathroom, after she exited the room of Residents #4 and #5. The IP further said that CNA #1 should have removed her gown and gloves, and performed had hygiene, as required, when she exited the room. 5. For Resident #2, the facility failed to ensure its staff implemented the facility's process relative to the use of PPE during an outbreak of COVID-19 on Unit Two. Specifically, the facility failed to ensure its staff implemented the use of: a.) eye protection during a treatment encounter with the Resident, and b.) a gown when she provided high contact care to the Resident, who was identified as negative for COVID-19 and required Enhanced PPE Precautions, when there was an active outbreak of COVID-19 on the Unit. Review of the Massachusetts Department of Public Health guidance, titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, Appendix A: PPE Used When Providing Care to Residents in Long Term Care, dated 10/13/22, included the following for the care of COVID-19 negative residents on units with uncontrolled transmission and at facility discretion: - The Enhanced PPE sign was recommended for use outside of COVID-19 negative resident rooms. - COVID-19 negative refers to a resident who has not tested positive in the past 30 days. - Resident case means a case that was potentially acquired in the facility. - Use of a facemask (or N95 respirator or alternative if ongoing transmission on unit), face shield/goggles, gown, and gloves. Gown and glove use can be prioritized for high-contact resident care activities . - Examples of high contact resident care activities included: dressing, bathing/showering, transferring, providing hygiene, . and changing briefs or assisting with toileting. Resident #2 was admitted to the facility in November 2022. Review of the Resident's clinical record indicated no evidence that the Resident had been positive for COVID-19 within the previous 30 days. On 11/10/22, between 9:30 A.M. and 9:40 A.M., the surveyor observed the following: - Therapist #1 was in Resident #2's room and was assisting the Resident to position him/herself in their wheelchair, next to the bed, and the bathroom door was open. - The Therapist wore a facemask and gloves. She was not wearing a gown or eye protection. - Once the Therapist finished assisting the Resident to position next to the bed, she turned and closed the bathroom door, then exited the Resident's room. At this time, the surveyor also observed signage posted outside of Resident #2's room door which indicated that Enhanced Precautions were required and included the following: - The use of protection (goggles or face shield) was required for resident care encounters. - The use of a gown was required for high contact resident care. During an interview on 11/10/22 at 9:40 A.M., Therapist #1 said that there was an outbreak of COVID-19 on the Unit and that posted signage outside of resident room doors indicated what precautions staff were required to take when providing care to residents. She said that the signage posted outside of Resident #2's room door indicated PPE that was required for care with the Resident, and that she had just finished a treatment encounter with the Resident for assistance with activities of daily living, which included: bathing, dressing, toileting and personal hygiene, and transfers. When asked about PPE requirements during treatment encounters and high-contact resident care activities, Therapist #1 said that the use of a gown for high-contact care activities was not required. When asked about the use of eye protection and about the signage instructions for the use of a gown during high-contact resident care activities, Therapist #1 reviewed the sign with the surveyor. She said that the items indicated by a green check mark on the sign were required for resident encounters and that eye protection was required. Therapist #1 then removed a pair of goggles from her shirt pocket and put them on, then said that she did not wear them during her treatment encounter with Resident #2. Therapist #1 then said that, as far as she knew, she was not required to wear a gown for high-contact activities with Resident #2, or for any residents who required Enhanced PPE Precautions, because there was no green check mark next to it on the sign. She further said that she did not wear a gown when she provided high-contact care to Resident #2 on 11/10/22 because she did not think it was required. During an interview on 11/10/22 at 9:50 A.M., the IP said that the facility was experiencing an outbreak of COVID-19 on Units One and Two and that the facility process was to implement the guidance from the Massachusetts DPH relative to Enhanced PPE Precautions for COVID-19 negative residents on affected units. The IP said that all residents who were negative for COVID-19 were placed under Enhanced PPE Precautions during the outbreak period and that staff were required to wear eye protection during all treatment encounters and that they were also required to wear gowns when they provided high-contact care to those residents. The IP said that although the guidance indicated that use of gowns was at the facility's discretion for COVID-19 negative residents on affected units, it had been determined by the facility that use of gowns for these residents during high-contact care was to be implemented as a strategy to help mitigate the spread of COVID-19. The IP said that Therapist #1 should have implemented the use of eye protection and a gown, as required, during her treatment encounter with Resident #2 on 11/10/22 when she provided high-contact care activities to the Resident.

Based on record review and interview, the facility failed to assess for symptoms of COVID-19 at the required frequency for Residents on one out of three units to prevent and control the spread of COVID-19 during an outbreak. Findings include: Review of a Massachusetts Department of Public Health (DPH) circular letter titled Update to Caring for Long-Term Care Residents During the COVID-19 Response, dated 1/25/22, indicated 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. Review of the Center for Disease Control and Prevention (CDC) website, updated 2/22/21, indicated the symptoms of COVID-19 included, but were not limited to 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, and diarrhea. During an interview on 3/11/22 at 10:04 A.M. the Infection Preventionist (IP) said the facility identified the start of an outbreak when one staff member and five residents tested positive on 2/24/22. She further said unit three was considered the unit where the outbreak occurred. residents #4, 7, and 10 resided on Unit 3. Resident #4: *Review of the February and March 2022 Treatment Administration Records (TAR) indicated Resident #4 was assessed for the signs and symptoms of COVID-19 twice a day. Further review indicated there was no evidence the Resident was assessed for the symptoms of COVID-19 every shift as required, during an outbreak. Resident #7: *Review of the February and March 2022 TARs indicated Resident #7 was assessed for the signs and symptoms of COVID-19 twice a day. Further review indicated there was no evidence the Resident was assessed for the symptoms of COVID-19 every shift as required during an outbreak. Resident #10 *Review of the February and March 2022 TARs indicated Resident #10 was assessed for the signs and symptoms of COVID-19 twice a day. Further review indicated there was no evidence the Resident was assessed for the symptoms of COVID-19 every shift as required during an outbreak. During an interview on 3/11/22 at 12:01 P.M., the surveyor asked the IP for a copy of the policy for screening residents for symptoms of COVID-19. The IP said there was no facility policy specific to that and that all residents were assessed for the signs and symptoms of COVID-19 per the current DPH guidance. She further said the assessments were documented on the TAR. The IP reviewed the TAR's for Residents #4, #7 and #10 with the surveyor. She said the frequency of the assessments (for the symptoms of COVID-19) should have increased to every shift during the outbreak but they had not. She further said she had been on vacation when the outbreak occurred and no one knew to increase the assessments to every shift for residents on the affected unit.

Based on observation, policy review, and interview the facility failed to store food in accordance with professional standards for food safety for 3 out of 3 kitchenettes. Findings include: Review of the undated facility Food: Kitchenette policy, indicated the following: -Kitchen staff will label and date each item in the refrigerator using a 3-day window for usage. -Kitchen staff will be responsible for daily cleaning of the refrigerators, microwaves and snack areas. On [DATE] at 11:45 A.M., the surveyor observed Unit 1 kitchenette and the following items were in the refrigerator: -bag of grapes with an expiration date of [DATE] -Hi-Cal oral supplement, open, undated. -Natures Promise watermelon water, open, undated. -orange juice, half gallon jug, open, undated. During an interview on [DATE] at 1:31 P.M., the Day Supervisor said that the containers should have been dated when they were opened and had not been. On [DATE] at 1:00 P.M., the surveyor observed Unit 2 kitchenette and the following items were in the refrigerator: -Cola, open, undated -Ginger ale, open, undated -clear plastic bag with salad and salad dressing, undated -canvas bag with water bottle and food items -plastic container with red gelatin and a curdled white substance labeled with resident name, undated -butter substitute tub, open, undated -orange juice, gallon jug, open, undated During an interview on [DATE] at 1:37 P.M., Nurse #2 said the open containers should have been dated and had not been. She said resident items should be labeled and dated but had not been. On [DATE] at 12:10 P.M., the surveyor observed Unit 3 Kitchenette and the following items were found in the refrigerator: -open can of rainbow frosting with Best By date of [DATE], undated -gallon of orange juice, open, undated -half gallon of milk, open, undated -Banana Cream Chobani Complete, open, expired Feb. 12, 2022 -chocolate milk, open, expired Feb. 6, 2022 -Peppermint Coffee Mate, open, undated During an interview on [DATE] at 12:32 P.M. Nurse #1 said the open containers should have been dated when they were opened and had not been. She said the expired item should have been removed but had not been. During an interview on [DATE] at 3:06 P.M., the Food Service Director said that she cleaned the kitchenettes and made sure that the food from the facility was not expired but did not check anything that belonged to residents.

Based on record review and interviews, failed for one of one sampled resident (the Resident), who was assessed to require a pureed diet and aspiration precautions, the Facility failed to ensure the Resident received food items consistent with the physician ordered diet and adequate supervision while eating. On 8/29/10, the Activity Assistant gave the Resident a piece of "quick bread", left the Resident unsupervised while eating the food and approximately 10 minutes later, the Resident was found by the Housekeeper to be choking. The Resident required the [MEDICATION NAME] Maneuver to remove the solid food from the Resident's airway. The findings included: Review of the face sheet indicated the Resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Hospital discharge summary, dated 6/11/08, indicated the Resident had a modified [MEDICATION NAME] swallow, done on 6/9/08. The discharge summary indicated that the Resident should have a pureed diet with honey thickened liquids, aspiration precautions, and supervision during meals. Review of the annual Minimum Data Set (MDS) assessment, dated 6/23/10, indicated the Resident had difficulty with short and long term memory, and was moderately impaired for decision making. The MDS indicated the Resident required supervision for meals, had chewing and swallowing difficulties, and required a mechanically altered diet. Review of the care plan, dated 7/23/10 and developed to address the Resident's dysphagia (difficulty swallowing), indicated the Resident was receiving speech language therapy and was able to tolerate a pureed diet with honey thickened liquids. The care plan indicated the plan was to implement safe oral intake strategies especially throat clearing, swallowing with wet voice, and cues for slower oral intake rate. Review of the care plan, dated 8/20/10, developed to address the Resident's speech language therapy, indicated the Resident required a small spoon for meals and the Resident's speech language treatment was extended for 4 visits over the course of 2 weeks. Review of the speech language therapy progress note, dated 8/27/10, indicated the Resident was able to tolerate the current diet (pureed) and was beginning to independently use safe swallowing strategies, but still required some verbal cues. The note indicated the staff was inserviced. Review of the nurse's note, dated 8/29/10, for the 7:00 AM to 3:00 PM shift, indicated the Resident was given a "muffin" by the Activity Assistant, and the Resident choked on the "muffin". The note indicated the [MEDICATION NAME] maneuver was successfully performed by a nurse. The note indicated that the Physician and the Family were notified. Review of the incident report, dated 8/29/10, the Resident received a "muffin" at approximately 10:30 AM and at approximately 10:40 AM, the Housekeeper observed the Resident was choking. The report indicated that the [MEDICATION NAME] maneuver was performed, and the muffin came out of the Resident's mouth. The Activity Assistant was interviewed on 9/16/10 at 12:15 PM. The Activity Assistant said that on 8/29/10, when doing the coffee cart for residents, the Activity Assistant did not have the daily diet listing on the cart. The Activity Assistant said that the Facility policy was to have the diet listing with you when doing a food related activity. The Activity Assistant said the Activity Assistant assumed that since the "bread" was moist, the Resident could have a small piece. The Activity Assistant said that the assumption should not have been made. The Activity Assistant said the Activity Assistant gave the Resident a 2 inch by 2 inch by 1/2 inch thick piece of "quick bread" and then Activity Assistant went across the hall. The Activity Assistant said that the Activity Assistant had been trained and knew better. The Activity Assistant could not tell the Surveyor the reason why the Facility policy was not followed. The Housekeeper was interviewed on 9/16/10 at 11:10 AM. The Housekeeper said that on 8/29/10 at approximately 10:40 AM, the Housekeeper was in the television room, near the Resident's room when the Housekeeper heard a sound like someone choking. The Housekeeper said the Housekeeper went to the Resident's room and saw the Resident, seated in wheelchair by the window, with the hands on her chest, and food sticking out of the Resident's mouth. The Housekeeper said the Resident appeared to be a bit dusky blue in color, and was not coughing. The Housekeeper said the Housekeeper called to the Nurse to come to the Resident's room. The Nurse was interviewed on 9/16/10 at 1:20 PM. The Nurse said that the Nurse was in the hallway near the Resident's room when the Housekeeper yelled that there was something wrong with the Resident. The Nurse said that the Nurse went to the Resident's room and saw the Resident choking. The Nurse said the Nurse asked the Resident if the Resident could breathe or talk and the Resident was unable to. The Nurse said the Resident was very red in the face and the Resident's eyes were watering. The Nurse said the Nurse did the [MEDICATION NAME] maneuver 2 or 3 times before what looked to be "chewed muffin or quick bread" came out of the Resident's mouth. The Nurse said the physician was notified and ordered the Resident monitored for signs of aspiration (fever, cough). The Nurse said that a resident on a pureed diet should not have muffins or quick breads. The Activity Director was interviewed on 9/16/10 at 9:30 AM. The Activity Director said that on Sunday mornings, the activity staff were responsible to do the coffee cart on the units. The Activity Director said that any time a food related activity was done the activity staff were responsible to reference the daily diet listing for a resident's food and fluid consistency and diet. The Activity Director said that updated information on a resident's diet was available in the Activity Department and also from the Facility Dietary Department. The Activity Director said the Activity staff had been inserviced relative to food related activities prior to this incident, and were re-inserviced following the incident. The Activity Director said that the Activity Department also kept a communication book in the office and staff were to sign off when reading any communications. The Food Service Supervisor (FSS) was interviewed on 9/16/10 at 10:45 AM. The FSS said that the FSS prints out the Resident Diet listing every day or two, or more often if there are dietary changes, and provided a copy of the listing to the Activity Department. The FSS said the diet listing was also available in the main dining room for meals and activities. The FSS said that a resident on a pureed diet should not receive a muffin or quick bread of any kind. Review of the daily diet listing indicated the Resident was listed as being on a pureed diet with honey thickened liquids. Review of the personnel file for the Activity Assistant indicated that the Activity Assistant was provided with information relative to the Facility policy and procedure for providing food to residents. Review of the Activity Department Sunday schedule guidelines indicated that when doing the coffee cart, the current diet listing should be used. The guidelines indicated that any resident on a pureed diet was not allowed to have donuts or similar items, and any resident on aspiration precautions cannot be left alone with food. Review of the Facility list of Consistency Modified Diets for Chewing and Swallowing Problems, adapted from the National Dysphagia Diet, indicated that residents receiving a diet of pureed consistency were not able to eat bread or muffins. Review of the Facility policy relative to Food Related Activities indicated that during any time there was an activity relating to food, activity staff must have the diet listing available and reference the listing to insure that food served to residents is in accordance with that resident's diet.