Every finding on record at Steere House Nursing and Rehabilitation Center

Based on surveyor observation and staff interview, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety relative to staff practices in obtaining temperatures for the lunch meal.Findings are as follows:Review of the 2022 Food and Drug Administration Food Code, section 4-702.11 states in part, Utensils and food-contact surfaces of equipment shall be sanitized before use.During a follow up visit to the main kitchen on 3/3/2026 at 11:53 AM, the following was observed:-Dietary Cook, Staff H was observed obtaining the holding temperature of a pan of peas. She then removed the thermometer from the peas and obtained the holding temperature of a pan of mashed potatoes without first cleaning and sanitizing the probe (the metal piece of the thermometer that measures the temperature of the food).-Staff H removed the thermometer from the pan of mashed potatoes and then obtained the holding temperature of a pan of ground broccoli without first cleaning and sanitizing the probe.-Prior to obtaining the holding temperature of a pan of baked fish, Staff H dipped the probe of the thermometer in the sanitizer then wiped the probe with her bare hands and inserted the probe into a piece of the baked fish.During a surveyor interview immediately following the above observations with Staff H, she acknowledged that she did not sanitize the thermometer after obtaining the holding temperature of each vegetable and should not have used her bare hands to wipe the thermometer before inserting the probe into the fish.During a surveyor interview on 3/3/2026 at 12:03 PM with the Food Service Director, she indicated that she would expect the thermometer to be sanitized in between every food item and that it would be wiped with a clean cloth after being sanitized.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to the care of a peripherally inserted central catheter (PICC line- a type of Central Venous Catheter (CVC), inserted peripherally. It is a long thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) for 1 of 1 resident reviewed with a PICC line, Resident ID #34. Findings are as follows:According to Lippincott Nursing Procedures, Ninth Edition page 657, states in part, .Performing a CVC [central venous catheter- dressing change .Use a sterile measuring tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated .Administering drugs using a PICC .Review the patient's medical record for conformation of catheter type, size, and tip location .Review of a facility policy titled, Vascular Access Devices, PICC Catheter dated August 2016 states in part, .Verification of correct tip placement in the SVC [superior vena cava, a large vein that carries blood from the body back to the heart] should be completed by Xray or other approved technologies before starting an infusion. If transferred with line in place, obtain written report of part of pre-admission screening process.Measure circumference of upper arm before insertion as a baseline and when clinically indicated to assess for the presence of edema and possible deep vein thrombosis.Measure external length of PICC catheter.at insertion and measure when clinically indicated if catheter dislodgement is suspected. Compare to measurement obtained at insertion.Record review revealed that Resident ID #34 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, dementia with severe agitation and bacteremia (bacteria in the blood).1.Record review of a hospital document titled PICC insertion Record dated 2/10/2026, revealed the resident had to have a second PICC placed in his/her left arm after the resident removed the first one. Record review revealed the following physician's orders:2/12/2026: Cefazolin (antibiotic) 2 grams intravenously every eight hours for 32 days.2/17/2026: Change catheter site dressing weekly and include the arm circumference and catheter length.2/20/2026: Change catheter site dressing weekly and include the arm circumference and catheter length.Further record review failed to reveal evidence that, after the resident's PICC line was replaced on 2/10/2026, the facility verified that the catheter tip was correctly positioned in the SVC prior to using the line. As a result, the resident received antibiotics on 63 occasions without confirmation that the PICC tip was in the appropriate location Record review of the February 2026 Medication Administration Record (MAR) revealed a physician's order dated 2/17/2026 to change the PICC line dressing every 7 days and to measure the external length of the catheter and the arm circumference with each dressing change. Further record review revealed that the dressing change was signed off as not completed with a note that states, changed on 2/13.Record review of a nursing progress note dated 2/13/2026 states in part, .Patient have single lumen PICC Catheter on [his/her] LUA [left upper arm], dressing changed d/t [due to] patient c/o [complain of] discomfort, itching at the PICC line site. Dressing changed with help of Unit 1 nurse and patient's [family member] due combativeness . Record review failed to reveal evidence of the external catheter length measurement or the arm circumference with the above dressing change. 2.Further record review of the February 2026 MAR revealed a physician's order dated 2/20/2026 to change the PICC line dressing every 7 days and to measure the external length of the catheter and the arm circumference with each dressing change.The above order was signed off as completed on 2/21/2026 with a documented catheter length of 00 and an arm circumference of 00 and on 2/28/2026 with a documented catheter length of 6 centimeters (cm) and an arm circumference of 27 cm. Record review failed to reveal evidence that the provider was notified that the PICC line was documented as migrating 6 cm on 2/28/2026 (this indicates displacement of the tip of the catheter from the intended position, increasing the risk for complications such as clot development, infection and vessel perforation) from the initial placement. Furthermore, the record revealed that the resident continued to receive his/her antibiotic 15 times without confirmation that the PICC tip was in the correct location.During a surveyor interview with the Director of Nursing Services on 3/5/2026 at 12:05 PM, she revealed that it would have been her expectation that the admitting nurse would have obtained a report with confirmation of the catheter placement before administering the resident's antibiotic. She further revealed that it would have been her expectation that if the catheter was measured to migrate 6 cm that the provider would be notified.During a surveyor interview with the Unit Manager on 3/5/2026 at 12:44 PM, she provided hospital documentation with confirmation of the catheter placement, she further revealed that she retrieved the information from the hospital after it was brought to the facility's attention by the surveyor.During a surveyor interview with the physician on 3/5/2026 at 1:40 PM, she revealed that it would have been her expectation that the facility would obtain confirmation of the catheter placement and external catheter length on admission from the hospital. She further revealed that she was not notified that the PICC line was documented as migrating 6 cm on 2/28/2026

Based on clinical record review and staff interview, the facility failed to ensure that residents who require dialysis (a medical treatment that filters waste and excess fluid from your blood when your kidneys can no longer function properly) receive such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the residents' goals and preferences for 1 of 2 residents reviewed who receive dialysis, Resident ID #87.Findings are as follows:Review of a facility policy last revised on 8/19/2024 titled, Dialysis Patients; Care of, states in part, .A continuity of care (COC) must be completed and sent to and from nursing facility and dialysis center with each transfer. The charge nurse shall carefully review the COC upon resident return from dialysis to ensure awareness and follow through with any recommendations or interventions necessary.Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis.Record review of an Annual Minimum Data Set assessment dated [DATE] revealed the resident has a Brief Interview for Mental Status score of 5 out of 15, indicating severe cognitive impairment.A. Review of the physician's orders revealed s/he receives dialysis services every Monday, Wednesday, and Friday.Additional record review revealed a physician's order dated 1/16/2026 which states in part, RESIDENT GETS WEIGHED PRE AND POST DIALYSIS: PLEASE RECORD IN MATRIX [electronic medical record] POST DIALYSIS WEIGHT ON MON/WED/FRI.Record review failed to reveal evidence of pre- and post-dialysis weights documented in the resident's electronic medical record for 2/22/2026 and 3/2/2026.Further record review failed to reveal evidence of a COC document received upon return from the dialysis center, including pre-and post-dialysis weights on the above-mentioned dates.During a surveyor interview on 3/4/2026 at 1:19 PM with Licensed Practical Nurse, Staff A, she indicated that the resident went to the dialysis center on Sunday 2/22/2026 and returned to the facility without a COC document. Staff A indicated that she called the dialysis center for any updates but did not obtain his/her pre- and post-dialysis weights.During a surveyor interview on 3/4/2026 at 3:48 PM with Registered Nurse, Staff B, she indicated that on 3/2/2026, the resident returned from the dialysis center without a COC document, including his/her pre-/post-dialysis weights. Further, she was unable to provide evidence that she obtained the resident's weights from the dialysis center.B. Record review revealed a physician's order dated 1/19/2026 for calcitriol (a medication prescribed to treat low calcium levels due to kidney disease) 0.5 micrograms (mcg) to be given every morning on Monday, Wednesday, and Friday.Record review of a progress note dated 1/21/2026 revealed recommendations from the dialysis center to discontinue the resident's calcitriol as the resident receives this medication at the dialysis center. Record review of a progress note dated 2/11/2026 revealed the same recommendations to discontinue the calcitriol as the resident receives this medication at the dialysis center.Record review failed to reveal evidence that the resident's provider was notified of the dialysis center's recommendation to discontinue the resident's calcitriol.Record review of the January, February and March 2026 Medication Administration Records revealed that the resident continued to receive calcitriol from 1/23/2026 through 3/4/2026.During a surveyor interview with Staff A and Staff B on 3/4/2026 at 3:48 PM, they were unable to provide evidence that the provider was notified of the dialysis center's recommendations to discontinue the resident's calcitriol.During a surveyor interview on 3/5/2026 at 12:51 PM with the Clinical Manager at the dialysis center, she revealed the dialysis center notified the facility of the recommendations to discontinue the resident's calcitriol in January and February of 2026. Additionally, the calcitriol had been previously administered to the resident at the dialysis center until it was discontinued on 12/11/2025, the resident should not be receiving this medication at all.During a surveyor interview on 3/5/2026 at 1:27 PM with the resident's Physician, she revealed that her expectation is that staff would call the dialysis center for the resident's pre-and post-dialysis weights if the resident returned to the facility after dialysis without the COC document. Additionally, she would expect nurses to notify the provider of any recommendations made by the dialysis center. Further, she revealed that she typically agrees with the nephrologist's (a medical doctor that specializes in diseases of the kidneys) recommendations from the dialysis center and she would have expected the calcitriol be discontinued.During a surveyor interview on 3/5/2026 at 1:52 PM with the Director of Nursing Services (DNS), she indicated that when a resident leaves the facility to receive dialysis, they leave with a COC document and upon return to the facility the resident returns with that same COC document. Additionally, the nurse should review the COC for pre- and post-dialysis weights and any special occurrences, or recommendations. If the resident returned from the dialysis center without the COC document, she would expect the nurse to call the dialysis center to obtain the resident's weights. Further, she would expect the nurse to notify the provider of any new recommendations made by the dialysis center. The DNS was unable to provide evidence that the provider was notified of the nephrologist's recommendations to discontinue the resident's calcitriol medication on 1/21/2026 or on 2/11/2026, and she was unable to provide evidence that the facility obtained the resident's pre-and post-dialysis weights on 2/22/2026 and on 3/2/2026 after arriving without the weights from the dialysis center.

Based on record review and staff interview, the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments, and considering the number, acuity, and diagnoses of the facility's resident population, in accordance with the facility assessment, for 4 of 6 direct care staff reviewed, Staff C, D, E, and F. Additionally, the facility failed to have the appropriate competencies and skill sets relative to care of a peripherally inserted central catheter (PICC line; is a type of Central Venous Catheter (CVC), inserted peripherally. It is a long thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) for 5 of 5 nurses reviewed, Staff C, D, E, G and H.Findings are as follows:Record review of the Facility assessment dated [DATE] revealed that competency-based mandatory trainings designed to meet the needs of the residents are required for direct care staff, including Registered Nurses (RN), Licensed Practical Nurses (LPN), and Nursing Assistants (NA). Additionally, competencies are completed upon hire and annually.1. Record review failed to reveal evidence that the following direct care staff had completed annual education and competencies:-RN Staff C, with a date of hire: 2/24/2023-RN Staff D, with a date of hire 11/4/2025-LPN Staff E, with a date of hire 10/11/2021-NA Staff F, with a hire date of 4/29/20242. Record review of the facility assessment revealed that the facility provides treatment and services for the resident population including, but not limited to, intravenous (IV) medication administration and PICC line care and dressing changes. Record review of the education and competency files for Staff C, D, E, G, and H failed to reveal evidence that they had completed their yearly competencies, including midline/central line dressing changes per the facility assessment.During a surveyor interview the with ADON on 3/5/2026 at 1:48 PM, she was unable to provide evidence that the above-mentioned direct care staff members had completed their yearly competencies according to the facility assessment, as required.Cross Reference F 684

Based on clinical record review and staff interview, the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 1 resident reviewed who was ordered a Hemoglobin A1c (HbA1c, a blood test that shows the average level of blood sugar over the past 2 to 3 months) level, Resident ID #3. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus (DM; a metabolic disorder characterized by high blood sugar resulting from the body's inability to use insulin properly and the inability to produce enough insulin). Record review of a progress note dated 2/19/2026, authored by the provider, revealed a plan to check the resident's HbA1c level for his/her DM management, as the resident's last documented HbA1c level was 11.5 (normal HbA1c level is below 5.7). Record review revealed a physician's order, dated 2/19/2026, to obtain a HbA1c on 2/24/2026. Record review of the laboratory results failed to reveal evidence that the HbA1c was obtained as ordered. During a surveyor interview on 3/5/2026 at 1:34 PM with Infection Preventionist, she acknowledged that the HbA1c was not obtained. Additionally, she was unable to provide evidence that the facility notified the provider that the HbA1c was not obtained or that the facility attempted to obtain the ordered bloodwork after 2/24/2026. During a surveyor interview on 3/5/2026 at 1:34 PM with the Director of Nursing Services, she would have expected that the nurse and/or the provider would have followed up with the laboratory to obtain the ordered bloodwork.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide and prepare food in a form designed to meet individual needs for 3 of 6 residents reviewed with a physician's order for a ground texture diet, Resident ID #s 58, 44, and 365. Findings are as follows: Review of the Unidine diet manual states in part, Mechanically Altered [diet] .Breads need to be slurried/pre-gelled through entire thickness .seeds must be avoided .vegetables with less than 1/2 [inch] pieces Review of the diet manual addendum titled [NAME] House Approved Diets states in part, Ground - For residents who have difficulty chewing or swallowing. Meats are ground or finely chopped and served moist or with gravy/sauce . Further review of the addendum failed to indicate whether or not breads are to be given to residents prescribed a ground diet. 1. Record review revealed Resident ID #58 was admitted to the facility in March of 2022 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing). Review of a speech therapy progress note dated 8/2/2024 revealed that the resident had a coughing episode while eating an english muffin. Further review revealed it was recommended that the resident's diet be downgraded to ground texture and for his/her food to be cut into bite sized pieces and served with extra gravy. Additional review revealed dysphagia interventions were required to maximize safe intake by mouth. Record review revealed a physician's diet order dated 8/2/2024 for ground texture and to cut food into bite sized pieces with extra gravy. Review of the menu utilized on 10/28/2024 revealed residents on a ground diet were to be served garlic bread. During a surveyor observation on 10/28/2024 at 12:27 PM, the resident was served a piece of toasted garlic bread approximately 3 inches long, and whole dry donut holes with the lunch meal. Further observations failed to reveal evidence that the staff cut the garlic bread of the donut holes into bite sized pieces, as ordered. Additionally, the resident was observed to be coughing while eating. During a surveyor interview on 10/28/2024 at 12:40 PM with Certified Medication Technician, Staff D, she indicated that the resident should not have been served garlic bread or the donut holes. Additionally, she removed the garlic bread and replaced the donut holes with moistened ones that she cut into small pieces. During a surveyor interview on 10/28/2024 at 12:42 PM with Dietary Aide, Staff E, who was plating residents' food, he indicated that he is unaware of what should be served to residents who have an order for a ground diet. Additionally, he indicated that he served garlic bread to the residents with a ground diet order. During a surveyor interview on 10/28/2024 at 12:45 PM with Licensed Practical Nurse (LPN), Staff F, she indicated that residents with a ground diet order should be served something soft that can be cut up and should not be served garlic bread. During a surveyor observation on 10/29/2024 at 9:20 AM, the resident was observed to be eating whole pieces of toast. During a surveyor interview on 10/29/2024 at 10:14 AM with the Food Service Director (FSD), she indicated that the facility follows the Unidine diet manual; however, refers to an addendum for diet orders. She further indicated that a ground diet order would include mechanically altered, soft foods, without seeds or nuts. Additionally, the FSD indicated that she and the dietitian are responsible for creating diets and menus. Furthermore, she indicated that residents on ground diets should not receive garlic bread. She acknowledged that the garlic bread that was served to the residents prescribed a ground diet on 10/28/2024 was an error on the menu. Review of the menu utilized on 10/29/2024 revealed residents on a ground diet were to be served pears, instead of watermelon. During a surveyor observation on 10/29/2024 at 12:36 PM, the resident was served chunks of watermelon with seeds, a dry dinner roll, and cauliflower that was not cut into bite sized pieces with lunch. During a surveyor interview on 10/29/2024 at 12:40 PM with Cook, Staff G, he indicated that the Nursing Assistants (NAs) serve the residents the fruits. He further indicated that he served the residents who were prescribed a ground diet a whole dinner roll and that he refers to the menu that is on the steam tray cart. Additionally, he indicated that residents with a ground diet order should not have received watermelon because it contains seeds. During a surveyor interview on 10/29/2024 at approximately 12:45 PM with Nursing Assistant (NA), Staff H, who was in the dining room serving residents their meal trays, she indicated that she was unaware what the residents' diet orders were or where the information was listed. During a surveyor interview on 10/29/2024 at 12:58 PM with NA, Staff I, she indicated that she served the resident watermelon and that she was unaware of the menu that indicates what should be served for each diet order. Additionally, she indicated that she was unaware that residents prescribed a ground diet should not have received the watermelon. During a surveyor interview on 10/29/2024 at 1:26 PM with the Registered Dietitian, he indicated that he develops the menus with the FSD by referring to the Unidine diet manual and the addendum. During a surveyor interview on 10/29/2024 at 1:45 PM with the Speech Language Pathologist (SLP), she indicated that she evaluates all of the residents on admission and if there is a concern with coughing or choking with eating. She further indicated that residents prescribed a ground diet may have bread, if it is soft, and that garlic bread may or may not be safe depending on how soft it is. When the SLP was questioned on who determines if the bread or garlic bread being served to the residents prescribed a ground diet is soft enough she was unable to provide an answer. Additionally, she indicated that she would expect staff to cut food into approximately 1 inch by 1 inch bite sized pieces if the resident has an order for bite sized foods. During a surveyor interview on 10/29/2024 at 3:27 PM with the Medical Director, he indicated that the dietitian and kitchen staff develop the menu and that the SLP, gives recommendations for the physician ordered diets. He further indicated that he would expect a resident who is prescribed a ground diet order to receive foods that are in small pieces. Additionally, he indicated that he would expect staff that are serving the residents' food to know what the diet order is and what they can and cannot be served. 2. Record review revealed Resident ID #44 was readmitted to the facility in September of 2024 with diagnoses including, but not limited to, acute respiratory failure and end stage renal disease. Record review revealed a physician's order dated 9/12/2024 for a ground texture diet. During a surveyor observation on 10/29/2024 at 9:35 AM in the presence of NA, Staff J, the resident was observed to be eating two whole slices of toasted white bread. During a surveyor interview immediately following the above observation, Staff J, acknowledged that the resident was eating toasted white bread. Additionally, she indicated that the resident eats toasted white bread often and that she was unaware that the resident should not have been served the toasted bread. During a surveyor observation on 10/29/2024 at 12:35 PM, the resident was observed eating two whole grilled cheese sandwiches. During a surveyor interview on 10/29/2024 at approximately 12:40 PM with LPN, Staff C, she acknowledged that the resident was served whole grilled cheese sandwiches. Additionally, she indicated that she thought it was okay for the resident to eat a whole grilled cheese sandwich on a ground diet. During a surveyor interview on 10/29/2024 at 2:40 PM with the SLP, she indicated that she had not recently assessed the resident and that she was unaware that the resident had a physician's order for a ground texture diet. 3. Record review revealed Resident ID #365 was admitted to the facility in October of 2024 with diagnoses including, but not limited to, dementia and dysphagia. Record review of a physician's order dated 10/28/2024 revealed a diet order for ground texture and thin liquids. Record review of a progress note dated 10/28/2024, authored by the SLP, revealed that the resident's diet texture was downgraded to a ground texture, on 10/28/2024 related to dysphagia. During a surveyor observation of the breakfast meal on 10/29/2024 at approximately 9:00 AM the resident was observed eating over medium eggs with 3 pieces of toasted bread. During a surveyor interview on 10/29/2024 at approximately 9:10 AM, with NA, Staff K, she indicated that she was unaware if the resident could have toast. She further indicated that the meal was plated by the kitchen staff. During a surveyor interview on 10/29/2024 at approximately 9:15 AM, with Registered Nurse, Staff L, she acknowledged that the resident was on a ground diet and had been served toasted bread. During a surveyor observation of the lunch meal on 10/29/2024 at approximately 12:40 PM the resident was observed eating a garden salad with 2-3-inch pieces of grilled chicken, sliced tomatoes, sliced strawberries, and chunks of watermelon with seeds. Additionally, the resident's son was observed to be prompting the resident to swallow his/her food several times while eating this meal. During a surveyor interview on 10/29/2024 at approximately 12:50 PM, with the SLP, she revealed that the resident should not have received toast with breakfast or the grilled chicken salad for lunch as s/he was on a ground texture diet. She further revealed on 10/29/2024, after the lunch meal, the resident's diet was further downgraded to a pureed textured diet. During a surveyor interview on 10/30/2024 at approximately 11:00 AM with the Director of Nursing Services, she was unable to provide evidence that the above residents were served a therapeutic diet as prescribed by the physician. The facility's failure to provide and prepare foods in a form designed to meet individual needs for Resident ID #s 58, 44 and 365 placed the residents at risk for more than minimal harm, impairment, or death.

41729 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biological's in accordance with currently accepted professional principles relative to 1 of 2 medication rooms observed, 2 of 5 medication carts observed, and 1 of 1 resident observed with medications stored at his/her bedside, Resident ID #1. Review of the facility's policy titled Medication Storage states in part, Medications and biological's are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel .Outdated, contaminated, discontinued, or deteriorated medications are immediately removed from stock, disposed of according to procedures for medication disposal . 1a. During a surveyor observation on [DATE] at 1:37 PM in the presence of Licensed Practical Nurse, Staff C, of the third-floor medication room refrigerator, revealed a bottle of Lorazepam intensol (a medication used to treat anxiety) with an open date of [DATE] and expiration date of [DATE]. During a surveyor interview at the time of this observation with Staff C, she acknowledged the Lorazepam was expired and should have been discarded. 2a. During a surveyor observation on [DATE] at 1:57 PM in the presence of Certified Medication Technician (CMT), Staff M, of the second-floor medication cart the following was revealed: - Latanoprost ophthalmic solution 0.005% eye drop (a medication used to lower pressure in the eyes) with an open date of [DATE] and a discard date of [DATE]. Manufacturer's instruction indicates to discard the eye drops four weeks after opening. - Stye sterile lubricant eye ointment with an open date of [DATE] and discard date of [DATE]. During a surveyor interview at the time of the above observations with Staff M, she acknowledged the eye drops were expired and should have been discarded. 2b. During a surveyor observation on [DATE] at 8:33 AM in the presence of CMT, Staff B, of the third-floor medication cart the following was revealed: - Latanoprost ophthalmic solution 0.005% eye drop with an open date of [DATE] and a discard date of [DATE]. - Brimonidine tartrate 0.2% eye drop (a medication used to lower high fluid pressure in the eye), open and undated. Manufacturer's instruction indicates to discard the eye drop four weeks after opening. During a surveyor interview at the time of the above observations with Staff B, he was unable to provide evidence of when the Brimonidine tartrate eye drops were opened and indicated that both of the eye drops are to be discarded. 3. Record review revealed Resident ID #1 was admitted to the facility in May of 2022 with diagnoses including, but not limited to, dementia and chronic pain. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 12 out of 15, indicating the resident has impaired cognition. During surveyor observations on [DATE] at 9:34 AM, [DATE] at 9:30 AM, and on [DATE] at 1:20 PM revealed the following medications were left unattended on the resident's bedside table: - Asper Cream with lidocaine 4.3 ounce (oz) (a medication used to treat pain) - Vaporizing rub 3.4 oz. (a topical ointment used to relieve cough, congestion, and soothe sore muscles) - Arthritis and Sport penetrating heat rub 16 oz (a medication used to treat pain) During a surveyor interview on [DATE] at 1:20 PM with Resident ID #1, s/he indicated that s/he applies the above-mentioned medications by him/herself. Record review failed to reveal evidence that the resident was evaluated to self-administer his/her medications. Additional record review failed to reveal evidence of a physician's order for the Asper Cream, vaporizing rub, or the penetrating heat rub. During a surveyor interview on [DATE] at 1:26 PM with Registered Nurse, Staff N, she acknowledged that the above-mentioned medications were at the resident's bedside. She further indicated that she was unaware that the medications were at the resident's bedside until it was brought to her attention by the surveyor. During a surveyor interview on [DATE] at 3:26 PM and on [DATE] at 9:06 AM with the Director of Nursing Services, she was unable to explain why the eyedrops, eye ointment, and Lorazepam were not discarded appropriately. Additionally, she indicated that she would not expect medications to be left at the resident's bedside without an order or a self-medication administration assessment completed. 46118

41729 48928 50004 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections by failing to place residents on Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities) for 1 of 3 residents reviewed with a Multi-Drug Resistant Organism (MDRO) infection, Extended Spectrum Beta Lactamase (ESBL-an infection that is resistant to multiple antibiotics), Resident ID #27. Additionally, the facility failed to provide a sanitary environment and to help prevent the development of infections for 1 of 2 residents reviewed relative to the use of a Bilevel positive airway pressure device (BIPAP, a device that provides breathing support which is administered through a face mask or nasal mask), Resident ID #44. Furthermore, the facility failed to conduct appropriate infection control practices relative to performing hand hygiene during meal service, for 1 of 3 staff members observed, Dietary Aide (DA), Staff P. Findings are as follows: Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) last reviewed 8/1/2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with MDRO infection or colonization . 1. Record review revealed that Resident ID #27 was readmitted to the facility in September of 2024 with a diagnosis including, but not limited to, urinary tract infection, positive for ESBL. Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. Further review revealed that the resident is dependent on staff for toileting and is frequently incontinent of urine. Record review of the resident's urine culture results revealed the following: 8/29/2024- revealed that the patient had a urinary tract infection, which was positive for ESBL. During multiple surveyor observations throughout the survey process from 10/28/2024 through 10/31/2024 failed to reveal evidence of an isolation cart or signage posted outside of the resident's room to indicate that s/he requires EBP due to his/her history of ESBL in his/her urine. During a surveyor interview on 10/30/2024 at 10:31 AM with Licensed Practical Nurse, Staff C, she revealed the resident was not on precautions at that time. During surveyor interviews on 10/30/2024 at approximately 11:00 AM and 10/31/2024 at 11:25 AM, with the Infection Preventionist (IP), she revealed that when a resident with a MDRO completes their antibiotic the facility removes them from contact precautions and does not utilize EBP for ESBL. She further acknowledged that Resident ID #27 was not currently on precautions for the ESBL. Additionally, she could not provide evidence that follow up urine cultures were completed to verify Resident ID #27 was no longer positive for ESBL to ensure that s/he could not transmit the infection to staff or other residents in the facility. 2. Review of the manufacturer's instructions for a BIPAP machine titled [NAME] Respironics user manual dated April 2016, states in part, .Hand washing can be performed daily. Dishwashing can be performed once a week .Clean the heated tubing before first use and weekly. Wash the parts of the tank in the dishwasher (top shelf only) or in a solution of warm water and a mild liquid dishwashing detergent. Gently wash the middle seal. Rinse the parts with clean water. Wipe the parts completely on the top and bottom. Allow them to air dry . Record review revealed that Resident ID #44 was readmitted to the facility in September of 2024 with diagnoses including, but not limited to chronic obstructive pulmonary disease and acute respiratory failure. Record review of a Quarterly Minimum Data Set Assessment completed on 10/7/2024, revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition. Review of the October 2024 Treatment Administration Record revealed a physician's order to use a BIPAP machine every night at bedtime. Additional review revealed that the order was signed off as completed every night from 10/1 through 10/29/2024. Record review failed to reveal evidence of documentation or a physician's order to clean the BIPAP machine tubing and mask per the manufacturer's instructions. During a surveyor observation on 10/30/2024 at 8:51 AM in the presence of LPN, Staff C, the resident's BIPAP was noted to have an accumulation of pink and white matter on the inside of the mask. Staff C, acknowledged this observation and revealed that she was unsure of the cleaning process for the equipment. During a surveyor interview on 10/29/2024 at 12:56 PM with the Director of Nursing Services (DNS), she indicated that the facility utilizes an outside company to clean the BIPAP machines weekly and that she would provide documentation that this was being completed. During a subsequent interview on 10/30/2024 at 8:38 AM with the DNS, she revealed that when she called the outside company to obtain documentation for the above BIPAP machine's cleaning schedule, she was informed that they do not clean or maintain the BIPAP machines in the facility. She further acknowledged, the resident does not have an order in place to clean the BIPAP equipment and was unable to provide evidence that the machine was cleaned, as required per the manufacturer instructions. 3. During a surveyor observation of the meal service on 10/28/2024 at 12:35 PM in the TCU unit, kitchenette area, DA, Staff P, was observed plating resident meals from a buffet table. Upon receiving a slip containing an alternative lunch item that was not provided on the buffet table, Staff P then stepped away and used the phone to contact the kitchen, wearing the same glove that he was wearing while plating meals. Following the phone call, Staff P, returned to the buffet table to resume plating resident meals, wearing the same gloves he wore to use the phone. He then picked up a sandwich, removed the protective wrap, touched the sandwich with his gloved hand, and reached into a bin containing lettuce and sliced tomato to add to the sandwich plate. Immediately upon the above observation, the surveyor intervened and questioned Staff P regarding hand hygiene and his knowledge of preventing food contamination. Staff P indicated that he was unaware that the gloves should be changed after using the phone and prior to touching the residents food. Additionally, he left the service area to obtain clean gloves. During a surveyor interview on 10/31/2024 at 8:47 AM with the Food Service Director, she indicated that she would have expected Staff P to change his gloves prior to touching food after using the phone and to have clean gloves readily available at the service area.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #2 and #3, resulting in significant injury of Resident ID #2. Findings are as follows: Review of a facility policy titled, Abuse prohibition states in part, .It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse .Abuse: Willful infliction of injury .resulting in physical harm .Examples of abuse include but are not limited to the following: Physical - Hitting, punching, pinching, kicking . Record review reveals a facility reported incident of resident-to-resident abuse was submitted to the Rhode Island Department of Health on 5/17/2024. The report indicates that Resident ID #2 reported to staff that Resident ID #3 had kicked him/her when s/he was exiting the bathroom. Additionally, Resident ID #2 sustained a skin tear to his/her left leg. Review of the 5-Day Investigation Report dated 5/22/2024, revealed that after the facility's investigation, the allegation of resident-to-resident abuse was substantiated as Resident ID #3 admitted to hitting Resident ID #2 with a trash can. Record review revealed Resident ID #2, the victim, was admitted to the facility in August of 2023 with diagnoses including, but not limited to, adjustment disorder with anxiety and disorders of the brain due to a temporal mass (mass on the temporal lobe of the brain that may affect essential functions including comprehension, emotions, and memory). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderately impaired cognition. Review of a progress note dated 5/17/2024 at 1:30 PM authored by Registered Nurse, Staff A, revealed that Resident ID #2 approached the nurses' station with his/her pant leg rolled up exposing an open area that was not there prior. The progress note further revealed that Resident ID #2 indicated that when s/he was exiting the bathroom, the roommate kicked him/her. Additionally, the open area on Resident ID #2's left shin required it to be cleansed and dressed with wound treatment supplies. Review of a document titled, Event Report dated 5/17/2024 revealed Resident ID #2 sustained a 1.7 centimeter (cm) by 1.4 cm open area to his/her left shin requiring a normal saline cleanse, the application of steri-strips (thin adhesive bandages used to close cuts or wounds), the application of xeroform (sterile wound dressing), and coverage with a clean dry dressing. Further review of the above-mentioned document revealed that Resident ID #2's wound was treated from 5/17/2024 through 6/16/2024, a duration of 31 days. Record review revealed Resident ID #3, the perpetrator, was admitted to the facility in July of 2022 with a diagnosis including, but not limited to, left lower arm fracture. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. Review of a progress note dated 5/17/2024 at 6:36 PM revealed that Resident ID #3 was in agreement to move to a different room due to the altercation with his/her roommate, Resident ID #2. Record review revealed that Resident ID #3 has had 7 room changes since his/her admission in July of 2022. During a surveyor interview on 7/30/2024 at 1:34 PM with Staff A, she revealed that Resident ID #3 has been moved several times in the past as s/he can be a difficult roommate. She further revealed that Resident ID #2 sustained a wound to his/her left shin and was followed by the provider for his/her left shin wound and required daily dressing changes for approximately 1 month. During a surveyor observation on 7/30/2024 at 1:38 PM of Resident ID #2 in the presence of Staff A, revealed a noticeable discolored scar and indentation to his/her left shin. During a surveyor interview on 7/30/2024 at 1:41 PM with Resident ID #3, s/he revealed that s/he recalled the altercation with Resident ID #2 and indicated that s/he grabbed a trash can and hit Resident ID #2 in the leg with it. Additionally, s/he acknowledged that it was a deliberate act. During a surveyor interview on 7/30/2024 at 2:28 PM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence that Resident ID #2 was kept free from physical abuse.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an accident for 1 of 3 residents reviewed for elopement, Resident ID #1. Findings are as follows: Review of a facility policy titled, Identification of High Risk Elopement Residents states in part, Purpose: To ensure the safety and well being of all residents with a potential for wandering/eloping from the facility .Residents who were not identified to be 'at risk for elopement' on admission, but are demonstrating behaviors such as .accessing the elevator or exit doors are considered to be 'at risk for elopement.' Review of a community reported complaint allegation submitted to the Rhode Island Department of Health on 7/26/2024 revealed that Resident ID #1 was evaluated at the emergency room following a fall from his/her wheelchair. Additionally, Resident ID #1 had wheeled him/herself out the front door of the facility, the wheelchair began to roll downhill, and Resident ID #1 fell out of his/her wheelchair to avoid oncoming traffic. Record review revealed that the resident was admitted to the facility in March of 2022 with diagnoses including, but not limited to, mild cognitive impairment and a history of falling. Additionally, the resident resides on the second floor and has unrestricted access to the second-floor lobby where the main elevator is located, which leads to the main entrance located on the first floor. Review of a quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 4 out of 15 indicating severe cognitive impairment. Further review revealed that the resident utilizes a wheelchair for mobility and can independently wheel a minimum of 150 feet in a corridor or similar space. Record review revealed the following progress notes: - 7/26/2024 at 3:48 PM revealed that the resident was found outside of the facility lying on the ground with a bump to his/her forehead with active bleeding and skin tears to his/her left arm, and was extremely confused. Additionally, Nursing Assistant (NA), Staff B, witnessed the resident wheel him/herself out of the facility and the resident was engaging in conversation with another person when his/her wheelchair began to roll. Staff B chased after the resident and witnessed him/her fall from his/her wheelchair onto the ground. Further, Emergency Medical Services was contacted and s/he was transported to the hospital. - 7/26/2024 at 5:17 PM revealed that the resident was administered medication to lower his/her blood pressure in the emergency room as his/her blood pressure was elevated at 210/94 (normal blood pressure is 120/80). - 7/27/2024 at 12:03 AM revealed that the resident returned from the hospital and was noted with a skin tear to his/her head and left arm, a hematoma (abnormal pooling of blood under the skin that can be caused from injury or trauma) to his/her left forehead, and facial bruising. Additionally, the skin tears required treatments that consisted of a normal saline cleanse, the application of steri-strips (thin adhesive bandages used to close cuts or wounds), the application of xeroform (sterile wound dressing), and coverage with a clean dry dressing. Further, the resident was diagnosed with a urinary tract infection and was started on a 7-day course of antibiotic therapy. - 7/29/2024 at 1:35 PM revealed that the resident indicated the above-mentioned injury was still causing him/her discomfort. Review of the July 2024 Medication Administration Record (MAR) revealed that the resident had been receiving Tylenol (medication to treat pain) 1 gram (g) twice daily. Additionally, s/he had an as needed order for Tylenol 1g once a day which had not been utilized prior to the incident that occurred on 7/26/2024. Further review of the MAR revealed the resident received Tylenol on 7/28 and again on 7/30/2024 for complaints of pain. Review of a document titled, Elopement Risk Evaluation dated 6/19/2024, authored by Registered Nurse, Staff C, revealed that the resident was not deemed an elopement risk, however required Supervision - oversight, encouragement or cueing for locomotion off of the unit (how the resident moves to and returns from off-unit locations). Further, the document indicated to refer to the Activities of Daily Living (ADL) flow chart in the Resident Assessment Instrument (RAI) Manual to facilitate accurate coding. Review of the RAI Manual, Version 3.0 dated October 2023, states in part, .Supervision or touching assistance .For example, the resident requires verbal cueing, coaxing, or general supervision for safety to complete the activity . During a surveyor interview on 7/30/2024 at 12:50 PM with Staff C, she acknowledged she was the nurse that completed the Elopement Risk Evaluation. She further revealed that she did not utilize the RAI manual to accurately code the Elopement Risk Evaluation, however the resident is with staff while off the unit and that is why she indicated on the assessment that the resident requires supervision while off the unit. Additionally, she revealed that when the resident is off the unit, s/he is under general supervision by staff and provided the examples of when the resident is participating in activities or watching a movie. During a surveyor interview on 7/30/2024 at 10:24 AM with Staff B, she revealed that she was outside the facility by the main entrance on her break when she observed the resident wheel him/herself out of the front doors. Staff B indicated that no staff was present with the resident. Staff B further revealed that she was on her cell phone and looked up and saw the resident engaged in conversation with a visitor, then resumed looking at her cell phone. Staff B indicated that she heard the resident scream and looked up from her cell phone to see that the resident was rolling down the parking lot and she began to chase him/her but was unable to catch him/her before s/he fell from his/her wheelchair. Further, Staff B indicated to the surveyor the location of where the resident fell , which was at the exit of the parking lot where the parking lot adjoins the street. During a surveyor interview on 7/30/2024 at 1:12 PM with the Director of Nursing Services, she revealed that the resident should be in generally supervised areas. She was unable to explain how the resident was able to exit his/her unit, take the elevator to the 1st floor main lobby, and exit the building without staff properly supervising the resident while off the unit. She was unable to provide evidence that the resident received adequate supervision to prevent an accident.

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 3 residents reviewed for a urinary tract infection (UTI), Resident ID #1. Findings are as follows: Record review revealed that the resident was admitted to the facility in March of 2022 with diagnoses including, but not limited to, mild cognitive impairment and history of falling. Review of a progress note dated 7/27/2024 at 12:03 AM revealed that the resident returned from the hospital following a fall and was diagnosed with a UTI. Additionally, s/he was started on Cephalexin (an antibiotic) 500 milligrams (mg) every 12 hours for 7 days. Review of a physician's order dated 7/27/2024 revealed Cephalexin 500mg give 1 tablet every 12 hours with an end date of 8/2/2024. Record review failed to reveal evidence that a care plan was developed and implemented for the UTI that the resident is currently being treated for. During a surveyor interview on 7/30/2024 at 10:43 AM with Minimum Data Set Coordinator, Staff D, she acknowledged that the resident's comprehensive care plan was not developed to include a UTI. She revealed that it should have been updated right away to include a UTI. During a surveyor interview on 7/30/2024 at 10:50 AM with Director of Nursing Services, she revealed that she would expect that the resident's comprehensive care plan would have been developed to include a focus area for a UTI. Cross reference F 689

Based on surveyor observation, record review, resident and staff interview it has been determined that the facility failed to ensure that all licensed nurses have the specific skill sets necessary to care for residents' needs for 1 of 1 resident reviewed, relative to the use of a hydrocollator (thermostatically controlled water bath for placing cloth heating pads or hotpacs) resulting in a burn, Resident ID #21. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .To assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being .'Competency' is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . Record review of the Hydrocollator Heating Units User Manual revealed in part under Safety Precautions, .Constantly monitor HotPac application to ensure that the skin is not becoming too hot. Damage to skin can occur from exposure to extreme heat or cold. Note instructions for proper use .Never lay or sit on top of the HotPac .DO NOT use HotPac directly over cuts, abrasions or wounds .The water temperature in the Hydrocollator is approximately 71 degrees C [Celsius] (160 degrees F [Fahrenheit]), and the water scalding temperature is approximately 49 degrees C (120 degrees F) . Record review of the facility policy titled, PT [Physical Therapy] Hot Pack Program revealed in part, .Wrap with 8 layers of toweling or additional if necessary for specific resident .Assist resident to position of comfort: Supine [lying face up] with knees flexed over pillow; Side-lying with knees semi-flexed and pillow between knees; Prone [lying face down] is usually difficult for this age group .Place call bell close so resident may call if he/she [has] problems (too warm, etc.) .Check area after 5 minutes (if very red add more toweling) . Record review revealed the resident was admitted to the facility in January of 2021, with diagnoses to include, but not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, contracture of left hand, chronic back pain, and abnormalities of gait and mobility. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status with a score of 14 out of 15 indicating that the resident is cognitively intact. It further reveals that s/he requires extensive assistance of two people for bed mobility. Record review revealed a physician's order dated 8/30/2023 to Apply Hydrocollator Hot pack to upper back 2x [times] day for 20 minutes, then remove Under Special instructions it states, .place multiple layers of towel between residents skin/clothing and the Hydrocollator to prevent skin burns. This order was discontinued on 10/16/2023. Record review of an event report dated 10/12/2023 at 2:24 PM states in part, .Physician notified: Yes .[Physician] in this afternoon saw patient .This shift patient was noted to have a [reddened] area to lower back. Measurements: 5 cm [centimeters] x 3 cm skin appears to have slipped off .Evaluation Notes: Wound to back healing, no abuse suspected, caused by hydrocollator . Record review of a physician's order dated 10/12/2023 revealed a treatment to cleanse the open area to the back with normal saline and cover with allevyn (non-adhesive dressing) daily. This order was discontinued on 10/19/2023. Additional record review of a physician's order dated 10/17/2023 revealed a treatment for Silvadene (topical medication used to treat or prevent serious infection on areas of skin with second- or third-degree burns) to be applied to the lower back wound twice daily. During a surveyor interview on 11/30/2023 at approximately 9:45 AM with Physical Therapist, Staff A, she revealed that the nurses complete the hydrocollator treatment with the resident. She was unaware of how the nurses were trained. She further revealed that she would expect the special [NAME] cloth cover and 6 to 8 towel layers to be used to wrap the HotPac. Additionally, she said if the resident was laying on the HotPac she would expect that the most layers would be used to protect the resident's skin. Record review of the Nurse Medication Administration History for the period 10/1/2023 through 10/31/2023 revealed that Licensed Practical Nurse, Staff B and Registered Nurse, Staff C, had both applied the hydrocollator HotPac to the resident on multiple occasions. During surveyor interviews on 11/30/2023 at 10:35 AM and 11:56 AM with the resident, s/he revealed that they had a burn on their back because the hydrocollator was too hot a couple of times when the nurses applied it. The resident also revealed that s/he would lay on the HotPac in the bed, and once it was set up, the nurses did not stay with him/her to monitor him/her during the treatments. The resident further revealed that s/he would use the call bell if it got too hot, or needed to be repositioned as s/he is unable to fully reposition him/herself. During surveyor interviews on 11/30/2023 at 10:26 and 11:57 AM with Staff B, she revealed that she wraps the hydrocollator HotPac in 3 to 4 towels and the resident lays on it in bed for 20 minutes. She further acknowledged that she does not stay with the resident during the treatment, and that the resident is unable to reposition him/herself. During a surveyor telephone interview on 11/30/2023 at 11:09 AM with Registered Nurse, Staff C, she revealed that she would wrap the HotPac in 4 to 5 towels when she used it on the resident. She acknowledged that she had not received formal education on how to use the hydrocollator, and she did not stay with the resident to provide constant monitoring during the treatments. During a surveyor interview on 11/30/2023 at 11:29 AM with Licensed Practical Nurse, Staff D she revealed that when she received the hydrocollator order she had educated a few of the nurses to use multiple towels, but she was unaware that the nurse should have been providing constant monitoring of the resident during treatment. She further revealed that she was in-serviced years ago by therapy but acknowledged that the facility has not in-serviced the nurses on the use of the hydrocollator since. Additional record review of the facility's PT Hot Pack Program policy failed to reveal evidence of instructions or guidance to constantly monitor the resident during hydrocollator application treatments to ensure the skin does not become too hot as indicated in the Hydrocollator Heating Unit User Manual. The policy also indicated that the resident could lay down in a supine position while using the hydrocollator which does not follow the manufacturer's instructions. During a surveyor interview on 11/30/2023 at 11:19 AM and 1:55 PM with the Director of Nursing Services she revealed that this resident was the only one the nurses applied the hydrocollator HotPac for, because she gets it twice daily. She failed to provide evidence of nursing competencies or education for the use of the hydrocollator. She further revealed that she would expect the staff to follow the facility policy for the hydrocollator. She was unable to provide evidence that the policy was in accordance with the user manual.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections relative to disinfecting glucometers (a device used to monitor blood glucose) for 2 of 3 residents observed who require blood glucose monitoring, Resident ID #s 51 and 53; and 1 of 1 resident observed for a wound dressing change, Resident ID #357. Findings are as follows: 1. According to the facility's policy last revised January of 2023 titled, General Infection Control Policies states in part, .All items used for the resident are to be cleaned and disinfected before use and/or are to be designated for the resident's use only .Small non-disposable equipment such as glucometers .are to be cleaned and appropriately disinfected after each use for an individual resident. Manufacturer's guidelines should be followed when cleaning glucometer machines . Review of the glucometer's User Instruction Manual titled, Assure Prism multi, states in part, .For multiple patient use .Cleaning and Disinfecting .The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. a) Record review revealed Resident ID #51 was readmitted to the facility in October of 2022 with a diagnosis including, but not limited to, type II diabetes. Additionally, his/her blood sugars are monitored four times a day. b) Record review revealed Resident ID #53 was readmitted to the facility in November of 2022 with diagnoses including, but not limited to, type II diabetes and long-term use of insulin. Additionally, his/her blood sugars are monitored once a day on Mondays, Wednesdays, and Fridays. During surveyor observations on 11/29/2023 at 11:02 AM during the medication administration task with Licensed Practical Nurse (LPN), Staff B, the following observations were made: - Staff B was observed obtaining Resident ID #51's blood sugar with a multi-use glucometer. After obtaining Resident ID #51's blood sugar, Staff B then placed the unclean glucometer in a basket of clean, glucose monitoring supplies, and returned to the nurses' cart. Staff B was not observed to have cleaned or disinfected the multi-use glucometer prior to placing it back in the nurses' cart. - Staff B then retrieved the same multi-use glucometer and basket of supplies from the nurses' cart and proceeded to Resident ID #53's room to obtain his/her blood sugar. Staff B was not observed to have cleaned or disinfected the glucometer prior to obtaining Resident ID #53's blood sugar. During a surveyor interview immediately following the above observations on 11/29/2023 at 8:20 AM with Staff B, she acknowledged that she did not clean and disinfect the multi-use glucometer after obtaining Resident ID #51's blood sugar and placed the unclean glucometer back in the nurses' cart with clean supplies. She further acknowledged that she should have cleaned and disinfected the glucometer prior to obtaining Resident ID #53's blood sugar. During a surveyor interview on 11/29/2023 at 12:41 PM with the Director of Nursing Services (DNS), she revealed that Staff B should have cleaned and disinfected the multi-use glucometer in between obtaining blood sugars for Resident ID #s 51 and 53. 2. Review of an undated facility policy titled, Clean Dressing Technique states in part, .Gather and set up necessary supplies in the resident area .Establish a clean field .Open supplies onto clean field .Establish a container for soiled dressings .Wash hands (Hand sanitizer may be used) and put on clean gloves . Record review revealed Resident ID #357 was admitted to the facility in November of 2023 with diagnoses that include, but are not limited to, heart failure and acute respiratory failure. Record review revealed the resident has a stage 2 pressure ulcer (wound with partial thickness skin loss) to his/her coccyx with a physician's order to change the dressing daily and as needed. During a surveyor observation on 11/29/2023 at approximately 9:06 AM of the resident's wound dressing change, LPN, Staff D was observed to establish a clean field on the resident's bed and she placed all of the clean dressing supplies on an unused, disposable barrier. Staff D then went and retrieved a trash can with her bare hands, which had soiled contents within it, brought it to the resident's bedside, and placed it on the floor. Without performing hand hygiene, after just handling the trash container, she began handling contents on the clean field with her bare hands and was observed to open and date the clean dressing that was applied to the resident's wound. During a surveyor interview immediately following the dressing change on 11/29/2023 at 9:23 AM, Staff D acknowledged that she handled the trash can with her bare hands and did not perform hand hygiene prior to handling the clean dressing supplies. She further acknowledged that she should have performed hand hygiene prior to touching the resident's clean dressing. During a surveyor interview on 11/29/2023 at 10:41 AM with the DNS, she revealed she would expect that staff would not handle clean dressing supplies after touching the trash. She acknowledged that Staff D should have performed hand hygiene prior to handling the clean supplies and was unable to provide evidence that the facility provided a safe and sanitary environment to help prevent the transmission of infections. 50004

Based on surveyor observation and staff interview, it has been determined that the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles for 3 of 4 medication carts observed and 4 of 4 medication storage rooms observed. Findings are as follows: Review of a facility's policy titled Storage of Medication dated 5/2016 revealed in part, .PROCEDURES .2. Controlled medications must be stored separately from non-controlled medications. The access system (key, security codes) used to lock Schedule II medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications. Schedule II medications and preparations must be stored in a separately locked permanently affixed compartment . 1. A. During a surveyor observation of the 2nd floor Certified Medication Technician (CMT) medication cart on 9/16/2022 at 8:25 AM in the presence of CMT Staff A revealed the following: - A medication cup with 2 white capsules located in the top drawer - 1 Geri-care Milk of Magnesia 16-ounce (oz.) bottle opened and not dated. Manufacturer's instructions state, Use within 6 months of opening During an interview immediately following the observation with Staff A, she revealed that the 2 pills were Acidophilous and that she took them out of the med room refrigerator and placed them in the top draw to give to a resident during her medication pass. She further indicated that she was unaware that the Milk of Magnesia bottle should be dated when opened. B. During a surveyor observation of the 3rd floor CMT medication cart on 9/16/2022 at 9:49 AM with CMT Staff B revealed the following: - 1 Geri-care Milk of Magnesia 16 oz bottle opened and not dated. Manufacturer's instructions state, Use within 6 months of opening During an interview immediately following the observation with Staff B, he indicated that he was unaware that that the Milk of Magnesia bottle should be dated when opened. C. During a surveyor observation of the 3rd floor Nurse's medication cart on 9/16/2022 at 9:54 AM in the presence of Licensed Practical Nurse, Staff C, revealed the following: - 1 bottle of [MEDICATION(S)] solution labeled with Resident ID #36's information opened and not dated - 1 bottle of [MEDICATION(S)] solution labeled with Resident ID #81's information opened and not dated - 1 bottle of [MEDICATION(S)] solution labeled with Resident ID #101's information opened and not dated During an interview immediately following the observation with Staff C, she revealed that she was unaware that the [MEDICATION(S)] solution bottles should be dated when opened. Review of a document titled Abridged List of Medications with Shortened Expiration Dates from the facility's pharmacy revealed that [MEDICATION(S)] solution's beyond use date is one year after opening. 2. A. During a surveyor observation of the 2nd floor medication storage room on 9/16/2022 at 8:35 AM in the presence of Licensed Practical Nurse, Staff D, revealed a medication refrigerator not locked with [MEDICATION(S)] [MEDICATION(S)] (a controlled substance, scheduled medication used to treat anxiety) inside along with non-scheduled medications. During an interview immediately following the observation with Staff D, she revealed that the medication refrigerator does not have a lock but the medication storage room door remains locked. She further revealed that the nurses and CMT's have keys to the medication storage room. B. During a surveyor observation of the 1st floor unit medication storage room on 9/16/2022 at 8:45 AM in the presence of Registered Nurse, Staff E revealed a medication refrigerator not locked with [MEDICATION(S)] [MEDICATION(S)] inside along with non-scheduled medications. During an interview immediately following the observation with Staff E, she revealed that the medication refrigerator in the medication storage room does not have a lock and that the nurses and CMT's have keys to the medication storage room. C. During a surveyor observation of the 3rd floor medication storage room on 9/16/2022 at 11:36 AM in the presence of Staff C revealed a medication refrigerator not locked with [MEDICATION(S)] [MEDICATION(S)] inside along with non-scheduled medications. During an interview immediately following the observation with Staff C, she revealed that only nurses and CMT's have keys to the medication storage room and that the medication refrigerator is not locked. D. During a surveyor observation of the TCU (Transitional Care Unit) medication storage room on the 1st floor on 9/16/2022 at 11:38 AM with Licensed Practical Nurse, Staff F revealed a medication refrigerator not locked with a pharmacy narcotic emergency kit (Ekit) inside along with non-scheduled medications. During an interview immediately following the observation with Staff F, she revealed that nurses and CMT's have keys to the medication storage room. During a surveyor interview with the Assistant Director of Nursing Services (ADNS) on 9/16/2022 at 11:53 AM she revealed that there should be no loose pills in the medication cart without a resident's name on the packaging and that she was unaware that Milk of Magnesia and [MEDICATION(S)] had to be dated when opened. The ADNS further indicated that the facility's pharmacy recently brought to their attention that controlled substances such as [MEDICATION(S)] had to be stored by double lock in the medication storage refrigerator Review of a document from the facility's pharmacy titled Controlled Substances Audit dated 8/12/2022 revealed that the [MEDICATION(S)] ([MEDICATION(S)]) liquid was not stored by double lock in the refrigerator and that the Ekit were not stored securely. During a subsequent interview with the ADNS and the Administrator on 9/19/2022 at 10:07 AM, they acknowledged that the double lock containers had not been installed since they were made aware that scheduled medications need to be under double lock by the pharmacy on 8/12/2022.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure staff utilized appropriate Personal Protective Equipment (PPE), performed proper hand hygiene during dressing changes and cleaned high touch surfaces according to professional standards for Resident ID #'s 28, 33, and 67. Findings are as follows: 1. Record review of the facility's policy titled, Hand Hygiene, states in part, POLICY: Consistent, appropriate hand hygiene is the primary means of preventing the transmission of infection .Alcohol based hand rub (ABHR)- refers to a 60 to 95% [MEDICATION(S)] or [MEDICATION(S)] containing preparation base designed for application to the hands to reduce the number of viable microorganisms. Hand Hygiene- is a general term that applies to washing hands with water and either plain soap or soap/detergent containing antiseptic agent: OR thoroughly applying an alcohol -based hand rub .Some of the times when Hand hygiene is to be performed include the following .after removing gloves .gloves are not a substitute for hand hygiene . 1.a. Record review revealed Resident ID# 28 was admitted to the facility in January of 2021 with a stage 2 pressure ulcer on his/her sacrum. During a surveyor observation on 6/22/2021 at 9:40 AM of Resident's ID# 28's sacral wound dressing change with Registered Nurse, Staff E, after removing the dirty dressing from the wound and cleansing the area, Staff E failed to perform hand hygiene or use an ABHR before donning a new pair of gloves. Staff E then retrieved a different pair of gloves from her scrub top pocket. After donning the gloves, she continued to apply the ordered wound treatment to the resident's sacral wound. During a surveyor interview on 6/22/2021 at 9:56 AM with Staff E, she acknowledged she did not perform hand hygiene or use an ABHR after removing her dirty gloves and prior to donning new gloves. Additionally, she acknowledged she should have used new gloves from a box of gloves, not her scrub top pocket. During a surveyor interview on 6/22/2021 at 12:17 PM with the DNS, she indicated she expects staff to perform hand hygiene or use an ABHR during a wound dressing change after removing dirty gloves. 1.b. Record review revealed Resident ID# 33 was admitted to the facility in April of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor observation on 6/23/2021 at 8:55 AM of Resident ID #33's gastrostomy tube dressing change with Licensed Practical Nurse, Staff A, after removing the dirty dressing from the gastrostomy tube and cleansing the area, Staff A failed to perform hand hygiene or use an ABHR before donning a new pair of gloves. Staff A then retrieved a new pair of gloves from a box of gloves and continued to apply the clean dressing to the Resident ID#33's gastrostomy tube site. During a surveyor interview on 6/23/2021 at 8:59 AM following this observation, Staff A acknowledged she did not perform hand hygiene or use ABHR after removing dirty gloves and applying clean ones. During a surveyor interview on 6/23/2021 at 10:00 AM with the Director of Nursing Services, she indicated she expects staff to perform hand hygiene or use ABHR during a dressing change after removing dirty gloves and prior to applying clean gloves. 2. Record review of the facility infection control policy title Accepting Admissions during COVID-19 Pandemic revealed that newly admitted residents, not COVID-19 vaccinated should be quarantined for a 14-day period. In addition, the policy indicates that quarantine unit signage should be posted indicating the required Personal Protective Equipment (PPE) that should be donned prior to entering the quarantine room. The required PPE is an N-95 mask, gown, gloves, and face shield/eye protection. During the entrance conference with the Director of Nurses Services (DNS), on 6/21/2021 at approximately 9:43 AM, she indicated that she expects staff to wear full PPE to enter the quarantine room. Record review for Resident ID# 67 revealed the resident was admitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has not been vaccinated for COVID-19. During a surveyor observation on 6/24/2021 at 10:41 AM, Staff F, Occupational Therapist was observed inside Resident ID# 67's room wearing only a gown and a surgical mask. During a surveyor interview immediately following this observation, Staff F acknowledged he was not wearing the appropriate PPE and should have been wearing an eye protection and an N-95 mask. During a surveyor interview on 6/24/2021 at 10:45 AM with License Practical Nurse, Staff C, she acknowledged that the sign outside the room did not indicate that an N-95 mask or eye protection were required to be worn prior to entering the room. During a surveyor interview on 6/24/2021 at approximately 1:00 PM with the Minimum Data Set (MDS) Director/ Infection Preventionist (IP), she acknowledged that the sign that was outside of the resident's room was inaccurate and it should have indicated the need to use an N-95 mask and eye protection prior to entering the room. During a surveyor interview with the DNS on 6/24/2021 at 11:30 AM, she was unable to explain why staff were not wearing the correct PPE when entering a quarantine room. 3. During a surveyor interview with the MDS Director/IP Nurse, on 6/24/2021 at approximately 9:45 AM, she indicated that the Maintenance/Environmental Services (EVS) Department was responsible for the cleaning of high touch surfaces in the facility. During a surveyor interview with EVS staff, Staff G, on 6/24/2021 at 10:53 AM, she revealed she tries to clean the high touch surfaces once a day. When asked where she documents the cleaning of high touch surfaces, she provided the surveyors with a document titled COREWORKS High Touch Point Disinfecting. This document was blank and failed to reveal that the cleaning of high touch surfaces was completed. During an interview with the Director of Maintenance on 6/24/2021 at 11:03 AM, he acknowledged that his department was responsible for the cleaning of high touch surface areas in the facility. He then provided the surveyors with a document titled COREWORKS High Touch Point Disinfecting dated 12/30/2020, which he indicated was the last documented cleaning schedule of high touch surfaces for the facility. During a surveyor interview with the DNS, on 6/24/2021 at 11:30 AM, she was unable to provide evidence that the EVS/maintenance department have been cleaning high touch services since 12/30/2020.

Based on surveyor observation, record review, and resident and staff interview, it has been determined the facility failed to ensure assessments accurately reflect the resident's status for 3 of 26 sample residents, Resident ID#s 28, 35, and 84. 1. Record review revealed Resident ID# 28 was admitted to the facility in January of 2021 with a stage 2 pressure ulcer on his/her sacrum. Record review of a document titled, Wound Assessment Report revealed that on 2/3/2021 the pressure ulcer was documented as a stage 2 pressure ulcer. Further review of this document revealed that on 2/10/2021, the pressure ulcer was documented as a stage 3 pressure ulcer. Record review of a document titled, Wound Assessment Report revealed that on 4/7/2021, 4/14/2021, 4/22/2021, and 4/28/2021, the pressure ulcer continued to be documented as a stage 3 pressure ulcer. Review of a 4/29/2021 quarterly Minimum Data Set, (MDS), assessment revealed the resident continued to be coded as having a stage 2 pressure ulcer, despite wound assessment documentation indicating the pressure ulcer was a stage 3. During a surveyor interview on 6/24/2021 at 8:53 AM with the MDS Director, she acknowledged Resident ID# 28 has a stage 3 pressure ulcer on his/her sacrum. She revealed the pressure ulcer on the resident's sacrum progressed from a stage 2 to a stage 3 pressure ulcer while at the facility. She acknowledged the 4/29/2021 quarterly MDS assessment was coded inaccurately and should reflect the presence of a stage 3 pressure ulcer and not a stage 2. 2. Record review revealed Resident ID# 35 was admitted to the facility in January of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident ID# 35's progress notes revealed the following: - January 2021 admission note which states in part, Resident arrived via ambulance .on 2L [liters] oxygen. - 2/12/2021 physician's note which states in part, .[CONDITION(S)] and is dependent on supplemental oxygen . - 3/31/2021 nursing note which states in part, .remains on continuous o2 [oxygen] @ [at] 2L [liters] via N/C [nasal cannula, device used to deliver supplemental oxygen] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] [a device used to deliver supplemental oxygen] at bedtime to maintain 02 > [greater than] 92%. During a surveyor interview on 6/21/2021 at 10:21 AM with Resident ID# 35, s/he was observed to be receiving oxygen via NC. S/he revealed s/he has been receiving oxygen for a long time. Additional observations were made of Resident ID# 35 receiving 2 liters of oxygen via NC on 6/22/2021 at 10:30 AM and on 6/23/2021 at 9:17 AM and 1:41 PM. Review of a 1/20/2021 admission MDS assessment and a 4/22/2021 quarterly MDS assessment, under Section O for Special Treatments, Procedures, and Programs, failed to indicate Resident ID #35 was receiving oxygen therapy while a resident of the facility. During a surveyor interview on 6/23/2021 at 12:13 PM with the MDS Director she acknowledged Resident ID# 35's admission and quarterly MDS assessments were coded inaccurately for oxygen therapy. 3. Record review revealed Resident ID# 84 was admitted to the facility in March of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 3/23/2021 Dietary progress note states in part, .Dentition: Edentulous . Review of a 6/14/2021 nursing progress note states in part, .pt [patient] noted to not have any teeth . During a surveyor interview on 6/21/2021 at 3:18 PM with Resident ID# 84, s/he was observed to be edentulous. Review of a 3/31/2021 annual MDS assessment under Section L for Oral/Dental Status, failed to reveal evidence that Resident ID# 84 was coded as edentulous (lacking teeth). Review of a 4/8/2020 care plan for ADL [activities of daily living] Functional / Rehabilitation Potential, last edited on 4/1/2021, which states in part, [the resident] is highly involved with [his/her] personal care (has natural teeth able to self brush). During an interview on 6/24/2021 at 12:13 PM with the MDS Director, she stated the MDS assessment should indicate Resident ID# 84 is edentulous. Additionally, she acknowledged the care plan was also inaccurate.

Based on surveyor observation, record review and staff interview, it has been determined the facility failed to develop a comprehensive person-centered care plan for each resident to include services that are to be furnished to attain or maintain the resident's highest practicable physical well-being as required for 2 of 4 sample residents reviewed for oxygen use, Resident ID#s 35 and 70. Findings are as follows: 1. Record review revealed Resident ID #35 was admitted to the facility in January of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 5/17/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] [a device used to deliver supplemental oxygen] at bedtime to maintain 02 > [greater than] 92%. Review of Resident ID# 35's progress notes revealed the following: - 5/26/2021 physician note at 2:21 PM, .on 2 liter nasal canula [sic.] . - 5/30/2021 nursing note at 2:02 PM, .remains on continuous 02 @ [at] 2L [liters] via N/C [nasal cannula]. - 6/02/2021 nursing note at 8:25 PM, .remain[s] on continuous o2 [oxygen] @ [at] 2L via N/C . The following observations were made of Resident ID# 35 receiving 2 liters of oxygen via nasal cannula: - 6/21/2021 at 10:21 AM - 6/22/2021 at 10:30 AM - 6/23/2021 at 9:17 AM and at 1:41 PM During a surveyor interview on 6/23/2021 at 1:53 PM while observing Resident ID #35, with Licensed Practical Nurse, Staff Nurse A, she acknowledged the resident was receiving oxygen via nasal cannula. Review of Resident ID# 35's comprehensive person-centered care plan failed to reveal goals or interventions for the use of oxygen therapy. During a surveyor interview on 6/23/2021 at 12:13 PM with the Minimum Data Set (MDS) Director, she acknowledged that Resident ID# 35 was receiving oxygen therapy and was not care planned for its use. 2. Record review revealed Resident ID# 70 was admitted to the facility in December of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual MDS assessment, dated 5/21/2021, under Section O Special Treatments, Procedures, and Programs, revealed Resident ID# 70 was coded as receiving oxygen therapy. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 2L [2 liters per minute] via n/c [nasal cannula; a device used to deliver oxygen] continuous. The following surveyor observations revealed this resident was receiving 2 liters of oxygen via NC: - 6/21/2021 at 11:55 AM - 6/21/2021 at 12:33 PM - 6/22/2021 at 9:16 AM - 6/22/2021 at 12:27 PM Review of Resident ID# 70's comprehensive person-centered care plan failed to reveal goals or interventions for the use of oxygen therapy. During a surveyor interview on 6/24/2021 at 10:37 AM with the MDS Director, she acknowledged that Resident ID# 70 was receiving oxygen therapy and was not care planned for its use.

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to assure that services being provided meet professional standards of quality for 2 of 26 sample residents reviewed, Resident ID#s 23 and 35. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of Resident ID# 23's clinical record revealed s/he was admitted to the facility in June of 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident ID# 23's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Frequency: Once A Day on Mon, Wed, Fri . During a dressing change observation in the presence of two surveyors on 6/21/2021 at 1:16 PM with the Nursing Supervisor and License Practical Nurse, Staff D, Staff D was observed cleaning and irrigating the wound using normal saline, (a mixture of salt and water. It is called normal because its salt concentration is similar to tears, blood and other body fluids, 0.9% saline). During an interview with Staff D immediately following this observation, she acknowledged that she had cleansed the wound with normal saline in error and should have used Vashe. During an interview on 6/21/2021 at 3:10 PM with the Director of Nursing Services, she indicated that the Nursing Supervisor and Staff D had already informed her they did not use Vashe as ordered to cleanse Resident ID# 23's wound. Additionally, she revealed she expects staff to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Record review revealed Resident ID# 35 was admitted to the facility in January of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 5/17/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] [NC; a device used to deliver supplemental oxygen] at bedtime to maintain 02 > [greater than] 92%. Review of Resident ID# 35's progress notes revealed the following: - 5/26/2021 physician note from 2:21 PM which states, .on 2 liter nasal canula . - 5/30/2021 nursing note from 2:02 PM which states, .remains on continuous 02 @ [at] 2L via nasal cannula. - 6/02/2021 nursing note from 6:40 AM which states, .on O2 @ 2 liters via nasal cannula . The following observations were made of Resident ID #35 receiving 2 liters of oxygen via NC: - 6/21/2021 at 10:21 AM - 6/22/2021 at 10:30 AM - 6/23/2021 at 9:17 AM and 1:41 PM During a surveyor interview on 6/23/2021 at 1:53 PM while observing Resident ID# 35 with Licensed Practical Nurse, Staff Nurse A, she acknowledged the resident was receiving oxygen via nasal cannula. She indicated Resident ID# 35 receives continuous oxygen throughout the day. During a surveyor interview on 6/24/2021 at 1:21 PM with the Director of Nursing Services, she acknowledged that Resident ID #35 receives oxygen during the day. Additionally, she acknowledged the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on surveyor observation, record review and resident and staff interview, it has been determined the facility failed to provide, based on the comprehensive assessment, care plan, and the preferences of each resident, a program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for 1 of 1 resident whose primary language is Spanish, Resident ID# 84. Findings are as follows: Record review of a document titled, Facility Assessment, dated 3/10/2021, for Ethnic, Cultural or religious factors affecting .activities . states in part, We do have non-English speaking residents and some Spanish speaking population .Books & paperwork in different languages. DNS [Director of Nursing Services], Activity Director and Culinary Director & team are involved in these aspects of care and services to ensure cultural, ethnic and or religious preferences are honored. Record review revealed the resident was admitted to the facility in March of 2018, was discharged and readmitted in May of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 3/31/2021 annual Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident is cognitively intact. Further review revealed on section A1100 for Language, the question, Does the resident need or want an interpreter to communicate with a doctor or health care staff? for which the answer was coded as, Yes. Additionally, the resident's preferred language was documented as Spanish. Review of a 4/8/2020 care plan for Communication, last revised on 4/1/2021, states, [the resident] is at risk for communication secondary to Spanish speaking .able to understand very little English. Further review revealed interventions including, .Provide [the resident] a Spanish speaking interpreter as warranted . Review of a 4/8/2020 care plan for Activities, last revised on 4/9/2021, states in part, I am Spanish speaking but can understand some basic English .I like .being outdoors . During a surveyor interview on 6/21/2021 at 3:21 PM with the resident, in Spanish, when asked about activities at the facility, s/he revealed that s/he does not go outside anymore, because of the pandemic. During a surveyor interview on 6/22/2021 at 10:02 AM with the resident, s/he revealed when s/he receives the daily activities calendar, but it is in English and s/he would prefer it in Spanish, as she cannot read English. During a surveyor interview on 6/24/2021 at 9:15 AM with the resident, his/her daily activities calendar for 6/23/2021(the day before), was observed in her room in English. The document was translated by the surveyor for the resident. There was an activity noted to have had taken place at 2:15 PM that read, Let's go outside. The resident revealed s/he does not read English and did not understand what the daily activities calendar stated. S/he indicated s/he was not offered to go outside yesterday and did not go outside. During a surveyor interview on 6/24/2021 at 10:05 AM and at 1:16 PM with the Activities Director, she acknowledged the resident did not attend the outdoor activity that took place on 6/23/2021 at 2:15 PM. She indicated she did not ask the resident if s/he wanted to join the outdoor activity and should have. She revealed the last time the resident went outside for an activity was prior to his/her hospitalization that occurred in May of 2021.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers for 1 of 3 sample residents reviewed relative to risk for pressure ulcers, Resident ID# 44. Findings are as follows: Record review for Resident ID #44 revealed s/he was admitted to the facility in August of 2005. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident was assessed as at risk for pressure and has a treatment to include, pressure reducing device for bed. Further review of the resident's record revealed a Braden Scale For Prediction of Pressure Sore Risk dated 4/25/2021, which indicated the resident's score was 10-12, placing them at a high risk for developing a pressure sore. Review of the resident's care plan revealed a Problem dated 8/13/2020 which states in part, [Resident] is at risk for altered skin integrity and recurrent pressure injuries . With an Approach dated 8/13/2020 for air mattress to bed. (A pressure-reducing mattress redistributes a patient's weight to relieve pressure points). Surveyor observations on 6/21/2021 at 10:28 AM, and on 6/22/2021 at 12:33 PM, revealed the resident was laying in bed on an air mattress, which was set to a weight of 320 lbs. Review of the resident's weights revealed s/he was last weighed on 6/4/2021 and had a weight of 195.2 lbs. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a surveyor interview with Registered Nurse,Staff B on 6/22/2021 at 2:00 PM she acknowledged the resident's air mattress was set to 320 lbs. During a surveyor interview with the MDS Director on 6/22/2021 at 1:04 PM, she revealed nursing staff should be monitoring the settings on the air mattress to ensure it is set as close to the resident's weight as possible.