Every finding on record at Sterling Village

Based on observations, record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for indwelling urinary catheters for three Residents (#15, #157 and #114), of six applicable residents, out of a total sample of 28 residents, increasing the Residents risk for indwelling urinary catheter complications.Specifically, the facility failed to:1. for Resident #15, replace the Resident's indwelling urinary catheter with the correct sized catheter as ordered by the Physician during the scheduled monthly catheter change, and secure the urinary drainage bag away from contaminated surfaces. 2. for Resident #157, maintain/secure the urinary drainage bag away from contaminated surfaces.3. for Resident #114, replace the Resident's indwelling urinary catheter with the correct sized balloon during the Resident's Physician ordered monthly indwelling urinary catheter change, increasing the Resident's risk for indwelling urinary catheter complications. Findings include:Review of the facility's policy titled Indwelling Urinary Catheter, revised 10/1/15, indicated the following: -A physician's order must be obtained for insertion of an indwelling (urinary) catheter. -The order must include the catheter size, balloon size, and frequency of change. Review of the facility's policy titled, Urinary Catheters, revised 10/1/25, indicated: -preventative measures for controlling common infections are a critical component of the overall plan of care for residents with a urinary catheter. -do not allow the catheter tubing, bag, or spigot to touch the floor. 1. Resident #15 was admitted to the facility in March 2020 with diagnoses including obstructive and reflux uropathy. Review of Resident #15's December 2025 Physician's orders indicated an order for: -Suprapubic catheter 18 FR (French: size) 10 cc (cubic centimeters measurement) balloon (inflatable device used to anchor the indwelling urinary catheter in the bladder). Change suprapubic tubing every 30 days and as needed for blockage, leakage or ill findings that require new tubing, every night shift every 30 days as needed for catheter care, dated 4/22/25. Review of Resident #15's Care Plans, last revised 6/18/25, indicated: -the Resident will remain free of catheter related trauma through review date. -16 FR, 10 cc changed monthly. -treatment as ordered. Review of the Minimum Data Set (MDS) Assessment, dated 11/13/25, indicated Resident #15: -was unable to complete the Brief Interview of Mental Status (BIMS) examination and had severely impaired cognitive skills for daily decision making. -was dependent for toileting. -had an indwelling urinary catheter. Review of Resident #15's December 2025 Treatment Administration Record (TAR) indicated the Resident's indwelling urinary catheter was changed on 12/7/25, to an 18 FR 10 cc [NAME]. Further review of the December 2025 TAR failed to indicate that the Resident's indwelling urinary catheter had been changed again any time after 12/7/25. On 12/18/25 at 8:06 A.M., the surveyor and Unit Manager (UM) #2 observed Resident #15 resting in bed which was in the low position with the urinary catheter drainage bag laying on the floor. The surveyor and UM #2 observed the Resident's current urinary catheter size to be 14 FR 10 cc balloon. During an interview at the time, UM #2 said that the Resident's catheter drainage bag should not be on the floor as it can lead to infection control issues. UM #2 also said that the Resident's catheter size should be an 18 Fr 10cc balloon as documented in the Physician's orders, and it was not, and the 14 Fr tube could potentially leak. UM #2 said that the Resident's catheter had been changed in the facility and not at Urology. 2. Resident #157 was admitted to the facility in December 2025 with diagnoses including obstructive and reflux uropathy. Review of Resident #157's Physician's orders for December 2025 indicated: -urinary catheter drainage bag, ensure Foley privacy bag is in place, start date 12/12/25. -change suprapubic catheter 24 FR 10 cc bulb (balloon) every 8 hours as needed for occlusion or leakage as needed, start date 12/12/25. Review of Resident #157's Care Plan for suprapubic catheter, initiated 12/16/25 indicated that the Resident will show no signs or symptoms of urinary infection through review date. On 12/17/25 at 9:14 A.M., the surveyor observed Resident #157 resting in bed with the urinary catheter bag that was touching the floor. On 12/18/25 at 7:56 A.M., the surveyor and UM #2 observed Resident #157 resting in bed with the urinary catheter drainage bag secured to the opposite side of the bed and laying on the Resident's floor mat. During an interview at the time, UM #2 said that the urinary drainage bag should not be laying on the mat due to potential for infection control concerns. During an interview on 12/18/25 at 10:39 A.M., the Director of Nursing (DON) said that the urinary drainage bags should not have been on the floor as it could potentially lead to an infection control issue. The DON also said that a smaller sized catheter than ordered by the Physician could lead to a potential in increased changes with the Resident's care, occlusion and leakage. 3. Resident #114 was admitted to the facility in May 2025 with diagnoses including neuromuscular dysfunction of the bladder. Review of Resident #114's active Physician Orders indicated the following: -Urinary catheter care every shift 16 FR 10 cc balloon, dated 5/6/25. -Catheter change monthly and as needed for accidental dislodgement, blockage, or leakage, in the evening, starting on the eleventh and ending on the eleventh every month, dated 8/11/25. Review of Resident #114's Indwelling Urinary Catheter Care Plan, initiated 5/9/25 and revised 12/4/25, indicated the following: -The Resident required the use of an indwelling urinary catheter due to urinary retention. -The Resident's catheter was a size 16 FR with a 10 cc balloon. Review of Resident #114's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15 total possible points. -The Resident required substantial/maximal assistance for lower body bathing and toileting. -The Resident had an indwelling urinary catheter. Review of Resident #114's December 2025 Treatment Administration Record (TAR) indicated the Resident's indwelling urinary catheter was changed on 12/11/25. Further review of the December 2025 TAR failed to indicate the Resident's indwelling urinary catheter had been changed again any time after 12/11/25. On 12/17/25 at 9:30 A.M., the surveyor observed Resident #114 was sitting in a wheelchair, facing his/her bed, and his/her legs were extended with his/her feet on the bed. The surveyor observed the Resident was wearing shorts, and a urinary catheter drainage tube was extended from under the Resident's shorts to a drainage collection bag that was positioned under the Resident's wheelchair. During an interview at the time, the Resident said that he/she required the use of an indwelling urinary catheter and that facility staff were supposed to change his/her indwelling urinary catheter monthly. On 12/19/25 at 3:35 P.M., the surveyor observed Resident #114's room lying uncovered on his/her bed, dressed in a t-shirt and shorts. The surveyor observed a urinary catheter drainage tube extending out from under the Resident's shorts to a drainage collection bag that was attached to the Resident's bedframe. At this time, Nurse #1 asked the Resident if she could observe his/her catheter size and the Resident agreed. During an interview at the time, Nurse #1 said that the Resident's indwelling urinary catheter size was 16 Fr with a 5 cc balloon. Nurse #1 said that the Resident's indwelling urinary catheter balloon was the wrong size. Nurse #1 said the [NAME] size should have been a 10 cc balloon, not a 5 cc balloon. Nurse #1 further said that the catheter balloon size was important because a catheter balloon size that was too small could cause the urinary catheter to move out of place and could result in blockage of urine. The surveyor and Nurse #1 reviewed the facility's Central Supply Closet immediately following the interview and observed that there were six 16 Fr indwelling urinary catheters with 10 cc ballons. At this time, Nurse #1 said all Nurses had access to the facility's Central Supply Closet. During an interview on 12/18/25 at 4:45 P.M., the DON said that the facility did not have a shortage of indwelling urinary catheter supplies. The DON said the Nurse should have obtained the proper size indwelling urinary catheter and balloon to replace Resident #114's indwelling urinary catheter on 12/11/25.

Based on observations, and interviews, the facility failed to maintain a clean and homelike environment for two Residents (#10 and #59) out of a total sample of 27 residents, and on one unit (Aspen Unit) out of three units observed.Specifically, the facility staff failed to ensure:-for Resident #10, that the Resident's enteral tube feeding (nutritional supplement provided through a tube to the stomach) equipment was maintained in a clean and sanitary manner.-for Resident #59, that the Resident's enteral tube feeding equipment pump and pole, and the Resident's upper left side bed rail located next to the feeding equipment was maintained in a clean manner. Findings includeReview of the facility policy titled Maintaining a Clean Environment, dated 9/1/04, indicated:-Items that collect dust or secretions may harbor microorganisms that can colonize and infect susceptible residents or be inhaled by employees performing cleaning tasks.-In certain areas, housekeeping will not be responsible for the care of specific fixtures and furnishings. These items may be the responsibility of Nursing Services, Dietary or Physical Therapy employees.-Establish a routine cleaning schedule for cleaning walls, floors, window frames, fixtures and furniture. Note: Clean obviously soiled items/areas between scheduled times. -Wash bed frames and mattresses using a disinfectant solution. -Clean furniture from top to bottom. Remove loose dirt and debris before washing or mopping. On 12/17/25 at 7:58 A.M., the surveyor observed multiple splattered, dried brown material on Resident #10's feeding tube pump. On 12/17/25 at 8:12 A.M., the surveyor observed multiple splattered, dried brown material on Resident #59's feeding tube pump and pole and the Resident's upper left side bed rail. On 12/18/25 at 7:27 A.M., the surveyor observed multiple splattered, dried brown, material on Resident #10's feeding tube pump. On 12/18/25 at 7:46 A.M., the surveyor observed multiple splattered, dried brown, material on Resident #59's feeding tube pump and pole and upper left side bed rail. On 12/22/25 at 7:31 A.M., the surveyor and Unit Manager (UM) #1 observed both Resident #10's tube feeding pump and Resident #59 feeding pump and pole and upper left side bed rail. The surveyor observed that both Resident's feeding tube equipment remained the same as previously observed with multiple areas of dried brown splattered material. During an interview at the time, UM #1 said that nursing staff were responsible for cleaning up all drips and spills on any Resident's medical equipment. UM #1 said if nursing staff were unable to get spills/stains off the equipment, then the nursing staff should notify housekeeping staff for assistance. UM #1 also said that the equipment for Resident #10 and Resident #59 had not been cleaned and should have been. During an interview on 12/22/25 at 7:59 A.M., the Director of Nursing (DON) said that all Resident equipment should be cleaned when the items become visibly soiled.

Based on observations, interviews, and record review, the facility failed to provide Activity of Daily Living (ADL - basic care tasks that an individual requires on a day-to-day basis such as grooming, eating, bathing, and dressing) care to one Resident (#127), of three applicable residents, out a total sample of 27 residents. Specifically, for Resident #127, the facility failed to provide grooming services for facial hair removal when the Resident's preference was daily facial hair removal and he/she was dependent on staff for assistance, causing a decrease in the Resident's quality of life. Findings include: Review of the facility policy titled Residents Rights, dated 9/1/04 included but was not limited to the following: Purpose: to promote the safety, comfort and well-being of all residents in the facility: >As a nursing home/rest home resident you have the right to be treated with dignity. Review of the facility policy titled A.M. Care, dated 9/1/04 included but was not limited to: Purpose: To facilitate resident's overall comfort, cleanliness, grooming >Encourage or assist the resident to be as independent as possible. Resident #127 was admitted to the facility in July 2021 with diagnoses including muscle weakness and Hemiplegia (paralysis of one side of the body)/Hemiparesis (weakness of one side of the body) Affecting Dominant Right Side. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #127: -had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of six out of a total possible score of 15 points. -was understood by others and could understand others. -had functional limitation in range of motion to one side of the upper extremity and one side of the lower extremity. -had not demonstrated rejection of care. -was dependent for personal hygiene. Review of Resident #127's ADL Person-Centered Care Plan, revised 11/4/25 included but was not limited to the following: -The Resident had self-care deficit related to right sided hemiparesis and weakness. -The Resident needed substantial/maximal assistance to dependence for personal hygiene. -The Resident's level of assistance required for ADL care may vary depending upon fatigue levels. On 12/17/25 at 8:54 A.M., the surveyor observed Resident #127 seated at the bedside in a wheelchair, dressed in a shirt, pants, socks and shoes. The surveyor also observed the Resident's face presented with short stubble hairs to the upper lip and chin. During an interview at the time, the Resident said he/she would like the hairs to be shaved but was unable to do it him/herself. On 12/18/25 at 3:46 P.M., the surveyor observed Resident #127 seated at the bedside, dressed for the day. The surveyor observed hair remaining to his/her upper lip, chin and also present at the bilateral jawline. During an interview at the time, Resident #127 said that he/she had not been offered or assisted with facial hair removal and would like to be shaved. On 12/22/25 at 8:36 A.M., the surveyor observed Resident #127 dressed for the day, seated at the bedside in a wheelchair and eating breakfast. The surveyor observed Resident #127 to have longer hair growth present to the upper lip, bilateral jaw lines and chin compared to the last observation on 12/18/25. During an interview at the time Resident #127 said that he/she had not been offered to have the facial hair removed. Resident #127 said that he/she did not like the scruff on his/her face and wanted all the facial hair to be shaved. During an interview on 12/22/25 at 8:56 A.M., Certified Nurse Aide (CNA) #1 said she was the CNA assigned to Resident #127 and that Resident #127 was assisted out of bed at 6:00 A.M. each day with help from the night shift (11:00 P.M.-7:00 A.M.) nursing staff. CNA #1 said the night shift staff were responsible to get the Resident washed, dressed, provide hygiene, and out of bed to his/her wheelchair. CNA #1 said Resident #127 was dependent for hygiene including shaving. The surveyor and CNA #1 observed Resident #127's face which remained with facial hair to the upper lip, chin and bilateral jaw lines. CNA #1 said that the Resident's facial hair appeared to have gone several days without being shaved. CNA #1 said that shaving of facial hair should be offered to the Resident daily. During an interview on 12/22/25 at 9:11 A.M., the Director of Nursing (DON) said removal of facial hair should be offered daily with morning care. The DON said not providing shaving to Resident #127, who wants to be shaved, would be a dignity concern.

Based on observation, interview, record and policy review, the facility failed to provide three Residents (#113, #20, and #92), out of a total sample of 25 residents, with an environment as free of accidental hazards as possible. Specifically, the facility staff failed to: 1. provide adequate supervision and food of the required texture to ensure Resident #113's safety while eating when the Resident had a diagnosis of Oropharyngeal Phase Dysphagia (disorder or impairment in the ability to swallow), required his/her food to be pureed (soft, smooth foods that require no chewing), and required supervision and verbal cues while eating, increasing the Resident's risk for aspiration (inhaling food/drink into one's airways or lungs, and can result in Pneumonia). 2a. appropriately review Resident #20's food allergy list, when the Resident with a documented allergy for green beans, was served green beans at mealtime, increasing the Resident's risk for adverse reactions to food consumption. 2b. provide adequate supervision for Resident #20 to ensure the Resident's safety while eating for a documented diagnosis of Oropharyngeal Phase Dysphagia, and required supervision and verbal cues for safety while eating, increasing the Resident's risk for aspiration. 3. provide supervision and adaptive equipment for Resident #92 when the Resident had a history of sustaining a burn from hot liquids, required hot liquids to be covered with a specialized lid, and required supervision for safety while eating/drinking, increasing the Resident's risk for sustaining further burn injuries. Findings include: Review of the facility policy titled Assisting the Resident to Eat, dated 9/1/04, indicated the following: -The purpose of the policy was to assist residents to eat and to provide nutrition for residents needing assistance to eat. -Examples of items that would be provided for residents included the ordered diet tray and self-help eating aids. -Staff were required to obtain the resident's tray, identify the resident, and verify that the correct diet was served. -Staff were to prepare food as necessary for the resident. -Staff were required to ensure that the consistency of foods were appropriate. -Staff were required to assist the resident as necessary. 1. Resident #113 was admitted to the facility in August 2023, with diagnoses including Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Malignant Neoplasm (abnormal growth of tissue that can be non-cancerous or cancerous) of the tongue, and Oropharyngeal Phase Dysphagia. Review of Resident #113's Cognitive Function Care Plan, initiated 8/4/23 and revised 12/18/24, indicated staff were to cue . and supervise the Resident as needed. Review of Resident #113's Nutrition Care Plan, initiated 8/7/23 and revised 12/18/24, indicated the following: -The Resident was at increased nutritional risk related to Dementia, Dysphagia, and Tongue Neoplasm. -Staff were required to serve the ordered diet to the Resident. Review of Resident #113's Swallowing Risk Care Plan, initiated 9/28/23 and revised 12/18/24, indicated the following: -Instruct Resident to .eat slowly and to chew each bite thoroughly. -Staff were required to monitor the Resident for any signs of dysphagia, including: pocketing, choking, coughing, drooling, holding food in the mouth, several attempts at swallowing, refusing to eat, and appearing concerned at meals. -The Resident was to eat only with supervision. Review of Resident #113's Speech/Language Pathology Evaluation, dated 4/11/24, indicated the following: -The Resident's family reported the Resident having had a history for having a tumor removed from the base of his/her tongue. -The Resident had experienced an approximate 15-pound weight loss over the previous four months. -The Resident's diet texture was for mechanical soft (type of texture-modified diet for people who have difficulty chewing and swallowing solid food items. -The Resident was referred for a Speech/Language Pathology Evaluation due to reports of the Resident coughing with PO (per os: Latin for by mouth) intake. -Due to the progressive nature of Dementia in the setting of a history for Neoplasm of the Tongue, weight loss, and reports of difficulty with PO intake, the Speech/Language Pathology Evaluation was warranted to support the Resident's safety . and to reduce the risks for aspiration and infection. -The Speech/Language Pathologist (SLP) observed the Resident coughing while eating lunch during the Speech/Language Pathology Evaluation. Review of Resident #113's September 2024 Physician's orders indicated an active Dietary Order dated 4/15/24, for pureed texture. Review of Resident #113's Speech/Language Pathology Discharge Summary dated 6/18/24, indicated the following: -Functional outcome skills for mastication (ability to chew), bolus preparation (when food is chewed into a cohesive unit, ready to be swallowed), anterior-posterior transfer (immediately before the initiation of a swallow, the front of the tongue rises as the back of the tongue drops, propelling the bolus backward), and swallow reflex were impaired. -The Resident required pureed foods. -Caregiver instruction had been completed. Review of Resident #113's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of a total 15 points. On 8/29/24 between 8:18 A.M. and 8:43 A.M., the surveyor observed a staff member tell Resident #113 that it was time for breakfast and that the Resident was to walk from his/her room to the dining room. The surveyor observed Resident #113 stand up from his/her bed and walk into the hallway with the staff member. The surveyor then observed the staff member move away from the Resident once the Resident walked to an area in the hallway close to the dining room entrance. At the same time, the surveyor observed another staff member remove a breakfast tray from the meal cart, turn toward Resident #113 and instructed the Resident to return to his/her room to eat breakfast. The surveyor then observed Resident #113 turn and walk with the staff member back to his/her room. The surveyor observed Resident #113 sit on the edge of his/her bed and the staff member set up the Resident's meal tray on the bedside table, and the meal tray included pureed eggs and hot cereal. The surveyor observed the staff member exit Resident #113's room once the meal tray was set up. The surveyor observed Resident #113 start to eat. The surveyor observed one staff member enter the Resident's room during this time to provide the Resident with some sugar for the meal, but no staff were observed remaining in the room to supervise the Resident. On 8/30/24 at 12:15 P.M., the surveyor observed Resident #113 seated in the hallway, eating lunch with two staff members present in the hallway assisting other residents to eat. The surveyor observed mashed potatoes, pureed green vegetables, and three chunks of solid white fish on Resident #113's plate. The surveyor observed Resident #113 use his/her spoon to press down on the fish, then mix it with the mashed potato, while the Resident cleared his/her throat. The surveyor then observed Resident #113's meal ticket on his/her meal tray that indicated the Resident required pureed food. At this time, Resident #113 said he/she had to be careful eating, and the surveyor immediately located Nurse #1 and notified her that the Resident had solid chunks of fish on his/her meal tray. Nurse #1 immediately went to Resident #113, observed the Resident's meal and said she did not know how the solid pieces of fish ended up on the Resident's tray. Nurse #1 said she would call the SLP to inquire about the Resident's ability to have fish that was not pureed. The surveyor observed Nurse #1 walk away from the Resident, down the hallway, and did not remove the fish from the Resident's plate. The surveyor then observed the Resident eat the pieces of fish that were left on his/her plate. During an interview on 8/30/24 at 12:25 P.M., with Nurse #1 and the Unit Manager (UM) #1, UM #1 said that Dietary Staff were required to send meals for residents to the units according to the residents' diet orders. At the time, Nurse #1 said she checked the meal trays prior to the meals being served on the unit and identified no discrepancies between diets ordered and diets served. UM #1 said having solid chunks of fish on Resident #113's meal tray must have been overlooked by both the Dietary Staff and Nurse #1 and would need to be investigated further. UM #1 also said she did not know why Resident #113 was instructed to eat in his/her room for the breakfast meal on 8/29/24. During a follow-up interview on 9/3/24 at 8:35 A.M., Nurse #1 said she was alerted by Certified Nurses Aide (CNA) #1 that Resident #113 had eaten most of his/her meal at lunch on 8/29/24, and had requested more potatoes. Nurse #1 said CNA #1 told her CNA #3 had scraped some potatoes from an unserved lunch tray onto Resident #113's plate and that the unserved lunch tray contained regular texture fish, not pureed fish. Nurse #1 further said CNA #3 should not have scraped food items from the unserved tray onto Resident #113's plate and that CNA #3 should have contacted Dietary staff to request additional food items specific to Resident #113's diet order when the Resident requested more food. CNA #3 was not available to be interviewed by the surveyor on 9/3/24. During an interview on 9/3/24 at 8:39 A.M., CNA #1 said she observed CNA #3 scrape mashed potatoes from an unserved lunch meal tray onto Resident #113's lunch plate on 8/30/24. CNA #1 said she observed that the unserved meal tray contained fish that had not been pureed, so she alerted CNA #3 to be careful because Resident #113 required pureed food items. CNA #1 said there must have been pieces of fish with the mashed potatoes that CNA #3 scraped onto Resident #113's plate. During an interview on 9/4/24 at 12:55 P.M., the SLP said he had provided services in the past relative to swallowing and cognition to Resident #113. The SLP said that Resident #113 was cognitively impaired, and also had Dysphagia. The SLP said that Resident #113 required a pureed diet and supervision while eating. The SLP said the Resident experienced food residue build up in his/her mouth with variable awareness that the food residue was present and required instruction from a staff member to perform a liquid rinse to clear the residue. The SLP further said the pureed food, supervision during meals, and cueing was required for the Resident's safety due to the risk for aspiration and Aspiration Pneumonia. The SLP also said that Resident #113's swallowing status had not changed since he/she was discharged from Speech/Language Pathology services on 6/18/24. 2. Resident #20 was admitted to the facility in December 2023, with diagnoses including Age-Related Cognitive Decline (difficulty with thinking, memory, concentration and other brain functions beyond what is typically expected due to aging), Chronic (persisting for a long time or continually occurring) Migraines (headaches that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head and is often accompanied by nausea, vomiting, and extreme sensitivity to light and sound), and Oropharyngeal Phase Dysphagia. Review of Resident #20's Cognitive Function Care Plan, initiated 12/12/23 and revised 8/21/24, indicated the following: -The Resident had impaired cognitive function related to impaired decision making. -Staff were required to cue . and supervise the Resident as needed. Review of Resident #20's Swallowing Risk Care Plan, initiated 12/12/23 and revised 8/21/24, indicated the following: -All staff to be informed of Resident's special dietary and safety needs. -Alternate small bites and sips. -Use a teaspoon for eating. -Encourage Resident to . eat slowly and to chew each bite thoroughly. -Monitor . for signs of Dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appearing concerned during meals. Review of Resident #20's Nutrition Care Plan, initiated 12/12/23 and revised 8/21/24, indicated the Resident was at increased nutritional risk related to . Dysphagia . Further review of the Resident's Nutrition Care Plan indicated staff were required to provide and serve the Resident's diet as ordered. Review of Resident #20's Speech/Language Pathology Discharge Summary, dated 1/29/24, indicated the following: -The Resident's attention, memory, and executive function (cognitive skills used to manage everyday tasks) skills were impaired. -The Resident reported globus (a persistent or intermittent non-painful sensation of a lump in the throat) when using a high rate of intake. -The Resident no longer reported globus when cues to slow his/her rate for intake and cues for alternating bites and sips were provided. -The Resident demonstrated impaired: mastication, bolus preparation, anterior-posterior transfer of bolus, and swallow reflex. -Caregiver training and instruction had been provided. Review of Resident #20's September 2024 Physician's orders indicated an active Dietary order dated 3/1/24, for mechanical soft food texture. 2a. On 9/3/24 at 12:01 P.M., the surveyor observed the door to Resident #20's room was half-way closed. The surveyor observed the foot of the Resident's bed from the hallway but was unable to observe whether the Resident was in the room. When the surveyor knocked on Resident #20's door, the Resident responded to come in. Upon entering the Resident's room, the surveyor observed there was no staff in the room with the Resident. Resident #20 was sitting up in bed, eating his/her lunch meal. The surveyor observed mechanical soft texture meat with gravy, mashed potatoes and green beans on the Resident's plate and the Resident was eating with a fork. The surveyor observed Resident #20's meal tray ticket that indicated the Resident had an allergy to green beans. Resident #20 said he/she could not eat green beans because green bean consumption made his/her migraines worse. The surveyor immediately located Nurse #1 and alerted her that Resident #20 had green beans on his/her tray and that the Resident's meal ticket indicated an allergy to green beans. Nurse #1 immediately removed Resident #20's meal tray, then called Dietary Staff for a new meal tray without green beans for the Resident. During an interview at the time, Nurse #1 said that she was unsure whether the green bean allergy was an actual allergy for Resident #20 or if it indicated a dislike for green beans. Nurse #1 said that often resident dislikes for food were indicated under the allergy section of the meal ticket. During an interview on 9/3/24 at 12:20 P.M., the UM said she would have to investigate whether green beans were an actual allergy or dislike for Resident #20. The UM also said she was not aware of Resident #20 requiring the use of a teaspoon for eating or requiring cues to eat slowly and chew each bite thoroughly. The UM further said she was not aware of the Resident's need to alternate small bites and sips while eating. During an interview on 9/3/24 at 12:43 P.M., the Dietitian said if a resident told the facility they had a food allergy, the facility was required to indicate that food item as an allergy as there would be no way to confirm the allergy. The Dietitian said if a food allergy was indicated for a resident, then the Resident should not be served the food item. The Dietitian further said he would have to look into whether green beans were indicated as an allergy or if they were a disliked food item for Resident #20. During a follow-up interview on 9/3/24 at 1:15 P.M., the Dietitian said that he identified in Resident #20's record that green beans were indicated as a food allergy and that the Resident should not have received green beans with his/her lunch meal on 9/3/24. During an interview on 9/3/24 at 1:30 P.M., Dietary Staff #2 said she was responsible for calling off the resident diets for the lunch meal tray line on 9/3/24. Dietary Staff #2 said she missed calling off Resident #20's green bean allergy, so the Resident received green beans with his/her lunch meal but should not have. Dietary Staff #2 said Nurse #1 called the Dietary department to request a replacement meal tray for Resident #20, and the replacement tray was provided to the Resident with carrots instead of green beans. During an interview on 9/3/24 at 2:20 P.M., the SLP said Resident #20 had impaired cognitive function and Dysphagia and required a modified diet texture of mechanical soft foods. The SLP said that due to the Resident's level of cognitive function for problem solving, Resident #20 required staff intervention during meals for taking small bites and alternating solids and liquids. The SLP also said Resident #20 was supposed to be eating with a teaspoon. The SLP said he had communicated all these interventions to staff and had recorded the interventions in the Resident's care plan. The SLP said that the interventions were still required for the Resident's safety while eating. 2b. On 9/3/24 at 2:40 P.M., the surveyor observed Resident #20 positioned in his/her bed with the head of the bed in an upright position and no staff were present in the Resident's room. The Resident was observed leaning to the right side, his/her head positioned down with his/her chin resting on his/her chest, and his/her eyes closed. The surveyor also observed that the Resident's lunch meal tray was still in front of him/her and contained mechanical soft meat with gravy, mashed potato, and diced carrots. The surveyor observed that the Resident's fork was in his/her hand. At that time, the surveyor spoke to Resident #20, the Resident opened his/her eyes briefly, then began to verbalize something the surveyor could not understand. The surveyor observed several small pieces of diced carrot on the tip of the Resident's tongue and protruding from behind the Resident's inner upper and lower lips while he/she was attempting to speak. The Resident kept his/her eyes closed and placed his/her index finger and thumb in his/her mouth and removed some of the pieces of diced carrot. The surveyor did not observe any staff member enter the Resident's room to monitor the Resident during the observation. On 9/3/24 at 2:45 P.M., CNA #4 said she was familiar with Resident #20 and provided care for the Resident often. CNA #4 said the Resident required no intervention from staff for eating other than setting up and cleaning up his/her meal tray. On 9/3/24 at 3:45 P.M., the Director of Nursing (DON) said she was unsure which residents in the facility required supervision throughout meals versus check-ins from staff, and that she would need to work with the SLP to figure this out. 45429 3. Review of the facility's policy titled Nutrition Policy, last revised 4/28/11, indicated: -A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition -the facility provides special eating equipment and utensils for residents who need them. Resident #92 was admitted to the facility in April 2024, with diagnoses including non-traumatic intracerebral hemorrhage (bleeding in the brain), dysphagia (swallowing difficulty) and hemiplegia (partial or total paralysis of one side of the body). Review of Resident #92's care plan for increased nutritional risk dated 4/26/24, indicated an intervention to provide and serve diet as ordered. Review of Resident #92's care plan for swallowing dated 4/29/24, indicated: -the Resident will have clear lungs, no signs and symptoms of aspiration (swallowing something that enters the airway or lungs). -monitor, document, report as needed any signs or symptoms of dysphagia (choking, coughing, drooling, holding food in mouth). -Resident to eat only with supervision. Review of the Speech and Language Pathology (assessment of communication disorders) Daily Note dated 5/24/24, indicated that the Speech Therapist (ST) recommended that Resident #92 have supervision for meals. Review of Resident #92's Nurses Progress Notes dated 7/4/24, indicated that the Resident had suffered a burn on the right thigh due to drinking hot tea that his/her spouse had given him/her. Further review of the Nurses Progress Notes indicated that the intervention for the burn incident was to provide a sip cup lid to prevent further burns from hot liquids. Review of Resident #92's Unusual Event Report dated 7/4/24, indicated: -that the Resident's spouse gave him/her tea, it had spilled on the Resident and burned him/her. -that it appeared the spouse had popped the blister of said burn. -that the intervention to prevent recurrence or injury was to provide a sip cup lid with hot liquids. Review of Resident #92's care plan for potential impairment to skin integrity last revised 7/4/24, indicated an intervention to provide a sip cup lid with hot drinks. Review of Resident #92's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #92: -was unable to complete the Brief Interview for Mental Status (BIMS) exam because they are rarely or never understood. -required set up assistance with eating (the ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on the table). Further review of the MDS Assessment revealed that Resident #92 had exhibited the following signs and symptoms of a swallowing disorder: -loss of liquids or solids from mouth when eating or drinking -coughing or choking during meals or when swallowing medications -complaints of difficulty or pain when swallowing Review of Resident #92's September 2024 Physician's orders indicated a sip lid with hot liquids, start date of 7/12/24. On 8/29/24 at 8:22 A.M., the surveyor observed Resident #92 sitting alone in his/her room eating breakfast. The surveyor observed there was a mug of thickened coffee with no sip cup lid on the Resident's breakfast tray. Review of Resident #92's meal ticket slip dated 9/3/24, generated by the facility's kitchen indicated a coffee mug with sip lid for all hot liquids. On 9/3/24 at 8:21 A.M., the surveyor observed Resident #92 sitting in his/her room eating breakfast and coughing. The surveyor requested CNA #2's assistance with the Resident as he/she had trouble communicating. During an interview at the time, CNA #2 said that the Resident wanted the assistance of the facility's ST because he/she was coughing because he/she had drank too much (breakfast beverage). On 9/3/24 at 8:26 A.M., the surveyor and CNA #2 observed Resident #92's breakfast tray and there was no sip cup lid observed on the Resident's coffee mug. During an interview at the time, CNA #2 said that she was familiar with Resident #92 and did not usually see a sip cup lid on the Resident's food tray. During an interview on 9/3/24 at 8:36 A.M., Nurse #2 said that Resident #92 was not supervised with meals. Nurse #2 also said that the Resident had required supervision with meals when he/she was first admitted to the facility, but they had improved and no longer required the supervision. On 9/3/24 at 12:09 P.M., the surveyor observed Resident #92 being supervised while eating in the dining room. During an interview at the same time, Nurse #2 said that there had been an err (error) and the Resident was now supervised with meals. During an interview on 9/3/24 at 12:41 P.M., the Dietitian said that he was aware that Resident #92 had experienced a burn while drinking and should have a sip cup lid with hot liquids for all meals. During an interview on 9/3/24 at 1:18 P.M., the Food Service Director (FSD) said that the facility had an ample supply of sip cup lids. The FSD also said that Resident #92 should have had a sip cup lid on his/her coffee mugs for all meals and he/she did not. During an interview on 9/3/24 at 1:34 P.M., Rehabilitation Services Staff (Speech Therapist) #1 said that he had evaluated Resident #92 and recommended that the Resident be supervised for all meals. Rehabilitation Services Staff #1 also said that his recommendations were noted in the Resident's electronic plan of care.

Based on record and policy review, and interview, the facility failed to ensure that one Resident (#52) out of a total sample of 25 residents was free from significant medications errors. Specifically, the facility staff failed to adhere to the Physician's orders to hold the dose of Losartan Potassium (a medication used to decrease blood pressure and decrease the incidence of Stroke in patients with Hypertension [HTN: high blood pressure. When the blood pressure measures consistently above 130/80 millimeters of mercury [mmHg]) for a Systolic Blood Pressure (SBP) of less that 110 mmHg. Findings include: Review of the facility policy titled Medication Pass Guideline, with a revision date of 2/12/15 indicated: >Physician's Orders: -Medications are administered in accordance with the written orders of the attending Physician. *If a dose seems excessive considering the resident's age and condition or a medication order seems to be unrelated to the resident's current diagnosis or condition, contact the Physician for clarification prior to administration of the medication. *Documentation of the interaction with the Physician in the progress notes and elsewhere in the medical record as appropriate. *The Nurse who receives the order is responsible for transcribing to the chart. Resident #52 was admitted to the facility in July of 2021, with diagnoses including Hypertension, Cerebral Vascular Accident (CVA: when blood flow to a part of the brain is stopped either by a blockage or a rupture of a blood vessel), Peripheral Vascular Disease (PVD: a slow progressive disorder of the blood vessels caused by narrowing, blockage or spasms in a blood vessel reducing blow flow to the limbs). Review of Resident #52's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating the Resident was cognitively intact. -The Resident had diagnoses including Hypertension, PVD and CVA. Review of Resident #52's Physician's orders dated 7/16/24, indicated: -Losartan Potassium oral tablet 50 milligrams (MG) (Losartan Potassium), Give 1 tablet by mouth every 12 hours related to Essential (Primary) Hypertension. -Hold for Systolic Blood Pressure (SBP) of less than 110 (mmHg). Review of Resident #52's August 2024 Medication Administration Record (MAR) indicated the Losartan Potassium medication had not been administered per the Physician's orders on the following dates: -8/9/24 with a SBP reading of 114 mmHg (higher than the ordered parameters to hold the medication) -8/11/24 with a SBP reading of 114 mmHg (higher than the ordered parameters to hold the medication) -8/19/24 with a SBP reading of 110 mmHg (higher than the ordered parameters to hold the medication) -8/25/24 with a SBP reading of 120 mmHg (higher than the ordered parameters to hold the medication) -8/27/24 with a SBP reading of 118 mmHg (higher than the ordered parameters to hold the medication) Review of Resident's #52 progress notes and clinical record did not indicate that the Physician was contacted for clarification of orders. During an interview on 9/3/24 at 2:16 P.M., Unit Manager (UM) #2 said the Losartan Potassium medication should have been administered to Resident #52 on the days documented in the August MAR when the SBP was greater than 110 mmHg. During an interview on 9/4/24 at 8:40 A.M., UM #2 said she could not locate any evidence in the clinical record of why the (Losartan Potassium medication) doses were not administered to the Resident when the SBP were within the parameters for (medication) administration. UM #2 said the medication should have been administered as ordered. During an interview on 9/4/24 at 9:20 A.M., the Director of Nursing (DON) said the Nurse administering the Resident's Losartan Potassium medication should have followed the parameters in the Physician's order and should have contacted the doctor (Physician) and documented why the doses were not administered.

Based on interview and policy review, the facility failed to develop an infection prevention and control policy and procedure (IPCP) in accordance with current accepted national standards and guidelines relative to controlling COVID-19 infection. Specifically, the facility failed to indicate what measures would be implemented to identify and control the spread of COVID-19 infection for residents and staff in the facility in the event of a COVID-19 outbreak. Findings include: Review of the CDC guidance titled Infection Control Guidelines: SARS-CoV-2, dated 5/8/23, indicated: -Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at Day 1 (where day of exposure is Day 0), Day 3, and Day 5. -Employers should be aware that other local, . state, . requirements may apply. Review of the Commonwealth of Massachusetts (MA) Executive Office of Health and Human Services Department of Public Health (DPH) Bureau of Health Care Safety and Quality guidance titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated: - . long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -If the long-term care facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago, then they should wait to test until 24 hours after any exposure, if known. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH Epidemiologist directs otherwise. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, dated 3/18/24, indicated: -Exposures that might require testing and/or restriction from work can occur both while at work and in the community. -Higher-risk exposures generally involve exposure of HCP's (Health Care Professionals - staff who work in healthcare settings) eyes, nose, or mouth to material potentially containing SARS-CoV-2 . -For this guidance an exposure of 15 minutes or more is considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period. -Following a higher-risk exposure, HCP should: -Have a series of three viral tests for SARS-CoV-2 infection. -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at Day 1 (where day of exposure is Day 0), Day 3, and Day 5. -Employers should be aware that other local, . state, . requirements may apply. Review of the facility's policy presented during the survey period, titled COVID-19 Policy All Inclusive, dated 5/4/24, indicated the following: -The facility was expected to follow the infection prevention and control practices recommended by DPH. -The facility's procedure for testing residents who were newly admitted and a close contact of a case of COVID-19 was to test the resident as soon as possible, but not sooner than 24 hours following exposure, then again on Day three and Day five, but did not indicate continued testing every 48 hours until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. -The facility's policy did not include any COVID-19 testing procedure for residents who were not newly admitted to the facility and had exposure to COVID-19. -The facility's policy did not include any COVID-19 testing procedure for facility staff with exposure to COVID-19. During an interview on 8/30/24 at 10:58 A.M., the Infection Preventionist (IP) said no outbreak or requisite outbreak testing was required if a positive case of COVID-19 was identified in the facility. The IP said that staff and residents only needed to be tested if they became symptomatic. During an interview on 9/3/24 at 11:25 A.M., the Risk Management Director said she was the responsible person to update the facility's COVID-19 policy and that she had updated the policy in May 2024. The Risk Management Director also said the facility was required to adhere to the MA DPH guidance relative to COVID-19 testing. The Risk Management Director said she thought that the COVID-19 testing guidance for staff had changed and that the facility would only test residents and staff who were symptomatic for COVID-19. The Risk Management Director further said she did not know that outbreak and requisite outbreak testing were still required when a positive COVID-19 case was identified in the facility.

Based on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurately coded to reflect the correct status for one Resident (#129) out of three applicable residents. Specifically, the facility staff failed to ensure that the MDS Assessment accurately reflected that Resident #129 was discharged home. Findings include: Resident #129 was admitted to the facility in July 2024, with diagnoses including urinary tract infection (UTI: bacterial infection of the urinary tract) and Sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune system to damage its own organs and tissues). Review of Resident #129's Nurses Progress Note dated 7/18/24, indicated that the Resident had chosen to be discharged home on the same day (7/18/24) against medical advice (AMA). Review of Resident #129's July 2024 Physician's orders indicated an order to discharge the Resident with medications and services on 7/18/24. Review of Resident #129's clinical record indicated that the Resident had signed a document releasing the facility of responsibility for his/her discharge on 7/18/24, and that the Resident would be discharged home with medications and Visiting Nursing Association (VNA) services. Review of Resident #129's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident was discharged to a short-term hospital. During an interview on 9/4/24 at 12:15 P.M., the MDS Nurse said that the MDS Assessment had been inaccurately coded and should have marked the Resident as discharged home.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of a narcotic medication as needed for pain, the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to transcribe into the Controlled Substance Log (a book used by nursing to keep an accurate count of all narcotics and to record administration of narcotics), a change in the directions for the use of the narcotic, and failed to document the administration of the narcotic in his/her Medication Administration Record. Findings include: Review of the Facility's policy, titled Medication Pass Guidelines, with a revision date of 02/12/2015, indicated the purpose was to assure the most complete and accurate implementation of physicians' medication orders for administration of drugs in an accurate manner. Further review of the Policy indicated the following: -Medications are administered in accordance with written orders of the attending physician. -Verify the medication label against the Medication Administration Record (MAR) for accuracy of drug frequency, duration, strength, route and form. -If the label and MAR are different, the physician's orders are checked for the correct dosage schedule. -Do not administer the medication until the discrepancy is resolved. -Record the name, dose, route, and time of medication on the MAR. Resident #1 was admitted to the facility in February 2016, diagnoses included acute kidney failure and Diabetes Mellitus. Review of Resident #1's Physician's orders for the month of January 2024 included the following: -Oxycodone (narcotic pain medication) 5 milligrams (mg) give one tablet by mouth every six hours as needed for moderate pain for two weeks (start date 01/03/24, end date 01/17/24) -Oxycodone 5 mg give two tablets (total of 10 mg) by mouth every six hours as needed for severe pain for two weeks (start date 01/03/24, end date 01/17/24) -Oxycodone 5 mg give one tablet by mouth every six hours as needed for moderate pain (start date 01/18/24) Review of the Controlled Substance Log indicated Resident #1's entry page for Oxycodone 5 mg tablets included the following instructions: Give one tablet every six hours as needed, give two tablets (10 mg) every six hours as needed for pain. However, the instructions did not include: to administer one tablet of Oxycodone 5 mg for moderate pain, two tablets (10 mg) for severe pain, or that the physician's order for the Oxycodone 10 mg was discontinued as of 01/17/24 Further review of Resident #1's entry page indicated that Resident #1 was administered two tablets of Oxycodone 5 mg tablets (to equal 10 mg) on 01/19/24 at 1:00 A.M. by Nurse #1 and at 12:40 P.M. by Nurse #3 (despite the order for Oxycodone 10 mg no longer being in effect> Review of Resident #1's MAR for the month of January 2024 indicated that although two tablets of the Oxycodone 5 mg that were signed out of the Controlled Substance Log on 01/19/24 at 1:00 A.M. and 12:40 P.M., the doses were not documented as administered on the MAR. During a telephone interview on 02/21/24 at 5:02 P.M., Nurse #1 said he worked on 01/18/24 during the 11:00 P.M. to 7:00 A.M. shift and administered Oxycodone 5 mg two tablets (10 mg) to Resident #1 at 1:00 A.M. on 01/19/24. Nurse #1 said that Resident #1 could get two tablets of Oxycodone 5 mg for severe pain. Nurse #1 said that his practice was to check the instructions on the medication blister package and also to check the instructions on the Controlled Substance Log. Nurse #1 said that he did not need to check anywhere else and did not need to document the administration of narcotic medications on Resident #1's MAR. The Surveyor was unable to interview Nurse #3, as he did not respond to the Department of Public Health's telephone or letter request for an interview. During an interview on 02/21/24 at 3:45 P.M., the Director of Nurses (DON) said that Resident #1's order for the Oxycodone 5 mg give two tablets (10 mg) as needed every six hours for severe pain was discontinued on 01/17/24 and should not have been administered on 01/19/24. The DON said that nursing should have documented all medications they administered on the resident's MAR.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy, with his/her Health Care Agent (HCA) making health care decisions for him/her, the facility failed to ensure the HCA was notified of the need to alter Resident #1's treatment plan regarding his/her medications, when on 1/09/23 the Nurse Practitioner wrote an order for nursing to discontinue some of Resident #1's medications, however his/her HCA was not notified or consulted with regarding the decision to discontinue the medications. Findings include: Review of the Facility Policy titled Change in Condition, dated 09/01/04, indicated the Facility would immediately inform the resident or the resident's legal representative when there was a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Review of the Facilities General Orientation guide for staff, dated 04/09 indicated the Facility is required to notify the resident or the resident's family of any significant change in the resident's treatment. Resident #1 was admitted to the Facility in September 2021, diagnoses included dementia, hypertension, hyperlipidemia, and failure to thrive. Review of Physician Progress Note, dated 09/07/2021, related to Invocation of Health Care Proxy/Durable Power of Attorney for Health Care, indicated Resident #1's Health Care Proxy was invoked on this date. Review of Resident #1's Physician's orders for August 2022, indicated that on 08/12/2022, a Physician's Telephone Order was obtained for Hospice screen and admission to Hospice Services. Review of Resident #1's Care Plan Meeting Review Record, dated 11/29/2022, indicated a Care Plan meeting was held for him/her at the Facility on this date. During an interview on 06/26/2023 at 11:29 A.M., Resident #1's Health Care Agent (HCA) said she participated in a Care Plan Meeting for Resident #1 at the Facility on November 29, 2022. The HCA said that during the meeting she was asked if she wanted some of Resident #1's medications discontinued and said she told staff in attendance at the meeting that she did not want any of Resident #1's medications discontinued. The Health Care Agent (HCA) said she was not notified by nursing on 01/09/2023, that the Nurse Practitioner provided an order for Resident #1, and that his/her medications were discontinued. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/06/23, indicated he/she was totally dependent on nursing staff to meet his/her care needs and that he/she had a Brief Interview for Mental Status (BIMS) with a score of 3, and was severely cognitively impaired, (score range 0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact). Review of Resident #1's Physician's orders for January 2023, indicated his/her orders for medications included the following: -Lisinopril (antihypertensive) 2.5 milligrams (mg) one tablet by mouth daily, -physician's parameters included to hold Lisinopril for systolic blood pressure less than 110, (systolic, top number in BP reading diastolic, bottom number in BP reading). -Amlodipine (antihypertensive) 10 mg one tablet by mouth every evening, -Lovastatin (treats high cholesterol) 20 mg one tablet by mouth every evening Review of Resident #1's Medication Administration Record (MAR) for January 2023, indicated that from 01/01/2023 through 01/09/2023 nursing documented the following; -Lisinopril administered daily, as ordered -blood pressure readings (related to the administration of the Lisinopril) ranged between 107/63 to 130/66. Further review of Resident #1's MAR from 01/01/2023 through 01/09/2023, indicated there was no documentation to support that his/her Lisinopril had been held by nursing, despite him/her having a documented BP of 107/63 (systolic pressure less than 110) on at least one occasion. -Amlodipine administered as ordered. - Lovastatin administered as ordered. Further review of Resident #1's Physician orders indicated that on 01/09/2023, a Physicians Telephone order was obtained and signed by the Nurse Practitioner to discontinue the following medications: -Lisinopril 2.5 mg, -Amlodipine 10 mg, and -Lovastatin 20 mg During an interview on 06/26/2023 at 10:40 A.M , the Nurse Practitioner (NP) said she did not speak with Resident #1's (HCA) prior to discontinuing his/her Lisinopril, Amlodipine and Lovastatin and said she thought the facility's nurse would speak with the HCA. The NP said her rationale for discontinuing Resident #1's medications was to maintain stable blood pressure readings. Review of Resident #1's Medical Record indicated there was no documentation to support that his/her Health Care Agent (HCA) was notified or consulted by nursing 01/09/23 regarding the Nurse Practitioners order to discontinue his/her medications. During an interview on 06/26/2023 at 1:20 P.M., Nurse #1 said that facility nurses can update the Health Care Agent if there are any change in treatment, but for a resident who is on Hospice it is mainly the Hospice nurse who does the family member/HCA updates for Hospice patients. During an interview on 06/26/2023 at 1:38 P.M., Nurse #2 said that if the resident's facility providers, (NP/MD) discontinued medications on a hospice resident, she said that she would update the Health Care Agent and the Hospice Nurse and then she would put the orders in the electronic medical system. During an interview on 06/26/23 at 1:50 P.M. the Unit Manager said Resident #1 had a steady decline and that his/her blood pressure was on the low side. The Unit Manager said that her expectation was that her staff (nurses on her unit) would call the Health Care Agent to ensure that they agree with any medication/treatment changes, the Unit Manager said that there was not a conversation with Resident #1's HCA in this case. During an interview on 06/26/2023 at 4:17 P.M., the Assistant Director of Nursing (ADON) said that if the resident cannot make their own health care decisions (and has an activated HCP) then their HCA would be the decision maker and the HCA would have the right to know about medication changes. During an interview on 07/11/2023 at 1:40 P.M., The Director of Nursing (DON) said for a resident with an activated HCP, if he/she experienced a significant change then his her HCA would be notified. The DON said for Resident#1 they felt his/her decline was more gradual and not considered a significant change. The DON said with a significant change the Physician or NP would speak to the nurses on the unit or the Unit Manager, and then they should notify the HCA.

Based on observation, record review, and interview, the facility failed to provide peripherally inserted central catheter (PICC: flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV]) care and services in accordance with professional standards of practice and plans of care for two Residents (#237 and #45), out of two residents receiving IV treatments via PICC, in a total sample of 26 residents. Specifically, facility staff failed to: 1. For Resident #237, obtain a baseline measurement for the external length of Resident #237's PICC from when it was placed to ensure the PICC had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm) prior to administering antibiotic therapy to the Resident via PICC when he/she returned to the facility from the acute hospital. Facility staff also failed to accurately measure the external length of the PICC and the Resident's arm circumference, as ordered by the Physician, when changing the PICC line dressing. 2. For Resident #45, measure the external length of the PICC weekly, as ordered by the Physician to prevent the risk for inadvertent PICC migration. Findings include: Review of the facility policy, titled Intravenous Therapy Policy, dated September 2019, included: Dressing changes . every seven days and as needed. Document external catheter length, arm circumference, and any adverse effects to dressing change. Review of the [NAME] Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation relative to PICC line migration and dressing changes: -Use a sterile measuring tape or 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. - Measure upper arm circumference when clinically indicated to assess for the presence of edema and deep vein thrombosis (DVT: blood clot in a deep vein); take the measurement four inches (10 centimeters) above the antecubital fossa (area of transition between the forearm and upper arm) and compare this measurement to the baseline. 1. Resident #237 was admitted to the facility in December 2013 with diagnoses including parotitis (painful swelling of one's parotid [area just in front of the ears] glands most commonly caused by a virus or bacteria) and sepsis (life-threatening organ dysfunction caused by a dysregulated host response to infection). Review of Resident #237's Minimum Data Set (MDS) assessment, dated 3/13/23, indicated he/she scored 13 out of 15 points on the Brief Interview for Mental Status (BIMS) Exam, indicating the Resident was cognitively intact. Review of a Minimum Data Set (MDS) assessment, dated 5/26/23, indicated Resident #237 was discharged to the acute hospital with return to the facility anticipated. Review of Resident #237's acute hospital PICC insertion record, dated 6/1/23, included: - A PICC, total of 42 centimeters (cm) in length, was placed via the Resident's right basilic vein (large vein in the upper arm). - Chest radiograph, post procedure, showed the catheter tip at the cavoatrial junction (point at which the superior vena cava [large vein that carries deoxygenated blood from the upper half of the body to the right atrium of the heart] meets and melds into the superior wall of the cardiac right atrium) and no kinks along the course of the catheter. Further review of the PICC insertion record did not indicate how much of Resident #237's total catheter length was external. Review of a Nurse's Note, dated 6/2/23, indicated Resident #237 returned to the facility on [DATE] with a PICC in his/her right upper arm. Further review of the Note included no evidence baseline measurements for Resident #237's external catheter length had been obtained relative to when the PICC was placed. Review of Resident #237's PICC Care Plan, dated 6/2/23, included the following: - Total catheter length: 42 cm. - External length: 6 cm. - Arm circumference: 14 cm. - Obtain internal and total length of catheter. - Change transparent dressing . weekly. - Measure external length of catheter and arm circumference. - Document findings. Review of Resident #237's June 2023 Physician's orders included: PICC line dressing change weekly and PRN (as needed). Document external catheter length and arm circumference, dated 6/2/23. Review of Resident #237's June 2023 Treatment Administration Record (TAR) indicated the Resident's PICC line dressing was changed on 6/9/23 and included the following: - The external PICC line length was measured at 0.5 cm. - The Resident's arm circumference measurement was documented as N/A (not applicable). On 6/13/23 at 10:50 A.M., the surveyor observed Resident #237 in his/her room. The Resident wore a short-sleeve hospital gown and his/her right upper extremity was visible from mid upper arm to hand. The surveyor observed a PICC in the Resident's right upper arm and there was a transparent dressing over the PICC which was dated 6/9/23. The surveyor also observed an IV pole at the head of the Resident's bed that held an empty bag of Cefazolin Sodium (antibiotic medication used to treat infection), dated 6/13/23. During this observation, Resident #237 said he/she had been hospitalized recently and had been receiving medication through the PICC in his/her right arm. The Resident also said he/she was not sure what facility staff did to assess the PICC. During an interview on 6/14/23 at 9:42 A.M., Nurse #6 said Resident #237 was on his assignment that day and that the Resident received antibiotics through the PICC. Nurse #6 said that initial measurements for external catheter length and arm circumference would have been obtained when the PICC was placed and staff were not required to perform any measurements of the external length of the PICC because the dressing held it in place, so the line would not migrate. Nurse #6 also said Resident #237's PICC dressing would be changed on an as needed basis if it became soiled, and the external length of the PICC did not need to be measured when the dressing was changed. During an interview on 6/14/23 at 12:10 P.M., Nurse #4 said he worked the day (7:00 A.M. through 3:00 P.M.) shift on Resident #237's Unit on 6/9/23, but he did not recall changing the Resident's PICC dressing. At this time, Nurse #4 reviewed Resident #237's TAR with the surveyor and said the Resident's PICC dressing was changed on the evening (3:00 P.M. through 11:00 P.M.) shift, by Nurse #5. Nurse #4 said the Resident's right arm circumference should have been measured and recorded and compared to the Resident's baseline measurement, but it was not. He also said the external catheter length measurement of 0.5 cm was typical for a PICC but was significantly different that the initial facility measurement from 6/2/23 of 6 cm, which was indicated in the Resident's care plan. Nurse #4 then said one of the measurements was inaccurate. During an interview on 6/14/23 at 1:29 P.M., Nurse #5 said he worked the evening shift at the facility on 6/9/23 and that Resident #237 was on his assignment. Nurse #5 said PICC dressing changes were required to be completed per order of the Physician and that when those dressings were changed, the Nurse was required to measure the external length of the line and the resident's arm circumference and compare them to the baseline measurements obtained when the PICC was placed to ensure no migration occurred. Nurse #5 said if the external length of the PICC was shorter or longer than the baseline measurement, this would be a problem. Nurse #5 then said Resident #237's PICC dressing change was scheduled to be completed on the day shift 6/9/23, but the Nurse on the day shift was unable to complete it, so Nurse #5 completed it on the evening shift. Nurse #5 further said 0.5 cm was typical for the external length of a PICC and that he did not measure Resident #237's arm circumference because he thought the Nurse on the day shift did that. During an interview on 6/14/23 at 2:17 P.M., the Assistant Director of Nursing (ADON) said the purpose of measuring the external length of a PICC line was to ensure the tip of the catheter had not migrated, and that if this occurred it would be a 911 call due to a potential risk for air embolus (blockage of blood supply caused by air bubbles in a blood vessel or the heart), and Physician contact would be required. The ADON also said arm circumference measurement was important as an increase in swelling could indicate complications such as DVT or infection. The ADON said measurements taken during weekly and PRN dressing changes were to be compared to baseline measurements for accuracy. During an interview on 6/14/23 at 5:13 P.M., UM #2 said she was the one who measured the external length of Resident #237's PICC on 6/2/23, after the Resident returned to the facility. UM #2 said the total length of the PICC was 42 cm, but there was no information available that indicated baseline measurements for the external length of the PICC. UM #2 also said the documented length for Resident #237's external PICC was not measured properly on 6/9/23, resulting in an inaccurate measurement, and that the Nurse should have obtained and recorded the Resident's arm circumference when the dressing was changed. UM #2 further said baseline outer lengths of Resident #237's PICC had not been obtained, as required, when Resident #237 returned to the facility. 45429 2. Resident #45 admitted to the facility in June 2021 with diagnoses including hammer toe of left foot and Dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of the clinical record revealed a PICC Insertion Record, dated 5/20/23, for expected intravenous therapy (IV) greater than 14 days. Review of Resident #45's Physician's orders for June 2023 indicated to document external catheter length and arm circumference in centimeters-one time a day every Sunday and every 24 hours as needed, with a start date of 5/22/23. Review of Resident #45's care plan for IV therapy dated 5/22/23, indicated an intervention to measure the external length of the catheter and arm circumference 2 centimeters (cm) above the insertion site and to document findings. Review of Resident #45's Treatment Administration Record (TAR) for May 2023 and June 2023 indicated that the weekly measurements of the external length of the catheter and arm circumference had not been completed as ordered on 5/28/23 and 6/11/23. During an interview on 6/14/23 at 12:54 P.M., Nurse #1 said that it was important to measure the PICC line catheter and arm circumference in order know if the PICC line had migrated (moved) and that it could be caustic to the Resident's veins. Nurse #1 reviewed Resident #45's TAR and progress notes with this surveyor and confirmed that there was no evidence that the measurements had been completed as ordered.

Based on record review and interview, the facility failed to accurately execute Advance Directives (written documents that tells your health care providers who should speak for you and what medical decisions should be made if you become unable to speak for yourself) for one Resident (#21) out of a total sample of 26 residents. Specifically, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) decisions were made by the designated and invoked (activated) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) for Resident #21, when the Resident was deemed as lacking the capacity for informed decision making by the facility's Physician. Review of the facility policy for Advance Directives, last revised 3/15/23, indicated that Advance Directives go into effect only after a person is declared incapable of making their own medical decisions. Findings include: Resident #21 admitted to the facility in February 2022. Review of the clinical record indicated that the Physician had invoked Resident #21's Health Care Proxy (HCP) on 2/22/22 for an indefinite duration. Review of Resident #21's Physician's orders for June 2023 (start date 11/28/22), indicated to follow the MOLST instructions and invoked HCP (start date 1/12/23). Review of the clinical record revealed a MOLST form signed on 6/1/23 by Resident #21 after his/her HCP had been activated. During an interview on 6/14/23 at 7:17 A.M., Social Worker (SW) #1 said that the MOLST form was not valid as it had been signed by the Resident after he/she had been deemed incapacitated by his/her Physician. SW #1 further said that the HCP should have signed the MOLST form and they did not.

Based on interview and record review, the facility failed to ensure one Resident (#337), out of a total sample of 26 residents, received care of a colostomy (a surgical procedure that creates an opening [stoma] from the large intestine through the abdomen allowing for stool to pass from the intestine to outside the body) system consistent with professional standards. Specifically, the facility staff failed to provide care and maintenance of the adhesive barrier/wafer pouching system per facility policy. Findings include: Review of the facility policy titled Colostomy and Ileostomy Care, dated 9/1/2004, indicated the following: - Most disposable pouching systems (used for the management of stool outside the body: consisting of a detachable bag to collect stool attached to an adhesive barrier/wafer that is affixed to the abdomen surrounding the colostomy opening) can be used from two to seven days. - Record the date and time of pouching system change in the treatment record. Resident #337 was admitted to the facility in June 2023 with a diagnosis of exploratory surgery with colostomy placement. Review of the Minimum Data Set (MDS) assessment information dated 6/7/23, indicated Resident #337 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. During an observation and interview on 6/14/23 at 2:02 P.M., the surveyor observed Resident #337 to have an adhesive barrier/wafer colostomy pouching system affixed to his/her left lower abdomen. Resident #337 said that he/she could not recall if the staff had ever changed the adhesive barrier/wafer pouching system. Review of the Physician's orders for Resident #337 dated June 2023, relative to colostomy management, indicated the following: - change colostomy bag every three days and as needed for soilage or displacement, order initiated on 6/7/23 - assess stoma site (opening of the intestine on the abdomen) and surrounding skin integrity every shift, order initiated on 6/7/23 Further review of the Physician's orders indicated no order to change the adhesive colostomy barrier/wafer pouching system. Review of the Resident's record indicated no documentation reflecting that the adhesive colostomy barrier/wafer pouching system had been changed. During an interview on 6/15/23 at 7:33 A.M., the surveyor and Nurse #3 reviewed the Physician's orders for Resident #337. Nurse #3 said that there were no Physician orders to change the adhesive colostomy barrier/wafer pouching system but there should have been orders to change the barrier/wafer pouching system routinely. During an interview on 6/15/23 at 7:47 A.M., Unit Manager (UM) #1 said that the Resident's adhesive colostomy barrier/wafer pouching system should be changed every three days. She then said that the adhesive colostomy barrier/wafer pouching system should be changed every day. She said that there were no orders for changing Resident #337's adhesive colostomy barrier/wafer pouching system in place, but there should be a Physician's order to change the pouching system routinely.

Based on policy review, observation, record review and interview, the facility failed to ensure its staff maintained appropriate infection control measures related to the use of Personal Protective Equipment (PPE) for two Residents (#125 and #52) out of a total sample of 26 residents. Specifically, the facility failed to ensure staff wore gowns and gloves when providing care for Resident's #125 and Resident #52 who were both on Contact Precautions (intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct of indirect contact with the resident or the resident's environment). Findings include: Review of the facility's policy, titled Transmission Precautions: Contact, dated 9/1/04, indicated the following: -In addition to Standard Precautions, Contact Precautions are used for residents known or suspected to be, infected or colonized with important microorganisms that can be transmitted by direct contact with the resident, or indirect (touching) with environmental surfaces or resident care items in the resident's environment. -Gloves should be worn when providing care that involves personal contact (e.g. changing clothes, toileting, bathing) or contact with items that may be contaminated by the organism. -Wear a clean, non-sterile gown upon entering a resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or items in the room. Review of the Centers for Disease Control and Prevention (CDC) website indicated health care personnel caring for patients on Contact Precautions must wear a gown and gloves for all interactions that involve contact with the patient and the patient environment. PPE should be donned (put on) prior to room entry and doffed (removed) at the point of exit. 1. Resident #125 was admitted to the facility in April 2023. Review of the infection line list for the Aspen Unit, provided by Unit Manager (UM) #3, indicated Resident #125 was on Contact Precautions for Vancomycin-Resistant Enterococci (VRE-germs that have developed a resistance to Vancomycin [an antibiotic used to treat some drug-resistant infections]) in the urine. Review of the June 2023 Physician's orders indicated an order to maintain Contact Precautions (VRE) every shift. On 6/13/23 at 4:04 P.M., the surveyor observed Resident #125 in bed, watching TV. There was a sign outside of the Resident's room that indicated the Resident was on Contact Precautions and gown and gloves were required to enter the room. On 6/14/23 at 10:10 A.M., the surveyor observed Housekeeper #1 in the Resident's room, mopping the floor. The Resident was seated in his/her wheelchair next to the bed. Housekeeper #1 held both sides of the wheelchair and moved the Resident to a different area in the room, so she could mop the rest of the floor. Housekeeper #1 did not have on a gown and gloves. During an interview on 6/14/23 at 10:13 A.M., the surveyor asked Housekeeper #1 if she needed to wear any PPE to enter the Resident's room. Housekeeper #1 said the gowns and gloves were only for Nurses and Certified Nurse Aides (CNAs). During an interview on 6/15/23 at 11:49 A.M., the Assistant Director of Nurses (ADON) said the Housekeeper should have had PPE on when she was in Resident #125's room. 44222 2. Resident #52 was admitted to the facility in February 2021. Review of the Resident's Physician's progress note in the clinical record dated 5/2/23, indicated that the Resident returned from the hospital on 5/2/23 with a diagnosis of infectious Gastroenteritis (an intestinal infection) and Colitis (an inflamed colon), and Enterocolitis (an inflammation throughout the intestine) due to Clostridium Difficile (C-diff: an infection of the intestine caused by the bacteria Clostridioides difficile). Review of the Resident's June 2023 Physician's orders included an order for Contact Precautions for C-diff every shift initiated on 5/2/23. Review of the Resident's June 2023 Treatment Administration Record (TAR) indicated that Contact Precautions for C-diff were in place for the Resident every shift from 6/1/23 through 6/13/23. On 6/13/23 at 1:15 P.M., the surveyor observed the Contact Plus Precaution sign located at the entrance to the Resident's doorway, which indicated that in addition to standard precautions staff and providers must wear gown and gloves when entering the room. On 6/13/23 at 1:40 P.M., during an observation and interview with Unit Manager (UM) #2, the UM told the surveyor that the Resident was on Contact Precautions for C-diff and she reviewed the Contact Plus Precaution sign with the surveyor. The surveyor then observed UM #2 enter the Resident's room without donning (putting on) a gown or gloves. UM #2 approached the Resident who was lying in bed, and picked up his/her bedside urinary drainage bag and tubing with her bare hands and relocated the bag and tubing to the other side of the bed. When the surveyor asked UM #2 about the use of gown and gloves when caring for the Resident, UM #2 said that she didn't need to wear a gown or gloves because she didn't handle the Resident's feces. During an interview on 6/14/23 at 8:32 A.M., the Infection Control Preventionist (ICP) said that the staff who entered the Resident's room to provide care should perform hand hygiene, and then don (put on) a gown and gloves because the Resident was on Contact Precautions due to a C-diff infection. The ICP said that the UM that touched the Resident's bedside urinary drainage bag and tubing should have been wearing a gown and gloves.

Based on document review, interview and observation, the facility failed to ensure staff wore the required Personal Protective Equipment (PPE), while on the second floor of the facility (location of all resident care areas). Findings include: Review of a facility document titled, PPE Requirements as of 11/5/20, indicated the following: -Masks are required at all times on the 2nd floor. -A Faceshield or goggles are required at all times on the 2nd floor. During an entrance interview on 1/5/21, the Assistant Director of Nurses (ADON) said all staff are required to wear a mask and eye protection when they are on the second floor of the facility. During an observation on 1/5/21 at 12:34 P.M., the surveyor observed Certified Nurse Aide (CNA) #1 pull her mask down and eat something while she stood in a resident's room with the resident present. CNA #1 was also wearing her goggles on the top of her head, and not over her eyes, as required. During an interview on 1/5/21 at 12:35 P.M., CNA #1 said she should have her mask and eye protection on at all times, but did not. During an observation on 1/5/21 at 12:41 P.M., the surveyor observed Nurse #1 walk out of a resident's room wearing his goggles on the top of his head, instead of over his eyes, as required. During an interview on 1/5/21 at 12:42 P.M., Nurse #1 said he should have had his eye protection on at all times, but did not.

Based on record review, document review, policy review, observation, and interview, the facility failed to ensure staff performed hand hygiene prior to donning (putting on) Personal Protective Equipment (PPE), and failed to disinfect equipment/supplies brought into a quarantined resident's room, as required, in order to prevent the potential transmission of infection, including COVID-19. Findings include: Review of Resident #1's medical record indicated he/she was admitted to the facility on [DATE]. Review of the Massachusetts Department of Public Health (DPH) precaution sign, dated 12/6/20, posted outside Resident #1's room, indicated Resident #1 was under quarantine and on Droplet/Contact Precautions. Further review of the precaution sign indicated the following: -Everyone that entered Resident #1's room must wash their hands when entering and exiting the room. -Only essential supplies in room. -Use dedicated or disposable equipment when available. -Minimize use of cellphones/pagers. -Clean and disinfect reusable equipment including intravenous pumps, cell phone or pagers (if used in room), and other electronics, supplies, and other equipment prior to removing from patient's room. Review of the facility's policy titled, Transmission Precautions: Contact, dated 9/1/2004, indicated Contact Precautions are used for residents known or suspected to have an infection that can be transmitted by direct contact with the resident, or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment. The policy also indicated the following: -After removing gloves and decontaminating hands, ensure that hands do not touch potentially contaminated environmental surfaces. Do this to avoid transfer of microorganisms to other residents or environments. -Clean and disinfect resident care equipment before using on another resident. During an observation on 12/22/20 at 2:03 P.M., the surveyor observed Scribe #1 typing on a laptop on top of a bedside table in the Aspen Unit Hallway. He donned (put on) a precaution gown and gloves, but did not perform hand hygiene prior to, as required. He then rolled the bedside table into Resident #1's room, with the laptop and a canvas bag full of wound care supplies on it. Physician Assistant (PA) #1 also walked into the room with him. At 2:15, Scribe #1 and PA #1 walked out of Resident #1's room pushing the bedside table with the laptop and canvas bag full of wound care supplies on it. During an interview on 12/22/20 at 2:17 P.M., PA #1 said she had just performed wound care on Resident #1, and Scribe #1 took notes on the laptop and handed her wound care supplies from the canvas bag as needed. She said she had Scribe #1 take the bedside table into resident rooms during wound care rounds so she had her supplies and lap top available to her. She said she had not disinfected the table or laptop and has never really thought about it, but should have. PA #1 also said she brought the canvas bag full of wound care supplies into resident rooms when on rounds, but hadn't thought about the supplies being contaminated after they had been brought into a quarantined resident's room when the resident is droplet/contact precautions. Scribe #1 he did not wash his hands before he donned his gown and gloves, but should have. During an interview on 12/22/20 at 2:43 P.M., the Assistant Director of Nurses (ADON) said all staff are expected to perform hand hygiene prior to donning PPE. She also said anything that goes into a quarantined resident's room must be cleaned before it comes out, and therefore, the laptop and table should have been disinfected, as required. The ADON said, PA #1 should not have brought all of the wound care supplies into Resident #1's room; she should have brought in only what she needed because now the unused supplies are contaminated and cannot be disinfected.

Based on policy review, observation, interview and record review, the facility failed to ensure staff adhered to proper infection control measures related to the use of Personal Protective Equipment (PPE), and failed to ensure residents were cohorted based on COVID-19 status. Findings include: A. The facility failed to ensure proper PPE was used during care for Resident #1 and Resident #6. 1. Review of the facility's COVID-19 status resident list indicated Resident #1 was on quarantine due to a recent hospital admission. Review of the facility Use of PPE policy, dated 10/5/20, indicated: -full PPE to include N95 respirator or alternative (facemask is acceptable if N95 respirator is not available or if resident not known to have exposure to a confirmed COVID case), face shield/goggles, gown and gloves to be worn for the care of quarantined (new admission or exposed to a confirmed COVID-19 case) residents. On 11/10/20 at 8:35 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 enter Resident #1's room. Outside of the room was a sign that indicated the resident was on Quarantine/Droplet Precautions and staff was to don (put on) a gown and gloves prior to entering the room. CNA #1 entered the room without donning a gown or gloves. The surveyor observed CNA #1 wheel Resident #1 into the bathroom and shut the bathroom door. Resident #1 did not have a mask on. During an interview on 11/10/20 at 8:47 A.M., CNA #1 said Resident #1 wasn't on her assignment so she didn't know that she was supposed to put on a gown and gloves to provide care. CNA #1 looked at the sign on the door and said she missed the sign and that was why she didn't put a gown on to toilet Resident #1. 2. Review of the facility's COVID-19 status resident list indicated Resident #6 had never tested positive for COVID-19. During an interview on 11/10/20 at 7:30 A.M., the Infection Control Nurse said that the last COVID-19 positive test result was from a staff member who tested positive on 11/5/20. Review of the Centers for Disease Control and Prevention (CDC) website, Preparation for COVID-19 in Nursing Homes, dated 6/25/20 indicated: -Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or Health Care Personnel is newly identified in the facility . Review of the facility policy Use of PPE policy, dated 10/5/20, indicated: -full PPE (face mask, face shield/goggles, gown, and gloves) to be worn for COVID negative residents when a new resident or staff case had been identified within the last 14 days. On 11/10/20 at 9:20 A.M., the surveyor observed a laboratory technician in Resident #6's room. Resident #6 did not have a mask on. The laboratory technician had a mask, eye protection, and gloves on but did not have a gown on. During an interview on 11/10/20 at 9:25 A.M., the laboratory technician said that she followed the signs on the door and since there was no precaution sign she didn't think she needed to wear a gown. B. The facility failed to ensure staff appropriately cohort two residents related to COVID-19 status. Review of the facility policy, Admissions During Coronavirus Outbreak, dated 10/5/20, indicated: -newly admitted or readmitted residents to the facility should be quarantined in a private room or dedicated quarantine space . Review of the facility COVID-19 resident status list indicated Resident #2 and Resident #3 shared a room and Resident #2 had never tested positive for COVID-19. Further review indicated Resident #3 was on quarantine due to a recent readmission from the hospital. On 11/10/20 at 8:50 A.M., the surveyor observed a sign outside of Resident #2 and Resident #3's room that indicated they both were on Quarantine/Droplet Precautions. During an interview on 11/10/20 at 8:54 A.M., Unit Manager #1 said that Resident #2 had never tested positive for COVID-19 so when Resident #3 returned from the hospital he put both of them on Quarantine/Droplet Precautions. During an interview on 11/10/20 at 3:00 P.M., the Administrator said there had been a breakdown in communication amongst staff. She said Resident #2 and Resident #3 should not have been placed in the same room.

Based on interview, policy review and record review, the facility failed to ensure all applicable residents were tested for COVID-19 following a newly identified COVID-19 positive staff member. Findings include: During an interview on 11/10/20 at 7:30 A.M., the Infection Control Nurse said that the last COVID-19 positive test result was from a staff member who tested positive on 11/5/20. Review of Centers for Medicare and Medicaid Services (CMS) memorandum, Ref: QSO-28-38-NH, revised 8/28/20, indicated: -If an outbreak (any new cases arise in the facility) occurs, test all residents and staff who previously tested negative until no new cases arise. -In keeping with Centers for Disease Control and Prevention (CDC) recommendations, staff and residents who have recovered from COVID-19 and are asymptomatic do not need to be tested for COVID-19 within 3 months after symptom onset. Until more is known, testing should be encouraged (e.g., in response to an exposure) 3 months after the date of symptom onset with the prior infection. Review of the facility policy, Testing of Staff and Residents, dated 10/5/20, indicated: -An outbreak is defined as a new COVID-19 infection in any health care personnel .or resident. -Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested . Review of the facility's COVID-19 resident testing log indicated residents on two out of three units who previously tested negative for COVID-19 had been tested since the outbreak. Further review indicated one unit's negative residents had not been tested and none of the residents' facility wide who had been recovered for greater than 90 days had been tested , as required. Review of the facility COVID-19 line list, dated 10/16/20, indicated of the 75 COVID-19 recovered residents, only 6 had been recovered for 90 days or less. During an interview on 11/10/20 at 1:40 P.M., the Infection Control Nurse said she only tested the residents who had direct contact with the COVID-19 positive staff member. She said she did not test all three units because the staff member had only been on two of them. During an interview on 11/10/20 at 2:50 P.M., the Director of Nurses and the Infection Control Nurse said they were unaware of the requirement to test all residents, except those recovered for 90 days or less, following a new positive case.

Based on observations and interviews, the facility failed to ensure Transmission Based Precautions (TPB) were implemented relative to donning Personal Protective Equipment (PPE) in accordance with the Centers of Disease Control and Prevention (CDC) guidance for COVID-19 care and services on 3 of 3 units. The facility also failed to ensure facility staff were appropriately screened for COVID-19 upon entering the facility on 1 of 3 units, as required, and failed to ensure the screening process included symptoms consistent with COVID-19. Findings include: Review of the CDC guidance Preparing for COVID-19 in Nursing Homes, updated 6/25/20, indicated the following: -Screen visitors for fever (Temperature =100.0 Fahrenheit), symptoms consistent with COVID-19 (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea), or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. -Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or Health Care Personnel (HCP) is newly identified in the facility; this could also be considered when there is sustained transmission in the community. -Implement Universal Use of Personal Protective Equipment Review of the CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 7/15/20, indicated the following: -Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection and ensure they are [MEDICATION NAME] source control. -Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature =100.0°F or subjective fever. -Ask them if they have been advised to self-quarantine because of exposure to someone with [DIAGNOSES REDACTED]-CoV-2 infection. -HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. -HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis).They should also: --Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. --Wear an N95 or equivalent or higher-level respirator, instead of a facemask, for: Aerosol generating procedures -For HCP working in areas with minimal to no community transmission, HCP should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. Universal use of a facemask for source control is recommended for HCP. Review of the facility policy entitled Coronavirus, revised 7/20/20, indicated the following: -all employees to wear mask -the nursing home or rest home must confirm that health care personnel do not have any signs or symptoms of COVID such as a cough, shortness of breath, sore throat, myalgia, chills, or new onset loss of smell or taste and a fever by taking each healthcare personnel's temperature upon arrival. The heath care worker's temperature must be below 100.0 degrees Fahrenheit (F) for him or her to enter the facility and provide care. -all health care personnel are permitted to come into the facility as long as they meet the CDC guidelines for health care personnel. Review of the facility education entitled PPE Requirements, revised 7/14/20, indicated the following: - Masks and goggles or face shields are to be worn at all times while on the second floor (the second floor houses all of the resident rooms) A gown is to be worn with: -a resident on quarantine (will have special contact/droplet precaution sign posted on the door) -a negative COVID patient during high contact (dressing, showering, ambulating, changing linens, wound care, changing briefs, bathing, transferring, providing hygiene, device care or use, and with any physical contact A. During a tour of the Aspen unit on 8/13/20, the following was observed: -10:00 A.M., Resident #1 was observed in the rehabilitation gym with Rehabilitation Staff #1. Rehabilitation Staff #1 had a face shield, face mask and gloves donned, but did not have a gown donned, while providing direct (hands on) assistance to Resident #1. During an interview conducted at this time, the Director of Nurses (DON) said that Resident #1 was negative for COVID-19. During an interview on 8/13/20 at 11:58 A.M., Rehabilitation Staff #1 said when directly touching a resident who is negative for COVID-19, the facility staff would have to don a face mask, eye protection, a gown and gloves. She said that she forgot to don a gown when working with Resident #1. -10:10 A.M., during a tour of the COVID-19 section of the Aspen unit, Nurse #1 and Certified Nurse Aide (CNA) #1 were observed seated across from each other at a table in the designated nurses station for COVID-19 resident care. Neither Nurse #1 nor CNA #1 had a face mask donned. -12:15 P.M., the surveyors entered the designated nurses station for COVID-19 resident care and observed Nurse #1 completing paperwork. He then proceeded to walk past the surveyors to answer the telephone that was ringing. Nurse #1 did not have face mask nor eye protection donned. B. During a tour of the Chestnut Unit on 8/13/20, the following was observed: -10:44 A.M., Nurse #2 provided hands on assistance to Resident #2, who was in a wheelchair, from a seated position to a standing position in order to be weighed. Nurse #2 had a face mask and eye protection donned, but did not have a gown nor gloves donned. Nurse #2 then provided hands on care to assist Resident #2 from the scale back to his/her wheel chair. During an interview on 8/13/20 at 10:59 A.M., Nurse #2 said that Resident #2 was negative for COVID-19. She further said that if staff were to physically touch Resident #2, they would need to don a face mask, eye protection, a gown and gloves. C. During a tour of the Birch Unit on 8/13/20, the following was observed: -12:30 P.M., Nurse #3, who had a face mask donned (did not have eye protection) was observed to apply a face mask to Resident #3 who was ambulating in the hallway. Unit Manager (UM) #1, who had only a face mask donned, also approached Resident #3 during this time to converse. Resident #3 was observed to continue to ambulate down the hallway and was approached by CNA #2 (who had only a face mask donned and had eye protection positioned on the top of her head). CNA #2 was observed to converse with Resident #3 and provide hands on assistance to re-direct him/her back down the hallway towards his/her room. While ambulating Resident #3, CNA #2 was observed to take her eye protection (which were on the top of her head) and put them on to cover her eyes. During an interview on 8/13/20 at 12:38 P.M., Nurse #3 said that for residents who are negative for COVID-19, staff are required to don a gown and gloves in addition to a face mask and eye protection. When the surveyor indicated that he was not wearing his eye protection, Nurse #3 said that sometimes they get foggy. During an interview on 8/13/20 at 12:40 P.M., CNA #2 said that Resident #3 was negative for COVID-19. She further said that she would have to wear a face mask and eye protection, but would also have to don a gown and gloves with close contact. She said that she was trying not to get too close to Resident #3 when they were ambulating because she did not have a gown and gloves on. When the surveyor indicated that her eye protection was on the top of her head and not donned while assisting Resident #3, she did not respond. During an interview on 8/13/20 at 12: 42 P.M., UM #1 said that all facility staff need to wear a face mask and eye protection. When the surveyor indicated that he did not have eye protection donned during the 12:38 P.M. observation, the UM said he went to the nursing station and put them on after. D. Review of the facility screening form entitled Prevent COVID-19 Start of Shift Daily Employee Screening Log, undated, indicated the following criteria to be completed: -First and Last name, -Temperature documentation -indication of cough, sore throat or new shortness of breath- if yes answer to any, see supervisor/Staff Development Coordinator The form did not indicate the updated signs/symptoms of COVID-19 which also includes chills, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting, and diarrhea. During an interview on 8/13/20 at approximately 10:10A.M., during the initial tour of the facility, the DON said that employee screening occurs on the nursing units after entrance into the facility. She said the Nurse on the unit would obtain the employee temperature. During an interview on the Chestnut unit on 8/13/20 at 10:59 A.M., Nurse #2 said that she would go to her assigned unit nursing station where she would take her own temperature and have another nurse verify it prior to starting her shift. She further said that if a temperature is present, her supervisor would be notified. During an interview on the Birch Unit on 8/13/20 at 11:30 A.M., CNA #3 said that employee screening had not been done for a while. She said during COVID, the facility staff would check her temperature and ask questions every week, but said that this had not occurred for a while. During a review of the COVID-19 binder for employee screening on the Birch unit, indicated the last documented evidence of employee screening that was conducted on the unit occurred in July (7/8/20 through 7/14/20). During an interview on 8/18/20 at 12:42 P.M., UM #1 said that he checked his own temperature prior to starting his shift, but did not document this information anywhere. When the surveyor asked if other employees on the unit had been screened for COVID-19 prior to starting their shift, he said he did not know. UM #1 said that there was no record on his unit to indicate that facility staff were checking their temperatures prior to their shift.

Based on observation, interview and record review the facility failed to appropriately use Personal Protective Equipment (PPE) related to COVID-19 on 1 out of 3 units. Findings include: During an interview on July 29, 2020 at 7:44 A.M., the Director of Nurses said the staff was wearing full PPE (gown, gloves, eye protection and a mask) for high contact care for the COVID-19 negative residents. Review of a Department of Public Health Memorandum for the Comprehensive use of PPE, dated July 6, 2020 indicated that gowns should be prioritized for the following activities: . During the following high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of healthcare providers, such as: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. During an observation and interview on the Aspen Unit on July 29, 2020 at 9:10 A.M., Nurse #1 went into a Resident #1's room that was listed on the Census sheet, given to the surveyor by the Director of Nursing, as being a COVID-19 negative resident. There was no PPE outside of the room or sign to indicate which PPE was required. Nurse #1 told the surveyor that the resident had never tested positive for COVID-19 and that he wore a mask, eye protection at all times and gloves if he were to come in close contact with the resident. He said he did not need to wear a gown. During an observation an interview on the Aspen Unit on July 29, 2020 at 9:48 A.M., Certified Nurse Aide (CNA) #1 went into a COVID-19 negative resident (Resident #2) room with a mask and eye protection on. CNA #1 went to Resident #2 and repositioned him/her in the bed. CNA #1 exited the room and performed hand hygiene. CNA#1 told the surveyor that Resident #2 is COVID-19 negative and he only needed to wear a mask and eye protection when caring for him/her.

Based on observation, interview and record review the facility failed to use Personal Protective Equipment (PPE) appropriately related to COVID-19 on 1 out of 3 units. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website, under Preparing for COVID-19 in Nursing Homes indicated the following: -Create a plan for managing new admissions and readmissions . Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Health Care Personnel should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Review of the facility's policy for Transmission Based Precautions, dated 9/1/04, indicated that in addition to standard precautions, contact precautions are used for residents with known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment .Wear a clean gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or items in the room. Remove the gown before leaving the resident's environment. During an observation and interview on July 14, 2020 at 9:27 A.M. on the Aspen Unit (quarantine wing- newly admitted or readmitted residents who are under a 14 day surveillance for signs and symptoms of COVID-19), Occupational Therapist (OT) #1 had a gown, mask, and eye protection on as she exited a resident room on the quarantine wing. She proceeded down the hall and to the therapy gym to wash her hands, still wearing the same PPE she had on while in the resident's room. OT #1 told the surveyor she should have taken the gown off before she exited the resident's room. During an observation and interview on July 14, 2020 at 9:38 A.M. on the Aspen Unit (quarantine), Housekeeper #1 entered a resident's room with only a mask and eye protection on. The resident was seated behind the bedside table that the housekeeper was cleaning. The resident did not have a mask on. When the housekeeper exited the resident's room, she told the surveyor she didn't see the sign outside the resident's room that indicated which PPE she needed. The sign indicated gown, mask, eye protection, and gloves were to be worn upon entering the room. She donned a gown and returned to the resident's room.

Based on observation, record review and interview, the facility failed to prevent a Deep Tissue Pressure Injury (DTPI-a skin injury cause by pressure) from developing, failed to provide the necessary treatment and services to promote healing for two pressure ulcers and failed to maintain infection control practices during a dressing change for one resident (#127) out of a total sample of 27 residents. Findings include: For Resident #127, the facility failed to A) Follow through with the initial rehabilitation screen in a timely manner, remove the source of identified pressure, provide physical therapy for positioning in a timely manner, and maintain an out of bed schedule. B) Failed to follow the plan of care recommended from the wound clinic and the Nurse Practitioner (NP) orders for positioning and pressure relief. C) Failed to maintain infection control while performing a dressing change. Resident #127 was admitted to the facility in June of 2018 with a diagnosis of Posterior encephalopathy syndrome (a syndrome characterized by confusion, headaches and seizures). Review of the Quarterly Minimum Data Set Assessment, dated 1/6/2020, indicated Resident #127 had severely impaired cognition as evidenced by a score of 7 out of 15 on the Brief Interview of Mental Status (BIMS), was an extensive assist of 2 for bed mobility, dependent for transfers, did not ambulate and had 2 facility acquired, unstageable pressure ulcers that were covered with either slough and/or eschar (dead tissue). A. Review of the Report of New Ulcer form, dated and timed on 11/15/19 at 12:30 P.M., indicated Resident #127 developed a DTPI (Wound #1), that measured 2 centimeters (cm), x 1.5 cm to the left calf. The report further indicated the cause of the DTPI was pressure and decreased immobility. A physician's orders was obtained to apply skin prep (a protective film) every shift and to obtain a rehabilitation screen. Review of the Report of a New Ulcer form, dated and times on 11/18/19 at 11:45 A.M., indicated Resident #127 developed a second DTPI (Wound #2) that measured 7 cm x 1.5 cm to the right calf. The report further indicated the cause of the DTPI was pressure, decreased mobility and external rotation of the hips. A physician's order was obtained to apply skin prep every shift, apply an alternating air mattress and apply Derma Savers (protective padded sleeve) to both lower legs at all times. Review of the Rehabilitation Screening Request form, dated 11/15/19, indicated Resident #127 needed to be screened for positioning due to the development of a new DTPI to the left calf. The Screening Request Form was signed and dated on 11/18/19 (3 days after originally requested), with the recommendation for the resident to be evaluated by a physical therapist for positioning. Under the comment section of the form, the physical therapist documented that she observed Resident #127 seated in a tilt in space wheelchair with elevating leg rest and a foot box (a device used for lower leg positioning in the wheelchair). The resident's hips were observed to be externally rotated which became even further rotated after 2 hours of sitting in the wheelchair. A Physical Therapy (PT) evaluation was recommended. Review of the PT Initial Evaluation form, dated 11/18/19, indicated Resident #127 had 2 new DTPI, one on each calf, and therapy was necessary to address proper positioning in the bed and wheelchair. The evaluation further indicated that therapy was needed to improve positioning and without therapy the resident was at risk for further skin breakdown. The Rehabilitation Staff (RS) #2 documented that she observed the resident with his/her hips externally rotated, while seated in the tilt in space wheelchair, with elevating leg rests and foot/leg support. The RS #2 also documented that Resident #127 was observed in bed with a heels-up cushion (a cushion that is placed under the resident's calves that keeps heels suspended off the bed) that applied pressure to the DTPI to both calves. Review of the Physician orders, dated 11/18/19, indicated: - Physical therapy 12 sessions in 4 weeks - Therapeutic exercise and activities - Wheelchair management The order did not address positioning in bed, although RS #2 identified a source of pressure to the resident's bilateral calves while in bed. Review of the daily therapy note, dated 11/18/19 (11 days after the physician orders were obtained), indicated Resident #127 was observed and positioned in his/her wheelchair by RS #3. The resident was not observed in bed. The plan was to consult with RS #2 before the next visit. Review of the daily therapy note, dated 12/4/19, indicated that RS #2 treated the resident. Resident #127 was observed in the wheelchair and in bed and repositioned to off load pressure to the bilateral lower calves. Review of a Rehabilitation Screening Request form, dated 12/5/19, indicated that nursing requested for Resident #127 to be seen by a physical therapist for positioning because the resident's DTPIs had worsened. Review of the Report of New Ulcer form, dated 12/6/19, indicated Resident #127 developed a new DTPI (this is the 3rd DTPI developed in 22 days) to the lower left calf (Wound #3) that measured 3 cm x 2.5 cm. Review of daily therapy note, dated 12/6/19, indicated that RS #2 treated Resident #127. The following care plan revisions were made: - Discontinue the heels-up cushion (this was 18 days after the physical therapist identified the cushion was causing pressure) -Place a flat line roll under the resident's ankles to off load heels without touching the pressure ulcers on the calves, and -Place linen rolls to both sides of the resident when in bed and in the wheelchair to prevent external rotation of the hip During an interview on 2/05/2020 at 7:23 A.M., the Rehabilitation Director (RD) said that she really could not remember when she received the Screening Request Form from nursing. If she received the screen on 11/15/19, and knew Resident #127 had developed a DTPI, the physical therapist would have screened the resident within 24 hours. The Rehabilitation Director said that the facility offers rehabilitation services 7 days a week. She said she really did not know why it took the department 3 days to screen the resident after the request was made. The surveyor asked if she was aware that over that 3 day period the resident developed a 2nd DTPI. The RD said that she was aware. During an interview on 2/05/2020 at 9:58 A.M., Rehabilitation Staff (RS) #2 said when she screened Resident #127 on 11/18/19 he/she had already developed the DTPI to both of his/her calves. She said on that day she screened the resident, she observed him/her in the wheelchair 2 times and in the bed 1 time. She said she noticed that when the resident was in the wheelchair for greater than 2 or 3 hours, the external rotation of the bilateral lower extremities would become worse and she believed the foot box on the wheelchair could have caused the pressure ulcers. RS #2 said she never made a formal out of bed schedule with nursing, but reinforced that the resident should not be out of bed any longer than 2 or 3 hours, but she did not document it anywhere. RS #2 said that when she observed the resident in bed, he/she was using the heels-up cushion and it was putting pressure on the DTPI, but she thought she should only make 1 adjustment at a time and believed the positioning in the chair was more important. RS #2 said after she initially screened Resident #127, she did not see the resident again until 12/6/19 (18 days later) because she was out sick. RS #2 said that when she assessed the resident on 12/6/19, she decided to discontinue the heels-up cushion. During an interview on 2/5/2020 at 1:30 P.M., with Rehabilitation Manager (RM), the surveyor asked, after the initial PT evaluation on 11/18/19, why Resident #127 wasn't seen for 11 days. She said that RS #2 was out sick for a period of time, so she reassigned the resident to RS #3. She was unable to answer the question related to the lapse in treatment. B. Review of the Weekly Wound Assessment Sheet indicated the following: - Left calf (Wound #1), 11/27/19, was a DTPI that measured 7 cm x 1.5 cm with no depth, no drainage. The skin was intact. - Wound #1, 12/5/19, DTPI that measured 7 cm x 1.5 cm, was covered with eschar had become worse, and is now an unstageable pressure ulcer. - Right calf (Wound #2), 11/27/19, was a DTPI that measured 2 cm x 1.5 cm. with no depth, no drainage. The skin was intact. - Wound #2, 12/5/19, the wound measure 1.5 cm x 1.5 cm, was covered by eschar, had become worse, and is now an unstageable pressure ulcer. - Left lower calf (Wound #3), 12/6/19 the resident developed a new, unstageable pressure ulcer. It measured 3 cm x 2.5 cm. it was covered by eschar. Review of the Nurse Practitioner (NP) note, dated 12/6/19, indicated Resident #127 had an unstageable pressure ulcer to the right calf and 2 unstageable pressure ulcers to the left calf. The upper left calf wound measure 1.5 cm x 1.5 cm and was covered by eschar and the lover calf wound was 3 cm x 2.5 cm and was necrotic. Review of the nurse's note, dated 12/6/19, indicated an order was obtained for a wound clinic consult for multiple non-healing lower extremity (calf) wounds. Review of the Weekly Wound Assessment Sheets for wound #1, #2 and #3 indicated from 12/6/19, until 1/15/20 when the resident went to the wound clinic the wounds remained unchanged. Review of the Wound clinic referral, dated 1/15/20, indicated the reason for the referral was Resident #127 had scabs to the bilateral lower extremities and the current treatment was skin prep. Further review indicated the following: -The left calf was debrided (a mechanical cleansing of a wound), -New treatment orders indicated to cleanse with soap and water, pat dry, apply Aquacel (a dressing that assist in prevention of infections and assist with healing) and wrap with gauze. -Pressure relief needed, place 2 pillows under the thighs to elevate calves off the bed surface, and -Reposition every 30 minutes during the day and every 2 hours in the evening and night. Review of the NP orders, dated 1/17/20, indicated: -place 2 pillows under thighs to elevate calves off bed surface and reposition every 30 minutes daily and every 2 hours at night. During an interview on 1/31/20 at 11:53 A.M., Resident #127's spouse said that he/she developed the pressure ulcers from being positioned incorrectly. On 2/4/20 at 10:10 A.M., the surveyor observed Resident #127 in bed. There was a pillow placed under the left calf and a pillow placed under the right calf. The pillows were applying pressure directly to the pressure ulcers. On 2/05/20 at 1:00 P.M., the surveyor observed Resident #127 in his/her room, seated in the tilt and space wheelchair, he/she had bilateral Derma Savers to the lower legs, there was one pillow under his/her calves causing pressure directly on the pressure ulcers. The resident's spouse was with the resident at that time and said that the staff always positions him/her with a pillow under his/her calves. During an interview on 2/05/20 at 2:28 P.M., Unit Manager (UM) #2 said when Resident #127 developed the first DTPI, on 1/15/20, he requested a PT screen. The resident then developed the second DTPI before the PT screened him/her. UM #2 said at that time, he never correlated it to the heels-up cushion. UM #2 said that when the physical therapist screened the resident on 11/18/19, it was not communicated to him that the physical therapist thought the heels-up cushion was causing pressure to the calves or he would have removed it. The surveyor asked if the facility every obtained a physician's order for the heels-up cushion and the UM #2 said, no, that it was a nursing measure to prevent pressure to the resident's heels. The surveyor then reviewed the wound clinic referral with UM #2 and asked if Resident #127 was positioned every 30 minutes as recommended by the clinic. UM #2 said that when he originally read the referral from the wound clinic, he had missed the recommendation for positioning, so the resident was never positioned every 30 minutes, as recommended. Directly after the above interview, the surveyor and UM #2 entered Resident #127's room. The resident was observed in bed with bilateral Derma Savers to his/her lower legs; there was one pillow under the right calf and another pillow under the left calf. UM #2 said that this was not the way the resident was supposed to be positioned because the pillows were causing pressure to his/her ulcers. UM #2 said Resident #127 was supposed to have a small roll under the ankles to relieve pressure to the calves and heels. C. On 2/4/20 at 11:20 A.M., during an observation of the treatment to Resident #127's pressure areas, Nurse #1 removed the Kerlix wrap from the resident's right calf. There was a Telfa pad (non-adherent dressing) stuck to the wound bed. Nurse #1 wet the Telfa pad and removed it. Once removed, the surveyor observed an open pressure ulcer that was approximately 6 cm long x 2 cm in width. The wound was covered with black eschar. Nurse #1 completed the right calf treatment with appropriate infection control. When Nurse #1 moved onto performing the dressing to the resident's left calf, she did not wash her hands or change her gloves in between different wound sites. After Nurse #1 removed the Kerlix wrap, there was an Abdominal pad (ABD- large dressing) and a Telfa pad under the Kerlix; the Telfa pad was stuck to the wound bed. She wet the Telfa pad and removed it. After the Telfa pad was removed, she then removed her gloves and washed her hands. Once the dressing was removed, the surveyor observed 2 wounds on the resident's calf. The upper wound measured approximately 2.5 cm x 1.3 cm with unknown depth due to the wound bed being covered with yellow slough. The lower wound was approximately 3 cm x 2 cm covered with black eschar. Nurse #1 performed the remaining of the treatment without any infection control issues. Directly after the above observation, the surveyor shared her observation of the breaches of infection control with Nurse #1. Nurse #1 said she made a mistake and was aware that she did not change her gloves or wash her hands in between the dressing changes to the left and right calf.

2. For Resident #8, the facility failed to ensure that the Physician's order was followed for implementing and documenting the results of a hydration program. Resident #8 was admitted to the facility in 9/02 with [DIAGNOSES REDACTED]. A review of the Physician's Order, from 1/3/13 to 5/23/13, indicated document "I & O (Intake (amount) and Output (amount)) Every Shift." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The following was noted: January 2013 There was no documentation that fluid intake and output amounts were recorded each shift, as ordered, on 1/3/13, or from 1/3-1/6/13, 1/8-1/9/13, and 1/14-1/31/13, per the "24 Hour Intake and Output Record." February 2013 There was no documentation that fluid intake and output amounts were recorded each shift, as ordered, from 2/1-2/2/13, 2/5-2/12/13, and 2/19-2/28/13, per the "24 Hour Intake and Output Record." March 2013 There was no documentation that fluid intake and output amounts were recorded each shift, as ordered, from 3/1-3/7/13, 3/10-3/28/13, and 3/30-3/31/13, per the "24 Hour Intake and Output Record." April 2013 There was no documentation that fluid intake and output amounts were recorded each shift, as ordered, from 4/1-4/30/13, per the "24 Hour Intake and Output Record." May 2013 There was no documentation that fluid intake and output amounts were recorded each shift, as ordered, from 5/1-5/23/13, per the "24 Hour Intake and Output Record." During discussion on 5/23/13 at 7:15 A.M., Unit Manager (UM) #3 said that the Physician's orders for I&Os every shift were not followed. Based on record review and interview, the facility failed to follow the written plan of care and/or Physician's orders for 2 (#1 and #8) of 24 sampled residents. Findings include. 1. For Resident #1, the facility failed follow the Physician's orders and the facility policy related to Foley catheter care. Resident #1 was admitted to the facility in 10/2009 with [DIAGNOSES REDACTED]. Review of the Indwelling Urinary Catheter Care Policy, dated 10/1/05, indicated the following: - Routine catheter care helps prevent infections and other complications, - Inspect outside of catheter where in enters the urinary meatus and tissue around meatus, - Secure catheter to thigh using leg strap, and - Provide enough slack before securing catheter to prevent tension on tubing. Review of the resident's Foley catheter plan of care (unclear of initial date) indicated the following interventions: - Urethral Stricture dilated (10/11/12), - Foley catheter for 14 days, may replace as needed for blockage (10/11/12), and - Foley catheter care every shift (10/11/12). Review of the Treatment Administration Record (TAR), dated 10/11/2012 through 10/25/12, did not indicate that the Foley catheter was secured using the leg strap to prevent tension on the tubing, per the facility policy. Review of the Nurse's Note, dated 10/24/12, indicated Resident #1 had scant amount of bleeding at insertion site of catheter due to the catheter tubing not being secured to the leg and pulling. House cream was applied, the area was reassessed, and no further bleeding was noted. Review of the Physician's orders, dated 11/7/12, indicated the following: - Insert a Foley catheter, - Foley catheter care every shift, - May replace Foley catheter as needed, and - Tape Foley catheter to belly. Review of the updated plan of care, dated 11/7/12, for the Foley catheter indicated the intervention to keep Foley catheter attached to lower abdomen. Review of the TAR, dated 11/2012, indicated the Foley catheter was inserted as ordered on [DATE], and the Foley catheter care was performed every shift. The order to attach the Foley catheter to the lower abdomen was not transcribed until 11/16/12, 10 days after the original order. Physician's order, dated 11/16/12, indicated a new [DIAGNOSES REDACTED]. On 5/24/13 at 10:35 A.M. during an interview with the Director of Nurses (DON) and Unit Manager (UM) #2, the UM said the order to tape the Foley catheter to the lower abdomen was never transcribed for 10 days after the order was obtained. The UM said it was an editing error. The surveyor reviewed the Facility's Foley catheter policy which indicated that staff were to secure the catheter to the resident's thigh to prevent tension. The surveyor inquired where the nurse's document the securement of the catheter. The DON said it was not the policy of the facility to document the securement of the catheter, but she expected it to be done. Please refer to F315.

Based on observation, record review and interview the facility failed to provide appropriate care and services for an indwelling Foley catheter for 1 (#1) out of 4 applicable residents in a total sample of 24. Findings include. For Resident #1, the facility failed to ensure that appropriate care and services were provided related to trauma, tissue damage from tension of a Foley catheter tubing. Resident #1 was admitted to the facility in 10/2009 with [DIAGNOSES REDACTED]. Review of the Indwelling Urinary Catheter Care Policy, dated 10/1/05, indicated the following: - Routine catheter care helps prevent infections and other complications, -Inspect outside of catheter where it enters the urinary meatus and tissue around meatus, - Secure catheter to thigh using leg strap, and - Provide enough slack before securing catheter to prevent tension on tubing. Review of the Annual Minimum Data Set Assessment, dated 9/9/12, indicated the resident was cognitively impaired, an assist with bathing, dressing and grooming, did not ambulate and was incontinent of bowel and bladder, and did not have a Foley catheter at this time. Review of an Urologist's report indicated the resident underwent [REDACTED]. The resident had a Cystoscopy, urethral dilation and placement of a difficult Foley catheter due to [MEDICAL CONDITION] and urethral strictures. Discharge orders from the Urologist included discontinuing the Foley catheter in 2 weeks. Review of the resident's Foley catheter plan of care (unclear of initial date), indicated the following interventions: - Urethral Stricture dilated (10/11/12), - Foley catheter for 14 days, may replace as needed for blockage (10/11/12), and - Foley catheter care every shift (10/11/12). Review of the Treatment Administration Record (TAR), from 10/11/12 to 10/25/12, indicated Foley catheter care was done every shift as ordered. There was no indication the Foley catheter was secured using the leg strap to prevent tension on the tubing, per the facility policy. Review of the Nurse's Note, dated 10/24/12, indicated Resident #1 had scant amount of bleeding at insertion site of catheter due to the catheter tubing not being secured to the leg and pulling. House cream was applied the area was reassessed, and no further bleeding was noted. There was no indication the Physician was notified at this time. The Foley catheter was discontinue on 10/25/12. Nurse's Note, dated 11/1/12 indicated the resident had a dark area on the tip of the penis. The Physician was notified. No further orders except to continue to monitor. Nurse's Note, dated 11/2/12 indicated the Foley catheter was draining yellow urine, although at this time the resident did not have a Foley catheter. On 11/2/12, the Physician examined the residents "excoriated urethral/gland area". A new order was obtained to cleanse urethral meatus/gland with normal saline and apply A & D ointment two times a day. Review of the TAR, date 11/2012, indicated the following: - 11/3/12, urethral area remains dark, -11/4/12, urethral area remains dark, -11/5/12, urethral area remains dark, no improvement, and 11/6/12, urethral area remains dark. Review of the Physician's progress note, dated 11/7/12, indicated the resident now has an open area with yellowish drainage on the penile meatus. The [DIAGNOSES REDACTED]." Review of the physician's orders [REDACTED]. - Insert a Foley catheter, - Foley catheter care every shift, - May replace Foley catheter as needed, - Discontinue the A & D ointment, and - Tape Foley catheter to belly. Review of the updated plan of care, dated 11/7/12, for the Foley catheter indicated the intervention to keep Foley attached to lower abdomen. Continued review of the TAR, dated 11/7/12 - 11/16/12, indicated the Foley catheter was inserted as ordered, Foley catheter care was performed every shift, but the order to attach the Foley catheter to the lower abdomen was not transcribed until 11/16/12, 10 days after the original order. Review of the Physician's progress note, date 11/15/12 indicated "the penile ulcer has now healed but pt (patient) has a split meatus...The meatus is splayed (split) with [MEDICATION NAME] wound edges and some granulation tissue. Problem, traumatic wound of the meatus likely secondary to Foley." physician's orders [REDACTED]. Again, an order was written to attach the Foley catheter to the lower abdomen. Review of the Urologist report, date 11/16/12, indicated the resident had "Traumatic [DIAGNOSES REDACTED] from Foley catheter traction. Foley on traction again today during exam". On 5/23/13 at 11:15 A.M., the surveyor entered Resident #1's room with Nurse #1. The Foley catheter was attached to bedside drainage and was in a privacy bag. Nurse #1 lifted the resident's johnny and removed the depends and showed the surveyor the tubing taped to the resident's lower abdomen. The resident's meatus was splayed down the center with healed tissue. Nurse #1 said the [DIAGNOSES REDACTED] was caused by the Foley catheter. He said it started as a small black dot and then became worse. During an interview on 5/24/13 at 10:35 A.M. with the Director of Nurses (DON) and Unit Manager (UM) #2, the DON said the resident was compromised and thought the nurses did a good job taking care of the resident. UM #2 nor the DON were aware that the Physician was not notified when the penile ulcer first appeared, or were they aware the order to tape the Foley to the lower abdomen was never transcribed for 10 days after the order was obtained. The UM #2 said it was an editing error. Then the surveyor reviewed the Facility's Foley catheter policy that indicated to secure the catheter to the resident's thigh to prevent tension, and asked where the nurse's document the securement of the catheter. The DON said it was not the policy of the facility to document the securement of the catheter, but she expected it to be done.