Every finding on record at Summer Commons

Based on record review and interviews, the facility failed to assess and monitor a resident after a fall and failed to follow their own Fall management and Neurological evaluation policies and procedures by obtaining neurological assessments for residents who had unwitnessed falls for 3 of 6 residents reviewed for falls. (Resident #9, #23, #71) The facilities Falls Management Policy last updated 2/2025 states under procedure; A fall incident report will be completed after a resident has had a fall, whether it is witnessed or not. Complete Post Fall Observation Tool, following a fall, to identify if the cause of the fall is related to mental status changes, physical limitations or environment factors. A neurological assessment tool will be initiated for falls where there is a known head bump. A neurological assessment will also be initiated for an unwitnessed fall in a resident who has a BIMS (Brief Interview for Mental Status) score of 12 or lower. The facilities Neurological Assessment Policy updated on 1/9/2025 states under procedure; Neurological assessment following resident head injury will be completed for all residents sustaining head trauma or suspected head trauma. In EMR (Electronic Medical Record): Neuro Checks will be conducted - every 15 min x4, every 30 min x4, every 1 hr. x4, every 4 hr. x2 and every 8 hr. x1. Frequency of neuro checks after 24 hours is determined by resident's observed signs and symptoms of neurological compromise. 1. Review of Resident #9’s quarterly Minimum Data Set (MDS) dated [DATE] revealed he/she had a Brief Interview for Mental Status (BIMS) of 5 of 15 indicating he/she was not cognitively intact. On 7/31/25 Resident #9 had an unwitnessed fall and was found lying on the floor. The nurses note dated 7/31/25 at 12:57 p.m., stated, “This writer was sitting at the nurses station when I heard housekeeping telling resident to hold on help was coming, this writer along with 2 CNAs (Certified Nursing Aids) looked around the corner and saw resident laying on the floor in front of [his/her] wheelchair near the visitor restroom. SLP (Speech therapists) states she saw resident attempting to reposition in wheelchair right before the fall. No observable injuries noted, no c/o pain. No indication resident hit head. Resident hoyered off the floor. VM (voice mail) left for POA (Power of Attorney), Copy of incident report in SBAR (Situation Background Assessment and Recommendations) book for provider.” Further review of the medical record lacked evidence of a post fall observation and the neurological assessments being completed after this fall. On 8/9/25 Resident #9 had another unwitnessed fall and was found lying on the floor. The nurses note dated 8/9/25 at 8:02 a.m., stated, “Unwitnessed fall, resident found in bathroom lying on [his/her] right side, Resident is alert and pleasantly confused. [He/she] said, I am in my bedroom, resident also said [he/she] hurt [his/her] forehead on floor. Resident was checked for injury, VSS (Vital signs stable), NVSS (neurological vital signs stable), rom (range of motion) x 4 to baseline. Safety checks throughout shift in place. Notified [resident representative]. Resident stated [he/she] was a little sore from fall. Tylenol given and taken for pain with good effect., will continue to monitor.” Further review of the “Neurological Check Flow Sheet” after this fall has only 5 of the 15 neurological assessments completed. On 8/25/25 at 2:31 p.m., during an interview, the Registered Nurse Manager of the July Unit confirmed the above stating the post fall observation and neurological assessments should be completed after an unwitnessed fall if the resident reports he/she hit their head and if the residents BIMS is below 12 then the neurological assessments should be completed regardless for any unwitnessed falls. 2. Review of Resident #23’s quarterly Minimum Data Set (MDS) dated [DATE] revealed he/she had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating he/she was moderately cognitively impaired. On 08/25/2025 at 10:53 a.m., in an interview with a surveyor, Resident #23 stated he/she had experienced “a bad fall,” but could not remember the details. A review of Resident #23’s clinical record revealed a progress note, dated 8/24/25, which stated “Writer entered room to find patient sitting on the floor. Writer asked patient what happened and he/she stated he/she was on his/her way from the bathroom and his/her feet got twisted up and he/she fell. Writer asked why his/her walker was over by the bathroom and patient stated he/she wasn't using it at the time. He/she states he/she does not remember hitting his/her head. Writer performed complete assessment of patient to find no injuries. (Pupils equal in roundness and reactive to light and accommodation) PERRLA intact, no signs or symptoms of trauma. Vital signs stable. Patient denies pain. Patient stated he/she did not need or want to go to the hospital. Writer called and left message with patient’s son. Notified provider.” A Neurological Check Flowsheet, dated 8/24/25, revealed only 3 of 15 neurological assessments had been completed. On 8/27/25 at 9:50 a.m., in a discussion with a surveyor, the Director of Nursing confirmed staff had not followed the facility’s policy after Resident #23’s fall on 8/24/25, as only 3 neurological assessments had been completed. 3. Review of Resident #71’s quarterly Minimum Data Set (MDS) dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) of 3 of 15 indicating severe cognitive impairment. On 9/16/24 at 10:15 a.m., there is documentation of an unwitnessed fall for Resident #71. There is an incident report stating that the Nurse Practitioner (NP) was in the facility at the time and evaluated the resident and had him/her sent to the Emergency Department (ED) for further evaluation and treatment. On 9/16/24 at 6:30 p.m., there is documentation of Resident #71 having an unwitnessed fall. The record lacks documentation of any further post fall evaluation or neurological assessments being done. On 9/16/24 at 7:30 p.m., there is documentation of another unwitnessed fall for Resident #71. Documentation of neurological assessments started at 7:30 p.m. and continued into the eighth hour after the fall. All other components of the neurological assessment were unremarkable. On 9/17/24 at 3:00 p.m., there is documentation of an unwitnessed fall for Resident #71. Due to extensive injuries, Resident #71 was sent to the local Emergency Department via Emergency Medical Services and then transferred to Maine Medical Center for further evaluation and treatment. On 8/26/25, in an interview with a surveyor, the Director of Nursing (DON) provided documentation for Resident #71's three falls on 9/16/24, and one fall on 9/17/24. The DON confirmed that there were no notes for monitoring Resident #71 with post fall documentation, and there were no neurological assessments documented for the second fall on 9/16/24. On 8/27/25 at approximately 9:00 a.m. in an interview with a surveyor, the July Unit Manager, reviewed the documentation for Resident #71 and confirmed that They should have done neuro checks after the second fall and did not. I was not here at the time, I had already left for the day.

Based on record review and interviews, the facility failed to ensure that the physician was notified of a wound culture and sensitivity (C&S) result when organisms were identified that were resistant to the antibiotic already ordered, for 1 of 1 residents reviewed for non-pressure related skin conditions (#52). A review of the facility's policies and procedures for Antibiotic Stewardship stated 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 12. When a culture and sensitivity (C&S) is ordered, lab results are received, and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. And, Antibiotic Stewardship - Orders for Antibiotics stated, 3. Appropriate indications for use of antibiotics include: a) Criteria met for clinical definition of active infection or suspected sepsis, and b) Pathogen susceptibility, based on culture and sensitivity to antimicrobial (or therapy begun while culture is pending). 6. When a culture and sensitivity (C&S) is ordered, lab results are received, and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. Review of Resident #52's clinical record revealed diagnoses that included chronic venous insufficiency with chronic wounds of both lower extremities. Resident #52 was followed weekly by the wound care specialist and received daily dressing changes to the lower extremities. The record contained a physician's order, dated 5/8/25, for Sulfamethoxazole/trimethoprim (Bactrim) suspension 200 mg/40 mg per 5 ml (milligrams per milliliter) - Give 10 ml by mouth twice daily for 10 days. A wound culture specimen was obtained on 5/5/25. A preliminary report on 5/7/25 stated Unable to evaluate culture for all pathogens due to overgrowth of Proteus. Final culture and sensitivity results, dated 5/10/25, noted 3 organisms present: Proteus mirabilis, Staphylococcus aureus, and Enterobacter cloacae complex. Proteus mirabilis was noted as resistant to the prescribed antibiotic. A nursing progress note, dated 5/8/25, stated 5/8/25 - Late Entry 5/7/2025: Wound Culture results received and this nurse advised nurse practitioner of results. She requested that I reach out to the wound nurse and let her know the results. Nurse Practitioner from (Wound Clinic) was advised and requested a copy of the results be sent to her so she could write antibiotic orders for the resident. A physician's note, dated 5/10/25 noted preliminary wound culture results from 5/7/25 were reviewed and to continue the prescribed antibiotic. On 5/14/25, the Wound Care Nurse Practitioner's note stated Wound cultures obtained were positive for Proteus mirabilis. (Resident #52) was placed on Bactrim DS (double strength) for 10 days. On 08/26/2025 at 12:20 p.m., in an interview with the Director of Nursing (DON), and the [NAME] President of Quality Improvement and Nursing Services, a surveyor discussed results of the wound culture indicating one of the organisms was resistant to Bactrim and the antibiotic was not changed based on the culture results. On 8/26/25 at 1:10 p.m., the Medical Director and DON met with 4 surveyors. The Medical Director reviewed the records with the surveyors and stated she had not been made aware of culture results indicating Proteus mirabilis was resistant to Bactrim, and based on those results, she would have switched the resident's antibiotic to a third generation cephalosporin. On 8/26/25 at 1:50 p.m., in an interview with a surveyor, the DON reviewed the facility's infection tracking, trending and monitoring logs. Resident #52's culture results had not been included. The DON confirmed the facility had failed to identify and report the results of the culture to ensure the use of the appropriate antibiotic as per its antibiotic stewardship program.

Based on record review and observation the facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection related to hand hygiene during medication administration for 1 of 4 residents observed. Finding:The facilities Medication Administration- General Guidelines with an effective date of 5/1/18 states in section A.2, Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly and section 2.b states, Hand sanitization is done with an approved sanitizer. between hand washings, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface.On 8/26/25 at 9:34 a.m. during observation of the medication administration pass on August unit, the Registered Nurse (RN) #1 was observed preparing medications for a resident when she stopped and picked up a piece of foil off the floor and then proceeded to prepare additional medications without performing hand hygiene.On 8/26/25 at 9:37 a.m. the surveyor discussed the lack of maintaining proper hand hygiene during medication preparation with RN#1.

Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 2 medication storage rooms observed (August Unit).On 8/26/25 at 9:15 a.m. a surveyor observed the [NAME] Unit medication room with the Registered Nurse Manager. The refrigerator contained an opened and undated multidose vial of Tuberculin Purified Protein Derivative (TB) with the following manufacturer's instructions of, Once entered, vial should be discarded after 30 days. At this time, the Registered Nurse Manager confirmed the above and discarded the TB vial.

Based on interviews, record reviews and observations the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident after each Minimum Data Set (MDS) 3.0 assessment for 2 of 18 residents (Resident #34 and #32), and failed to ensure a care plan was updated to reflect the current needs in the areas of falls and self-care deficit (Resident #43), and communication (Resident #6) for 4 of 18 residents whose care plans were reviewed.Findings: 1. On 8/25/25 at 9:53 a.m., during an interview, Resident #34 stated, Not that I know of when asked if he/she is invited and/or participates in his/her plan of care. Residents #34's medical record lacked evidence that a care plan meeting was held by the interdisciplinary team (IDT) after the Quarterly MDS dated [DATE]. On 8/26/25 at 1:31 p.m., during an interview, the Licensed Social Worker (LSW) stated Resident #34 has a Guardian and they couldn't get timing down for that IDT meeting but she had attempted to get corresponding dates that would work. On 8/26/25 at 1:36 p.m., during an interview, the LSW provided an email between her and the Guardian dated 6/11/25 and 6/12/25 attempting to plan a date for the IDT meeting. No further attempts were made to ensure Resident #34 had an IDT meeting. The LSW stated we both forgot, it just slipped us. 2. On 8/25/25 at 10:02 a.m., during an interview, Resident #32 stated, They don't tell us, when asked if he/she is invited and/or participates in his/her plan of care. Residents #32's medical record lacked evidence that a IDT meeting held on 8/21/25 included, to the extent possible, participation of Resident #32 to review and revise the care plan. On 8/26/25 at 1:31 p.m., LSW stated the IDT was held on 8/21/25 but resident was still eating so they had the meeting without him/her and the unit manager followed up with the resident after. 3. On 8/25/25 at 11:05 a.m., and at 1:28 p.m., on 8/26/2025 at 10:35 a.m., and at 2:52 p.m., and on 8/27/25 at 11:14 a.m., observation of Resident #43 in the recliner chair, with the call bell lying on the bed or wrapped around the bedside rail across the room and out of reach of the resident. On 8/25/25 at 1:36 p.m., during a resident representative interview, Resident #43's Power of Attorney stated, [he/she] really can't push the call bell, it's a useless object, [he/she] really can't put it together and [he/she] wasn't ever able to use the button around [his/her] neck at home either. Review of Resident #43's care plan updated on 7/22/25 states under the problem At Risk for falls related to weakness, impaired cognition with interventions of Place call bell/light within easy reach.Remind [Resident] to call for assistance before getting up to walk. Respond promptly to calls for assist to the toilet. Under the problem Self Care Deficit related to impaired cognition/communication, general debility secondary to dementia, inability to perform ADL tasks independently and BIMS score of 3 with interventions of Call bell within reach at all times. On 8/27/2025 at 11:16 a.m., both the Registered Nurse (RN#2) and the surveyor observed Resident #43 in the recliner with the call bell across the room on the side rail of the bed. The surveyor discussed the lack of access to the call bell and the care plan that is in place for this resident to have access to the call bell at all times. The RN#2 stated, I think [he/she] probably doesn't know what that is and confirmed the care plan does not reflect the current status of the resident relating to the use of a call bell. 4. Review of Resident #6's Minimum Data Set (MDS) Version 3.0 on 8/26/25 indicated the resident has unclear speech, sometimes makes self-understood, sometimes understands verbal content, sometimes can express ideas/wants. Review of the resident's care plan, last updated on 8/18/25, that addressed the concern of communication states the resident communicates mostly by reading/writing, pointing, picture paper, nod and shakes head. On 8/25/25 at 10:44 a.m. a surveyor attempted to interview Resident #6. The resident was able to respond to yes and no questions but unable to communicate his/her needs or wants to the surveyor. On 8/25/25 at 10:50 a.m. during an interview, Certified Nursing Assistant (CNA)#1 who was assigned to resident#6, stated that communication, is a work in progress and was not aware of any other ways to communicate with this resident. On 8/26/25 at 1:15 p.m. the surveyor met with the Registered Nurse (RN) Manager for the July unit and asked how the resident communicates and how staff communicates with Resident #6. The RN stated, he/she points, says yes/no, staff write stuff down, and stated that he/she wanted her remote earlier and that the resident communicated this by pointing and making a noise to get the staff's attention. When the surveyor asked if the resident could write she stated, no, [he/she] can't write. At this time, the surveyor discussed the residents care plan indicates he/she can write as a form of communication. The RN offered to demonstrate how she communicates with the resident. The resident was able to say yes/no, make facial expressions to express likes/dislikes, and was able to point to the call bell when asked how he/she lets staff know he/she needs something. When the RN asked Resident #6 if he/she can write he/she stated, no, but was given paper and pen. The resident was unable to write any sensical words on the paper. On 8/26/25 at 1:22 p.m. the RN manager confirmed Resident #6 could not communicate by writing and the care plan did not reflect the current status in that area of communication.

Based on interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) program, the facility failed to present evidence that the required members attended 3 of 4 quarters provided (January 2025, April 2025, and July 2025).On 8/27/25, a surveyor reviewed attendance sheets for the QAPI quarterly meetings. A review of the January 2025 QAPI attendance sheet lacked evidence that the Medical Director attended the meeting. The April 2025 QAPI attendance sheet lacked evidence that the Infection Preventionist attended the meeting. The July 2025 QAPI attendance sheet lacked evidence that the Director of Nursing attended the meeting. On 8/27/25 at 3:30 p.m., in a discussion with a surveyor, the Administrator confirmed the finding.

Based on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week on 5 of 62 days (December 2023 and January 2024) reviewed for RN coverage. Finding: On 1/24/2024, during a review of Daily Staffing Postings and nursing working schedules from 12/1/2023 - 1/24/2024, they indicated that on 12/16/23 (Wednesday), 12/17/23 (Thursday), 12/23/23 (Wednesday), 1/12/24 (Friday), and 1/13/24 (Saturday) the facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours. On 1/24/2024, at 10:45a.m., in an interview with the Director of Nursing, the surveyor confirmed the lack of RN coverage for a least 8 consective hours a day, 7 days a week on the dates identified in December of 2023 and January of 2024.

Based on observation, interview and record review, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 33 opportunities. The medication error rate was 6.06% Findings: The facility Eye Drop Administration Policy and Procedure, effective 5/1/2018 instructs nursing to put on examination gloves, with a gloved finger, gently pull down lower eye lid to form pouch, while instructing resident to look up. Place other hand against the resident's forehead to steady. Hold inverted medication bottle between the thumb and index finger and press gently to instill prescribed number of drops into pouch near outer corner of eye, while the eye is closed, use one finger to compress the tear duct in the inner corner of the eye for 1-2 minutes, wipe off tears or excess solution with clean the gods, cotton ball, or tissue, If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes then repeat procedure above and If administering medications to both eyes, use a different gloved finger to apply pressure to the inner tear duct. On 11/15/22 at 8:36 a.m., two surveyors observed a RN on the July Unit prepare and administer medications to Resident #16 and Resident #18. The following occurred: - Resident #16's medication included Clonazepam 0.25 mg and Tamsulosin 0.4 mg capsule with instructions of: Do not open/ crush/ chew. The RN popped out a Clonazepam tablet, dropping it on the medication cart then picking it up with her ungloved hand and placing it in the medicine cup with the other medications. She then applied gloves and removed the already obtained Tamsulosin capsule from the medicine cup, opened it up releasing the contents into the cup with the other medications. She then put all the medications into a white envelope, crushed the medications and then put the mixture back into the medicine cup adding vanilla pudding. At this time, the surveyor intervened and reviewed the Tamsulosin instructions of Do not open/ crush/ chew with the RN. A surveyor asked the RN if opening up the capsules and crushing them is her normal practice she stated, I do, not acceptable, I won't be doing it anymore and then stated, I guess it's too late now and proceeded to administer the medications. -Resident #18's medications included Artificial Tears, 1 drop to both eyes, Olopatadine eye drops,1 drop to both eyes, Keppra 500 mg tablet, Memantine 10 mg tablet, Vescepa 1 gram capsule- give 2 capsules and Levemir Insulin 25 units subcutaneous daily. The RN without applying gloves, held the resident's eyes open and administered olopatadine eye drops, wiping both eyes immediately with the tissue. Next, without waiting the time in-between eye drops, she again, with ungloved hands, held the resident's eyes open and administered the artificial tear eye drops, wiping both eyes immediately with the same tissue. Upon leaving the residents room the RN discarded the insulin needle into the sharps container. At this time, the surveyor discussed the concerns observed during the medication pass with the RN. On 11/15/22 at approx. 9:30 a.m., during an interview with the Director of Nursing and the [NAME] President of Clinical the surveyor discussed the crushing non crushable meds and giving them after surveyor intervention, and not waiting the in-between time when administering eye drops.

Based on observations and interviews, the facility failed to ensure that medications were stored properly by having unattended medication cards on top of the cart allowing residents and unauthorized persons access to them on 1 of 3 days of survey. In addition, the facility failed to ensure expired medications were removed from the supply available for use in 2 of 2 medication rooms (July and August). Findings: 1. On 11/15/22 at 8:36 a.m., during the medication pass observations, the Registered Nurse (RN) locked the medication cart leaving 3 blister packs of medication on top of the cart while she walked away and entered the medication room. The medications were unsecured for approx. 2 minutes. Upon return to the cart, the RN immediately unlocked the cart and put the blister packs away stating, she never leaves them on the cart. On 11/15/22 at approx. 9:30 a.m., this finding was discussed with the Director of Nursing and the [NAME] President of Clinical. 2. On 11/15/22 at 9:49 a.m., observation of the August unit medication room with the Director of Nursing (DON). Refrigerator #2 contained one opened multi use vial of Tuberculin Purified Protein Derivative (TB) with manufacturer's directions of discard opened product after 30 days, further observation reveals the TB vial did not have an opened date nor a discard date. At this time, the DON discarded the TB vial. 3. On 11/15/22 at 1:42 p.m., observation of July unit Medication room with the DON. Refrigerator #1 contained one opened multi use vial of TB with manufacturer's directions of discard opened product after 30 days, further observation reveals the TB vial was labeled with open date of 7/29/22 and an expiration date of 8/28/22. In addition there was one opened vial of Lispro insulin with no residents name and labeled with the date of opening as 7/30/22. At this time, the DON discarded both the TB and the insulin stating the insulin expires 28 days after opening.

Based on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food was labeled and dated in the refrigerator for 2 of 3 days of survey. In addition, the facility failed to monitor refrigerator/freezer temperatures and sanitizer bucket part per million (ppm) daily. Findings: 1. On 11/14/22 at 9:20 a.m., during the initial tour of the kitchen with the Dietician and the Food Service Director (FSD), the following was observed: A moderate amount of debris all over the floor, a heavy amount of dirt and debris on the bottom shelf of the food prep stand, two ceiling vents coated with dust and two ceiling vents with dust hanging from the vents. At this time, the FSD stated the facility currently did not have a cleaning schedule for the Kitchen. The refrigerator contained ham, cheese and eggs which were unlabeled and undated. The FSD and the Dietician confirmed the above concerns during the initial tour. 2. Review of the kitchen temperature logs/sanitizer bucket logs revealed the following: Refrigerator log lacks temperature monitoring since 11/10/22 Reach in freezer log lacks temperature monitoring for 11/11/22 and 11/13/22 Walk in freezer log lacks temperature monitoring since 11/1/22 Walk-in fridge log lacks temperature monitoring for 11/12/22 and 11/13/22 Sanitizer bucket log lacks monitoring of temperature and PPM's for 11/6/22, 11/7/22, and 11/13/22 3. On 11/15/2022, at 8:48 a.m. during the second kitchen tour with the Dietitian, the surveyor observed in the reach-in refrigerator, 2 packages of unlabeled and undated shredded cheese. In addition, a Cleaning checklist for Dietary Aids was observed in the corner of the kitchen above eye level, the last day of documentation was 3/13/22. On 11/15/22 at 10:00a.m., the above findings were confirmed with the Dietitian.

Based on observations, interviews and record reviews the facility failed to maintain an Infection Control Program designed to help prevent the development of infection related to oxygen tubing, bed pans and commodes for 3 of 3 days of survey and failed to prevent the possible transmissions of infections by handling medications and administering injection and eye drops with ungloved hands during medication administration for 2 of 2 medication pass observations. Findings: 1. On 11/14/22 at 11:51 a.m., 11/15/22 at 8:01 a.m., and 11/16/22 at 8:33 a.m., observations of room [ROOM NUMBER] to have Oxygen tubing and nasal cannula lying on the floor, a bed pan stored upside down on the toilet and a seat cushion stored between the toilet and the wall. 2. On 11/14/22 at 10:00 a.m., 11/15/22 at 8:15 a.m., and 11/16/22 at 8:41 a.m., observations of room [ROOM NUMBER] to have 2 commode buckets stored on the floor under the sink and a bed pan stored on the shower chair. 3. On 11/14/22 at 10:41 a.m., 11/15/22 at 11:36 a.m., and 11/16/22 at 8:43 a.m., observations of room [ROOM NUMBER]A bathroom to have a bed pan stored behind the toilet between the handrail and the wall, a commode bucket on the floor with a bariatric bed pan stored upside down on top of it, an emesis basin and a basin filled with boxes of denture cleaning tabs on floor under the sink. 4. On 11/14/22 at 10:44 a.m., 11/15/22 at 11:37 a.m., and 11/16/22 at 8:45 a.m., observations of room [ROOM NUMBER] bathroom to have a commode bucket on the floor with the lid on its side leaning against the wall. 5. On 11/14/22 at 10:46 a.m., 11/15/22 at 8:17 a.m., and 11/16/22 at 8:45 a.m., observation of room [ROOM NUMBER] bathroom to have a commode bucket stored on top of the toilet seat and another commode bucket stored on the shower chair. 6. On 11/14/22 at 11:20 a.m., 11/15/22 at 8:02 a.m., and 11/16/22 at 8:53 a.m., observation of room [ROOM NUMBER] bathroom to have a bed pan stored between the wall and the handrail. On 11/16/22 at 10:36 a.m., during an environmental tour with Director of Nursing (DON), the above findings were observed. 7. On 11/15/22 at 8:02 a.m., a surveyor observed a Registered Nurse (RN) on the August Unit prepare medication for Resident #39. During this observation, the RN had handled 2 separate medications with ungloved hands. At this time, in an interview with the RN, the surveyor confirmed the touching the pills and dropping the medication on the cart to be an infection control concern. 8. On 11/15/22 at 8:36 a.m., two surveyors observed a RN on the July unit prepare medications for both resident #16 and #13. During these observations, the RN handled 6 separate medications with ungloved hands and administered 2 separate eye drop medications without wearing gloves. In addition, the RN administered Insulin injection without wearing gloves, then engaged the safety slide on the needle and placed the used needle in her scrub pocket. Upon leaving the residents room the RN discarded the insulin needle into the sharps container. At this time, the surveyor discussed the infection control concerns with the RN. Facilities: Injectable Medication Administration Policy and Procedure, effective 5/1/2018 for subcutaneous injections, instructs nursing to put on gloves prior to administering the injection. Facilities: Eye Drop Administration Policy and Procedure, effective 5/1/2018 instructs nursing to put on examination gloves prior to administering the eye drops. On 11/15/22 at approx. 9:30 a.m., during an interview with the Director of Nursing and the [NAME] President of Clinical the surveyor discussed the multiple concerns during the medication pass observations.

Based on observations, record review and interviews, the facility failed to review and revise the care plan to reflect the current needs of 1 of 2 residents reviewed for respiratory. (#52) Finding: On 11/14/22 at 12:11. p.m., during an interview, Resident #52 stated, he/she only uses the oxygen during the night from 7p.m.-7a.m. At this time, the oxygen nasal cannula tubing was observed rolled up and stored under the handle of the oxygen concentrator. Resident #52's Significant Change Minimum Data Set (MDS) 3.0 comprehensive assessment, dated 6/28/22, reflected the use of oxygen therapy under section O0100 Special treatments. On review of Resident #52's current care plan, the surveyor could not locate a care plan to address oxygen therapy. On 11/16/22 at 10:36 a.m., the Director of Nursing confirmed the resident uses oxygen nightly and the care plan did not include the use of oxygen therapy.

Based on record review and interview, the facility failed to ensure an as needed (prn) psychotropic medication order met the required 14-day time limit or provided the rationale to extend the time limit beyond the 14 days, with the indicated duration, for 1 of 2 residents reviewed for pain management (Resident #51). Finding: During a review of Resident #51's clinical record, a surveyor noted an order, dated 8/1/22, for a psychotropic medication, Lorazepam, to give 0.5 milligrams (mg), 1 to 2 tablets by mouth every 4 hours as needed for anxiety. The surveyor noted no 14-day limit on the PRN order. On 11/16/22 at 3:30 p.m., the MDS (Minimum Data Set) Coordinator stated physician orders are renewed every 60 days and the lorazepam order had last been renewed on 9/20/22. The MDS Coordinator confirmed that the order did not have a 14-day time limit or rationale for continuing the order beyond the 14-day limit, with a specified duration of the order.

Based on observation, record review and interview, the facility failed to follow their own policy on oxygen (O2) storage and failed to obtain physician orders for oxygen therapy for 1 of 2 residents reviewed for respiratory care. (#52) Findings: Facilities Oxygen Use and Storage policy, revised 7/22, states under Section 5. Respiratory Care: Oxygen tubing should be discarded and changed every week. A label indicating the date and the initials of the staff changing the tubing should be applied to the tubing and Staff changing the tubing should document on the Treatment Administration Record (TAR) when the tubing has been changed following this policy. Facilities Oxygen Safety Precautions policy, revised on 5/18/22, states O2 tubing is changed weekly for those residents on continuous oxygen and anyone on PRN oxygen. When not in use O2 tubing should be stored in close about plastic bag attached to the concentrator. This will be documented on the tar in PCC. On 11/14/22 at 12:11. p.m., during an interview, Resident #52 stated, he/she only uses the Oxygen during the night from 7p.m.-7a.m. At this time, the oxygen nasal cannula tubing was observed to be unlabeled, rolled up and stored under the handle of the oxygen concentrator. Additional observations were made on 11/15/22 at 12:45 p.m. and 11/16/22 at 10:36 a.m., of the nasal cannula tubing, unlabeled, rolled up and stored under the handle of the oxygen concentrator. A review of Resident #52's physician orders lacked evidence of an order for oxygen therapy and oxygen tubing changes. A review of the TAR lacked evidence of oxygen tubing changes weekly. A review of nursing notes dated 6/27/2022 states, Resident noted to have audible wheezes and rapid respirations today, using accessory muscles with breathing short of breath with talking. O2 sat (oxygen saturation in the blood) 82 to 84% on room air, oxygen applied at 2L (liters) with sats up to 99%. A quarterly meeting note dated 6/29/2022 states, [Resident] is currently using O2 intermittently. 96% on 2L. Additional review of the vitals for pulse oximetry (O2 saturations in the blood) reveals he/she frequently uses oxygen of 2-3 Liters per minute. On 11/16/22 at 10:36 a.m., Director of Nursing (DON) and surveyor observed the oxygen tubing unlabeled and stored under the handle of the concentrator. The DON confirmed the resident uses oxygen nightly. At this time, the surveyor discussed the lack of tubing changes, storage of the tubing and the absence of a physician's order for oxygen.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare instructions necessary to properly care for the resident and failed to ensure that a resident, and/or resident representative, was provided a summary of the care plan for 2 of 3 residents sampled for new admissions (#44 & #113). Findings: 1. Resident #44 was admitted to the facility on [DATE] for rehabilitation. A clinical record review revealed that Resident #44 has a medical diagnosis of Atrial fibrillation and is prescribed an anticoagulant medication Eliquis 20 milligrams (mg) daily. Resident #44's baseline care plan or comprehensive care plan wasn't completed until 8/27/22, 12 days later. 37015 2. On 11/14/22 at 11:45 a.m., Resident #113 stated no one had met with him/her since admission to discuss care planning. Resident #113 stated he/she had not been provided a summary of the baseline care plan. A review of Resident #113's clinical record indicated he/she was admitted to the facility on [DATE]. The baseline care plan was initiated on 11/11/22. The clinical record lacked evidence that the resident, and/or resident representative, were provided a summary of Resident #113's baseline care plan. On 11/16/22 at 12:00 p.m., the Social Worker stated the facility does not provide copies of baseline care plans or conduct resident/family meetings to discuss care planning within 48-72 hours of admission. On 11/16/22 at 12:10 p.m., the findings were discussed with the Director of Nursing.

Based on observations, interviews and lunch meal test trays, the facility failed to serve hot foods for 1 of 2 lunch meals tested for appetizing temperatures. Findings: 1. On 11/14/22 at 3:47 p.m., during an interview with Resident #39 he/she stated the food is cold, cafe style food and not very good. On 11/15/22 at 1:04 p.m., in an additional interview, he/she stated the food temperature is cold and no different than normal. 2. On 11/14/22 at 1:12 p.m., during an interview with Resident #57, he/she stated the food, is horrible, over cooked and cold. On 11/15/22 at 12:59 p.m., in an additional interview, he/she stated, it was good for a change. The surveyor asked if the food was hot enough, he/she stated, not really, only about 2 degrees warmer. 3. On 11/14/22, during observation of the lunch meal pass on the August unit, a surveyor observed 2 residents returned their food, requesting it to be reheated. At this time, the Dietitian confirmed the residents request for reheating. 4. On 11/15/22, on the August unit, a regular diet meal was requested for a temperature and taste sensation test. The test tray was tested by two surveyors. The turkey tested at 97.3 degrees F and was very salty and had a taste sensation of lukewarm. On 11/15/22 at 1:30 p.m., during an interview with the Dietitian the above was discussed.

Based on observations, interviews, and record review, the facility failed to implement their own policy and Centers for Disease Control and Prevention (CDC) guidelines, by failing to ensure safe linen (soiled) handling, screening of health care personnel (ambulance staff) entering the facility and use of Personal Protective Equipment (PPE) for 1 of 1 day of survey (12/9/2020). Findings: 1. On 12/9/2020 at 9:40 a.m., a Certified Nursing Assistant (CNA) was observed exiting droplet precaution room [ROOM NUMBER] for a Person Under Investigation (PUI) with wet soiled linen in her left gloved hand, and a balled up blanket in her right gloved hand holding it against her gown, neither were bagged, and transported the soiled linen to the soiled utility room down the hall. In an interview with a surveyor, the CNA she stated she hasn't been told to bag dirty linen during transport and it doesn't have to. 2. On 12/9/2020 at 9:44 a.m., observation of 4 ambulance staff entered the facility through the 200's unit door, for a non-emergent transfer, without being screened for COVID -19 signs and symptoms. 3. On 12/9/2020 at 1:16 p.m., laundry staff was observed entering a PUI room without gloves. Approximately 1 minute later, she exited. In an interview with a surveyor, she confirmed she did not wear gloves in the PUI room. A review of CDC recommendations for Health Care Associated Infections, Appendix D - Linen and Laundry Management, last reviewed 3/27/2020, recommended the following for Long-Term Care Facilities: Place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. The CDC's Preparing for COVID-19 in Nursing Homes, updated 6/25/2020, states, under section Evaluate and Manage Healthcare Personnel, screen all HCP (Health Care Personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. The facility's Response to suspected infectious respiratory symptoms (e.g. COVDI-19) plan, created on 3/30/2020, indicated the following: -Section B: Persons Under Investigation. institute contact and droplet precautions plus eye protection for staff caring for the resident and roommate. This equates to gown, gloves, surgical mask and goggles. A face shield can be used in place of goggles, staff with casual contact with the resident (greater than 6 feet from the resident) or short term close contact (closer than 6 feet for less than 3 minutes) will wear gloves, gown, face mask and goggles or face shield -Section G: Transport to a higher level of care. Screen and mask EMS staff who enter the facility. The facility's Emerging Infectious Respiratory Disease Preparedness and Response Plan, revised on 6/9/2020, indicated the following: -Section 8: visitors and Other Activities. Other visits necessary for the resident or facility safety may be permitted to enter with appropriate screening and PPE use (e.g. EMS, Fire, State Officials, Equipment Vendors, Funeral home etc.) On 12/9/2020 at 1:45 p.m., the surveyor confirmed the findings of improper soiled linen handling, the lack of screening ambulance staff prior to entry (for non-emergent transfer), and the lack of glove use by laundry staff in a PUI room, with the Administrator and Director of Nursing.

Based on Interview, Observation, and Record Review the facility failed to implement the United States Centers for Disease Control's (CDC) and Centers for Medicare and Medicaid Services' (CMS) COVID-19 Long-Term Care Facility guidelines. This could affect 1 of 3 residents reviewed. Findings Include: Record Review of Resident #1 Progress Note dated 6/15/2020 revealed that Resident #1 was outside of facility property visiting c (with) dtr (daughter) s (without) wearing a mask and dtr was not wearing a mask. Resident was moved and placed on droplet precautions and resident must be supervised when going outside, he/she cannot be left unattended Observation during the facility tour revealed that Resident #1's room had a sign stating that the room was placed on Droplet precautions, however there was no isolation cart located outside the room, nor was there any gowns near the room. Interview during the facility tour with the facility Director of Nursing (DON) outside Resident #1's room revealed that Resident #1 was on precautions, however these precautions included staff wearing eye protection and a surgical mask within the room or if the resident was wearing a surgical mask then the staff could wear only a surgical mask. Interview on June 18, 2020 during the facility tour with a facility physician revealed that he/she was consulted about Resident #1 and it is his/her expectation that the resident would be place on precautions which include staff wearing eye protection, a mask, gown, and gloves when entering Resident #1's room and interacting with Resident #1. Interview with the DON on June 18, 2020 during the facility tour confirmed that Resident #1 went outside of the facility unattended and visited with and hugged his/her daughter (both of whom were unmasked during the interaction). Interview further confirmed that Resident #1 was not tested for COVID-19 nor was he/she placed on enhanced droplet precautions (which includes all persons entering the room to wear eye protection, a mask, gown, and gloves) after visiting with and hugging his/her daughter. Interview with the DON also confirmed that Resident #1's daughter was not screened for signs/symptoms of COVID-19 at the time of the visit. Record Review on 6/22/2020 of the CDC Preparing for COVID-19 in Nursing Homes updated on 6/19/2020 states Restrict all visitation to their facilities except for certain [MEDICATION NAME] care reasons, such as end-of-life situations. Record Review on 06/22/2020 of CMS S&C Memo QSO-20-14-NH states For ALL facilities nationwide: Facilities should restrict visitation of all visitors and non-essential health care personnel, except for certain [MEDICATION NAME] care situations, such as an end-of-life situation. In those cases, visitors will be limited to a specific room only. Facilities are expected to notify potential visitors to defer visitation until further notice (through signage, calls, letters, etc.).

Based on record reviews and interviews the facility failed to ensure that 3 of 5 residents reviewed for immunizations received pneumococcal vaccinations (Residents #20, #38 and #41). Findings: 1. During a review of Resident #20's immunization record, the surveyor noted the Resident received the Pneumococcal Conjugate Vaccine (Prevnar 13) on 5/15/18. The surveyor could not locate evidence that the second vaccine, Pneumococcal [MEDICATION NAME] Vaccine (PPSV23), was provided to the resident. In an interview with the Infection Preventionist on 12/10/19 at 11:45 PM, the surveyor confirmed that Resident #20 did not receive the PPSV23. 2. During a review of Resident #38's immunization record, the surveyor noted the resident received the PPSV23 on 10/1/07. The surveyor could not locate evidence that the second vaccine, Prevnar 13, was provided to the resident. In an interview with the Infection Preventionist, on 12/10/19 at 11:45 PM, the surveyor confirmed that Resident #38 did not receive the second pneumococcal vaccination. 3. During a review of Resident #41's immunization record, the surveyor noted the resident received the PPSV23 on 5/18/15, but could not locate evidence that the second vaccine, Prevnar 13, was provided to the resident. In an interview with the Infection Preventionist on 12/10/19 at 11:45 PM, the surveyor confirmed that Resident #41 did not receive the Prevnar 13 vaccination.

Based on record reviews and interviews the facility failed to ensure as needed (PRN) [MEDICAL CONDITION] medications met the required 14-day limit for 1 of 6 residents reviewed for unnecessary medications (Resident #5). Finding: A review of physician's orders [REDACTED]. On review of the resident's current physician's orders [REDACTED]. The medical record lacked evidence the medication order was stopped and there was no evidence the physician reviewed the order to provide rational to continue the (PRN) medication. On 12/10/19 at 2:51 PM in an interview with the Director of Nursing, the surveyor confirmed Resident #5 was prescribed a PRN antipsychotic since 10/8/19 with no stop date after 14 days and no re-evaluation of the order.

Based on record review and interviews, the facility failed to provide the necessary care and services to ensure 1 of 1 sampled resident (#1) was not neglected while using a bedpan. The facility's failure to ensure that a resident was not left on a bed pan. This neglect resulted in Resident #1 sustaining an injury from the prolonged pressure of the bedpan into his/her skin. Finding: Resident #1 had [DIAGNOSES REDACTED]. The annual MDS assessment for Resident #1, dated 6/13/10, documented that the resident was totally dependent on staff for toileting needs with the physical assistance of 1 person. A nurse's note, dated 11/6/10, at 1:30 a.m., documented that the resident was found on a bedpan with "dark red indentations noted from the rim of pan" in the resident's skin. In an interview with the Registered Nurse and the Acting Director of Nurses on 11/17/10, at 10:10 a.m., the surveyor was informed that the facility review of this incident was unable to determine who put the resident on the bed pan or how long the resident had been on the bed pan. On 11/17/10 at 2:38 p.m., the surveyor conducted an interview with the Certified Nursing Assistant (CNA) who discovered the resident on the bed pan. The CNA stated that at approximately 1:15 a.m. to 1:30 a.m. on the morning of 11/6/10, she had entered the resident's room with another CNA to check on the resident and reposition the resident. The CNA stated that when she was getting ready to reposition the resident, she noticed there was a bed pan underneath the resident. The CNA stated that the evening staff did not make them aware that anyone was on a bedpan and the bed pan was full of both stool and urine. The CNA stated that when the bed pan was removed the resident had a very dark red indentation of the skin which matched the outline of the bed pan. A review of the nurse's notes showed that the skin injury was monitored for 6 days and was documented as resolved on 11/12/10.

Based on record review and interview the facility failed to provide the necessary care and services to prevent the development of a pressure sore for 1 of 1 sampled resident (#1). This failure resulted in the development of a preventable stage 1 pressure sore. Finding: Resident #1 had [DIAGNOSES REDACTED]. The annual MDS assessment for Resident #1, dated 6/13/10, documented that the resident was totally dependent on staff for toileting needs with the physical assistance of 1 person. A nurse's note dated 11/6/10 at 1:30 a.m., documented that the resident was found on a bedpan with "dark red indentations noted from the rim of the pan" in the resident's skin. In an interview with the Registered Nurse and the Acting Director of Nurses (DON) on 11/17/10, at 10:00 a.m., the surveyor was informed that the facility review of this incident was unable to determine who put the resident on the bed pan or how long the resident had been on the bed pan. The surveyor reviewed the nurse's notes on 11/17/10, with the Acting DON, who stated, "it was a Stage 1," and showed the surveyor that the injury was monitored for 6 days and was documented as resolved on 11/12/10.