Every finding on record at Vantage Health & Rehab of New Bedford

Based on document review and interview, the facility failed to implement their abuse policy for injuries of unknown origin for one Resident (#25), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, undated, indicated but was not limited to the following: - It is the responsibility of our employees, agency staff, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source to facility management- The abuse coordinator in the facility is the Director of Nurses (DON)- To help with recognition of incidents of abuse the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: 1. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND 2. the injury is suspicious because of the extent of the injury; location of the injury; number of injuries observed at one particular point in time or the incidence of injuries over time. Resident #25 was admitted to the facility in July 2019 and had diagnoses including Alzheimer's disease, unspecified dementia, hypertension, and history of transient ischemic attack (TIA) (a temporary blockage of blood flow to the brain typically caused by a blood clot). Review of the Minimum Data Set (MDS) assessment, dated 11/20/25, indicated the Resident was dependent for all activities of daily living, including transferring in and out of the bed, used a wheelchair for dependent mobility and had limitations on one side of his/her upper body, was not on any anticoagulant medications (blood thinner medication that decreases the bloods' ability to clot, preventing the formation and growth of harmful blood clots), and did not have any physical behaviors or rejection of care behaviors. Review of the Brief Interview for Mental Status (BIMS) indicated the Resident is rarely or never understood and had severely impaired cognitive skills. Review of the medical record indicated the Resident's Healthcare proxy (HCP) was activated on 8/19/24. Review of the current Physician's Orders indicated but was not limited to:- Aspirin 325 milligrams(mg) one daily for TIA (3/22/25) During an interview on 2/17/26 at 9:30 A.M., the HCP for Resident #25 said the Resident is dependent on the staff for care and required two staff members for care. She said the Resident frequently suffers from bruises on their arms, legs, and thighs and the facility does not provide them with a source or cause of the bruising but instead uses the excuse that the Resident is on aspirin and therefore will bruise easier. She said they never have a reason of how the bruises occurred and she is concerned and has shared those concerns with the facility. During an interview on 2/18/26 at 11:21 A.M., the DON said she had provided the surveyor with six completed incident report (type: Bruise) and investigations for bruising found on Resident #25 on 5/6/25, 7/7/25, 7/17/25, 9/29/25, 10/15/25 and 2/9/26. She said she did not have any other investigations for the Resident and those provided were completed investigations. Review of the facility provided incident reports/investigations indicated the following: - 5/6/25: Description: at 8:00 P.M. on 5/5/25 the nurse was notified that the patient had a faint bruise to his/her left upper thigh during activities of daily living (ADLs); the area was assessed to be less than pink and miniscule; reassessed on 5/6/25 and the area became more prominent with purple discoloration 0.4 by (x) 0.4 centimeters (cm); skin prep to heels; all other skin to be within normal limits. Predisposing factors left blank. Two witness statements none indicate a source or cause of area. Change in condition assessment indicated bruise on left thigh and otherwise left blank. - 7/7/25: Description: During shower a penny sized bruise was observed on the left inner ankle. Predisposing factors indicate confusion and ambulating without assist (resident was non-ambulatory); one witness statement dated 7/3/25 indicating bruise found on the right leg during shower and reported to nurse. Change in condition form blank. No source or cause of bruise identified.- 7/17/25: Description: During routine A.M. shower a 2.5cm x 2.5cm deep purple-greenish discoloration on patients left lower ankle; no other bruises or injuries; no recent reports of injury were noted. Predisposing factors indicate confused, impaired memory and other (dependent for ADLs and mechanical lift (Hoyer)); no witness statements or change of condition. No source or cause of bruise identified.- 9/29/25: A source of injury was indicated on this incident report/investigation- 10/15/25: Description: HCP notified staff of discoloration to left forearm laterally; greenish-yellow dime sized discoloration observed; geri-sleeves were placed. Predisposing factors blank. Change in condition indicated Aspirin 325mg daily, Resident is currently a Hoyer for transfers and noted a yellow and greenish discoloration to the LLE [sic] (left lower extremity). No cause or source identified.- 2/9/26: Description: Nurse was notified that the Resident obtained what appears to be a bruise to the right upper arm, noted ecchymosis on mid anterior-forearm 3cm x 2cm yellow-brown-to purple consistent with resolving bruise. No additional markings. Predisposing factors blank. Change in condition indicated skin wound. Three witness statements none identify a source or cause of the wound. Five of six of the incident reports failed to indicate a source or cause of the injury to Resident #25. Review of the progress notes for Resident #25 from May 2025 through February 18, 2026, indicated, but were not limited to the following: 5/6/25 - deep purple area to left upper thigh - the note failed to indicate a potential source of injury5/30/25 - deep purple bruise looks self-inflicted - the note failed to indicate location of the bruise or why they believed it was self-inflicted7/7/25 - two small bruises right lower extremity (RLE) at inner shin - the note failed to indicate a potential source of injury7/17/25 - purple-blue bruise to left lower ankle - the note failed to indicate a potential source of the injury 10/8/25 - bruise to right shin - could possibly be because Resident crosses their legs - the note failed to indicate a cause/source that was verified or investigated10/14/25 - left forearm green-yellowish discoloration was positional and transfers - the note failed to indicate a cause/source of the bruise but provided factors that may lead to a source 2/9/26 - bruise to right forearm lines up with splint which is likely source of injury Review of the progress notes indicated seven incidents of bruising to the Resident from May 2025 to February 18, 2026. Six of the seven incidents failed to identify an investigated source or cause of injury, and six of eight incidents had incident reports initiated. Review of the Healthcare Facility Reporting System (HCFRS) from May 2025 to February 18, 2026, failed to indicate the injuries of unknown source had been reported to the Department of Public Health (DPH) in accordance with their abuse policy and guidance. During an interview on 2/19/26 at 2:35 P.M., the DON reviewed the surveyor's findings and said all the incidents without a known cause or source of how the bruise or discoloration may have occurred should have been reported to DPH in accordance with the facility abuse policy for investigation and to rule out potential abuse. She could not explain why the two documented incidents of bruising/discoloration on 5/30/25 and 10/8/25 had been unknown to her and therefore not investigated or reported. She said the Resident could not have self-inflicted injuries as he/she had no history of self-inflicting injuries, is not resistive to care, and had very limited mobility. She said she did not have any information on the 5/30/25 and 10/8/25 incidents and she had not reported any of the incidents of injury of unknown source in accordance with the facility abuse policy; the policy was not followed as it should have been. During an interview on 2/19/26 at 3:30 P.M., the Administrator said his expectation is that bruises or any injury of unknown origin/cause or source is reported and investigated as potential abuse in accordance with the facility policy and if that did not occur in these circumstances the policy was not implemented as it was supposed to be.

Based on document review and interview, the facility failed to report injuries of unknown origin for one Resident #25, out of a total sample of 17 residents.Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, undated, indicated but was not limited to the following: - It is the responsibility of our employees, agency staff, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source to facility management- The abuse coordinator in the facility is the Director of Nurses (DON)- To help with recognition of incidents of abuse the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: 1. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND 2. the injury is suspicious because of the extent of the injury; location of the injury; number of injuries observed at one particular point in time or the incidence of injuries over time. - Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the DON. In the absence of the DON such reports can be made to the supervisor on duty. Review of the facility's policy titled Residents Right to Freedom from Abuse, Neglect, Exploitation, dated 2024, indicated but was not limited to the following: - When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately.- Reporting the alleged violation within required timeframes pursuant to federal and state statues and regulations. - In response to allegations of abuse, neglect, exploitation or mistreatment the facility shall: ensure all alleged violations including injuries of unknown source are reported in the proper time frame and report the results of all investigations to the administrator and to other officials in accordance with state law, including the state surveying agency within five working days of the incident Resident #25 was admitted to the facility in July 2019 and had diagnoses including Alzheimer's disease, unspecified dementia, hypertension, and history of transient ischemic attack (TIA) (a temporary blockage of blood flow to the brain typically caused by a blood clot). Review of the Minimum Data Set (MDS) assessment, dated 11/20/25, indicated the Resident was dependent for all activities of daily living, including transferring in and out of the bed, used a wheelchair for dependent mobility and had limitations on one side of his/her upper body, was not on any anticoagulant medications (blood thinner medication that decreases the bloods' ability to clot, preventing the formation and growth of harmful blood clots), and did not have any physical behaviors or rejection of care behaviors. Review of the Brief Interview for Mental Status (BIMS) indicated the Resident is rarely or never understood and had severely impaired cognitive skills. Review of the medical record indicated the Resident's Healthcare proxy (HCP) was activated on 8/19/24. Review of the current Physician's Orders indicated but was not limited to:- Aspirin 325 milligrams(mg) one daily for TIA (3/22/25) During an interview on 2/17/26 at 9:30 A.M., the HCP for Resident #25 said the Resident is dependent on the staff for care and required two staff members for care. She said the Resident frequently suffers from bruises on their arms, legs, and thighs and the facility does not provide them with a source or cause of the bruising but instead uses the excuse that the Resident is on aspirin and therefore will bruise easier. She said they never have a reason of how the bruises occurred and she is concerned and has shared those concerns with the facility. Review of the facility provided incident reports/investigations indicated the following: - 5/6/25: Description: at 8:00 P.M. on 5/5/25 the nurse was notified that the patient had a faint bruise to his/her left upper thigh during activities of daily living (ADLs); the area was assessed to be less than pink and miniscule; reassessed on 5/6/25 and the area became more prominent with purple discoloration 0.4 by (x) 0.4 centimeters (cm); skin prep to heels; all other skin to be within normal limits. Predisposing factors left blank. Two witness statements none indicate a source or cause of area. Change in condition assessment indicated bruise on left thigh and otherwise left blank. - 7/7/25: Description: During shower a penny sized bruise was observed on the left inner ankle. Predisposing factors indicate confusion and ambulating without assist (resident was non-ambulatory); one witness statement dated 7/3/25 indicating bruise found on the right leg during shower and reported to nurse. Change in condition form blank. No source or cause of bruise identified.- 7/17/25: Description: During routine A.M. shower a 2.5cm x 2.5cm deep purple-greenish discoloration on patients left lower ankle; no other bruises or injuries; no recent reports of injury were noted. Predisposing factors indicate confused, impaired memory and other (dependent for ADLs and mechanical lift (Hoyer)); no witness statements or change of condition. No source or cause of bruise identified.- 9/29/25: A source of injury was indicated on this incident report/investigation- 10/15/25: Description: HCP notified staff of discoloration to left forearm laterally; greenish-yellow dime sized discoloration observed; geri-sleeves were placed. Predisposing factors blank. Change in condition indicated Aspirin 325mg daily, Resident is currently a Hoyer for transfers and noted a yellow and greenish discoloration to the LLE [sic] (left lower extremity). No cause or source identified.- 2/9/26: Description: Nurse was notified that the Resident obtained what appears to be a bruise to the right upper arm, noted ecchymosis on mid anterior-forearm 3cm x 2cm yellow-brown-to purple consistent with resolving bruise. No additional markings. Predisposing factors blank. Change in condition indicated skin wound. Three witness statements none identify a source or cause of the wound. Review of the progress notes for Resident #25 from May 2025 through February 18, 2026, indicated, but were not limited to the following: 5/6/25 - deep purple area to left upper thigh 5/30/25 - deep purple bruise looks self-inflicted7/7/25 - two small bruises right lower extremity (RLE) at inner shin 7/17/25 - purple-blue bruise to left lower ankle10/8/25 - bruise to right shin - could possibly be because Resident crosses their legs 10/14/25 - left forearm green-yellowish discoloration was positional and transfers 2/9/26 - bruise to right forearm lines up with splint which is likely source of injury Review of the progress notes indicated seven incidents of bruising to the Resident from May 2025 to February 18, 2026. Six of the eight incidents failed to identify an investigated source or cause of injury, and six of eight incidents had incident reports initiated. Review of the Healthcare facility reporting system from May 2025 to February 18, 2026, failed to indicate the injuries of unknown source had been reported to the Department of Public Health in accordance with guidance. During an interview on 2/19/26 at 2:35 P.M., the DON reviewed the surveyors' findings with the surveyor and said all the incidents without a known cause or source of how the bruise or discoloration may have occurred should have been reported to DPH in accordance with the facility abuse policy for investigation and to rule out potential abuse. he said she did not have any information on the 5/30 and 10/8/25 incidents. She said she had not reported any of the incidents as she should have. During an interview on 2/19/26 at 3:30 P.M., the Administrator said his expectation is bruises or any injury of unknown origin/cause or source is reported as potential abuse in accordance with the facility policy and that did not occur in these circumstances. During an interview on 2/19/26 at 3:34 P.M., the Chief Operating Officer for the facility said the facility is required to report any injuries of unknown source/origin within two hours to meet the regulatory standard and per the facility's abuse policies.

Based on document review and interview, the facility failed to investigate injuries of unknown origin for one Resident (#25), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, undated, indicated but was not limited to the following: - It is the responsibility of our employees, agency staff, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source to facility management- The abuse coordinator in the facility is the Director of Nurses (DON)- To help with recognition of incidents of abuse the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: 1. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND 2. the injury is suspicious because of the extent of the injury; location of the injury; number of injuries observed at one particular point in time or the incidence of injuries over time. Review of the facility's policy titled Residents Right to Freedom from Abuse, Neglect, Exploitation, dated 2024, indicated but was not limited to the following: - When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately.- Conduct a thorough investigation of the alleged violations - In response to allegations of abuse, neglect, exploitation or mistreatment the facility shall: ensure all alleged violations including injuries of unknown source have evidence that all alleged violations are investigated- Report the results of all investigations to the administrator and other officials in accordance with state law, including the state survey agency within five working days of the incident Resident #25 was admitted to the facility in July 2019 and had diagnoses including Alzheimer's disease, unspecified dementia, hypertension, and history of transient ischemic attack (TIA) (a temporary blockage of blood flow to the brain typically caused by a blood clot). Review of the Minimum Data Set (MDS) assessment, dated 11/20/25, indicated the Resident was dependent for all activities of daily living, including transferring in and out of the bed, used a wheelchair for dependent mobility and had limitations on one side of his/her upper body, was not on any anticoagulant medications (blood thinner medication that decreases the bloods' ability to clot, preventing the formation and growth of harmful blood clots), and did not have any physical behaviors or rejection of care behaviors. Review of the Brief Interview for Mental Status (BIMS) indicated the Resident is rarely or never understood and had severely impaired cognitive skills. Review of the medical record indicated the Resident's Healthcare Proxy (HCP) was activated on 8/19/24. Review of the current Physician's Orders indicated but was not limited to:- Aspirin 325 milligrams(mg) one daily for TIA (3/22/25) During an interview on 2/17/26 at 9:30 A.M., the HCP for Resident #25 said the Resident is dependent on the staff for care and required two staff members for care. She said the Resident frequently suffers from bruises on their arms, legs, and thighs and the facility does not provide them with a source or cause of the bruising but instead uses the excuse that the Resident is on aspirin and therefore will bruise easier. She said they never have a reason of how the bruises occurred and she is concerned and has shared those concerns with the facility. During an interview on 2/18/26 at 11:21 A.M., the DON said she had provided the surveyor with six completed incident report (type: Bruise) and investigations for bruising found on Resident #25 on 5/6/25, 7/7/25, 7/17/25, 9/29/25, 10/15/25 and 2/9/26. She said she did not have any other investigations for the Resident and those provided were completed investigations. Review of the facility provided incident reports/investigations indicated the following: - 5/6/25: Description: at 8:00 P.M. on 5/5/25 the nurse was notified that the patient had a faint bruise to his/her left upper thigh during activities of daily living (ADLs); the area was assessed to be less than pink and miniscule; reassessed on 5/6/25 and the area became more prominent with purple discoloration 0.4 by (x) 0.4 centimeters (cm); skin prep to heels; all other skin to be within normal limits. Predisposing factors left blank. Two witness statements none indicate a source or cause of area. Change in condition assessment indicated bruise on left thigh and otherwise left blank. - 7/7/25: Description: During shower a penny sized bruise was observed on the left inner ankle. Predisposing factors indicate confusion and ambulating without assist (resident was non-ambulatory); one witness statement dated 7/3/25 indicating bruise found on the right leg during shower and reported to nurse. Change in condition form blank. No source or cause of bruise identified.- 7/17/25: Description: During routine A.M. shower a 2.5cm x 2.5cm deep purple-greenish discoloration on patients left lower ankle; no other bruises or injuries; no recent reports of injury were noted. Predisposing factors indicate confused, impaired memory and other (dependent for ADLs and mechanical lift (Hoyer)); no witness statements or change of condition. No source or cause of bruise identified.- 9/29/25: A source of injury was indicated on this incident report/investigation- 10/15/25: Description: HCP notified staff of discoloration to left forearm laterally; greenish-yellow dime sized discoloration observed; geri-sleeves were placed. Predisposing factors blank. Change in condition indicated Aspirin 325mg daily, Resident is currently a Hoyer for transfers and noted a yellow and greenish discoloration to the LLE [sic] (left lower extremity). No cause or source identified.- 2/9/26: Description: Nurse was notified that the Resident obtained what appears to be a bruise to the right upper arm, noted ecchymosis on mid anterior-forearm 3cm x 2cm yellow-brown-to purple consistent with resolving bruise. No additional markings. Predisposing factors blank. Change in condition indicated skin wound. Three witness statements none identify a source or cause of the wound. Five of six of the reported incidents failed to indicate an investigation was completed to identify the source or cause of the injury to Resident #25. Review of the progress notes for Resident #25 from May 2025 through February 18, 2026, indicated but were not limited to the following: 5/6/25 - deep purple area to left upper thigh - the note failed to indicate a potential source of injury5/30/25 - deep purple bruise looks self-inflicted - the note failed to indicate location of the bruise or why they believed it was self-inflicted7/7/25 - two small bruises right lower extremity (RLE) at inner shin - the note failed to indicate a potential source of injury7/17/25 - purple-blue bruise to left lower ankle - the note failed to indicate a potential source of the injury 10/8/25 - bruise to right shin - could possibly be because Resident crosses their legs - the note failed to indicate a cause/source that was verified or investigated10/14/25 - left forearm green-yellowish discoloration was positional and transfers - the note failed to indicate a cause/source of the bruise but provided factors that may lead to a source 2/9/26 - bruise to right forearm lines up with splint which is likely source of injury Review of the progress notes indicated seven incidents of bruising to the Resident from May 2025 to February 18, 2026. Six of the seven incidents failed to identify an investigated source or cause of injury, and six of eight incidents had incident reports or investigation documentation initiated. Review of the Healthcare Facility Reporting System (HCFRS) from May 2025 to February 18, 2026, failed to indicate the injuries of unknown source had been investigated and reported to the Department of Public Health (DPH) in accordance with their abuse policy and guidance. During an interview on 2/19/26 at 2:35 P.M., the DON reviewed the surveyor's findings and said all the incidents of bruising or discoloration should have been investigated for a source or cause of the bruise. She said she did not have any further investigation or documents for the six known incidents, and she was not aware of the additional two incidents on 5/30/25 and 10/8/25 and therefore no investigation or reports are available. She said the Resident had factors that would make bruising more likely, but that is a factor in the investigation, not the cause of the bruising. She said these events should have been thoroughly investigated and gone through the facility process and did not. During an interview on 2/19/26 at 3:30 P.M., the Administrator said his expectation is bruises or any injury of unknown origin/cause or source is investigated as potential abuse in accordance with the facility policy and if that did not occur in these circumstances then the policy was not implemented as it was supposed to be.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections. Findings include:Review of the facility's policy titled Infection Prevention and Control Program, dated December 2023, indicated, but was not limited to, the following:-An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.-The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.-Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness.-Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications.-Outbreak management is a process that consists of:1) determining the presence of an outbreak.2) managing the affected residents.3) preventing the spread to other residents.4) documenting information about the outbreak5) reporting the information to appropriate public health authorities.6) educating the staff and the public.7) monitoring for recurrences.8) reviewing the care after the outbreak has subsided.9) recommending new or revised policies to handle similar events in the future.-Specific criteria will be used to help differentiate sporadic cases from true outbreaks or epidemics. During an interview on 02/18/26 at 4:17 P.M., the Infection Preventionist (IP) said the facility utilizes McGeer Criteria (standardized surveillance definitions used to identify and report infections) to determine if an illness rises to the level of an infection. She said she tracks all infections on a monthly line listing document. Review of the facility's monthly line listings for October, November, December 2025 and January 2026 indicated, but was not limited to, the following: October 2025-15 out of 28 residents failed to include signs and symptoms of an illness.-4 out of 10 urinary tract infections treated failed to include culture results identifying the organism/bacteria. November 2025-8 out of 26 resident infections failed to include signs and symptoms of an illness.-2 out of 9 urinary tract infections treated failed to include culture results identifying the organism/bacteria. December 2025-2 out of 11 resident infections failed to include signs and symptoms of an illness.-2 out of 3 urinary tract infections treated failed to include culture results identifying the organism/bacteria. January 2026-31 out of 40 resident infections failed to include signs and symptoms of an illness.-7 out of 11 urinary tract infections treated failed to include culture results identifying the organism/bacteria. During an interview on 2/19/26 at 11:14 A.M., the IP said she obtains the data to include on the monthly line listing from reviewing the 24-hour progress notes and antibiotic use report. She said the line listing document should have included all symptoms and culture results, but she has not been consistent with tracking the information. During an interview on 2/19/26 at 4:21 P.M., the Director of Nursing (DON) said the line listings should have included symptoms and culture results for accurate monitoring of infections within the facility. The DON said the line listings are inaccurate and incomplete.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include:Review of the facility's policy titled Antibiotic Stewardship Program, last revised December 2016, indicated but was not limited to the following:-Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.-The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.-When a culture and sensitivity is ordered lab results 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 the facility's policy titled Antibiotic Stewardship Review and surveillance of Antibiotic Use and Outcomes, last revised December 2016, indicated but was not limited to the following:-Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.-All clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee-The IP, or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics-Therapy may require further review and possible changes if:-The organism is not susceptible to antibiotic chosen.-The organism is susceptible to narrower spectrum antibiotic.-Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics.-At the conclusion of the review, the provider will be notified of the review findings. Review of the facility's policy titled Infection Prevention and Control Program, dated December 2023, indicated, but was not limited to, the following:-An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.-The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.-Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness.-Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. During an interview on 02/18/26 at 4:17 P.M., the IP said the facility utilizes McGeer Criteria (standardized surveillance definitions used to identify and report infections) to determine if an illness rises to the level of an infection. The IP said she keeps all McGeer criteria sheets with the line listings organized by month and year. She said she tracks all infections on a monthly line listing document. Review of the facility's monthly line listing documents for December 2025 and January 2026 indicated but were not limited to the following:December 2025Resident #22 had a urinary tract infection (UTI) concern with an onset date of 11/28/25. The surveillance indicated that the concern did rise to the level of infection as determined by the facility criteria, an antibiotic was prescribed for seven days. No McGeer criteria was located for the concern. Review of Resident #22's nursing progress notes indicated an antibiotic was initiated on 12/4/25 with symptoms documented of foul, cloudy urine. No further specific signs or symptoms of infection were indicated in the medical record. During an interview on 2/19/26 at 11:14 A.M., the IP said she cannot locate the McGeer criteria for Resident #22's concern. The IP reviewed the line listing document and progress notes. She said the line listing is inaccurate and the illness did not meet McGeer criteria for infection.Further review of Resident #22's medical record, including nursing, physician and nurse practitioner progress notes, failed to indicate reasoning for continued antibiotic usage even though the symptoms did not meet McGeer criteria. January 2026Resident #6 had a UTI concern with an onset date of 1/22/26. The surveillance indicated that the concern did rise to the level of infection as determined by the facility criteria, an antibiotic was prescribed for seven days. No McGeer criteria was located for the concern.Review of Resident #6's nursing progress notes indicated an antibiotic was initiated on 1/22/26 with symptoms documented of dark, yellow urine. No further specific signs or symptoms of infection were indicated in the medical record.During an interview on 2/19/26 at 11:34 A.M., the IP said she could not locate any McGeer criteria for Resident #6's concern for infection. The IP reviewed the line listing document and progress notes. She said the line listing is inaccurate and the illness did not meet McGeer criteria for infection.Further review of Resident #6's medical record, including nursing, physician and nurse practitioner progress notes, failed to indicate reasoning for continued antibiotic usage even though the symptoms did not meet McGeer criteria. During an interview on 2/19/26 at 12:21 P.M., the IP said she does not follow up with providers about antibiotics being prescribed when they do not meet McGeer criteria. She said she only tracks antibiotics on the line listing documents. During an interview on 2/19/26 at 4:21 P.M., the Director of Nursing (DON) said all concerns of infection need to have McGeer criteria completed to ensure an accurate overview of antibiotic use in the facility. She said the IP should be communicating with providers and documenting the rationale for continued antibiotic use in the medical record to ensure residents are not being placed on antibiotics unnecessarily.

Based on document review and interview, the facility failed to implement their grievance process and attempt to resolve grievances in a timely manner for one Resident (#25), out of a total sample of 17 residents.Findings include: Review of the facility's policy titled Grievance Policy, dated 1/5/26, indicated but was not limited to the following: - [Corporate Name] shall ensure that residents, family members, responsible parties are provided with a mechanism to communicate concerns, conflicts, complaints, grievances or opportunities for improvement in care and services- grievance forms are available for the resident, family, responsible party to complete on first floor bulletin board, through resident council activity staff, and with social services- it is the responsibility of all staff who hear a grievance to report it to their supervisor- investigation and resolution of grievances shall be completed in a timely manner (within 5 working days of receipt of the grievance form)- the individual initiating the grievance will be notified of the findings and method of resolution by the Director of Social Services or designee- the Director of Social Services will maintain grievance forms received and resolutions developed- the Director of Social Services will use the grievance tracking log to track the grievance process Resident #25 was admitted to the facility in July 2019 and had diagnoses including Alzheimer's disease, unspecified dementia, hypertension and history of transient ischemic attack (a temporary blockage of blood flow to the brain typically caused by a blood clot). During an interview on 2/17/26 at 9:30 A.M., the healthcare proxy (HCP) for Resident #25 said she had put in grievances for repetitive bruising and other care issues and had recently put in a few more grievances on 2/9/26 and had not heard back from the facility. She said the facility does not get back to her with resolutions and when they have meetings with her, they claim she is accusatory, but she is concerned about her family member and wants to make sure they are getting the best care and not getting hurt by staff. During an initial interview on 2/17/26 at 10:46 A.M., the Administrator said he is the facility's grievance officer, and he works closely with the social worker (SW). Review of the Grievance Book indicated the following from July 2025 to February 17, 2026 for Resident #25: - 8/5/25: Nature of concern: see attached - a social service progress note was attached to the grievance which indicated the following: family verbalized they feel staff is intentionally not answering the phone from 9:00 P.M. to 10:00 P.M., on Friday, Saturday and Sunday nights. Family expressed frustration with avoiding communication; SW informed family that is not the facility practice; SW suggested the family call when the receptionist is available, family not receptive to suggestionsDepartment notified: AdministratorActions taken: SW spoke with grievant and offered coping strategies and calling when receptionist is available at center; staff will be counselled as to gravity of responding to phone calls at all times day and nightFollow up: ombudsman will be made aware; family will continue to update SWResolution issued: 8/5/25 - SW spoke with grievant The record and grievance form failed to indicate Resident #25's family received any resolution to their grievance but instead was asked to plan phone calls around the availability of the facility's receptionist. - 11/25/25: Nature of concern: see attached - letter from family indicating concerns with ongoing bruises on Resident #25 whether related to Hoyer (mechanical lift used to move residents from one surface to another) or certified nurse aides (CNA) not handling the Resident gently and using lift pads/turning sheet. Letter continues to reference three bruises in September, three in October, one in November (current voiced issue from 11/22/25); concern continued to indicate when they voice concerns about grievances, they are told it is due to the Resident being on aspirin and they do not address the grievance or cause of bruises.Corrective actions: see attached there is no information attachedDate decision was issued: 12/2/25 Review of the record indicated two separate progress notes by the social worker regarding this grievance as follows: 11/28/25: received envelope with grievance dated 11/25/25, writer available in facility on 11/26 and did not reach out. SW notified administrator and ombudsman. 12/2/25: family recently shared care concerns and followed up with a grievance; education provided to family related to Resident #25 taking aspirin. The information on the grievance form and in the medical record failed to indicate a corrective action or resolution was offered to the family to address their concern of ongoing bruising to their family member. The Grievance Book and February Grievance Log failed to indicate the HCP for Resident #25 had filed any grievances in the month of February 2026 During an interview on 2/18/26 at 12:07 P.M., the Director of Nurses (DON) said the family had put in multiple grievances on 2/9/26 but could not speak to why they were not available for review in the Grievance Book. She reviewed the Grievance Book and Grievance Log and said she does not know why the process of tracking the grievances was not being followed as it should be and she would have to find the grievances for the survey team to review. During an interview on 2/18/26 at 12:36 P.M., the Ombudsman said she is very aware of ongoing issues and grievances that the family had provided to the facility regarding care issues and ongoing bruising to Resident #25. She said the family felt they got no response when providing verbal grievances and she encouraged them to put them in writing and photograph their concerns and the grievance form while slipping them under the SW door to prove they had been provided to the facility. She said she felt this way the facility could not tell the family they never received them and the family would have proof they provided them in writing. She said this shouldn't be necessary and the resident and families have the right to voice grievances verbally and have them resolved quickly but that process was not working at the facility. She said she had informed the facility numerous times it is their responsibility to be honest and communicate directly with the family to find a resolution to their concerns, but that doesn't seem to be happening, and the grievances have been ongoing for about a year. She said the family of Resident #25 has been consistently reporting to her that they are not receiving any resolutions to their concerns and they feel unheard. She said the facility SW reached out and informed her that the family left three grievances around 2/9/26 and the facility felt the grievances were repeat issues that had already been resolved. The Ombudsman said she informed the facility that they need to have good communication with the family and resolve concerns and she would only be involved at the family's request as her role is to advocate and speak on the behalf of the residents and their families to ensure their rights are being followed and this issues are ongoing which would indicate that is not happening. She said the facility and family have both informed her they are attempting to coordinate a meeting for next week to discuss these current grievances and the ongoing issues the family is reporting. During an interview on 2/18/26 at 1:47 P.M., CNA #1 said if a resident or family has a concern or complaint, she notifies the nurse or supervisor on duty. She said she doesn't know anything about the grievance process or use of grievance forms. During an interview on 2/18/26 at 1:54 P.M., CNA #3 said if a resident or family has a concern or complaint she attempts to fix the issue, but if she cannot she informs a nurse or supervisor so they can handle it. She said she doesn't know anything about grievance forms and is not part of the grievance process but would complete a witness statement if asked to do so by a nurse. During an interview on 2/18/26 at 2:00 P.M., CNA #4 said if a resident or family tells her a complaint or concern, she passes it along to the supervisor or nurse on duty. She said she had nothing to do with the grievance process or grievance forms and had never offered one to anyone or assisted in completing one. She said they were trained to just report issues. During an interview on 2/18/26 at 2:06 P.M., Nurse #3 said if a family or resident voices a complaint or concern to her she notifies the supervisor on duty or on call on the weekends. She said she does not have anything to do with the grievance process. During an interview on 2/18/26 at 2:47 P.M., the SW provided the survey team with the three grievances from Resident #25's family written on 2/9/26. She said she would expect that if any resident or family voices a concern to the staff they should encourage or help the family in completing a grievance form and they should also alert a nurse or supervisor to the situation. She said residents and their families have the right to voice grievances verbally but no form would be completed for those. She said the only way for the facility to track if a grievance is resolved and not ongoing is to ensure the resident or their family feels heard and the process is followed and documented well. She said she is not the grievance officer for the facility, but assists the Administrator with the investigation and relaying information to the families/residents in follow up. She said the Administrator maintains all grievances in the book, ensures they are complete and logs them. She said for the grievance in August 2025 education should have been done, but it may have been done verbally without documentation and that is why no proof is attached to the grievance itself. She said for the November grievance the staff explained the Resident is on medication that causes bruises and the family isn't understanding, but the facility informed the Ombudsman, so they are aware of the family issues. The SW reviewed the 2/9/26 grievances. She said they are not resolved and the information had not been discussed or provided to the family even though she signed the forms saying that the grievance was resolved and decision was provided on 2/9/26 for all three issues. She said the first issue of having other people's laundry in Resident #25's closet and concerns with inaccurate medical record documentation were new and reported to the Ombudsman as a resolution. She said that information wasn't shared with the family but looking at it now she can see that is not a real resolution. She said the splint being dirty was a new grievance, and the facility will put the splint on a cleaning schedule but that information hasn't been shared with the family yet. She said the grievance for the two welts on Resident #25's skin was also not resolved, but the team completed the form and signed it without relaying their findings or resolution to the family yet. She said they also found a skin check, dated 1/26/26, that indicated the skin issue wasn't there even though the family said they saw it on 1/22/26, (the family provided photographs of the areas that were dated 1/22/26). She said the corrective action indicated the Resident crosses her legs and is in the biggest brief the facility has (green). On review, she said she does not know how that resolution would prevent another issue of the same type and the information had not yet been shared with the family. She said she was asked to sign all three grievance forms as completed on 2/9/26 but they are not complete since the information hasn't been shared with the family and the family has requested a meeting to discuss ongoing issues. She said in retrospect ongoing issues of the same type would indicate they were not resolved. During an interview on 2/18/26 at 3:34 P.M., the Administrator said his expectation is that if any staff member receives a complaint or concern from a resident or family member that they try to correct the immediate issue, then notify the supervisors and either provide the resident/family member with a grievance form or complete one to ensure all concerns are documented and followed through in accordance with the facility policy. He said from there he expects that nursing or social service document the resolution. He said all issues need to be documented on a grievance form since it is the only way for the facility to track if issues are a pattern, ongoing, or unresolved. He said residents and their families have the right to formulate grievances both verbally and in writing. He said Resident #25's family had a threatening way about them and they see the same issues coming up over and over again after they address them and have reported this to the Ombudsman. He said he doesn't know if the facility had ever really resolved any of Resident #25's family's concerns. He reviewed the August 2025, November 2025 and February 9, 2026 grievance forms. He said looking at the area that documents corrective actions and resolutions does not seem to be providing resolutions to the issues, but instead defenses and excuses, which is probably why the issues were ongoing. He said really looking at the situation from a different perspective he can see that the facility had repeatedly provided defense and excuses and did not address the underlying issues in the grievances to resolve any of the concerns brought forward and can understand why the family is so frustrated. He said he realized that in allowing these grievances to go unaddressed with a proper resolution made him part of the problem and he planned on attending the meeting the family had requested. He said the grievance process was not in place as it was intended and Resident #25's grievances had not been resolved. During a follow up telephone interview on 2/20/26 at 11:21 A.M., the HCP for Resident #25 said the facility had not provided her any information to help resolve her grievances that she placed on 2/9/26, but had requested a meeting to discuss the ongoing concerns that have gone unresolved and she's hoping to get some information next week to resolve her concerns.

Based on document review and interview, the facility failed to ensure that monthly medication regimen reviews (MRR) were communicated to the provider and addressed in a timely manner for one Resident (#5), out of a total sample of 17 residents. Specifically, the facility failed to ensure recommendations by the pharmacy consultant to clarify two as needed (PRN) albuterol orders (respiratory inhaler), review risk versus benefit of Paxil (Paroxetine, an antidepressant) medication dosing of extended release (ER) 50 milligrams (mg) daily which is over the daily recommended dose of 37.5mg and recommend Narcan order (reverses opioid overdose) as needed (PRN) due to history of recent opioid overdose, was reviewed and responded to by the provider timely. Findings include:Review of the facility's policy titled Medication Regimen Reviews, undated, indicated but was not limited to the following:-The Consultant Pharmacist shall review the medication regimen of each resident at least monthly.-The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions. The Director of Nursing Services/designee shall ensure prompt (e.g. 5-7 business days) action and documentation occurs related to the Consultant Pharmacist's review and recommendations.-Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. Review of the facility's policy titled Consultant Pharmacist Reports, dated January 2024, indicated but was not limited to the following:-The Consultant Pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion.-A record of the Consultant Pharmacist's observations and recommendations is made available in an easily retrievable form to nursing, prescribers, and the care planning team.-This should include Documentation of the date each medication regimen review is completed and notation of the findings in the medical record.-Comments and recommendations concerning medication therapy and irregularities are reported in a timely manner to ensure the resident's safe and appropriate medication utilization. Resident #5 was admitted to the facility in November 2025 with diagnoses which included chronic obstructive pulmonary disease (COPD- chronic lung disorder resulting in blocked air flow in the lungs), major depressive disorder, and opioid dependence. Review of the Physician's Orders indicated Resident #5 was prescribed the following medications:-Albuterol Sulfate Inhalation Nebulization Solution (2.5mg/3 milliliters (ml)) 0.083% (Albuterol Sulfate) 1 Unit inhale orally via nebulizer every 4 hours PRN for Severe shortness of breath (SOB)/Wheezing, discontinued 2/18/26.-Paroxetine ER 25mg give two tablets = 50mg by mouth one time a day for depression, discontinued 10/21/25.-Paxil controlled release (CR) oral tablet ER 37.5mg one tablet by mouth one time a day related to major depressive disorder, start 10/22/26-Naloxone (Narcan) 0.4mg/ml inject 0.4mg/ml intramuscularly every 2 minutes as needed for sign of opioid overdose. May be repeated every two to three minutes until a response is obtained up to a maximum dose of 10mg. Monitor patient until emergency medical team arrives, start 10/21/25. Review of the progress notes indicated the following:-Pharmacy Consultant made recommendations on 9/17/25 to clarify two PRN albuterol orders, review the Paxil dosing of 50mg daily and recommended adding Narcan PRN.-Pharmacy Consultant made recommendations on 10/14/25 to clarify two PRN albuterol orders, review the Paxil dosing of 50mg daily and recommended adding Narcan PRN.-Pharmacy Consultant made recommendations on 12/16/25 to clarify two PRN albuterol orders.-Pharmacy Consultant made recommendations on 1/19/26 to clarify two PRN albuterol orders. Review of the medical record failed to include the pharmacy consultant recommendation reports made in September, October, and December 2025 and January 2026. Further review of the medical record indicated the physician was made aware of the pharmacy recommendations as follows:-Two albuterol orders discontinued on 2/18/2026, 154 days after the initial recommendation was made.-Paxil ER dosing clarified 10/21/25, 41 days after the initial recommendation was made.-Narcan PRN clarified 10/21/25, 41 days after the initial recommendation was made. During an interview on 2/19/26 at 10:02 A.M., Unit Manager (UM) #1 said the pharmacy consultant emails the recommendations to the unit managers and Director of Nursing (DON) monthly. She prints them and gives them to the provider for review. She documents the findings in a nursing note and gives the recommendations to the DON. During an interview on 2/19/26 at 1:59 P.M., the Pharmacy Consultant said she reviews all of the residents' medication orders monthly. She completes this remotely and in the facility. She said she sends all recommendations over through email to the unit managers and DON. The Pharmacy consultant said the facility has not been achieving 100% compliance with addressing her recommendations and she has seen an increase in duplicate recommendations. The surveyor and pharmacy consultant reviewed the recommendations for Resident #5 together. She said the facility did not address the recommendations timely as they should have. During an interview on 2/19/26 at 4:21 P.M., the DON said all pharmacy recommendations should be reviewed with the providers within a week or sooner of receiving them. She said they should be kept in the Resident's medical record, with the providers response documented. The DON said Resident #5's pharmacy recommendation reports for September, October, and December 2025 and January 2026 could not be located and were not reviewed and completed timely as required.

Based on document review and interview, the facility failed to develop baseline care plans for two Residents (#78 and #79), out of a total sample of 17 residents. Specifically, the facility failed to develop a baseline care plan:1. For Resident #78, that included the necessary care of a colostomy (a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body) and Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag); and2. For Resident #79, that included strategies to mitigate future falls and offer a copy of those care plans to the Resident/healthcare proxy (HCP).Findings include:Review of the facility's policy titled Care Plans - Baseline, dated 2017, indicated but was not limited to the following: - a person-centered baseline care plan to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission-baseline care plans include a minimum of: physician orders, initial goals based on admission orders, therapy and social services -a copy of the baseline care plan or a summary thereof shall be provided to the resident/representative with documentation in the medical record 1. Resident #78 was admitted to the facility in February 2026 with diagnoses including necrotizing fasciitis (an aggressive skin and soft tissue infection that cause necrosis (death) of the muscle fascia and subcutaneous tissues). During an observation with interview on 2/17/26 at 10:14 A.M., the surveyor observed Resident #78 in bed with the head of bed elevated and a Foley catheter drainage bag hanging on the left side of the bed frame. The Resident said he/she had an ostomy. During an interview on 2/17/26 at 4:07 P.M., Certified Nurse Assistant (CNA) #1 said she cares for the Resident daily and the Resident has had a Foley catheter and ostomy since admission. Review of Resident #78's medical record indicated but was not limited to the following: - 48-hour baseline care plan summary: failed to include any information on colostomy care or Foley catheter care. The treatment and orders frequency section of the document was blank- baseline care plan V2 document with section 3C - Bowel and bladder: failed to indicate the Resident had an indwelling Foley catheter or ostomy, section 5 - Summary and signatures: failed to indicate any resident or staff signatures and was blank- Progress notes at the time of admission indicated the Resident presented to the facility with a colostomy and Foley catheter. During an interview on 2/19/26 at 9:01 A.M., Nurse #1 said he completed the majority of admissions on the unit. He said he completes all the admission paperwork but is never involved in the baseline care plan process. He believes it's completed at the management level. During an interview on 2/19/26 at 12:04 P.M., Unit Manager #1 said the process for baseline care plans is that the interdisciplinary team meets about 72 hours after admission and invites the resident/family to discuss appointments, therapy, and discharge plans. She said care plans are not created based off that meeting they are usually made within 21 days. She said a care plan for an ostomy or indwelling catheter is not necessarily in place until the 21-day comprehensive care plans are done. During an interview on 2/19/26 at 2:25 P.M., the Director of Nurses (DON) said the baseline care plan process should be completed in the first 48 hours following admission and cover all the basic things the resident had been admitted for like catheters and ostomies. She reviewed the medical record for Resident #78 and said the process was not followed as it should have been. 2. Resident #79 was admitted to the facility in February 2026 with diagnoses including: metabolic encephalopathy (a form of abnormal brain metabolism characterized by memory loss, dizziness, and generalized weakness), insomnia, weakness and abnormality of gait and mobility. During the survey the surveyor made the following observations of Resident #79 at the following days and times: - 2/17/26 at 8:10 A.M., lying in bed with his/her feet hanging off the right side of the bed and his/her legs wrapped in the bed sheet, the privacy curtain was closed halfway making the Resident not visible from the hallway- 2/17/26 at 12:00 P.M., sitting in a wheelchair with two leg rests, the Resident had removed their left foot from the leg rest and was trying to self-propel in the chair, with little to no success- 2/18/26 at 6:55 A.M., privacy curtain was closed halfway, the Resident was not visible from the hallway; upon entering the room the Resident pulled back the privacy curtain quickly and was sitting on the left edge of the bed by the footboard facing the bedroom door and requesting help to get out of bed During an interview on 2/17/26 at 1:10 P.M., the Resident's HCP said she felt the transition from the hospital to the facility had not been very smooth and that the facility was not communicating well with her. She said the day of admission she informed the staff Resident #79 is impulsive and had a significant fall history with frequent falls at home and she isn't sure the staff understand the Resident's needs. She said a few days later she requested to meet with them to review her concerns for the continued fall risk and the privacy curtain always being closed when she comes in preventing the staff from being able to see or supervise the Resident from the hallway as they pass by. She said the facility told her when she asked to meet with them that they would provide her with care plan information in a few weeks at a meeting to take place in March. She said they did not offer her any documentation of the meeting that occurred the day she requested they speak with her about her concerns. She said the Resident is at the facility because of their confusion and history of falling and she is worried they are not doing what they can to prevent that. Review of the medical record for Resident #79 indicated but was not limited to the following: - no 48-hour baseline care plan summary was in the record- the completed admission assessment indicated the Resident was admitted for weakness and falls at home and the resident was disoriented and required assistance for care and had balance problems- baseline care plan V2 document with section H - Safety risk: no history of falls; section 5 - Summary and signatures: failed to indicate any resident/family or staff signatures and was blank- review of all progress notes from date of admission through 2/18/26 indicated the Resident had advanced dementia, recurrent falls, and poor safety awareness; the notes failed to indicate that the Resident's HCP had baseline care plans developed or reviewed or they were offered a copy of those documents. During an interview on 2/19/26 at 11:46 A.M., Unit Manager #1 said the process for baseline care plans is the interdisciplinary team meets about 72 hours after admission and invites the resident/family to discuss appointments, therapy and discharge plans. She said care plans are not created based off that meeting they are usually made within 21 days. She said care plans for fall prevention are not always put in place prior to the 21-day comprehensive care plan creation. She said there was a meeting with Resident #79's HCP, but no baseline or comprehensive care plan was created at that time and therefore the HCP was not offered any documents or a summary of the care the facility planned to provide prior to the scheduled March care plan meeting. She said she thinks there is a misunderstanding with the process. During an interview on 2/19/26 at 2:28 P.M., the DON said for baseline care plans the facility should be identifying care needs that need to be addressed prior to the comprehensive care plan meeting or development of the comprehensive care plans and that is at the 48-hour mark following admission. She said falls is definitely one of the items that should be addressed on the baseline care plans to be sure the resident can be kept safe. She reviewed Resident #79's documentation and said the Resident did not have a baseline care plan developed or implemented for prevention of falls and he/she should have since it is the reason for their admission to the facility. She said it doesn't seem as though the staff understand the purpose of the baseline care plan process and the process needs work.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards by failing to implement physician's orders to discontinue Oxycodone (a pain medication), for one Resident (#5), out of a total sample of 17 residents, resulting in Resident #5 receiving the medication for 22 extra days. Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize errors.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Medication and Treatment Orders, undated, indicated but was not limited to the following:-Orders for medications and treatments will be consistent with principles of safe and effective order writing-Orders for medications must include quantity or specific duration of therapy Resident #5 was admitted to the facility in August 2025 and had diagnoses which included metabolic encephalopathy (condition which brain function is disturbed due to diseases or toxins), chronic pain syndrome and opioid (pain medication) dependence. Review of the Minimum Data Set (MDS) assessment, dated 12/19/25, indicated Resident #5 was receiving opioid medication. Review of Resident #5's Hospital Discharge summary, dated [DATE], indicated he/she should receive Oxycodone 5 milligrams (mg) by mouth every 6 hours as needed for severe pain (7-10) for up to 10 days max (maximum). Review of Resident #5's Physician's Orders indicated but was not limited to:-Oxycodone 5mg oral tablet, give one tablet by mouth every 6 hours as needed for severe pain (7-10) for up to 10 days max daily amount 20mg, start date 8/28/25 discontinued 9/30/25. Review of Resident #5's August and September 2025 Medication Administration Record (MAR) indicated he/she had received the medication for 22 extra days. Review of Resident #5's progress notes failed to indicate a provider had been consulted to extend the duration of Oxycodone. During an interview on 2/19/26 at 10:02 A.M., Unit Manager (UM) #1 said all orders are reviewed by a second nurse to complete a second check, and she completes a third check the following day to ensure there are no errors. UM #1 reviewed Resident #5's discharge summary and the MARs for August and September 2025. UM #1 said the order should have been transcribed with a stop date of 9/8/25, and it was not. During an interview on 2/19/26 at 4:21 P.M., the Director of Nursing (DON) said the Oxycodone order should have had a stop date, and the physician's order was not followed. She said her expectations are for all medication orders to be triple checked to ensure they are completed accurately.

Based on observation and interview, the facility failed to ensure the appropriate modified texture diet was prepared and served for one test tray. Specifically, the facility failed to ensure broccoli was prepared and served in a form designed to meet the individual needs of Residents on a dysphagia advanced diet. Findings include:Review of facility's Diet Guide Sheet indicated the facility was to serve chopped broccoli florets to residents on a dysphagia advanced diet with their lunch on 2/18/26. On 2/18/26 at 12:11 P.M., a test tray was performed; the meal requested included dysphagia advanced texture. The test tray included broccoli florets and stalks. The surveyor observed the florets ranged approximately between dime-sized to quarter-sized and the stalks ranged approximately between dime-sized to nickel-sized on the test tray. On 2/18/26 at 12:11 P.M., the surveyor sampled two broccoli stalks noting the flesh was very tender and easily crushed between the tongue and roof of the mouth while the outer skin remained intact. On 2/18/26 at 12:25 P.M., the surveyor observed one Resident, dining on the second floor, who was on a dysphagia advanced texture and had received broccoli cuts that consisted of all broccoli stems. During an interview on 2/18/26 at 2:30 P.M., the Food Service Director (FSD) said she orders broccoli florets when the food vendor has them in stock and broccoli cuts when the broccoli florets are unavailable. The FSD said she had not collaborated with the Speech Language Pathologist (SLP) regarding this substitution. The FSD said she believed broccoli cuts were comparable to the chopped broccoli florets that were indicated for the dysphagia diet. During an interview on 2/19/26 at 9:14 A.M., Rehabilitation Services Staff (RSS) #2, who was the SLP, said chopped broccoli florets should be served for the dysphagia advanced texture, which could include a portion of the upper tender stalk. RSS #2 said broccoli stalks from the lower stem should not be served on the dysphagia advanced diet. During an interview on 2/19/26 at 9:40 A.M., RSS #2 said dysphagia advanced texture meals should leave the kitchen in the appropriate modified texture and staff on the floor were available to assist with additional cutting of food beyond the recommended diet texture. During an interview on 2/19/26 at 3:16 P.M., the Director of Nursing (DON) said she expected residents on dysphagia advanced diets to receive chopped broccoli florets per the Diet Guide Sheet.

Based on interview and record review, the facility failed to maintain complete medical records for two Residents (#5 and #72), out of a sample of 17 residents. Specifically, the facility failed: 1. For Resident #5, to ensure the medical record accurately reflected advance directives as indicated on the Resident's Massachusetts Medical Orders for Life Sustaining Treatment form (MOLST); and2. For Resident #72, to ensure the medical record included the physician's documentation of encounters with the Resident from May 2025 through August 2025. Findings include: 1. Review of the facility's policy titled Advance Directives, dated as revised September 2022, indicated but was not limited to the following: -The resident has the right to formulate an advance directive, including the right to accept or refuse medical treatment. Advance directives are honored in accordance with state law and facility policy. -The Director of Nursing (DON) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record. Resident #5 was admitted to the facility in November 2025 with diagnoses which included chronic obstructive pulmonary disorder (COPD- chronic lung disorder resulting in blocked air flow in the lungs), major depressive disorder, and opioid dependence. Review of the medical record indicated the Resident and Attending Physician initiated a new MOLST on 2/16/26. The MOLST reflected the following advance directives: Do Not Resuscitate (DNR); Do Not Intubate and Ventilate; Do Not Use Non-invasive Ventilation; Do Not Transfer to Hospital; No Dialysis; No Artificial Nutrition; and Do Not Use Artificial Hydration. Review of Resident #5's current Physician's Orders indicated, but was not limited to, the following: -Full Code/MLOST [sic], active, 8/28/25 During an interview on 2/18/26 at 10:31 A.M., Nurse #2 said the code status is put into the computer from what is determined on the MOLST form. Nurse #2 reviewed Resident #5's MOLST and the physician's order in the record and said the Resident should not have an order for a full code. The order was not transcribed correctly. During an interview on 2/19/26 at 4:21 P.M., the Director of Nursing (DON) said the information in the medical record should be accurate and complete. 2. Review of the facility's policy titled Charting and Documentation, dated as revised in 2008, indicated but was not limited to: Policy Statement – All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record; Policy Interpretation and Implementation – All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. Resident #72 was admitted to the facility in August 2023 with diagnoses including congestive heart failure, dementia, dysphagia, sepsis, and chronic kidney disease. Review of Resident #72's medical record failed to indicate documentation of provider visits from 4/30/25 through 8/31/25, a total of 124 days. During an interview on 2/19/26 at 11:47 A.M., Unit Manager (UM) #2 reviewed Resident #72's medical record and could not find provider visit notes from 4/30/25 through 8/31/25. During an interview on 2/19/26 at 2:56 P.M., UM #2 said the facility was still trying to locate provider notes from April to August 2025. UM #2 said she would expect provider notes to be in the Resident's medical record. During an interview on 2/19/26 at 3:16 P.M., the Director of Nursing (DON) said Resident #72's medical record should include all provider notes.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen floor was maintained in a sanitary and safe condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: -6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. -6-501.13 Cleaning Floors, Dustless Methods. (A) Except as specified in (B) of this section, only dustless methods of cleaning shall be used, such as wet cleaning, vacuum cleaning, mopping with treated dust mops, or sweeping using a broom and dust-arresting compounds. (B) Spills or drippage on floors that occur between normal floor cleaning times may be cleaned: (1) Without the use of dust-arresting compounds; and FDA Food Code 2022 Chapter 6. Physical Facilities Chapter 6 - 9 (2) In the case of liquid spills or drippage, with the use of a small amount of absorbent compound such as sawdust or diatomaceous earth applied immediately before spot cleaning. On 2/24/25 at 8:10 A.M., the surveyor observed the main kitchen area. The maroon tile flooring in the kitchen had visible dark debris and was soiled in multiple areas of the kitchen, but most prominently on the area of the kitchen floor before the dish room. At this time, the surveyor observed the kitchen staff completing the breakfast tray line and the last meals were sent to the units. There were no dirty breakfast dishes that had been returned to the kitchen at this time. The floor in the dish room had a rubber mat with towels underneath and many orange-colored food spills within the holes of the mat. On 2/26/25 at 8:26 A.M., the surveyor observed the main kitchen area. The maroon tile flooring had areas where the floor was soiled and was not clean. During an interview on 2/26/25 at 8:30 A.M., the Food Service Director (FSD) said the cleaning process for the kitchen floor was for a designated cleaning staff member to clean the kitchen on Tuesdays and Thursdays including cleaning the main kitchen area floor, the dish room floor and the rubber mats in the dish room. She said the evening dietary staff were to mop the floor in the main area of the kitchen every night, but they did not clean the dish room floor or dish room rubber mats. She said the kitchen floor did not look clean on Monday (2/24/25) and could have been more thoroughly cleaned the previous evening. She said the food debris in the rubber mats on Monday had probably been from the previous night. During an interview on 2/26/25 at 12:15 P.M., the FSD said she had discussed the process for cleaning the kitchen floor with her staff and discovered that the evening dietary staff did not know where the mop heads were, so they had not been mopping the kitchen floors at the end of the night. She said that was why the kitchen floor was not clean on Monday (2/24/25) because it had not been cleaned since Thursday (2/20/25).

Based on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to ensure active involvement of all required members when conducting the facility assessment. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance, dated 6/18/24, indicated but was not limited to the following: -In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process: a. Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and b. Direct care staff, including but not limited to, Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, Nursing Assistants, and representatives of the direct care staff, if applicable c. The facility must also solicit and consider input received from residents, resident representatives, and family members. Review of the facility's policy titled Facility Assessment, revised December 2023, indicated, but was not limited to, the following: -A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. -The team responsible for conducting, reviewing, and updating the facility assessment includes the following: a. The administrator; b. A representative of the governing body; c. The medical director; d. The director of nursing services; e. The infection preventionist; and f. The director (or designee) from the following departments: (1) environmental services; (2) physical operations; (3) food and nutrition services; (4) social and activity services; and (5) rehabilitative services. Review of the Facility Assessment, dated February 2025, indicated but was not limited to: -Names/Titles of individuals involved in completing the assessment: Administrator, Director of Nursing, A member of the Governing Body, Medical Director, RN Consultant. The Facility Assessment failed to solicit input from direct care staff or residents, resident representatives, or family members. During an interview on 2/27/25 at 10:56 A.M., Consultant Nurse #1 said the facility assessment was updated in February 2025. Consultant Nurse #1 said the leadership team was involved in updating the facility assessment but no resident or resident representative or direct care staff input was included.

Based on observations, interview, and records reviewed, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections for five Residents (#227, #50, #30, #23, and #38), out of a total sample of 19 residents. Specifically, the facility failed to: 1. For Residents #227, #50, and #30, ensure staff maintained Transmission Based Precautions as indicated; 2. For Resident #23, ensure that the oxygen concentrator was maintained in a clean/sanitary condition; and 3. For Resident #38, ensure that Enhanced Barrier Precautions were maintained as indicated. Findings include: 1. Review of the facility's policy titled Isolation- Categories of Transmission-Based Precautions, dated as revised October 2018, indicated but was not limited to: -Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents -Transmission based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. -When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution a. The signage informs the staff of the type of CDC precaution(s), instructions for use of personal protective equipment (PPE), and/or instructions to see a nurse before entering the room b. Signs and notifications comply with the resident's right to confidentiality or privacy -Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment a. Staff and visitors will wear gloves (clean, non-sterile) when entering the room b. Staff and visitors will wear a disposable gown upon entering the room and removed before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed A.Review of Centers for Disease Control and Prevention guidance titled Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), Appendix A: Figure. Example of Safe Donning and Removal of Personal Protective Equipment (PPE), updated 11/27/23, indicated for donning a gown to: -Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back -Fasten in back at neck and waist Resident #227 was admitted to the facility in February 2025 with diagnoses which included pneumonia, methicillin-resistant Staphylococcus aureus (MRSA) in his/her nares Review of Resident #227's Physician's Orders indicated but were not limited to: -Contact precautions related to MRSA in nares, dated 2/24/25 On 2/26/25 at 8:20 A.M., the surveyor observed a contact precaution sign posted on the doorway entrance of Resident #227's room. The surveyor observed Nurse #2 enter the room, provide the resident his/her breakfast, and adjust pillows under his/her legs. Nurse #2's gown was not secured around her neck exposing her shoulders and chest. Nurse #2 left the room and returned at 8:25 A.M., prior to entering the room she donned a new set of personal protective equipment (PPE); her gown was again unsecured around her neck exposing her shoulders and chest. During an interview on 2/26/25 at 10:42 A.M., the Infection Control Nurse said Resident #227 required contact precautions because he/she had MRSA in his/her nares. The Infection Control Nurse said gowns should be fastened around the neck and the shoulders and chest should be covered. 49424 B. Resident #50 was admitted to the facility in October 2023 with diagnoses including overactive bladder. Review of Resident #50's Physician's Orders indicated but were not limited to: -Precautions -Contact precautions related to Extended-Spectrum Beta-Lactamases (ESBL) in urine, dated 2/3/25 On 2/24/25 at 9:45 A.M., the surveyor observed a sign outside Resident #50's room which indicated Stop Contact Precautions Everyone Must: -Clean their hands, including before entering and when leaving the room. -Providers and staff must also put on gloves before room entry. Discard gloves before room exit. -Put on gown before room entry. Discard gown before room exit. -Do not wear the same gown and gloves for the care of more than one person. -Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 2/24/25 at 9:46 A.M., the surveyor observed Nurse #1 in the Resident's room administering eye drops to the Resident without PPE. During an interview on 2/24/25 at 9:48 A.M., Nurse #1 said PPE was only needed for direct care with residents on contact precautions. She said only gloves were required when administering #50's medications. On 2/25/25 at 8:08 A.M., the surveyor observed Unit Manager #1 enter Resident #50's room, deliver the breakfast tray to the Resident, and assist with setting up the tray. The surveyor observed the contact precaution sign outside of Resident #50's room. During an interview on 2/24/25 at 12:59 P.M., the Infection Preventionist said that anyone who enters the room for a Resident on contact precautions should perform hand hygiene, put on gloves, and don (put on) a gown. He said the nurse and unit manager should have been wearing the PPE instructed on the sign before entering the room. During an interview on 2/25/25 at 10:43 A.M., Clinical Consultant #1 said any staff member entering a room with contact precautions should be following all the instructions on the sign. C. Resident #30 was admitted to the facility in January 2025 with diagnoses including urinary tract infection. Review of Resident #30's care plan indicated: -Focus: I require contact precautions due to positive ESBL of urine, dated 2/3/25. On 2/24/25 at 9:49 A.M., the surveyor observed a contact precaution sign outside of Resident #30's room. On 2/24/25 at 9:50 A.M., the surveyor observed Rehab Staff #2 in Resident #30's room placing a gait belt around the Resident and touching the Resident offering assistance without wearing gloves or a gown as indicated. During an interview on 2/24/25 at 9:52 A.M., Rehab Staff #2 said she did not need to wear any PPE because PPE was only required for assisting the resident with toileting. On 2/25/25 at 08:06 A.M., the surveyor observed Unit Manager #1 entering Resident #30's room with his/her breakfast tray. The surveyor observed Unit Manager #1 setting up the breakfast tray, cleaning his/her tray table, and leaving the Resident's room without performing hand hygiene. On 2/26/25 at 8:49 A.M., the surveyor observed the Activities Director with no gloves or gown donned assisting Resident #30 by wrapping a blanket around the Resident. She turned off the Resident's call bell and left the room without performing hand hygiene. During an interview on 2/26/25 at 8:55 A.M., the Activities Director said she did not wear any PPE in the Resident's room because she didn't think it was required. She said that she took the blanket off the Resident's bed and draped it on the Resident. She said after reading the sign on the door she should have worn PPE. During an interview on 2/26/25 at 8:58 A.M., the Infection Preventionist said any staff entering a room for a Resident on contact precautions needs to follow all the instructions on the sign posted. 15214 2. Review of the National Institutes of Health (NIH), Oxygen Therapy and the Risk of Infection for Health Care, 2020, indicated but was not limited to: A dirty oxygen concentrator filter can make you sick, as it can allow bacteria and other contaminants to build up and be inhaled with the oxygen, potentially leading to respiratory infections, especially for individuals with compromised immune systems or existing lung conditions; therefore, it's crucial to regularly clean and replace filters according to manufacturer instructions. Resident #23 was admitted to the facility in April 2024 with diagnoses which included congestive heart failure, other allergic rhinitis, and cough. Review of Resident #23's Physician's Order indicated: -oxygen via nasal cannula, 2 liters per minute continuously, to maintain an oxygen saturation greater than 90% every shift. Further review of the physician's order failed to indicate an order for the cleaning (who or when) of the oxygen concentrator filter. On 2/27/25 at 11:20 A.M., the surveyor observed Resident #23 lying in bed with a nasal cannula oxygen tube in his/her nose dated 2/26/25, with oxygen flowing at 1 liter per minute (LPM) via an oxygen concentrator. The filter on the oxygen concentrator was observed to be completely coated with light gray dust and there was no indication as to when the filter was cleaned last. During an interview on 2/27/25 at 11:30 A.M., the Clinical Consultant said that she was not sure of who was responsible for cleaning the oxygen concentrator filter or the schedule for cleaning. She said there was no order for cleaning the filter. The Consultant said that there was an infection control concern with the oxygen concentrator filter not being maintained in a clean and sanitary condition. 3. Resident #38 was admitted to the facility in August 2023 with diagnoses which included acute respiratory failure, chronic cough, and benign prostatic hypertrophy. Review of Resident #38's medical record indicated that the Resident was on Enhanced Barrier Precautions (EBP) due to the presence of a urinary catheter and an open wound. On 2/27/25 at 11:50 A.M., the surveyor observed an EBP sign posted at the doorway indicating staff were to sanitize their hands, don gloves and a gown, (apply a mask if there is a risk of splashes or spray) prior to entering the room to provide care or treatment. A precaution cart with PPE was observed outside the Resident's room. On 2/27/25 at 11:53 A.M., the surveyor observed Nurse #6 enter Resident #38's room without sanitizing her hands and donning a gown and gloves. Once in the room, Nurse #6 touched various items like the door handle and room curtain as she prepared to perform the treatment to the Resident's wound. During an interview on 2/27/25 at 12:10 P.M., Nurse #6 said that she didn't realize that she had entered the Resident's room without performing hand hygiene and donning the appropriate PPE. During an interview at 2/27/25 at 12:10 P.M., the Corporate Consultant said Nurse #6 failed to follow the posted signage for EBP for a Resident with a urinary catheter and an open wound.

Based on record review and interview, the facility failed to ensure the Resident Representative was notified of a fall for one Resident (#58), out of a total sample of 18 residents. Specifically, the facility failed to ensure the activated Health Care Proxy (HCP- health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was notified of an elopement attempt resulting in the Resident wandering to the basement of the building. Findings include: Resident #58 was admitted to the facility in July 2024 with diagnoses including but not limited to dementia and history of repeated falls. Review of the Minimum Data Set (MDS) assessment, dated 1/2/25, indicated Resident #48 had a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 which indicated the Resident had a severe cognitive impairment. Review of Section E, titled Behavior indicates Resident #48 wandered 4-6 times during the Assessment Review Date (ARD). During an interview on 2/24/25 at 8:50 A.M., Unit Manager #1 said the Resident had an incident on 2/17/25 where he/she wandered on to the elevator and was found in the basement exit seeking. She said Resident #58 has been on 1:1 supervision with staff since the incident. During an interview on 2/24/25 at 2:53 P.M., the Resident's HCP said the facility staff had not called her to update her on the incident that occurred. She said she received some details from her sister and a private duty home health aide but never received a clinical update from the facility staff. She said she was not sure what interventions were in place after the incident. Review of the Massachusetts Health Care Proxy, dated 12/2006, indicated Resident #58 had appointed a HCP and an Alternative HCP. Review of the HCP Activation form, dated 6/2024, indicated the physician determined the Resident lacked the capacity to make health care decisions and the HCP has been activated related to dementia, and the expected duration was indefinite. Review of an Incident Report, dated 2/17/25, indicated that the physician was notified on 2/17/25 and a family member (not the named HCP) was notified on 2/24/25. During an interview on 2/28/25 at 3:12 P.M., Unit Manager #1 said she frequently speaks with Resident #58's family member but was not sure if that family member was the primary HCP. She said if the facility needed to contact a family member for the Resident, they would call the family member she usually speaks with. Unit Manager #1 reviewed the face sheet and said that the staff were not calling the HCP. She said the HCP has the designation under contact type listed as Emergency Contact #1, HCP. During an interview on 2/26/25 at 3:22 P.M., Social Worker #2 said the HCP should be called for updates related to health care decisions and needs. During an interview on 2/27/25 at 11:38 A.M., Clinical Consultant #1 said the primary HCP was not called or notified of the incident as she should have been.

Based on interview and document review, the facility failed to ensure two Residents (#54, #51) were informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Care Plans - Baseline, revised 5/2022, indicated but was not limited to the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. -The resident and their representative will be provided a summary of the baseline care plan that includes, but is not limited to the following: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. 1. Resident #54 was admitted to the facility in July 2024 with diagnoses including diabetes and chronic pain. Review of Resident #54's most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #54 was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #54's medical record failed to include documentation indicating a baseline care plan was developed within the first 48 hours following the Resident's admission and provided to the Resident. During an interview on 2/26/25 at 4:29 P.M., Consultant Nurse #2 said the facility has no record of a baseline care plan developed for Resident #54. During an interview on 2/27/25 at 10:56 A.M., Consultant Nurse #1 said she did not know the facility's process for the development of the baseline care plan prior to her arrival in December. Consultant Nurse #1 said all newly admitted residents should have a baseline care plan developed within 48 hours of admission and the baseline care plan should be reviewed with the resident/resident's representative and a summary of the baseline care plan should be provided in writing. 49424 2. Resident #51 was admitted to the facility in July 2024 with diagnoses including Chronic Obstructive Pulmonary Disease. Review of the MDS assessment, dated 12/30/24, indicated Resident #51 had a BIMS score of 15 out of 15 which indicated the Resident was cognitively intact. During an interview on 2/24/25 at 1:52 P.M., Resident #51 said he/she doesn't recall reviewing the initial plan of care within 48 hours of admission. The Resident also said he/she did not receive a copy of the baseline care plan. Review of Resident #51's medical record failed to include documentation indicating a baseline care plan was developed within the first 48 hours following the Resident's admission. During an interview on 2/25/25 at 10:11 A.M., Clinical Consultant #3 said the baseline care plans are created within 48 hours of admission and reviewed with the Resident. She said she could not find evidence of a baseline care plan or evidence that the Resident received a copy as he/she should have.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for one Resident (#72), in a total sample of 19 residents. Specifically, the facility failed for Resident #72, to implement a care plan and individualized interventions related to changes in their mood including crying. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022 indicated but was not limited to: -The comprehensive, person-centered care plan: includes measurable objectives and timeframes; -describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -includes the resident's stated goals upon admission and desired outcomes; -reflects currently recognized standards of practice for problem areas and conditions; -when possible, interventions address the underlying source(s) of the problem area(s), not just the symptoms or triggers; -assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Resident #72 was admitted to the facility in January 2025 with diagnoses of dementia and depression. Review of the Minimum Data Set (MDS) assessment, dated 2/3/25, indicated Resident #72 scored 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had a severe cognitive impairment. Review of the care plans indicated Resident #72 had a Focus of mood disorder related to depression, with a goal to remain free of signs or symptoms of distress, symptoms of depression, anxiety or sad mood through review date. The interventions included administering medications as ordered to monitor for the side effects and effectiveness of medications and to arrange for psychiatric services as indicated. On 2/24/25 at 9:55 A.M., the surveyor observed Resident #72 in bed and was able to converse with the surveyor. Resident #72 started to cry and stated he/she did not know where their spouse was or when he/she saw them last. The Resident said he/she missed their spouse and was lonesome. On 2/26/25 at 10:25 A.M., the surveyor observed Resident #72 sitting up in a wheelchair watching television in their room. The Resident engaged in greeting the surveyor and then started to tear up and cry. The Resident said he/she did not think their spouse knew where he/she was but hoped they did. During an interview on 2/26/25 at 12:25 P.M., Certified Nursing Assistant (CNA) #2 said she was familiar with Resident #72 and that the Resident would often cry any time their spouse was not at the facility and the spouse visited daily. During an interview on 2/26/25 at 12:30 P.M., the spouse of Resident #72 said Resident #72 cried a lot. The spouse said they hoped the newly added medication to help with appetite (Remeron) would also help with the crying, but nothing had changed yet. During an interview on 2/26/25 at 12:45 P.M., CNA #1 said Resident #72 cries the moment their spouse leaves. She said she worked the previous evening, and the Resident cried from the moment their spouse left until the Resident said to the CNA it's time for me to get washed up and go to bed. She said she offers the Resident reassurance, but she was not sure how much more they could do. During an interview on 2/26/25 at 1:06 P.M., the Nurse Practitioner (NP) said she was unaware that Resident #72 cried every day. She reviewed the physician visits from the primary physician and the other NP and said there was no indication in the medical notes that the Resident was presenting with crying. She said the Remeron was added related to weight loss and there was no mention in the note about the Resident's mood. During an interview on 2/26/25 at 1:34 P.M., Nurse #4 said she was the nurse for Resident #72 and she had recently heard about Resident #72 being weepy about his/her spouse and just tried to offer the Resident reassurance that the spouse was coming back. During an interview on 2/26/25 at 1:35 P.M., Social Worker #2 said she was unaware Resident #72 had been crying and had not heard anything and would follow up with the surveyor about the interventions or if the Resident had been referred to psychiatric services for follow up. During an interview on 2/26/25 at 3:18 P.M., Social Worker #1 said she met with Resident #72 and their spouse on this day and they declined psychiatric services. She said there were no interventions for the Resident's mood prior to the surveyor inquiry because she was not aware the Resident had been crying every day. She said the process was for the interdisciplinary team to discuss all the residents and she had not been told about Resident #72. She said the staff should have provided this information so that the plan of care for the Resident could have been updated to include individualized interventions.

Based on observations, interviews, and records reviewed for one Resident (#227) of 19 sampled residents, the facility failed to ensure a resident was provided care in accordance with professional standards of practice. Specifically, for Resident #227, the facility failed to administer medications as ordered. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Medication Therapy, dated as revised 2007, indicated but was not limited to: -All medication orders will be supported by appropriate care processes and practices Resident #227 was admitted to the facility in February 2025 with diagnoses which included pneumonia, methicillin-resistant Staphylococcus aureus (MRSA) in his/her nares Review of Resident #227's current Physician's Orders included but were not limited to: -Mirtazapine (antidepressant) 7.5 milligrams (mg) by mouth daily at bedtime, dated 2/25/25 Review of Resident #227's February 2025 Medication Administration Record (MAR) indicated he/she had not received Mirtazapine on 2/25/25. Review of Resident #227's progress notes indicated Nurse #5 had not administered the Mirtazapine because the medication was unavailable. Further review of Resident #227's medical record failed to indicate a provider was made aware the medication was not available. During an interview on 2/26/25 at 7:55 A.M., Resident #227 said he/she saw a consultant yesterday and was supposed to start a new medication, he/she even signed a consent form for it, but the medication was never provided. During an interview on 2/26/25 at 9:04 A.M., Nurse #3 (Acting Unit Manager) reviewed Resident #227's medical record and said the Mirtazapine had not been administered and was marked as unavailable. Nurse #3 said when a medication was unavailable the nurse should check the emergency medication supply kit and call the provider for alternate orders. Nurse #3 reviewed the emergency medication supply kit and noted Mirtazapine 15 milligrams was available. During an interview on 2/26/25 at 1:23 P.M., Nurse #5 said Resident #227 did not receive the Mirtazapine on 2/25/25 because the medication had not come in from the pharmacy. Nurse #5 said she asked the other nurse working and was told the facility did not have any Mirtazapine available. Nurse #5 said she did not call the provider because he was the one who wrote the order and he had just left the building. Nurse #5 said he would have known the pharmacy did not deliver the medication so he should have known it would not have been administered. Nurse #5 said she was unaware of the emergency medication supply kits. During an interview on 2/26/25 at 1:13 P.M., Consulting Staff #2 said the facility was aware the medication was not administered and Nurse #5 should have called the provider for further instructions.

Based on record review and staff interview, the facility failed to provide showers for two dependent Residents (#23 and #34), in a total sample of 19 residents. Findings include: 1. Resident #23 was admitted to the facility in September 2021 with diagnoses which included unspecified lack of coordination, muscle weakness, and unspecified fracture of the right femur. Review of the Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS indicated the Resident had bilateral impairment of the lower extremities and was dependent for showering/bathing. Review of Resident #23's care plan for Activities of Daily Living (ADL), dated 9/5/24, indicated that he/she was dependent on staff for shower/bathing, personal hygiene, toileting hygiene, and upper/lower body dressing. During an interview on 2/24/25 at 12:30 P.M., the Resident and the Resident's daughter both said that the Resident does not get a shower since he/she was not able to walk. The Resident said he/she would love a shower. During an interview on 2/27/25 at 8:20 A.M., Certified Nursing Assistant #3 (CNA) said that the Resident had not received a shower since he/she fractured his/her right hip on 4/29/24. CNA #3 said the Resident has expressed a desire to take showers. On 2/27/25 at 8:25 A.M., CNA #3, who routinely cares for the Resident, said that the facility does not have the right size Hoyer pad for showering the Resident. During an interview on 2/27/25 at 10:56 A.M. the Director of Nursing (DON) said that the facility found a shower pad for the Hoyer lift (mechanical lift) and was going to give the Resident a shower today. The DON said she didn't know why there was such a delay in getting a shower pad so Resident #23 could have a shower. 2. Resident #34 was admitted to the facility in September 2023 with diagnoses which included cerebral vascular accident (CVA), myocardial infarction (MI), and atrial fibrillation. Review of the MDS assessment, dated 12/31/24, indicated Resident #34 scored 14 out of 15 on the BIMS assessment which indicated the Resident was cognitively intact. The MDS indicated Resident #34 required substantial/maximum assistance with showering/bathing. Review of Resident #34's care plan for Activities of Daily Living (ADLs), included, but was not limited to the following: I need assistance with my ADLs due to Decreased strength and endurance due to a-fib, CAD, Hx (history of) MI, Impaired cognition due to CVA -I will maintain my current level of function through the review date *Shower/bathe-Dependent *Toileting Hygiene-Dependent During an interview on 2/27/25 at 8:35 A.M., CNA #3 said that the Resident is bathed/showered on the 3:00 P.M.-11:00 P.M. shift and she was unsure if the Resident received a regular shower versus a bed bath. CNA #3 said that residents are supposed to be showered weekly. During an interview on 2/27/25 at 9:53 A.M., Resident #34 said that he/she does not get showered and couldn't remember the last time he/she was showered. He/She said that instead of showers, he/she receives bed baths from the CNAs who care for him/her. He/She said the bed baths are not as good as getting a shower as the bed baths don't provide washing of his/her feet or head which he/she preferred. During an interview on 2/27/25 at 11:00 A.M., the DON said that every Resident should receive a shower weekly. She said she wasn't aware that the Resident was not receiving weekly showers.

Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure medications were not left unattended in Resident #7's room. Findings include: Review of the facility's policy titled Administering Oral Medications, dated 2001, indicated the following: -Remain with the resident until all medications have been taken. Resident #7 was admitted to the facility in May 2021 with diagnoses including but not limited to Parkinson's disease and dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated severe cognitive impairment. On 2/25/25 at 8:12 A.M., the surveyor observed Resident #7 sitting on the edge of the bed eating breakfast. Next to the Resident's breakfast tray there was a medication cup with eight pills in it. Resident #7 was unable to identify any of the medications or say when they received the medications. During an interview with observation on 2/25/25 at 8:15 A.M., Unit Manager #1 said the nurses should remain with the residents until all the medications are taken. She said it is important to verify whether the medications were taken. If they are left with the resident, then it cannot be verified that the medications were taken appropriately. She said there were eight medications remaining in the cup on the Resident's bedside table. During an interview with an observation on 2/25/25 at 8:22 A.M., Nurse #7 said he did not see Resident #7 take the medications. He said it appeared as if the Resident was going to take the medications when he left the room. He said he did not stay with the Resident to ensure they were taken appropriately. Review of Medication Administration Record, dated 2/25/25, indicated the Resident was administered the following medications: -Amlodipine Tab (treat high blood pressure) 10 milligrams (mg) -Aspirin Tab (pain reliever) 325 mg -Lorazepam Tab (treat seizures) .5 mg -Losartan Potassium Tab (treat high blood pressure) 50 mg -Methimazole Tab (treat hyperthyroidism) 5 mg -Metoprolol Tab (treat high blood pressure) 25 mg -Calcium Chew plus Vitamin D -Vitamin B12 250 micrograms (mcg) During an interview on 2/25/25 at 9:57 A.M., Clinical Consultant #1 said no medications should be left at the bedside, and the nurse should have remained with Resident #7 to ensure the medications were taken appropriately and as ordered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at risk for falls and required the use of a chair alarm in an effort to prevent falls, the Facility failed to ensure his/her assistive devices were functioning properly to prevent incidents and/or accidents resulting in an injury. On 4/07/24 after Resident #1 was found on the floor in the hallway after a fall, it was determined that his/her chair alarm was found to be in the off position and therefore had not sounded to alert staff that he/she was in motion. Resident #1 sustained a laceration to the left side of his/her head, was transferred to the Hospital Emergency Department for evaluation, required staples to close the laceration, was diagnosed with multiple fractures as a result of the fall and was admitted for treatment. Findings include: Review of the Facility's Policy titled, Fall Policy, dated 10/2022 indicated the following: -it is the policy of the facility to ensure that residents who are fall risks are assessed accurately with interventions in place to prevent further falling; -in the event of a fall, the team leader will do a full body assessment, assess for injury and arrange for medical treatment as needed; -an incident report and an investigation of fall will be completed by the licensed nurse; -employee statements are obtained, and written on witness statement sheet; -Unit Manager/Supervisor/Designee will ensure completeness of forms, initiate or add components of the care plan and forward to the Director of Nurses(DON); -upon determination of the cause of injury, the corrective action will be initiated; -the DON will meet with the Staff Development Coordinator to plan educational session in response to any identified area of concern and ensure follow-up if needed. Review of the Facility's Policy titled, Falls Prevention, dated 5/2018 indicated the following: -it is the policy of the facility to assess all residents for fall risk and upon determination, implement interventions in accordance with regulation; -upon determination that a resident is at risk for falls, a Red Falling Star symbol is placed on each identified resident's door name plate, wheelchair (if applicable) or name bracelet (as a last resort); -the resident's name is placed on the Falls Prevention Plan list and a copy is forwarded to Nurse Managers and all department heads; -the Falls Prevention Team decides which additional interventions are required. Review of the Facility Policy titled, Chair/Bed Alarm System, dated 7/2012 indicated the following: -the facility shall use a chair/bed alarm system to monitor the wheelchair/bed activity of the resident who stands, attempts to stand or attempts to get out of bed without asking for assistance and who's ambulatory and/or transfer status is not at an independent/safe level; -the licensed nurse will determine if an alarm is needed and the Falls Prevention Committee will be notified of alarm use; -if an alarm is used it will be documented on the care plan and electronic Certified Nurse Aide (CNA) flow sheet; -if an alarm is needed on a chair the alarm will be permanently placed on the rear of the wheelchair/chair utilizing a strap and the alarm cord will be attached to the back of the residents clothing with a prime snap; -alarm is to be checked daily to assure it is in working order. Resident #1 was admitted to the Facility in October 2023, diagnoses included acute on chronic congestive heart failure, fracture of the left third and fourth metacarpal bones, type 2 diabetes mellitus, non-ST elevation myocardial infarction, history of falls, atrial fibrillation, Parkinson's and dementia. Review of Resident #1's Fall Risk Assessment, dated 01/30/24, indicated he/she was assessed as being at risk for falls. Review of Resident #1's CNA Resident Care Instructions, (used as a reference guide by CNA's), dated 10/27/23, indicated that he/she was on fall precautions and that he/she utilized bed and chair alarms for safety. Review of Resident #1's Care Plan related to Falls, dated 10/29/23, indicated he/she was at high risk for falls, and interventions included: anticipate resident needs with regard to Activities of Daily Living (ADL's), use appropriate assistive device and level of assistance, star outside door, and chair/bed alarms. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/24, indicated he/she required supervision or touch assistance with transfers and had moderate cognitive impairment Review of the Facility's Internal Investigation Report, dated 04/07/24, indicated that between 10:30 A.M. and 11:45 A.M., Resident #1 had set off his/her chair alarm twice, was attempting to stand up and noted to be trying to turn off his/her chair alarm. The Report indicated that at approximately 11:45 A.M., a family member of another resident informed a nurse that Resident #1 was on the floor in the hallway. The Report indicated that the nurse responded immediately and noted blood and a laceration on the left side of Resident #1's head. The Report indicated that Resident #1's chair alarm was noted to be on the seat of the wheelchair and not behind his/her wheelchair where it had been mounted. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department (ED) for further evaluation and treatment. The Report indicated that Resident #1 sustained a left parietal (top and side of skull) laceration that required three staples, a left distal clavicle (collarbone) and left femoral neck (hip) fracture from his/her injuries. Review of Resident #1's Hospital Discharge Summary, dated 04/12/24, indicated that Resident #1 presented to the Hospital ED after an unwitnessed fall at the Nursing Home and complained of left shoulder and left hip pain. The Summary indicated that an x-ray revealed that Resident #1 had a left distal clavicle fracture and a left femoral neck fracture and he/she underwent a left hip hemiarthroplasty (surgical procedure to treat a fractured hip). The Summary indicated that Resident #1 was also noted with a left scalp laceration, and it was repaired with three staples by the emergency room (ER) physician. The Summary indicated that Resident #1 was admitted to the Hospital for treatment of his/her injuries. Review of a Nurse Progress Note, dated 4/07/24, (written by Nurse #2), indicated that at 11:50 A.M., Resident #1 was found on the floor in the hallway by a family member of another resident. The Note indicated that Resident #1 had sustained a laceration on the left side of the head, 911 (Emergency Services) was notified and Resident #1 was transferred to the Hospital ED for evaluation. The Note further indicated that Resident #1 had deactivated the chair alarm, transferred him/herself out of the chair and walked out into the hallway. During a telephone interview on 4/29/24 at 9:47 A.M., Nurse #2 said that Resident #1 was found lying on his/her left side on the floor in the hallway by a family member of another resident. Nurse #2 said she immediately ran down to assess Resident #1 and found him/her bleeding from the left side of the head, said she applied a pressure dressing to his/her head until 911 arrived. Nurse #2 said that Resident #1's chair alarm did not sound, said that {although none of the staff saw him/her do it, they believe} Resident #1 had deactivated and turned the chair alarm switch to the off position, got out of the chair and walked out into the hallway where he/she was found. Nurse #2 said that there have been times when Resident #1 has removed his/her alarm, has deactivated the alarm and turned it off. During an interview on 4/24/24 at 1:20 P.M., (which included review of her written witness statement), CNA #2 said that on 4/07/24 at 10:30 A.M., Resident #1 set off his/her chair alarm and was sitting in the wheelchair with the alarm sounding. CNA #2 said that she reset Resident #1's chair alarm and made sure it was in the on position. CNA #2 said that there have been times when Resident #1 had removed his/her chair alarm and turned it to the off position. CNA #2 said that at 11:30 A.M., prior to going on her lunch break, she checked on Resident #1 and said that his/her chair alarm was in the on position. During an interview on 4/24/24 at 1:36 P.M., (which included review of her written witness statement), CNA #1 said that on 4/07/24 sometime around 11:45 A.M., Resident #1 set off his/her chair alarm, she went in to check on him/her and asked him/her if she needed to go to the bathroom or needed anything else. CNA #1 said that Resident #1 said he/she did not need anything. CNA #1 said she reset Resident#1's chair alarm and made sure it was in the on position. CNA #1 said that she left Resident #1's room to take care of another resident and when she came out of the resident's room, she saw Resident #1 lying on the floor in the hallway with the nurse. CNA #1 said that she did not hear Resident #`1's alarm sound and said that she went to check Resident #1's chair alarm and found it on his/her wheelchair in the off position. CNA #1 said that there have been times when Resident #1 has removed his/her chair alarm and turned it to the off position. Review of a Resident Incident/Accident Report, dated 04/07/24, indicated that Resident #1 was found on the floor in the hallway by a family member of another resident and was noted to have sustained a laceration to his/her left side of the head. The Report indicated that {although he/she was not seen by staff doing so, it was believed} Resident #1 had switched his/her chair alarm to the off position. Per staff interviews, prior to the fall Resident #1 had been left in his/her room, in the wheelchair by the window where he/she liked to be. Resident #1 was therefore able to get up, ambulate across and out of his/her room, before being found on the floor in the hallway. During an in-person interview on 04/24/24 at 2:50 P.M., and a follow up telephone interview on 05/01/24 at 10:20 A.M., the Director of Nurses (DON) said that Resident #1 had set off the chair alarm a couple of times during the morning on 04/07/24 and the CNA's had answered his/her alarm and turned the chair alarm back on. The DON said a few minutes after one of the CNA's left Resident #1's room, Resident #1 was found on the floor in the hallway by another resident's family member. The DON said at that time his/her chair alarm did not sound. The DON said it was her expectation that staff place the chair alarm in a location that the resident cannot reach and said that {although none of the staff saw him/her do it, they believed} Resident #1 removed his/her chair alarm by pulling on the cord and somehow reached the chair alarm and turned off the alarm that morning. The DON said that she was unaware that Resident #1 had tried to remove his/her chair alarm before and had turned off the chair alarm before and said this was the first time she was made aware that Resident #1 had done this before.

Based on records reviewed and interviews for 12 of 12 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12), the Facility failed to ensure they implemented and maintained an infection prevention and control program designed to provide a safe environment, to help prevent the development and transmission of COVID-19 infection (an acute respiratory illness in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions), as required and per Facility Policy. -Certified Nurse Aide (CNA) #1, who was last tested by the Facility on 05/09/22 for COVID-19, failed to continue to test weekly at the Facility, failed to provide proof of weekly testing by a testing site in the community to the Facility from 05/16/22 through 05/25/22 as required, and continued to work at the Facility providing direct care to residents during that time. -5/16/22 (Monday), CNA #1 failed to get tested at the Facility, said she was tested on [DATE] at CVS Pharmacy, failed to provide proof as required, but was allowed to work on 5/18/22, 5/19/22, 5/20/22, and 5/21/22 providing direct care to residents. -5/23/22 (Monday) CNA #1 failed to get tested at the Facility, said she was tested on [DATE] at CVS Pharmacy, failed to provide proof as required, but was allowed to work on 5/24/22 and 5/25/22 providing direct care to residents. -On 5/26/22 (Thursday), CNA #1, who still failed to provide proof of compliance with Facility weekly COVID-19 testing requirements, worked at the Facility providing care to residents for over two hours, was tested by the Facility for COVID-19 and tested positive. -As a result, the Facility whose last documented positive case of COVID-19 was back on 1/24/22, experienced an outbreak where 12 residents and eight staff members tested positive between 05/30/22 through 06/10/22. Five of those residents received direct care from CNA #1, three of the residents were roommates of the residents who received direct care from CNA #1 and five residents required administration of therapeutic medication for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] their signs and symptoms. Findings include: Review of Massachusetts Department of Public Health (DPH) Memorandum, titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, dated 9/24/21, indicated all Long-Term Care Facilities must screen all individuals entering the facility, including healthcare personnel. The Memorandum indicated the following: -every Facility should have a process to ensure everyone arriving to the facility is assessed for symptoms of COVID-19 (cough, shortness of breath, sore throat, myalgia (muscle pain), chills, new onset loss of smell or taste, and fever). -long-term care facilities are required to perform weekly surveillance testing of all staff. Review of the Facility Policy titled Coronavirus Surveillance, Detection, and Management of an Outbreak, dated as revised April 2022, indicated it included the following: -all individuals upon entering the facility, including staff and visitors, will be screened for any signs and symptoms of COVID-19 (cough, shortness of breath, sore throat, myalgia, chills, or new onset of loss of smell or taste, and a fever), and exposure to others with suspected or confirmed [CONDITION(S)]-Co V-2 infection -facility personnel will require having their temperature taken at minimum daily -if an employee calls out sick, they will be instructed to call the Infection Preventionist or manager to determine when they are allowed to return to work -all employees are to be Polymerase Chain Reaction (PCR) tested weekly, (Facility tests on Mondays) -an outbreak is defined as one or more affected residents or staff with presumed or positive COVID-19 Review of the Facility's Internal Investigation Timeline, indicated the following: -5/16/22 (Monday) Facility weekly PCR testing day, Interim Infection Control Preventionist (ICP) called CNA #1 because she had not completed her weekly PCR testing, needed to get tested in the community by 5/19/22 and bring in proof of her results. CNA #1 said that she was tested in the community on 5/15/22 (Sunday) and did not have results yet. -5/18/22 (Wednesday) and 5/19/22 (Thursday), the Director of Nurses (DON) spoke to CNA #1 on several occasions and CNA #1 said that she got tested in the community at a local CVS Pharmacy and the results were negative. DON expressed the importance of testing and need for CNA #1 to provide to the Facility with proof of the results of her tests. -5/23/22 (Monday) Facility weekly PCR testing day, the ICP called CNA #1 and notified her that she needed to get tested at Facility and CNA #1 said she was going to get tested that day in the community at a local CVS Pharmacy. -5/25/22 (Wednesday), call placed to CNA #1 to follow up about testing, no response. -5/26/22 (Thursday), CNA #1 was screened upon entering the Facility before the start of her 7:00 A.M. to 3:00 P.M. shift. CNA #1 completed and signed the screening form indicating she had no signs or symptoms of COVID-19, and no exposure. CNA #1 was called and a text was sent to her to follow up with testing. CNA #1 came to the office, said she was not feeling well, Binax test was performed, and the result was positive. CNA #1 then told the ICP that she was not tested on [DATE] or 5/23/22 and still did not have results from the other test she had gotten back on 5/15/22. CNA # 1 was questioned about her resident care assignment and was sent home. Residents who had potential for exposure were tested [DATE] and testing continued. -5/27/22 (Friday), the Administrator spoke with CNA #1 and asked about her testing. CNA #1 initially told the Administrator that she had been tested in the community at a local CVS Pharmacy on 5/15/22 and 5/22/22 and said she (CNA #1) was told by the Pharmacy that her results were negative but that the pharmacy was unable to access the test results. The Administrator asked CNA #1 what the results of her 5/22/22 test was, and CNA #1 said she did not know. CNA #1 was told by the Administrator that she needed to get the test results immediately. CNA #1 eventually told the Administrator that she did not get tested on [DATE] and was only tested on [DATE]. Review of the Facility Weekly Surveillance testing results for CNA #1, dated as collected 5/09/22, indicated she tested negative for her weekly COVID-19 PCR test. Further review of the Facility weekly Surveillance testing results for the weeks of 5/16/22 and 5/23/22, indicated CNA #1 did not get a PCR test in the Facility (or by a community Provider with documentation to support test results) as required by the Facility on a weekly basis. Review of the Employee Illness Reporting Logs dated Monday 5/16/22, and Monday 5/23/22, indicated that CNA #1 called out of work. Review of the Facility Weekly Surveillance Testing Line Listing Form, dated 5/23/22, indicated CNA #1 did report new onset of symptoms, which included congestion, a runny nose, and that she was feeling tired. During an interview on 06/14/22 at 1:52 P.M., the Interim ICP said that on Monday 05/23/22, CNA #1 was due for her weekly PCR test, but called out that day. The Interim ICP said that she was not aware that CNA #1 was out sick on 05/23/22. The Interim ICP said that on Thursday 5/26/22, she called and texted CNA #1 to ask her for the past two weeks PCR test results from the test she had done in the community. The Interim ICP said, unbeknownst to her CNA #1 was working that day, and said CNA #1 came to her office, said she was not feeling well, so she Binax tested CNA #1 and the results were positive. The Interim ICP said that CNA #1 was sent home and she notified the DON and Administrator. During an interview on 06/16/22 at 12:26 P.M., the Administrator said that during their Investigation while doing a Root Cause Analysis, the Facility became aware that CNA #1 called out sick on 05/23/22 with respiratory symptoms. The Administrator said that CNA #1 worked on 05/24/22 and 05/25/22 and said that on her screening attestations, CNA #1 indicated that she did not have any symptoms of illness. The Administrator said that on 05/26/22, CNA #1 said that she did not feel well, even though her screening attestation indicated that she did not have any symptoms of illness, was Binax tested and the results were positive for COVID-19. Review of CNA #1's Timecards dated 5/16/22 through 5/26/22, indicated she was scheduled and worked at the Facility on, 5/18/22, 5/19/22, 5/20/22, 5/21/22, 5/24/22, 5/25/22, and 5/26/22, despite not providing proof of weekly testing in the community or being tested weekly in the Facility, as required. Review of Daily Screening Tool, completed by CNA #1 prior to the start of her shifts, dated 5/18/22, 5/19/22, 5/20/22, 5/21/22, 5/24/22, 5/25/22, and 5/26/22 indicated she attested to the following: -not having or within the last 10 days experiencing any new onset of symptoms of a respiratory infection such as sore throat, headache, runny nose, fever, cough, shortness of breath, fatigue, muscle aches; -not had a confirmed COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -not had a community exposure to someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of CNA #1's Assignment Sheet, dated 5/26/22, indicated she was assigned eight resident rooms on Unit 2 East, (203N, 205S, 206N, 206S, 207N, 208N, 208S, and 211S). Review of CNA #1's Assignment Sheet, dated 5/26/22, indicated that she was assigned to and provided direct care to the following four residents, who tested positive for COVID-19, Resident #1, Resident #3, Resident #8, and Resident #9. In addition to her assigned resident's, CNA #1 provided direct care to other resident's when she assisted CNA #2 with her assignment. As a result of CNA #1 not being tested weekly as part of the Facility's surveillance program, for two consecutive weeks (5/16/22 and 5/23/22), not being removed from the schedule during that time period, and subsequently testing positive for COVID-19 on 5/26/22, residents and staff were exposed to COVID-19 and an outbreak of COVID-19 occurred. -5/30/22, Resident #1 tested positive. -5/31/22, Resident #2 and Resident #4 tested positive, another CNA tested positive. -5/31/22, All residents were Binax tested . -6/01/22, Resident #3, Resident #5, and Resident #6 tested positive. -6/01/22, All Resident's being tested daily, another CNA tested positive. -6/02/22, Resident #7 tested positive, another CNA and a Nurse tested positive. -6/03/22, Resident # 8 tested positive, another Nurse tested positive. -6/04/22, Resident #9 and Resident #10 tested positive, another Nurse tested positive and a housekeeper tested positive. -6/05/22, another CNA tested positive and a dietary staff member tested positive. -6/06/22, Resident #11 tested positive. -6/10/22, Resident #12 tested positive. 1) Resident #1 was admitted to the Facility in December 2019, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #1 was exposed to COVID-19 on 5/26/22. Resident #1 was Binax tested negative on 5/26/22, however, on 5/30/22 he/she tested positive. Review of Resident #1's Physician Orders, dated 5/31/22, indicated to administer Paxlovid (antiviral medication used to treat high risk patients with COVID-19) 300 milligrams (mg) by oral route two times daily for 5 days. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Treatment Administration Record (TAR) and Nurse Progress Notes, dated 6/01/22 through 6/04/22, indicated that he/she exhibited multiple symptoms of COVID-19 including nasal congestion, non-productive cough, fatigue and his/her lung sounds were diminished. 2) Resident #2 was admitted to the Facility in April 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #2 was exposed to COVID-19 on 5/26/22. Resident #2 was Binax tested negative on 5/26/22, however, on 5/31/22 he/she tested positive. Review of Resident #2's Physician Orders, dated 6/03/22, indicated to administer Monoclonal Antibody Therapy as ordered, Bebtelovimab 175 mg, via intravenous injection. Review of Resident #2's Intravenous Infusion Intake Record, dated 6/04/22, indicated he/she received Bebtelovimab 175 mg via intravenous injection, as a one-time dose. Review of Resident #2's TAR and Nurse Progress Notes, dated 6/01/22 through 6/07/22, indicated that he/she exhibited multiple symptoms of COVID-19 including an occasional productive cough, nasal congestion, wheezing upon exertion, rhonchi, sore throat, and his/her lung sounds were diminished. 3) Resident #3 was admitted to the Facility in May 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #3 was exposed to COVID-19 on 5/26/22. Resident #3 was Binax tested negative on 5/26/22, however, on 6/01/22 he/she tested positive. Review of Resident # 3's TAR and Nurse Progress Notes, dated 6/01/22 through 6/06/22, indicated he/she exhibited some symptoms of COVID-19 including cough, nasal congestion, fatigue, and loose stools. Resident #3's Health Care Agent (HCA) declined the offered Paxlovid treatment. 4) Resident #4 was admitted to the Facility in November 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #4 was exposed to COVID-19 on 5/30/22. Resident #4 was Binax tested on [DATE] with positive results. Review of Resident #4's TAR and Nursing Progress Notes, dated 5/31/22 through 6/04/22, indicated he/she remained asymptomatic despite his/her being COVID-19 positive. HCA declined Paxlovib treatment. 5) Resident #5 was admitted to the Facility in May 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #5 was exposed to COVID-19 on 5/30/22. Resident #5 was Binax tested negative on 5/31/22, however, on 6/01/22 he/she tested positive. Review of Resident #5's TAR and Nursing Progress Notes, dated 6/01/22 through 6/04/22, indicated he/she remained asymptomatic despite his/her being COVID-19 positive. 6) Resident #6 was admitted to the Facility in August 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #6 was exposed to COVID-19 on 5/30/22. Resident #6 was Binax tested negative on 5/31/22, however, on 6/01/22 he/she tested positive. Review of Resident #6's TAR and Nursing Progress Notes, dated 6/01/22 through 6/06/22, indicated he/she exhibited symptoms of COVID-19 including congested cough, nasal congestion, abnormal lung sounds, and was pale in color. The Facility offered HCA the choice to send Resident #6 to the hospital, however, the HCA prefer that he/she remained at the Facility to be treated. 7) Resident #7 was admitted to the Facility in April 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #7 was exposed to COVID-19 on 5/26/22. Resident #7 was Binax tested negative on 5/26/22, however, on 6/02/22 he/she tested positive. Review of Resident #7's TAR and Nursing Progress Notes, dated 6/01/22 through 6/06/22, indicated he/she remained asymptomatic despite being COVID-19 positive. 8) Resident #8 was admitted to the Facility in December 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #8 was exposed to COVID-19 on 5/26/22. Resident #8 was Binax tested negative on 5/26/22, however, on 6/03/22 he/she tested positive. Review of Resident #8's TAR and Nursing Progress Notes, dated 6/03/22 through 6/06/22, indicated he/she exhibited symptoms of COVID-19 including productive cough, nasal congestion, and a headache. 9) Resident #9 was admitted to the Facility in May 2017, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #9 was exposed to COVID-19 on 5/26/22. Resident #9 was Binax tested negative on 5/26/22, however, on 6/04/22 he/she tested positive. Review of Resident #9's Physician Orders, dated 6/03/22, indicated to administer Monoclonal Antibody Therapy as ordered, Bebtelovimab 175 mg via intravenous injection. Review of Resident #9's Intravenous Infusion Intake Record, dated 6/04/22, indicated he/she received Bebtelovimab 175 mg via intravenous injection, as a one-time dose. Review of Resident #9's TAR and Nurse Progress Notes, dated 6/02/22 through 6/07/22, indicated that he/she remained asymptomatic despite testing positive for COVID-19. 10) Resident #10 was admitted to the Facility in February 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #10 was exposed to COVID-19 on 5/30/22. Resident #10 was Binax tested negative on 5/31/22, however, on 6/04/22 he/she tested positive. Review of Resident #10's TAR and Nurse Progress Notes, dated 6/05/22 through 6/07/22, indicated that he/she exhibited multiple symptoms of COVID-19 including nasal congestion, shortness of breath, decreased oxygen saturation level of 84 percent on room air (normal range is between 95% and 100%) and required oxygen at 4 liters. Review of Resident #10's Physician Orders, dated 6/07/22, indicated to transfer him/her to the Hospital Emergency Department for evaluation. Resident #10 was admitted from 6/07/22 through 6/11/22 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 11) Resident #11 was admitted to the Facility in May 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, dated May 2022, indicated Resident #11 was exposed to COVID-19 on 5/31/22. Resident #11 was Binax tested negative on 5/31/22, however, on 6/06/22 he/she tested positive. Review of Resident #11's Physician Orders, dated 6/07/22, indicated to administer Monoclonal Antibody Therapy as ordered, Bebtelovimab 175 mg via intravenous injection. Review of Resident #11's Intravenous Infusion Intake Record, dated 6/07/22, indicated he/she received Bebtelovimab 175 mg via intravenous injection, as a one-time dose. Review of Resident #11's TAR and Nurse Progress Notes, dated 6/06/22 through 6/09/22, indicated that he/she remained asymptomatic despite being positive for COVID-19. 12) Resident #12 was admitted to the Facility in June 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Weekly Surveillance Testing Line Listing Form, date June 2022, indicated Resident #12 was exposed to COVID-19 on 5/31/22. Resident #12 Binax tested positive on 6/09/22. Review of Resident #12's Physician Orders, dated 6/10/22, indicated to administer Monoclonal Antibody Therapy as ordered, Bebtelovimab 175 mg via intravenous injection. Review of Resident #12's Intravenous Infusion Intake Record, dated 6/10/22, indicated he/she received Bebtelovimab 175 mg via intravenous injection, as a one-time dose. Review of Resident #12's TAR and Nurse Progress Notes, dated 6/08/22 through 6/12/22, indicated that he/she remained asymptomatic despite testing positive for COVID-19. During an interview on 06/15/22 at 9:02 A.M., CNA #1 said that she did not get PCR tested at the Facility on 05/16/22 or 05/23/22 because she called out sick. CNA #1 said that she got tested for COVID-19 on 05/15/22 at a local CVS Pharmacy in the community and said that the results were negative. CNA #1 said that she continued to work at the Facility and said no one asked her for the test results and said no one tested her for COVID-19 until 05/26/22. CNA #1 said that the Interim ICP called her on 05/26/22 and asked her for the past two weeks COVID-19 test results that were done in the community. CNA #1 said that since she was working at the Facility on 05/26/22, she went to the Interim ICP's office and told her that she was feeling sick. CNA #1 said that was when the Interim ICP Binax tested her, and said the results were positive so she was sent home. CNA #1 said the Facility blamed her for the COVID-19 outbreak. During an interview on 06/14/22 at 1:52 P.M., the Interim Infection Control Preventionist (ICP) said they have not had any positive cases of COVID-19 in the Facility since January of 2022. The Interim ICP said that the Facility does weekly PCR testing on Monday's and said that if a staff member is not working on Monday, they can come in to get their weekly testing done or get their weekly PCR testing done at a testing site in the community. The Interim ICP said that staff are required to bring in their PCR results, that were done in the community, as soon as the results are available, but within the same week. The Interim ICP said that CNA #1's last weekly PCR test was done at the Facility on 05/09/22 and it was negative. The Interim ICP said that CNA #1 was due for her weekly PCR test on Monday 05/16/22, but that she called out due to a car accident, and that CNA #1 said that she got tested in the community on 05/15/22. The Interim ICP said that she informed CNA #1 that she needed to bring in the 05/15/22 PCR test results, the next time she worked. The Interim ICP said that when she did not receive CNA #1's weekly PCR results, for the week of 5/16/22, she notified the Director of Nurses (DON) and the Administrator that CNA #1 did not bring in her weekly PCR results. The Interim ICP said that on Monday 05/23/22, CNA #1 was due for a weekly PCR test but had called out. The Interim ICP said she contacted CNA #1 who told her that she had gotten a PCR test in the community and said she told CNA #1 to bring in the results of her weekly PCR test. The Interim ICP said that on Thursday 5/26/22, she called and texted CNA #1 to remind her to bring in her weekly PCR test results. The Interim ICP said, unbeknownst to her, CNA #1 was working that day, and came to her office and said that CNA #1 told her she was not feeling well. The Interim ICP said she Binax tested CNA #1, the test was positive for COVID-19 and CNA #1 was sent home. The Interim ICP said that CNA #1 had been in direct contact with several residents on 05/26/22, said that all of the affected residents were tested and that some of those residents tested positive for COVID-19. The Interim ICP said that she was under the impression that CNA #1 had done her weekly PCR testing in the community and said that she was waiting for CNA #1 to bring in proof of the results. The Interim ICP said that she should have done a Binax test on CNA #1 when she did not bring in her weekly PCR results and said that it was an oversight. During an interview on 06/15/22 at 2:05 P.M., CNA #2 said (on 5/26/22) that she worked with CNA #1 and that CNA #1 told her she was sick and said that her throat was bothering her. CNA #2 said that CNA #1 sounded sick, had a nasally voice and had coughing during her shift. CNA #2 said that she told CNA #1 that she should go get a Binax test. CNA #2 said that she was Binax tested on multiple days, after working with CNA #1 and being exposed to Covid-19 and initially tested negative. CNA #2 said that on 06/01/22, she was sick and tested positive for COVID-19 and went home. During an interview on 06/15/22 at 2:18 P.M., CNA #3 said that she worked with CNA #1 on Tuesday 5/24/22 during the 7:00 A.M. to 3:00 P.M. shift. CNA #3 said that CNA #1 told her that she was sick and did not feel well and said that she told CNA #1 to go get a Binax test. CNA #3 said that CNA #1 did not look sick or have any visible symptoms of being sick when she worked with her. CNA #3 said she did not report that CNA #1 told her that she felt sick to anyone. During an interview on 06/15/22 at 2:45 P.M., CNA #4 said that she worked with CNA #1 on 05/25/22 and said that she heard CNA #1 cough multiple times during the eight-hour shift. CNA #4 said that she asked CNA #1 if she was sick and said that CNA #1 told her she was not sick. During an interview on 06/15/22 at 3:00 P.M., the Director of Nurses (DON) said the last required weekly PCR test for CNA #1 that was done at Facility, was on 05/09/22. The DON said that CNA #1 told her that she was tested for COVID-19 in the community for her weekly testing on 05/16/22 and 05/23/22. The DON said that she believed that CNA #1 was tested for COVID-19 in the community and said that she was waiting for CNA #1 to bring in proof of her COVID-19 test results. The DON said that CNA #1 continued to work and provide direct care to the residents from 5/18/22 until 05/26/22, even though she did not bring in any proof of being tested in the community for her weekly testing. The DON said that CNA #1 should have had a Binax test in the Facility and should have been taken off the schedule until she had her weekly PCR test done or brought in proof that it was done in the community. During an interview on 06/15/22 at 3:30 P.M., the Administrator said that on 05/26/22, CNA #1 said that she did not feel well, even though her screening attestation form indicated that she did not have any symptoms of illness, said she was Binax tested , and the results were positive for COVID-19. The Administrator said CNA #1 should not have worked at the Facility providing direct care to the residents without having proof of having her weekly PCR testing done in the community. The Administrator said that CNA #1 should have been required to have a Binax test done at the Facility, prior to providing direct care to the residents, when she did not bring in proof of her community testing PCR results.

Based on records reviewed and interviews for 12 of 12 sampled residents, (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12), the Facility failed to ensure they implemented an effective COVID-19 (an acute respiratory illness in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) surveillance testing program in order to identify and prevent the transmission of COVID-19 as required, when a Certified Nurse Aide (CNA) #1 chose not to be tested on Monday 5/16/22 and Monday 5/23/22 at the facility to comply with the weekly testing requirement, and told the facility she was tested in the community at a local pharmacy. However when CNA #1 failed to provide proof of testing as required, she was not removed from the schedule and continued to provide direct care to residents for almost two weeks, before finally being tested at the Facility on 5/26/22, at which point she tested positive for COVID-19. -5/09/22 (Monday) CNA #1 tested by the Facility for COVID-19 and was negative. -5/16/22 (Monday) CNA #1 did not get tested at the Facility, said she was tested at CVS Pharmacy on 5/15/22, however, she did not provide proof of testing to the facility as required, was not removed from the schedule, and worked 5/18/22, 5/19/22, 5/20/22, and 5/21/22 providing direct care to residents. -5/23/22 (Monday), CNA #1 did not get tested at the Facility, said she was tested at CVS on 5/22/22, but again did not provide proof of testing as required, was not removed from the schedule, and worked 5/24/22 and 5/25/22, providing direct care to residents. -5/26/22 (Thursday), CNA #1, worked at the Facility providing direct care to residents for over two hours, and was tested by the facility for COVID-19 and tested positive. As a result of failing to implement an effective surveillance program for COVID-19, (Facility's last documented positive case of COVID-19 was back on 1/24/22) the Facility experienced an outbreak with 12 residents and eight staff member testing positive for COVID-19 from 05/30/22 through 06/10/22. Five of those residents received direct care from CNA #1, three of those residents were roommates of the residents who received direct care from CNA #1 and five residents required therapeutic treatment with medication for COVID-19. Findings include: Review of Massachusetts Department of Public Health (DPH) Memorandum, titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, dated 9/24/21, indicated all Long-Term Care Facilities must screen all individuals entering the facility, including healthcare personnel. The Memorandum indicated the following: -every Facility should have a process to ensure everyone arriving to the facility is assessed for symptoms of COVID-19 (cough, shortness of breath, sore throat, myalgia (muscle pain), chills, new onset loss of smell or taste, and fever); -long-term care facilities are required to perform weekly surveillance testing of all staff. Review of the Facility Policy titled Coronavirus Surveillance, Detection, and Management of an Outbreak, dated as revised April 2022, indicated it included the following: -all individuals upon entering the facility, including staff and visitor, will be screened for any signs and symptoms of COVID-19 (cough, shortness of breath, sore throat, myalgia, chills, or new onset of loss of smell or taste, and a fever), and exposure to others with suspected or confirmed [CONDITION(S)]-Co V-2 infection; -facility personnel with require having their temperature taken at minimum daily; -if an employee calls out sick, they will be instructed to call the Infection Preventionist or manager to determine when they are allowed to return to work; -all employees are to be Polymerase Chain Reaction (PCR) tested weekly, (Facility tests on Mondays); -an outbreak is defined as one or more affected residents or staff with presumed or positive COVID-19; Review of the Facility's Internal Investigation Timeline, dated as follows, indicated that: -5/16/22 (Monday), Facility weekly PCR testing day, Interim Infection Control Preventionist (ICP) called CNA #1 because she had not completed her weekly PCR testing at the Facility, needed to get tested in the community by 5/19/22 and bring in proof of her results. CNA #1 said that she was tested on [DATE] at a CVS Pharmacy testing site and did not have results yet. -5/18/22 (Wednesday) and 5/19/22 (Thursday), the Director of Nurses (DON) spoke to CNA #1 on several occasions and CNA #1 said that she got tested in the community and the results were negative. DON expressed the importance of testing and the need for CNA #1 to provide the Facility with proof of her testing results. -5/23/22 (Monday) Facility weekly PCR testing day, the ICP called CNA #1 and notified her that she needed to get tested at Facility and CNA #1 said she was going to get tested that day in the community. -5/25/22 (Wednesday), call placed to CNA #1 to follow up about testing, no response. -5/26/22 (Thursday), CNA #1 was screened upon entering the Facility prior to the start of her shift (7:00 A.M. to 3:00 P.M.) and indicated she had no signs or symptoms, no exposure, to COVID-19. The Interim ICP called and texted CNA #1 to follow up on her (CNA #1's) testing, and CNA #1, who was working that day, came to the ICP's office. CNA #1 said she was not feeling well, Binax test was performed, and the result was positive. CNA #1 then told the Interim ICP that she had not been tested in the community on 05/22/22 and still did not have any results from the other test she had gotten. CNA # 1 was questioned about the resident's she cared for and her assignment and was sent home. Residents who had potential for exposure were tested . -5/27/22 (Friday), the Administrator spoke with CNA #1 and asked about her COVID-19 testing. CNA #1 initially told the Administrator that she had been tested in the community at CVS Pharmacy on 5/15/22 and 5/22/22, was told that the result was negative and that CVS was unable to access the test report. The Administrator asked CNA #1 what the results of her 5/22/22 test was, and she said she did not know. When CNA #1 was told by the Administrator that she needed to get the test results immediately, CNA #1 told the Administrator that she did not get tested on [DATE] and was only tested on [DATE]. Review of the Facility Weekly Surveillance testing results for CNA #1, dated as collected 5/09/22, indicated she tested negative for her weekly COVID-19 PCR testing. Further review of the Facility's weekly Surveillance testing results for the week of 5/16/22 and 5/23/22, indicated CNA #1 did not get a PCR test as required by the Facility on a weekly basis. The Facility was unable to provide documentation as proof to support that CNA #1 had been compliant with their weekly testing requirements, by getting tested in the community. Review of the Employee Illness Reporting Log dated 5/16/22, and 5/23/22, indicated that CNA #1 called out of work both days, which were Mondays and the Facility weekly testing day. Review of the Facility Weekly Surveillance Testing Line Listing Form, dated 5/23/22, indicated CNA #1 had reported new onset of symptoms including some congestion, a runny nose, and that she was feeling tired. During an interview on 06/14/22 at 1:52 P.M., the Interim Infection Control Preventionist (ICP) said the Facility has not had positive cases of COVID-19 in the facility since January of 2022. The Interim ICP said the Facility does weekly PCR testing on Monday's and said that if a staff member is not working on Monday, they can either come in to get their weekly testing done that day or get their weekly PCR testing done in the community. The Interim ICP said that staff are required to bring in their weekly PCR results, that were done in the community, as soon as the results are available, but within the same week. The Interim ICP said that CNA #1's last weekly PCR test was done at the Facility on 05/09/22 and it was negative. The Interim ICP said that CNA #1 was due for her weekly PCR test on 05/16/22, said that she called out due to a car accident, and said that CNA #1 said that she got tested in the community on 05/15/22. The Interim ICP said that she informed CNA #1 that she needed to bring in the 05/15/22 PCR results, the next time she worked. The Interim ICP said that when she did not receive CNA #1's weekly PCR results, for the week of 5/16/22, she notified the Director of Nurses and the Administrator. The Interim ICP said that on 05/23/22, CNA #1 was due for her weekly PCR test, said that she called out and said that the Employee Illness Log indicated that CNA #1 was not sick. The Interim ICP said that on 5/26/22, she called and texted CNA #1 to ask her for the 5/15/22 and 5/22/22 PCR test results that were done in the community. The Interim ICP said unbeknownst to her, CNA #1 was working that day, and came to her office, and told her she was not feeling well. The Interim ICP said she tested CNA #1 with a Binax test, that CNA #1 tested positive for COVID-19 and was sent home. The Interim ICP said she notified the DON and the Administrator. During an interview on 06/15/22 at 3:30 P.M. the Administrator said that CNA #1 worked on 05/24/22 and 05/25/22 at the facility and that CNA #1 had indicated on her screening attestation form that she did not have any symptoms of illness. The Administrator said that on 05/26/22, CNA #1 said that she did not feel well, even though her screening attestation form indicated that she did not have any symptoms of illness, said she was Binax tested , and the results were positive for COVID-19. The Administrator said that CNA #1 should not have worked at the Facility providing direct care to the residents without having proof of having her weekly PCR testing done in the community. The Administrator said that CNA #1 should have had a Binax test done at the Facility, prior to providing direct care to the residents when she did not bring in her PCR test results. During an interview on 06/15/22 at 3:00 P.M., the Director of Nurses (DON) said that CNA #1's last weekly PCR test, that was done at Facility, was on 05/09/22. The DON said that CNA #1 told her that she was tested for COVID-19 in the community for her weekly testing on 05/15/22 and 05/22/22. The DON said that CNA #1 continued to work and provide direct care to the residents until 05/26/22, even though she had not provided her COVID-19 test results as proof of being tested in the community for her weekly testing. The DON said that CNA #1 should have been taken off the schedule until she had her weekly PCR test done by the Facility or brought in proof that it was done in the community. Although the facility required CNA #1 to be tested for COVID-19 weekly, the Facility was aware she had not participated in weekly testing on Mondays at the Facility and was non-compliant with providing supporting documentation for proof of her test results from an outside source. CNA #1 was not removed from the schedule and continued to provide direct care to residents from 5/16/22 through 5/26/22. Review of CNA #1's Timecard from 5/16/22 through 5/26/22, indicated she worked 5/18/22, 5/19/22, 5/20/22, 5/21/22, 5/24/22, 5/25/22, and 5/26/22. Review of Daily Screening Tool dated 5/18/22, 5/19/22, 5/20/22, 5/21/22, 5/24/22, 5/25/22, and 5/26/22 indicated that CNA #1 attested to the following: -not having or within the last 10 days experiencing any new onset of symptoms of a respiratory infection such as sore throat, headache, runny nose, fever, cough, shortness of breath, fatigue, muscle aches; -not had a confirmed COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -not had a community exposure to someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of CNA #1's Assignments, dated 5/16/22 through 5/26/22, indicated CNA #1 was assigned to work on Unit 2 East. In addition to her assigned residents on Unit 2 East, CNA #1 provided direct care to other resident's when she assisted CNA #2 with her assignment. As a result of residents and staff coming into contact with CNA #1, either directly or indirectly being exposed to COVID-19 the following 12 residents and eight staff members tested positive in the Facility for COVID-19 after 5/26/22: -On 5/30/22, Resident #1 tested positive and required the administration of Paxlovid (antiviral medication used to treat high risk patients with COVID-19) 300 milligrams (mg) by oral route two times daily for 5 days. -On 5/31/22, Resident #2 tested positive and required the administration of Monoclonal Antibody Therapy Bebtelovimab 175 mg, via intravenous injection as a one-time dose on 6/04/22; Resident #4 tested positive, a CNA tested positive; -On 5/31/22, All Facility residents were Binax tested ; -On 6/01/22, Resident #3, Resident #5, and Resident #6 tested positive. -On 6/01/22, All Resident's being tested daily, another CNA tested positive. -On 6/02/22, Resident #7 tested positive, another CNA and a Nurse tested positive. -On 6/03/22, Resident # 8 tested positive, another Nurse tested positive. -On 6/04/22, Resident #9 tested positive and required the administration of Monoclonal Antibody Therapy as ordered, Bebtelovimab 175 mg intravenous injection on 6/04/22; and Resident #10 tested positive and on 6/07/22 was sent to the Hospital Emergency Department for evaluation and required admission, another Nurse tested positive, and a housekeeper tested positive; -On 6/05/22, another CNA tested positive, and a dietary staff member tested positive; -On 6/06/22, Resident #11 tested positive and required the administration of Bebtelovimab 175 mg via intravenous injection, as one-time dose on 6/07/22. -On 6/10/22, Resident #12 tested positive and required the administration of Monoclonal Antibody Therapy as ordered, Bebtelovimab 175 mg via intravenous injection, as a one-time dose. During an interview on 06/15/22 at 9:02 A.M., Certified Nurse Aide (CNA) #1 said that she did not get PCR tested at the Facility on 05/16/22 and 05/23/22 because she called out sick. CNA #1 said that she got tested for COVID-19 on 05/15/22 at CVS Pharmacy and said that the results were negative. CNA #1 said that she continued to work at the Facility and said no one asked her for the test results and said no one tested her at the Facility for COVID-19 until 05/26/22. CNA #1 said that the Interim ICP called her on 05/26/22 and asked her for the past two weeks COVID-19 test results that were done in the community. CNA #1 said that she was working at the Facility on 05/26/22, so she went to the Interim ICP's office and told her that she was feeling sick. CNA #1 said that was when the Interim ICP Binax tested her, said that the Binax results were positive and she was sent home. CNA #1 said the Facility blamed her for the COVID-19 outbreak.