Every finding on record at Webster at Rye

Based on observation, interview, and record review, the facility failed to develop and implement policies for water management to minimize the risk for waterborne diseases for a facility census of 47 residents and to follow professional standards for infection control practices for medication administration for 1 of 27 medications observed. (Resident identifier is #11).Findings include:Review on 8/12/26 of the facility's, Legionella Water Management Plan, dated 3/25/26, revealed that the plan was not specific to the facility. Further review revealed that the potential risk areas: water stagnation, inconsistent water temperatures, biofilm and sediment accumulation, and aerosol-generating devises were not identified where they were in the facility or what the facility was doing to mitigate the risks. Interview on 8/12/26 at 10:08 a.m. with Staff F (Infection Prevention) confirmed that the water management plan provided was not specific to the facility and did not identify where and what they were doing to minimize the risk for Legionella and other waterborne diseases. Review on 8/12/26 of the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings dated September 30, 2025, revealed, .3. Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in you building water systems . Each potentially hazardous condition should be addressed individually with a control point, measure, and limit . 5. Establish Ways to Intervene When Control Limits Are Not Met . You should plan for your monitoring results to vary over time and be prepared to apply corrective actions. Corrective actions are taken in response to systems performing outside of control limits . Resident #11 Standard:[NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021, Chapter 31, pages 640 and 641 revealed the following Medication Administration .Administering Oral Medications, . Clean gloves if handling an oral medication, . Implementation 1.a. Perform hand hygiene, . g. Prepare solid forms of medications, . g2. When using a blister pack, pop medications through foil or paper backing into a medication cup. Observation on 8/11/26 at approximately 7:25 a.m. of Staff A (Registered Nurse) administering medications to Resident #11 revealed Staff A dropped Resident #11's Lyrica capsule out of the medication blister card onto the medication cart, picked it up with his/her bare fingers, and placed it into the medication cup with Resident #11's other pills. Interview on 8/11/26 at approximately 7:30 a.m. with Staff A confirmed the above findings. Review on 8/12/26 of the facility policy titled, Medication Administration, Dated 10/25, revealed: .5. When administering medications the Unit Nurse will: . Perform hand hygiene before and after each resident medication pass, .

Based on interview and record review, the facility failed to provide a rationale to extend a PRN (as needed) anti-anxiety medication beyond the 14 days when prescribed for 1 of 1 resident reviewed for behavioral-emotional in a final sample of 13 residents (Resident identifier is #10).Findings include:Review on 8/11/26 of Resident #10's physician orders revealed an order, dated 6/26/26, for Ativan 2mg (milligrams)/ml (milliliter) Give 0.5ml sublingually every 2 hours as needed for Anxiety or Dyspnea with no specified duration of the PRN order.Review on 8/11/26 of Resident #10's physician and provider notes revealed that there was no documentation for a rationale to extend the PRN Ativan. Interview on 8/12/26 at approximately 8:30 a.m. with Staff D (Director of Nursing) confirmed the above findings.Review on 8/12/26 of facility policy titled Psychopharmacological Drugs dated 8/25/22 revealed, .All PRN psychotropic medications will be ordered with a 14 date stop date and a reassessment of the medication will be made at the end of the 14th day.

Based on observation, interview, and policy review, the facility failed to implement their personal food policy for 1 of 1 kitchenette observed. Findings include:Review on 8/11/26 of the facility's policy, Foods Brought By Family & Visitors, undated, revealed, .4. All foods placed in the refrigerator for the patient/resident is to be labeled with the residents' name and date the product was made. All food items need to be discarded 72 hours or three days after item was brought into the facility.Observation on 8/11/26 at approximately 9:00 a.m. of the reach-in refrigerator in the kitchenette revealed the following:One (1) glass container of what appeared to be soup, a milky gray appearance, with a date of 7/2/26 and no resident name;One (1) plastic container of what appeared to be a sandwich with no date or resident name;One (1) plastic container of an unknown substance with no date or resident name;One (1) glass bowl of cottage cheese with no date or resident name;One (1) Chobani Protein Drink with an expiration date of 7/7/26 and no resident name;Two (2) Chobani Protein Drink with an expiration date of 7/8/26 and no resident name;One (1) Rockin Protein Drink with no date or resident name.Interview on 8/11/26 at approximately 9:15 a.m. with Staff E (Director of Food Services) confirmed the above findings and revealed the above food items were not provided to the residents by the facility. Staff E stated that it is the facility policy to label items with the resident name and date and to discard prepared items after 72 hours or by the manufacturer's expiration date.

Based on observation, interview, and record review, it was determined that the facility failed to ensure sanitization of dishware in 1 of 1 kitchen observed.Findings include:Review on 8/20/25 of the facilities policy High-Temperature Dish out of temperature policy, undated, revealed the following: .Required temperature (per regulatory standards) .Final Rinse Cycle: Minimum temperature 180 degrees F [Fahrenheit] . 1. Immediate Verification Check the machine's temperature gauges. Confirm accuracy with a thermometer or heat sensitive test strip on dishes during the final rinse. Record out-of-range reading in the dishwasher temperature log.3 .Do not continue dishwashing until proper sanitation can be ensured. 4. Implement Back up Sanitation .Switch to 3- Compartment Sink Method .Observation on 8/19/25 at approximately 8:14 a.m. in the kitchen revealed Staff E (Cook) loading morning dirty dishes into the high temperature dish machine. The dish machine achieved a maximum temperature of 172 degrees Fahrenheit during the final rinse. Observation on 8/19/25 at approximately 12:45 p.m. in the kitchen with Staff C (Director of Dietary Services) revealed the high temperature dish machine achieved a maximum temperature of 168 degrees Fahrenheit during the final rinse. Review on 8/19/25 of the Dish machine temperature logs, revealed that the final rinse temperature of the dish machine had not been recorded since 7/28/25.Interview on 8/19/25 at approximately 12:45 p.m. in the kitchen with Staff C confirmed the above findings. Further interview with Staff C revealed that the dishes washed in the morning at a final rinse of 172 degrees Fahrenheit were not rewashed and were used to serve lunch.

Based on interview and record review, it was determined that the facility failed to implement antibiotic use protocols that address unnecessary or inappropriate antibiotic use for 1 of 6 residents reviewed for antibiotic stewardship. (Resident identifiers is #38.) Findings include:Resident #38Review on 8/21/25 of Resident #38's physician's order revealed an order dated 7/7/25 for Cipro for an UTI.Review on 8/21/25 of Resident #38's medical record revealed no antibiotic time out was completed for the above antibiotic.Review on 8/21/25 of Resident #38's Revised McGeer Criteria for Infection Surveillance Checklist, dated 8/5/25, for the UTI infection on 7/7/25 did not meet criteria.Interview on 8/21/25 at 8:12 a.m. with Staff A (Director of Nursing) confirmed that the above facility's policy titled Antibiotic Management did not include Antibiotic Stewardship or the use of an antibiotic time out. Further interview revealed that the facility did not document time-outs for antibiotic use. Staff A revealed that the facility follows the CDC for antibiotic use guidelines.Review on 8/21/25 of the CDC (Centers for Disease Control and Prevention) Core Elements of Antibiotic Stewardship for Nursing Homes, dated 3/18/24 and retrieved from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html revealed, . Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available.Review on 8/20/25 of the facility's policy tiled Antibiotic Management revealed, As any type of medication, if an antibiotic is to be started, it will be on an individualized based on the symptom criteria, the prescriber will order as based on resident's history and clinical situation. The MD/NP [Medical Doctor/Nurse Practitioner] will order any lab work that may be expected while on a specific antibiotic. The antibiotic prescribed should be of the narrowest of the spectrum for achieving the intended effect.

Based on interview, record review, and policy review, it was determined that the facility failed to implement an ongoing systematic collection of surveillance data during a SARS-CoV-2 (COVID-19) outbreak from 7/7/24 to 7/25/24 and failed to ensure a system for identifying residents with COVID-19 through timely testing for 1 of 10 residents reviewed with respiratory symptoms (Resident Identifier is #99). Findings include: Interview with Staff C (Director of Nursing) on 8/13/24 revealed that Staff C was providing a new COVID-19 Line List for July 2024, originally provided on 8/12/24, due to some inaccuracies identified by the facility that had been corrected. Review on 8/13/24 of the facility's COVID-19 Line List for July 2024, received on 8/13/24, revealed changes had been made to the list provided on 8/12/24 related to symptom onset, test collection dates, and symptom information. Interview with Staff C on 8/14/24 revealed that Staff C was providing a new COVID-19 Line List for July 2024 to replace the list provided on 8/13/24, due to additional inaccuracies identified by the facility that had been corrected. Review on 8/14/24 of the facility's COVID-19 Line List for July 2024, received on 8/14/24, revealed additional changes had been made to the list provided on 8/13/24 related to symptom onset, test collection dates, and symptom information. Further review revealed that Resident #99 was on the COVID-19 Line List provided on 8/14/24 and it indicated that Resident #99's symptoms started on 7/7/24. Review on 8/12/24 of Resident #99's medical record revealed a Progress Note dated 7/6/24 that stated: Resident continues with cold sx [symptoms] prn [as needed] tussin [cough medication] given at 0945 [9:45 a.m.] and 1345 [1:45 p.m.] with positive effect. Resident refused neb [nebulizer] tx [treatment]. Resident was put on O2 [oxygen] on the previous shift for O2sat 90% RA [Oxygen saturation at 90% on room air] with dyspnea [shortness of breath]. O2 has had good effect 95% 2L/min [2 liters per minute] via nasal canula. Interview on 8/14/24 with Staff C confirmed the above findings and the above progress note stating Resident #99 had respiratory symptoms prior to 7/6/24. The provider ordered a COVID-19 test for Resident #99 on 7/7/24 and the result was positive. Review on 8/14/24 of facility policy titled, Webster at Rye COVID-19 Resident and Staff Testing Policy revealed: Webster at Rye follows the latest CDC [Center for Disease Control and Prevention] guidelines for testing for COVID-19 of residents and staff. Review on 8/14/24 of the Center for Disease Control and Prevention guidance Infection Control Guidance: SARS-CoV-2, dated 6/24/24, accessed at https://www.cdc.gov/covid/hcp/infection-control/index.html, revealed the following: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible.

Based on observation, interview, and record review, it was determined that the facility failed to determine if self-administration is appropriate for a resident for 1 of 1 resident reviewed for respiratory care. (Resident Identifier #152). Findings include: Observation on 8/13/24 at approximately 9:15 a.m. of Resident #152 revealed Resident #152 sitting up in their recliner chair with 3 medicine cups sitting on the side table next to them. Further observation revealed one medicine cup to contain seven pills and three capsules, and the two other medicine cups to each contain a liquid (one was very light blue in color and the other was a pale orange color). Interview on 8/17/24 at approximately 9:20 a.m. with Staff E (Registered Nurse (RN)) confirmed the above findings. Further Interview with Staff E revealed that the medication cups observed contained Resident #152's morning medications that were administered by Staff F (RN). Staff E confirmed that Resident #152 does not have an order to self administer medications and does not have an assessment to self administer their medications. Interview on 8/13/24 at approximately 1:30 p.m. with Staff C (Director of Nursing) confirmed that Resident #152 should not be self administering their medications. Review on 8/14/24 of facility policy titled, Medication Administration General Guidelines, effective 1/21, revealed: .15. Residents are allowed to self-administer medications when specifically authorized by the prescribe, the nursing care center's interdisciplinary Team [IDT], and in accordance with procedures for self-administration of medications and state regulations . Review on 8/14/24 of facility policy titled, Medication Administration Self-Administration by Resident, effective 11/17, revealed: .Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure food was stored at the proper temperature in 1 of 1 kitchenettes observed. Findings include: Review on 8/12/24 at approximately 9:45 a.m. of the kitchenette refrigerator temperature logs revealed the following missing temperatures: June 2024 6/11/24 (PM), 6/12/24 (PM), 6/13/24(PM), 6/14/24 (AM and PM), 6/15/24 (AM and PM), 6/16/24 (AM), 6/17/24 (PM), 6/18/24 (PM), 6/19/24 (PM), 6/22/24 (PM), 6/23/24(PM), 6/24/24(PM), 6/25/24(PM), 6/26/24(PM), 6/27/24 (PM), 6/28/24 (PM), 6/29/24(AM and PM), and 6/30/24 (AM and PM). July 2024 7/12/24 (PM), 7/13/24 (PM), 7/15/24 (PM), 7/16/24 (AM and PM), 7/18/24 (PM), 7/19/24 (PM), 7/20/24 (AM and PM), 7/21/24 (AM and PM), 7/22/24 (AM and PM), 7/23/24 (AM and PM), 7/24/24 (PM), 7/25/24 (PM), 7/26/24 (AM) 7/27/24 (AM and PM), 7/28/24 (AM and PM), 7/29/24 (AM and PM) and 7/31/24 (AM). August 2024 8/7/24 (AM), 8/8/24 (AM), 8/10/24 (AM), and 8/11/24 (AM and PM). Interview on 8/12/24 at approximately 9:45 a.m. with Staff B (Food Services Director) confirmed the above finding. Review on 8/16/24 of the Food and Drug Administration [FDA] Food Code, dated 2017, retrieved from: https://www.fda.gov/media/110822/download, revealed: Certain foodborne pathogens that are anaerobes or facultative anaerobes are able to multiply under either aerobic or anaerobic conditions. Therefore special controls are necessary to control their growth. Refrigerated storage temperatures of 5 C (41 F) may be adequate to prevent growth and/or toxin production of some pathogenic microorganisms . Review on 8/12/24 of facility policy titled, Food Storage, revealed: .3. Cold foods shall be maintained at temperatures of 40 degrees Fahrenheit or below .5. Thermometers are located in each refrigerator and freezer and temperatures are checked and recorded twice daily to ensure proper storage of temperatures .

Based on observation, interview, and record review it was determined that the facility failed to ensure that medications were labeled with an opened date or use by date and expired medications were removed from use for 1 out of 2 medication carts and 1 out of 1 medication room observed (Resident Identifiers are #26 and #96). Findings include: Southwest Medication Cart Observation on 6/6/23 at approximately 8:00 a.m. of the medication room with Staff C (Registered Nurse) revealed the following: Resident #26's Timolol Meleate 0.5% [percent] eye drop with an opened date of 3/25/23 and a pharmacy sticker that stated discard 60 days after opening; Resident #96's Dorzolamide HCL [Hydrochloric acid] 2% Ophthalmic Solution (eye drop) with no opened date and a pharmacy expired sticker dated 5/31/23. Interview with on 6/6/23 at approximately 8:15 a.m. with Staff C confirmed the above findings. Staff C confirmed that the medications identified were currently ordered and in use. Facility Medication Room Observation on 6/6/23 at approximately 8:30 a.m. of the medication room with Staff B (Registered Nurse) revealed the following: Two unopened bottles of Naproxen Sodium 220 milligram (mg) with an expiration date of 4/2023; 1 opened vial of Tuberculin Purified Protein Derivative (Tubersol) with no open or use by date. Interview on 6/6/23 at approximately 8:50 a.m. with Staff B confirmed the above findings. Staff B confirmed the medications were house stock and were currently available for use. Review on 6/7/23 of the facility policy titled Storage of Medication, dated 1/2021, revealed .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedure for medication disposal . Review on 6/7/23 of Tuberculin Purified Protein Derivative (Tubersol) manufacturer's instructions revealed .A vial of Tubersol which has been entered and in use for 30 days should be discarded .

Based on interview and record review it was determined that the facility failed to follow physician's orders for 1 resident in a final sample of 13 residents (Resident Identifier is #34). Based on interview and record review determined that the facility failed to monitor a resident's weight for 1 resident reviewed in a final sample of 13 residents. (Resident Identifier is #32). Findings include: Resident #34 Review on 6/6/23 of Resident #34's Medication Administration Record (MAR) revealed the following physician's orders: May 2023 Amlodipine Besylate Oral Tablet 10 milligrams (mg) Give 1 tablet by mouth one time a day for Hypertension (HTN), Hold for Systolic Blood Pressure (SBP) less than 120/70, order date 4/28/23. May 13th SBP was 109 and medication was documented as being administered. June 2023 Amlodipine Besylate Oral Tablet 10 mg, Give 1 tablet by mouth one time a day for HTN, Hold for SBP less than 120/70, order date 4/28/23. June 5th SBP was 110 and medication was documented as being administered. Interview on 6/7/23 at approximately 8:45 a.m. with Staff B (Assistant Director of Nurses) confirmed the above findings. Review on 6/7/23 of the facility policy titled, Medications, undated revealed: .1. Drugs must be administered in accordance with the written orders of the attending physician. Resident # 32 Review on 6/6/23 of Resident #32's medical record revealed that he/she was admitted to the facility on [DATE] with a diagnosis of Congestive Heart Failure (CHF). Review on 6/6/23 of Resident #32's weights revealed the following weights: 5/15/23 weight was 236.8 obtained with hoyer 5/29/23 weight was 224.0 obtained with hoyer 6/5/23 weight was 228.6 obtained while sitting Interview on 6/7/23 at approximately 10:00 a.m. with Staff B (Assistant Director of Nursing) confirmed that there was no documented weight on admission until 4 days after admission and that there was no reweight done on 5/29/23 with a 12.8 pound loss being identified until 6/5/23. Review on 6/7/23 of the facility policy titled, Weight and Height Documentation, Revised on 4/22 revealed: All residents are to have a height and weight done upon admission. All residents/patients are to be weighed weekly on their shower/bath day. Each resident must be weighed on the same scale each week and with all the items. If there is a three-pound discrepancy from the previous weight, reweigh at that time and be sure scale is calibrated.

Based on interview and medical record review it was determined that the facility failed to ensure the resident's right to formulated advance directives for 1 out of 13 residents reviewed for advance directives (Resident Identifier is #13). Findings include: Review on [DATE] of Resident #13's Electronic Health Record (EHR) revealed that Resident #13 was a full code. Review on [DATE] of Resident #13's paper medical record revealed on the chart binder a sticker indicating full code. Further review of Resident #13's paper medical record revealed that Resident #13 had a Do Not Resuscitate (DNR) order signed by the physician on [DATE]. Interview on [DATE] at approximately 12:10 p.m. with Staff A (Registered Nurse) revealed that he/she would first look at the band on a resident's arm to determine a residents code status, if resident did not have a wrist band on he/she would then look in the EHR, and lastly would check the binder of a residents paper medical record. Observation on [DATE] at approximately 12:12 p.m. of Resident #13's arms revealed that he/she was not wearing a wrist band. Interview on [DATE] at approximately 12:13 p.m. with Resident #13, their spouse, and Staff A revealed that Resident #13 wishes to be a DNR. Review on [DATE] of the facility policy titled, Advance Directives, dated [DATE] revealed: . 7. Code Status Consent- This form will be completed by the resident and/or the activated DPOA (Durable Power Of Attorney) for healthcare or guardian. This consent indicates the resident's desire relative to CPR (Cardio Pulmonary Resuscitation). It may be revised at any time. If there is a change in status, it must be documented in the medical record by the physician. Code Status is in effect when signed and order placed in medical record. 8. Wrist Band- Blue wrist, indicating DNR, will be applied by nursing staff once code status is established. .

Based on interview and record review, it was determined that the facility failed to properly assess for the proper positioning of 2 of 2 residents reviewed for the use of a Broda chair (a wheel chair that tilts back) and failed to ensure that staff were trained for the competent use of the Broda chair. (Resident identifiers are #1 and #2.) Findings include: Review on [DATE] of Broda Operation Manual retrieved from https://brodaseating.com/products/all/ read, in part, .2. Safety Requirements 2.1 . Before the chair is put into service, this manual must be read thoroughly by the caregiver(s) directly responsible for the resident's care. After the chair is put into service, this manual must be read thoroughly by any new caregivers prior to operating or moving the chair Prior to first use, the customer must arrange for an in-service on the operation and safety requirements in this manual . The primary caregiver must maintain a list of caregivers who have read this manual and who they have authorized to operate and move the chair 2.2 . Broda chairs are intended exclusively for residents of long-term care institutions who are under the care of professional caregivers. The suitability of a Broda chair must be determined by a qualified caregiver who is familiar with the seating needs of the intended resident Interview on [DATE] at approximately 12:50 p.m. with Staff A (Director of Nursing) revealed that there were 2 residents who used a Broda chair, including Resident #1 who had expired. Staff A revealed that staff are not trained or have competencies in the use of Broda chairs. Staff A revealed that training was completed after Resident #1 fell out of the Broda chair, but the training did not include any competencies for the use of the Broda chairs or for the individual resident. The training only stated during meals the chair is to be upright and after meals it is to be reclined for safety. Do not leave them upright. All staff was educated on this. Staff A revealed that the facility has no policy for the use of Broda chairs. Telephone interview on [DATE] at 11:55 a.m. with Staff A confirmed that there was no staff competencies for the Broda chairs, there was no individualized assessments for Resident #1 or #2 for the Broda chair. Review on [DATE] of an email provided by Staff B (Administrator) revealed the following: -Confirmed there was 1 current resident (Resident #2) using a Broda chair, and 1 discharged resident (Resident #1); -Confirmed there was no individualized assessments completed for either resident for the Broda chairs; -The facility did not have a policy for Broda chair use; -The facility did not train or assess the competency of the staff prior to the use of the Broda chair for Resident #1 or #2.

Based on record review and interview, it was determined that the facility failed to develop interventions for the use of the Broda chair in a comprehensive person centered care plan in 2 of 2 residents reviewed. (Residents identifiers are #1 and #2.) Findings included: Review on [DATE] of RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) Position on the Application of Wheelchairs, Seating Systems, and Secondary Supports for Positioning vs (versus) Restraint retrieved from https://brodaseating.com/education/seating-positioning/#,d+[DATE]d8a,d+[DATE]b1a read, in part, .Seating Assessment and Documentation. A comprehensive clinical assessment of seating and positioning needs is essential to ensure that the most appropriate supports are used with the intention of achieving proper body position . Review on [DATE] of Broda Basics: Personalization The Value of a Positioning Wheelchair retrieved from https://brodaseating.com/education/broda-basics/personalization/ read, in part, .Tilt should not be used when . the use of tilt is not listed or indicated in the patients care plan . Interview on [DATE] at approximately 12:50 p.m. with Staff A (Director of Nursing) revealed that there were 2 residents who used a Broda chair, including Resident #1 who had expired. Staff A revealed that staff do not assess for Broda chairs and that the facility had completed an inservice that all residents who use Broda chairs should be reclined for resident safety. Review on [DATE] of the facility's inservice (not dated, but signed by staff on [DATE] and [DATE]) revealed that All residents that require the use a Broda chair must be in an upright position with all meals. Once they have finished eating the Broda chair should be reclined for resident safety. If a resident is not within eyesight of staff, the chair should be reclined Resident #1 Review on [DATE] of Resident #1's care plan revealed that on [DATE] the intervention Broda wheelchair used for distance mobility and is propelled by staff. Resident #2 Review on [DATE] of Resident #2's New Restraint/Position Device Assessment completed [DATE] revealed that the broda wheelchair was to be used when out of room. Review on [DATE] of Resident #2's care plan revealed that on [DATE] the intervention . is seated in a Broda chair for mobility. Review on [DATE] of an email provided by Staff B (Administrator) confirmed there was no individualized assessments completed for either resident for the Broda chairs and that the facility did not have a policy for Broda chair use.

1. Based on observation, interview, review of the facility Employee/Visitor COVID-19 Questionnaire and policy review, it was determined that the facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidelines for universal masking in a facility with a census of 41 residents. Findings include: Observation on 7/7/21 at approximately 8:45 a.m. of Staff A (PT (Physical Therapist) entering room [ROOM NUMBER] with their face mask below their nose. Interview on 7/7/21 at approximately 8:45 a.m. with Staff A confirmed that their face mask was below their nose. Observation on 7/7/21 at approximately 10:15 a.m. of Staff C (Contracted Flooring Installer) revealed that their surgical mask was below their chin while coming out of room [ROOM NUMBER] where a resident was in their bed. Review on 7/7/21 of the facility Employee/Visitor COVID-19 Questionnaire dated 7/7/21 for Staff C revealed that Staff C was not 14 days beyond a second COVID-19 vaccination. Observation on 7/7/21 at approximately 10:16 revealed Staff B (Contracted Flooring Installer) standing outside of room [ROOM NUMBER] where a resident was in their bed . Staff B did not have a face mask on. Interview on 7/7/21 at approximately 10:16 a.m. with Staff E (DON/IP) Director of Nurses/Infection Preventionist) revealed that Staff E's expectations of all staff in the facility is expected to wear a face mask at all times. Review on 7/7/21 of the facility Employee/Visitor COVID-19 Questionnaire dated, 7/7/21 for Staff B revealed that Staff B was not 14 days beyond a second COVID-19 vaccination. Review on 7/8/21 of the facility policy titled COVID-19 Policy, Updated 01/13/21 revealed: .Personal Protective Equipment .Any visitor and or staff member in the building will wear a mask at all times. Review on 7/9/21 of The CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-COV-2 Spread in Nursing Homes, updated 3/29/21 revealed: .Educate Residents, Healthcare Personnel, and Visitors about [CONDITION(S)]-CoV-2, Current Precautions Being Taken in the Facility, and Actions They Should Take to Protect Themselves .Reinforce sick leave policies and remind HCP (Health Care Personnel) not to report to work when ill.Source Control and Distancing Measures. Implement Source Control Measures .HCP should wear well- fitting source control at all times while they are in the healthcare facility, including in breakrooms or there spaces where they might encounter co-workers 2. Based on observation, interview, and record review, it was determined that the facility failed to follow hand hygiene practices consistent with accepted standards of practice for infection control while providing wound care in 3 out of 3 wound care dressings observed (for 2 of 2 Residents) in a final survey sample of 41 residents. (Resident identifiers are #13 and #25.) Findings include: Review on 7/9/21 of the Centers for Disease Control and Prevention Hand Hygiene in Healthcare Settings retrieved from https://www.cdc.gov/handhygiene/providers/index.html read, in part, . Introduction to Hand Hygiene . Why Practice Hand Hygiene? Cleaning your hands reduces: The spread of potentially deadly germs .Use an Alcohol-Based Hand Sanitizer . Before moving from work on a soiled body site to a clean body site on the same patient . After contact with blood, body fluids or contaminated surfaces . Glove Use . Change gloves and perform hand hygiene during patient care, if . gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body sited on the same patient . Resident #13 Observation on 7/9/21 at 9:20 a.m. of Staff F (Registered Nurse) providing wound care to Resident #13's sacral wound revealed that Staff F donned clean gloves, removed and discarded the soiled dressing. Without changing gloves, Staff F cleaned the sacral area, picked up a pen, initialed/dated the clean dressing and applied it to the sacral area. Staff F adjusted the bed linens and pushed the button to adjust the bed down. Staff F then removed the gloves and performed hand hygiene. Interview on 7/9/21 at 9:30 a.m. with Staff F confirmed they did not change gloves during the wound care. Staff F stated they would only change gloves and perform hand hygiene if visibly dirty. Staff F was unsure of the facility's policy regarding when to perform hand hygiene during wound care. Resident #25 Observation on 7/9/21 at 10:10 a.m. of Staff F providing sacral wound care to Resident #25 revealed that Staff F donned clean gloves, removed and discarded the dirty dressing and removed one dirty glove. Staff F donned a new glove, cleansed the sacral area and removed their gloves. Without sanitizing their hands, Staff F then donned new gloves, dried the sacral area with a 4x4 gauze and applied the adhesive foam dressing. Staff F then removed their gloves and washed their hands. rObservation on 7/9/21 at approximately 10:15 a.m. of Staff F providing abdominal wound care to Resident #25 revealed that Staff F donned clean gloves and removed the soiled dressing with visible serosanguineous drainage on it. Staff F removed the dirty gloves, and without sanitizing their hands, donned clean gloves. Staff F cleaned the abdominal wound and removed the dirty gloves and donned new ones without hand sanitizing. Staff F then packed the wound with 4x4 gauze and covered it with a dressing. Staff F then removed their gloves and performed hand hygiene. Interview on 7/9/21 at 10:50 a.m. with Staff E (Director of Nursing) confirmed that both hand hygiene and glove changes should be performed during wound care after removing the soiled wound dressing and before applying the clean dressing. Interview on 7/9/21 at 11:10 a.m. with Staff F confirmed that they did not change gloves during wound care for Resident #13 because they only touched the outside of the dressing which was not dirty. Staff F confirmed that they did not perform hand hygiene after removing the dirty dressings on both wound cares for Resident #25 and only changed gloves. Staff F stated they would perform hand hygiene if their hands were visibly dirty. Interview on 7/9/21 at approximately 12:40 p.m. with Staff E revealed the facility did not have competencies for wound care hand hygiene, including for Staff F. Staff E also stated the facility did not have a wound care policy and procedure. Review of the facility's Infection Control Overview dated 8/17/2107 [sic] read, in part, . Gloves and Handwashing .The following are examples of when gloves and hand washing should be done .Before and after touching soiled linen, dressings . After removing gloves .

Based on observation, interview, and record review, it was determined that the facility failed to maintain oxygen concentrators in clean operating condition for 1 out of 1 oxygen concentrator observed. (Resident identifier is #9.) Findings include: Observation on 07/07/21 at approximately 09:20 a.m. revealed that Resident #9's Oxygen (O2) concentrator filter was dirty with visible dust and debris adhered to it. Interview and observation on 7/9/21 at approximately 12:15 p.m. with Staff E confirmed that the filter was dirty. Interview on 7/9/21 at approximately 1:30 p.m. with Staff G (Director of Housekeeping) revealed that the O2 concentrator filters have not been cleaned since the week of 2/22/21 and that this filter was last cleaned on 2/26/21. Review on 7/9/21 at approximately 1:45 p.m. of the Oxygen Concentrator Filter Log confirmed the above. Review on 7/12/21 of the manufacturer's instructions for the above Oxygen Concentrator revealed that the . patient must clean this filter weekly

Based on observation and interview, it was determined that the facility failed to maintain a fan and an air conditioning unit in sanitary condition for food service safety in the main kitchen. Findings include: Review on 7/9/21 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017 revealed the following: - Page 511: Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need . to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. - Page 512: 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. - Page 531: 6-202.12 Heating, Ventilating, Air Conditioning System Vents. Heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents. Observation on 7/7/21 at approximately 9:05 a.m. of the main kitchen revealed a circulating fan attached to the wall above the dishwashing area (and pointing towards the dishwashing area) that had visible dust on it. The fan was on. Additionally, there was an air-conditioning unit above the dishwashing area that had visible dust on it. Interview on 7/7/21 at 9:05 a.m. with Staff D (Food Service Director) confirmed that both the fan and the air-conditioning unit had dust on them. Staff D stated that the fan and the air-conditioning units were cleaned by maintenance on the work order request system. Interview on 7/9/21 at 1:25 p.m. with Staff D revealed that there were no logs kept of when the fan and air-conditioning unit had been cleaned. Staff D stated that the air-conditioning unit had been placed in May and would have been cleaned then. Staff D was unsure when the fan had last been cleaned. Staff D stated that neither were on a schedule cleaning rotation.

Based on record review and interview, it was determined that the facility failed to establish an infection control program that identifies the communicable disease [DIAGNOSES REDACTED] (TB) for all residents and staff. The facility failed to have in practice a working program that provides an adequate system of surveillance designed to identify possible cases of [DIAGNOSES REDACTED] in 2 residents out of a survey sample of 12 residents, and 1 staff out of 5 staff. (Resident identifiers: #2 and #4.) Findings include: Resident #2 Review on 12/28/16 on Resident #2's medical record revealed that the 2-step TB test had not been performed as per Center for Disease Control (CDC) guidelines/recommendations. The TB step #1 was performed on 12/23/15 and had a notation of historical written next to it in the record. There was no evidence in the resident's record that the TB Step #2 had been performed. Interview on 12/29/16 with Staff A (Director of Nursing-DON) revealed that it is allowable at this facility for a resident to decline the second step TB test and not receive a chest x-ray as is recommended by the CDC. Instead, the facility reviews a symptoms check list with the resident that identifies an active disease process of Tubercilosis. The DON further explained that it is not the practice of this facility to perform a chest x-ray if the 2 step TB test is not performed. The CDC recommends that a two step TB test be performed on every resident on admission, and reviewed annually. If the 2 step TB test cannot, or is not performed, a chest x-ray is then recommended. There was no evidence that a chest x-ray had been performed in the absence of the two step TB test for this resident. Resident #4 Review on 12/29/16 of Resident #4's medical record revealed Resident #4 had a negative 1st step TB read on 12/10/15 and refused the second step TB. Interview with Staff A on 12/29/16 at 10:22 a.m. confirmed the above findings and revealed when a resident refuses a TB test they would be asked a series of TB related questions. If the resident's answers to those questions would indicate they were at risk for TB they would then have a chest X-ray. Interview also revealed that Resident #4 was not asked a series of TB related questions nor did Resident# 4 have a chest X-ray. New Hampshire Code of Administrative Rules, Chapter He-P 800, Part He-P 813, New Hampshire Nursing Home Rules, effective 1/26/11, page 33, section 811.13 (i)(1)-(2) states (1) Prior to having contact with clients, all personnel shall: Submit to the licensee the results of a physical examination or a health screening and submit results of a 2-step [DIAGNOSES REDACTED] (TB) test, Mantoux method, or other method approved by the Centers for Disease Control, conducted not more than 12 months prior to employment. (2) Be allowed to work while waiting for the results of the second step of the TB test when the results of the first step are negative for TB; Review of employee records on 12/30/16 revealed Staff C (License Nursing Assistant) did not have a 2 step TB test upon hire (date of hire 10/31/16). Interview on 12/30/16 at approximately 10:15 a.m. with Staff D (Director of Human Resources) confirmed the above finding and revealed that Staff C told the facility that Staff C had a history of [REDACTED]. Interview also revealed that Staff C did not have a chest X-ray.

Based on record review and interview, it was determined that the facility failed to follow physician's orders for wound assessment for 1 resident out of a survey sample of 12 residents. (Resident identifier is #2.) Findings include: Review on 12/28/16 of Resident #2's medical record revealed an order for [REDACTED]. Physician's order dated 12/5/16 stated that nursing was to assess the wound twice per day (BID). There were daily assessments in the nurses notes that reflected that an assessment of the wound was done once daily. There were no notes in the resident record to demonstrate that an order change was requested or made to reduce the assessments by the nursing staff to once per day. Interview on 12/30/16 with Staff A (Director of Nurses) confirmed the above findings.

Based on record review and interview, the facility failed to maintain a complete medical record with informed consents for each resident for 1 resident in a sample of 2 resident on anti-psychotic medications. (Resident identifier #8.) Findings include: Review on 12/30/16 of Resident #8's Medication Administration Record [REDACTED]. Give 400 mg (milligrams) by mouth at bedtime for [MEDICAL CONDITION]. (Order Date 11/16/16). Review of Resident #8's medical record revealed the medical record did not contain an informed consent form for [MEDICATION NAME]. Interview on 12/30/16 at approximately 11:55 a.m. with Staff A (Director of Nursing) confirmed the above findings and revealed there was no documentation of consent for [MEDICATION NAME] for Resident #8.

Based on record review and staff interview the facility failed to notify the Physician to request an alternate pain medication for one newly admitted resident who was not receiving effective pain relief. For one resident in a survey sample of 11 residents. (Resident Identifier is #10) Findings include: Resident #10 Medical record review on 10/23/14 revealed Resident #10 was admitted to the facility on [DATE] following a interochanteric section femur [MEDICAL CONDITION]. Review of Resident #10's TEMPORARY CARE PLAN- ADMITTING, dated 10/14/14-"Pain R/t (related to) L (left) Hip Surgery S/P Fx H (status [REDACTED]. The Goal documents: "Pt (patient) will be comfortable, and state adequate relief from pain medication(s) [MEDICATION NAME] (narcotic pain medication). Review of the MD orders indicate an order for [REDACTED]. Review of the 48 HOUR PAIN LOG, reveals:At line entry 4:00 PM "15:20 pm (3:20 pm) given [MEDICATION NAME] for c/o (complaint of) 8/10 L (left) hip pain + abd pain/pelvis discomfort." 6:00 PM (Resident #10) states no relief pain remains 8/10. At line entry 8:00 PM "Given [MEDICATION NAME] 100 mg, + PRN (as needed) [MEDICATION NAME] at 1940 (7:40 pm) states no relief yet. 10:00 PM "Requesting pain med, not due yet. Is upset that [MEDICATION NAME] is not here yet." Interview at approximately 11:45 am on 10/23/14 Staff B, RN, Assistant DON indicated that the [MEDICATION NAME] medication ordered by the physician had not been delivered yet on 10/14/14 following admission and stated the facility did not have [MEDICATION NAME] Pain medication in the emergency medication kit (E-kit). Interview on 10/23/14 with Staff C, LPN, Staff Ed/Development, at approximately 1:00 pm, indicated that while [MEDICATION NAME] medication is not in the E- kit, the nurse on duty should have notified the Physician that Resident #10's pain was not relieved by the [MEDICATION NAME] and to request if another medication can be ordered/given until the [MEDICATION NAME] is delivered. Staff B confirmed that [MEDICATION NAME] was delivered approximately 3:05 am. Review of the Pain log reveals [MEDICATION NAME] at 4:00 am and 6:00 am Resident #10 is sleeping no Signs & Symptoms Pain level 2/10 pain and at 6:00 am no S/S of pain.

Based on interview and record review the facility failed to ensure that 1 resident in a standard survey sample of 11 residents received the prescribed therapeutic diet resulting in hospitalization . (Resident identifier is #3.) Findings include: Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#3 due to a history of dysphagia. Review of a Dysphagia Consult Request form dated 6/5/13 completed by Staff D (Speech Therapist) revealed Resident #3 was on a ground diet with thin liquids. The notes dated 6/5/13 recommend repeat MBS (Modified [MEDICATION NAME] Swallow) to rule out aspiration and determine all necessary swallowing strategies. Review of the plan of care for Resident #3 on 11/14/13 with a revision of 5/20/13 completed by Staff E (Registered Dietitian) revealed a Focus area as Nutritional problem related to therapeutic diet, dysphagia, mechanically altered diet, vision impaired. Interventions included to provide, serve diet as ordered. 90 gm. consistent carbohydrate diet order Level 3 dysphagia, ground meats. Record review on 11/14/13 revealed that on 6/5/13 Resident #3 had a change of diet by Staff D to "Ground - Please cut up all fruits/vegies (sic) /muffins etc.". Physician orders [REDACTED].#3 for 6/8/13 was "Downgrade pt to level 3 ground texture. Keep any dietary restrictions." This diet order had an original date of 5/14/2013 and was again signed by the physician on 6/10/13. Review of the nurses notes on 11/14/13 identified that on 6/8/13 Resident #3 had a coughing spell after lunch with copious amount of sputum and that the resident refused the supper meal due to the earlier incident with the lunch meal. Nurse notes from 6/9/13 document Resident #3 was refusing medications and was vomiting her food up with regurgitation and thick mucous with little to no food. Resident #3 was seen at the facility by the physician on 6/10/13. Physician notes of 6/10/13 revealed a [DIAGNOSES REDACTED]. The notes document the patient states approximately 3 days of difficulty swallowing and intermittently feels like something squeezing or pushing through esophagus into stomach. The physician orders [REDACTED]. Record review on 11/14/13 of the MBS report of 6/11/13 revealed an impression of : "Reflux, Reflux of [MEDICATION NAME] into pharyngeal space with aspiration, significant stasis of [MEDICATION NAME], slow [MEDICATION NAME] passage." Resident #3 was sent to the hospital for evaluation and treatment of [REDACTED]. Record review of the hospital History & Physical Report dated 6/11/13 revealed that Resident #3 presented to the hospital with the chief complaint of inability to swallow food and saliva. The notes further state that the resident's symptoms began abruptly on the afternoon of June 8th. ..."On that day, the patient was eating a hot dog at lunchtime, approximately 12:00 noon. Because of her chronic vision impairment, a family member was cutting up her hot dog for her, but 1 piece in particular was fairly large and she decided to swallow that piece in its entirety. Immediately after swallowing that piece of hot dog, she felt an extreme sense of pain in her chest and from that point onward, she has been unable to swallow additional food, beverage or even saliva". Record review on 11/14/13 of the Hospital Discharge Summary Report dated 6/18/13 revealed that the resident had an extraction of meat products including a chunk of hot dog via endoscopy during the hospital stay. During an interview with Resident #3 on 11/14/13, Resident # 3 confirmed being fed a cut up hot dog about 1 1/4 inch size on 6/8/13 at the noon meal by a family member that caused pain in her esophagus and it hurt every time Resident #3 attempted to swallow after that until the extraction of the hot dog at the hospital. During an interview with Staff B (Director of Dietary Services) on 11/14/13, Staff D produced the menu for the Dysphagia Level 3- Ground Diet delivered for the noon meal on 6/8/13. The menu was Hot Dog/Grilled Roll (ground) or Hamburger with gravy (ground). This surveyor asked Staff B during the interview to explain how the resident received a cut up hot dog on the tray, Staff B stated the Cook on duty did not recall the incident and neither did the dietary aides on duty. Staff B did state that as a result of investigation by Staff B, Staff B determined that the cook did not receive the diet change slip order for the ground diet from 6/5/13 and "probably just made a mistake". Staff B further stated that after the incident Staff B implemented the posting of the "Resident Diet List" in both nursing home dining rooms. Staff B states since 6/11/13 the lists are updated with each diet change and reviewed by the Staff E (Dietitian) weekly. During an interview on 11/14/13 with Staff A (Director of Nursing), Staff A revealed that the facility staff did not complete an incident report or document a complete investigation of the incident. Staff A stated the facility did not complete a full investigation to determine how Resident #3 received a cut up hot dog on 6/8/13 at the noon meal when the physician diet order at the time was for a ground diet.

Based on interview and record review the facility failed to ensure that 1 resident in a standard survey sample of 11 residents received the prescribed therapeutic diet resulting in hospitalization . (Resident identifier is #3.) Findings include: Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#3 due to a history of dysphagia. Review of a Dysphagia Consult Request form dated 6/5/13 completed by Staff D (Speech Therapist) revealed Resident #3 was on a ground diet with thin liquids. The notes dated 6/5/13 recommend repeat MBS (Modified [MEDICATION NAME] Swallow) to rule out aspiration and determine all necessary swallowing strategies. Review of the plan of care for Resident #3 on 11/14/13 with a revision of 5/20/13 completed by Staff E (Registered Dietitian) revealed a Focus area as Nutritional problem related to therapeutic diet, dysphagia, mechanically altered diet, vision impaired. Interventions included to provide, serve diet as ordered. 90 gm. consistent carbohydrate diet order Level 3 dysphagia, ground meats. Record review on 11/14/13 revealed that on 6/5/13 Resident #3 had a change of diet by Staff D to "Ground - Please cut up all fruits/vegies (sic) /muffins etc.". Physician orders [REDACTED].#3 for 6/8/13 was "Downgrade pt to level 3 ground texture. Keep any dietary restrictions." This diet order had an original date of 5/14/2013 and was again signed by the physician on 6/10/13. Review of the nurses notes on 11/14/13 identified that on 6/8/13 Resident #3 had a coughing spell after lunch with copious amount of sputum and that the resident refused the supper meal due to the earlier incident with the lunch meal. Nurse notes from 6/9/13 document Resident #3 was refusing medications and was vomiting her food up with regurgitation and thick mucous with little to no food. Resident #3 was seen at the facility by the physician on 6/10/13. Physician notes of 6/10/13 revealed a [DIAGNOSES REDACTED]. The notes document the patient states approximately 3 days of difficulty swallowing and intermittently feels like something squeezing or pushing through esophagus into stomach. The physician orders [REDACTED]. Record review on 11/14/13 of the MBS report of 6/11/13 revealed an impression of : "Reflux, Reflux of [MEDICATION NAME] into pharyngeal space with aspiration, significant stasis of [MEDICATION NAME], slow [MEDICATION NAME] passage." Resident #3 was sent to the hospital for evaluation and treatment of [REDACTED]. Record review of the hospital History & Physical Report dated 6/11/13 revealed that Resident #3 presented to the hospital with the chief complaint of inability to swallow food and saliva. The notes further state that the resident's symptoms began abruptly on the afternoon of June 8th. ..."On that day, the patient was eating a hot dog at lunchtime, approximately 12:00 noon. Because of her chronic vision impairment, a family member was cutting up her hot dog for her, but 1 piece in particular was fairly large and she decided to swallow that piece in its entirety. Immediately after swallowing that piece of hot dog, she felt an extreme sense of pain in her chest and from that point onward, she has been unable to swallow additional food, beverage or even saliva". Record review on 11/14/13 of the Hospital Discharge Summary Report dated 6/18/13 revealed that the resident had an extraction of meat products including a chunk of hot dog via endoscopy during the hospital stay. During an interview with Resident #3 on 11/14/13, Resident # 3 confirmed being fed a cut up hot dog about 1 1/4 inch size on 6/8/13 at the noon meal by a family member that caused pain in her esophagus and it hurt every time Resident #3 attempted to swallow after that until the extraction of the hot dog at the hospital. During an interview with Staff B (Director of Dietary Services) on 11/14/13, Staff D produced the menu for the Dysphagia Level 3- Ground Diet delivered for the noon meal on 6/8/13. The menu was Hot Dog/Grilled Roll (ground) or Hamburger with gravy (ground). This surveyor asked Staff B during the interview to explain how the resident received a cut up hot dog on the tray, Staff B stated the Cook on duty did not recall the incident and neither did the dietary aides on duty. Staff B did state that as a result of investigation by Staff B, Staff B determined that the cook did not receive the diet change slip order for the ground diet from 6/5/13 and "probably just made a mistake". Staff B further stated that after the incident Staff B implemented the posting of the "Resident Diet List" in both nursing home dining rooms. Staff B states since 6/11/13 the lists are updated with each diet change and reviewed by the Staff E (Dietitian) weekly. During an interview on 11/14/13 with Staff A (Director of Nursing), Staff A revealed that the facility staff did not complete an incident report or document a complete investigation of the incident. Staff A stated the facility did not complete a full investigation to determine how Resident #3 received a cut up hot dog on 6/8/13 at the noon meal when the physician diet order at the time was for a ground diet.