Every finding on record at West Side House LTC Facility

Based on observation, and interview, the facility failed to follow professional standards of practice for food safety in the main kitchen to prevent the potential spread of foodborne illnesses to residents who are at high risk. Specifically, the facility failed to ensure food temperatures were taken and documented prior to meal service in the facility's main kitchen to ensure the food temperatures were within acceptable parameters for food safety. Findings include: Review of the facility policy titled Food Temperature Testing, dated July 2013, indicated the following: -Temperature of food items in the steam table are to be taken at the beginning of service and at the end of service using the following method: a. Sanitize thermometers by cleaning with alcohol wipes. b. Insert the thermometer into food items in steam table. Take reading and document on Daily Temperature Checklist for Meal Service form after temperature plateaus. -Temperatures are to be taken from the steam table for all three meals on a daily basis. During a kitchen observation on 12/27/24, the surveyor observed the following: -11:20 A.M., the steam table contained the following items: >Whole baked fish >Pureed fish >Rice Pilaf >Mashed potato >Whole carrots >Ground carrots >Pureed carrots >Gravy -a pan of Barbecued pulled pork on the stove top. On 12/27/24 at 11:35 A.M., the surveyor observed the cook (Dietary Staff #2) begin to plate food from the steam table. The surveyor did not observe food temperatures being taken of the food on the steam table prior to the beginning of meal service. On 12/27/24 at 11:51 A.M., the surveyor and Dietary Staff #1 reviewed the Daily Temperature Checklist for Meal Service and found that no food temperatures had been documented on 12/27/24 for the breakfast or lunch meals. Dietary Staff #1 asked Dietary Staff #2 about the food temperatures missing from the Daily Temperature Checklist. Dietary Staff #2 said that she had a bad habit of not writing down the temperatures when she takes them but that she had taken the food temperatures for breakfast and lunch meals, and she remembered them. During an interview following the observation on 12/27/24 at 11:51 A.M., Dietary Staff #1 said that food temperatures should be taken, and the temperatures written on the Daily Temperature Checklist prior to tray line start. Dietary Staff #1 further said that all of the food temperatures from breakfast and lunch looked like too much information to remember. Review of the Daily Temperature Checklist for Meal Service forms dated 12/1/24 through 12/27/24 indicated the following meal temperatures were not taken: -12/1/24: no dinner meal temperatures -12/5/24: no breakfast, lunch or dinner temperatures -12/6/24: no breakfast, lunch or dinner temperatures -12/9/24: no dinner temperatures -12/15/24: no breakfast, lunch or dinner temperatures -12/16/24: no dinner temperatures -12/20/24: no dinner temperatures -12/27/24: no breakfast or lunch temperatures During an interview on 12/27/24 at 1:05 P.M., Dietary Staff #2 said that her routine was to check the food temperatures when the food was done. Dietary Staff #2 said that food temperatures were taken because bacteria could grow in food and result in foodborne illness. Dietary Staff #2 further said that the temperature of food in a steam table should be taken because sometimes steam tables are unreliable and the temperature of the food items could drop. During an interview on 12/27/24 at 1:31 P.M., the Food Service Director (FSD) said food temperatures should be taken three times, when the food was done cooking, when the food was placed on the steam table, and right before the meal service starts. The FSD said she had educated the Cooks about this, and that it was her responsibility to check to see that the Cooks check the food temperatures and record the results, but this had not been done.

Based on observation, interview, and record review, the facility failed to ensure the right of residents to be free from physical restraints for one Resident (#2) out of a total sample of 14 residents. Specifically, for Resident #2, the facility failed to: -appropriately assess and re-assess the use and the need for a wheelchair seat belt used as a restraint when the Resident was seated in the wheelchair. -obtain informed consent and review the risk/benefits with the Resident's Representative for the use of the wheelchair seat belt, which was used to prevent Resident #2 from sliding off the wheelchair, increasing the potential risk of accidental falls and injury. Findings include: Review of the facility policy titled Device/Restraints Policy and Procedure, revised April 2017, indicated it was the policy of the facility to ensure each resident attains/maintains the highest practicable well-being in an environment that improves functional status and ability. The policy also included the following: -every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience . -when the use of restraints is indicated, the facility will use the least restrictive alternative for the least amount of time and document ongoing evaluation of the need for the restraints. -physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -physical restraints may include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions and lap trays that the resident cannot remove easily. -also included as restraints are facility practices that meet the definition of a restraint, such as: >using the side rails that keep a resident from voluntarily getting out of bed. >tucking in or using velcro to hold a sheet, fabric, or clothing tightly so that a resident's movement is restricted. >placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out of the bed. >using a device in conjunction with a chair, such as trays, tables, bars or belts, that the resident cannot remove easily, that prevent the resident from rising. -removes easily means that the manual method, device, material, or equipment can be removed intentionally by the same manner as it was applied by the staff (e.g., side rails are put down, not climbed over) considering the resident's physical condition and ability to accomplish the objective . -convenience is defined as any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by a facility and not in the resident's best interest. -freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control. -before initiating any device that has a potential to act as a restraint, the licensed nursing staff shall determine the necessity of initiating a device/restraint by completing the Device/Physical Restraint Assessment Form. -The Device/Physical Assessment will include the medical justification, risk factor and potential complication. The form is forwarded to the licensed nursing staff to review with the resident and next of kin or responsible party. -The restraint policy is reviewed, and authorization is obtained. -In the event the resident is confused and unable to sign the authorization, a verbal authorization will be obtained from the next of kin or legal guardian until written authorization is obtained. -The team will assure the process is complete and the restraint will be added onto the resident's care plan and ADL guide/Kardex. -The Device/Physical Restraint Assessment form is then filed in the resident's chart. -There must be written, signed, and dated physician's orders for devices/physical restraints, and all orders must be reviewed and signed with each required physician's visit. -The need for the continued device/restraint or restraint reduction trials will be conducted quarterly with the MDS review, while restraints are being used. Resident #2 was admitted to the facility in March 2019, with diagnoses including Non-Alzheimer's Dementia, Traumatic Brain Injury (TBI), Major Depressive Disorder, and Anxiety. Review of Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #2 was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. On 12/26/24 at 9:29 A.M., the surveyor observed Resident #2 seated in a wheelchair with a seat belt on while in the dining area after the breakfast meal. During an interview at the time, the Resident said he/she kept the seat belt on for safety. On 12/26/24 at 9:32 A.M., the surveyor and the Unit Manager (UM) observed Resident #2 seated in a wheelchair with the seat belt on while in the dining room. During an interview at the time, the UM said Resident #2 preferred the seat belt on him/her while seated for fear of falling or sliding out of the chair. Review of Resident #2's December 2024 clinical record did not indicate any assessments for the use of the seat belt while the Resident is in the wheelchair. During an interview on 12/26/24 at 12:44 A.M., the Director of Nursing (DON) said there was no assessment indicating the need/use of the wheelchair seat belt. During an interview on 12/26/24 at 2:07 A.M., the Rehabilitation Director and the DON said Resident #2 was admitted to the facility in 2019 with his/her own wheelchair with the seat belt. The Rehabilitation Director and the DON said Resident #2 had not been assessed for the seat belt, neither had there been a Physician's order or consent from the Resident's Guardian for the use of the seat belt in the wheelchair. During a follow-up interview on 12/27/24 at 1:05 P.M., the DON said Resident #2 should have been assessed for the use of the seat belt, but the assessment had not been done. The DON said if the seat belt were to be used, the Resident's Guardian would need to be educated on the seat belt use, consent would have to be obtained, a Physician's order for the use of the seat belt would need to be in place, and the seat belt use as a restraint would need to be reviewed periodically.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice during a bolus feeding (a method of tube feeding administering a dose of the formula through a feeding tube using a catheter syringe [syringe without a needle]) procedure for one Resident (#51) out of a total sample of 14 residents. Specifically, for Resident #51, the facility failed to: -appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other residents within the facility. -perform hand hygiene procedure as required between glove changes while providing care. -open/pierce a Jevity (therapeutic nutrition) container foil in a sanitary manner. Findings include: Review of the facility policy for Enteral (passing through the intestines) Tube Feeding via Syringe (Bolus), last revised November 2018 indicated: -use aseptic technique (refers to the manner of handling, preparing, and storing medications and injection equipment/supplies (e.g., syringes, needles) to prevent microbial contamination and infection) when preparing and administering enteral feedings -wash hands and dry thoroughly -wear clean gloves -remove gloves and discard into designated container -wash your hands Review of the facility policy titled Enhanced Barrier Precautions (EBP), last Revised August 2022, indicated the following: -EBP's are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to Residents. -gloves and gowns are applied prior to performing high contact resident care activity >examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: -dressing -bathing/showering -transferring -providing hygiene -changing linens -changing briefs or assisting with toileting -device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator -wound care >EBP's remain in place for the duration of the resident's stay or until . the discontinuation of the indwelling medical device that places them at increased risk. >Signs are posted on the door or wall outside the resident's room indicating the type of precautions and Personal Protective Equipment (PPE) required. Resident #51 was admitted to the facility in February 2024, with diagnoses including Adult Failure to Thrive and Dysphagia. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #51: -was cognitively intact as evidenced by a score of 15 out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. -had symptoms of a swallowing disorder, holding food in the mouth/cheeks or residual food in the mouth after meals. -had weight loss of 5% or more in a month or 10% or more in 6 months. Review of Resident #51's December 2024 Physician's orders indicated: -24 French (a universal gauge system to measure the size of catheters) gastrostomy [g-tube] placed 12/13/24 -every shift check g-tube (feeding tube) placement, dated 12/13/24 -Jevity 1.5 calorie, 120 milliliters (ml) via enteral tube every 4 hours, start date 12/20/24 -Resident to sit up during g-tube feeding. Have head of bed elevated to 45 degrees and sit up at least 1 hour after the feeding, start date 12/13/24 Review of Resident #51's Comprehensive Person-Centered Care Plan dated 12/18/24, indicated: -that the Resident needs a feeding tube due to malnutrition and weight loss. -Enhanced Barrier Precautions every shift On 12/26/24 at 9:38 A.M., the surveyor observed EBP signage posted outside of Resident #51's room which indicated: >for Everyone: -to cleanse hands before entering and when leaving the room. >for Providers and Staff: -wear gloves and a gown for high contact resident care activities including device care or use: central line, urinary catheter, feeding tube, tracheostomy On 12/26/24 at 9:42 A.M., the surveyor observed the following while Nurse #1 performed a bolus feeding to Resident #51 in the Resident's room: -Nurse #1 removed (doffed) her gloves and did not perform hand hygiene after taking off the gloves. -Nurse #1 removed a set of keys from her pocket, using one key to pierce the foil barrier of the Jevity container to access the tube feed formula. -Nurse #1 provided a water flush, then bolus feeding and then another water flush to Resident #51without wearing the required gloves during the entire high contact treatment. During an interview immediately following the observation on 12/26/24 at 10:01 A.M., Nurse #1 said that she should have washed her hands after removing the gloves, that she should not have used a key to open the Jevity bottle and that she should have worn gloves while administering the feeding and water flushes to Resident #51, but she did not. During an interview on 12/26/24 at 10:54 A.M ., the Director of Nursing (DON) said that Nurse #1 should have worn gloves while administering the bolus feeding and water flushes to Resident #51. The DON also said that Nurse #1 should not have used a key to open the Jevity container and should have washed her hands after removing her gloves.

Based on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for one Resident (#19) out of a total sample of 14 residents. Specifically, for Resident #19, the facility staff failed to accurately code the use of an antipsychotic medication on one MDS Assessment. Findings include: Resident #19 was admitted to the facility in December 2024 with diagnoses including Paranoid Delusions. Review of Resident #19's December 2024 Physician orders indicated the following order dated 12/6/24: -Zyprexa (antipsychotic medication) 5 milligram (mg) oral. -Give 5 mg every night at 9 P.M. Review of Resident #19's MDS Assessment, dated 12/12/24, did not indicate that the Resident received the antipsychotic medication during the MDS Assessment observation period (12/6/24 - 12/12/24). Review of Resident #19's December 2024 Medication Administration Record (MAR) indicated the Zyprexa medication was administered to Resident #19 during the observation period for the Resident's MDS assessment dated [DATE]. During in interview on 12/27/24 at 9:14 A.M., the MDS Nurse said that Resident #19 received the Zyprexa medication during the observation period for the MDS assessment dated [DATE]. The MDS Nurse said that the antipsychotic medication should have been coded on the MDS Assessment as having been taken during the observation period. The MDS Nurse further said that the use of antipsychotic medication should have been coded on Resident #19's MDS assessment dated [DATE], but it was not.

Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2), who were severely cognitively impaired and had court ordered legal guardianships in place, the Facility failed to ensure that staff implemented and followed the Facility Abuse Prohibition Policy when, on 10/17/24, although Nurse #1 and Nurse #2 were made aware of an allegation of abuse, that Resident #1 was at Resident #2's bedside engaged in a sexual act, neither of them reported the allegation to the Director of Nursing or Administrator, and as a result, they were not made aware until more than 12 hours later, when Nurse #3 became aware and reported the allegation. Findings include: Review of the Facility Policy titled Abuse Prevention Policies and Procedures, revised 4/2017, indicated that all staff members are responsible for reporting incidents that may constitute or lead to any form of resident abuse, neglect, mistreatment, exploitation or misappropriation. The Policy indicated that upon observation of potential/alleged resident abuse, the observing staff member is required to intervene, stop the potential/alleged abuse, and report to their supervisor. Review of the Facility Reporting Resident Neglect/Abuse Policy, dated 4/2017, indicated that when notified that a staff member believes that a Facility resident has been abused, the supervisor will notify the Administrator/Director of Nursing Services. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/18/24, indicated that staff members reported that on 10/17/24 around 7:00 P.M., Resident #2 was observed lying in bed with his/her pants and underwear pulled down and Resident #1 was sitting in his/her wheelchair at the bedside, resting his/her head in the area of Resident #2's exposed genitalia. Resident #1's clinical record indicated he/she was admitted to the Facility during March of 2019 and his/her diagnosis included dementia, traumatic brain injury and depression. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/03/24 indicated that his/her cognitive patterns were severely impaired. Resident #1's clinical record indicated that the court appointed a legal guardian for him/her in June of 2019. Resident #2's clinical record indicated he/she was admitted to the Facility during May of 2023 and his/her diagnosis included metabolic encephalopathy, traumatic brain injury, depression and HIV. Review of Resident #2's MDS Assessment, dated 10/03/24 indicated that his/her cognitive patterns were moderately impaired. Resident #2's clinical record indicated that the court appointed a legal guardian for him/her in March of 2024. During a telephone interview on 11/15/24 at 1:20 P.M., Certified Nurse Aide (CNA) #1 said that on 10/17/24 around 7:00 P.M., she entered Resident #2's room via the adjoining bathroom and saw Resident #2 on his/her bed with his/her pants and underwear pulled down and his/her genitalia was exposed. CNA #1 said Resident #1 was seated in his/her wheelchair next to Resident #2's bed with his/her head on Resident #2's genitalia moving up and down. CNA #1 said that when she entered the room, Resident #1 moved his/her head away from Resident #2 and Resident #2 pulled his/her shirt down. CNA #1 said that she went back through the adjoining room and told CNAs #2 and CNA #3 what she saw. During telephone interviews on 11/16/24 at 10:40 A.M. with CNA #2 and 11/20/24 at 3:10 P.M. with CNA #3 they said the following: On 10/17/24 around 7:00 P.M., CNA #1 told them that something sexual was going on between Residents #1 and #2 in Resident #2's room. They went into Resident #2's room and saw Resident #2 in his/her bed and Resident #1 seated in his/her wheelchair next to Resident #2's bed. CNA #2 and CNA #3 said Residents #1 and #2 told them that they were watching television. CNAs #1, #2 and #3 said that they told Nurse #1 what CNA #1 witnessed between Residents #1 and #2. During an interview on 11/20/24 at 8:10 A.M. by telephone, Nurse #1 said that on 10/17/24 after dinner, CNA #2 told her that CNA #1 said Resident #1 was in Resident #2's room. Nurse #1 said that when Resident #1 came to the nurses' station she asked him/her what he/she had been doing in Resident #2's room and he/she said that they were playing cards. Nurse #1 said that later on during the 3:00 P.M. to 11:00 P.M. shift, CNA #2 told her that although Resident #2 had been in bed and covered by blankets when staff saw Resident #1 beside his/her bed, when staff later pulled back Resident #2's blankets, they saw that Resident #2 was naked. Review of Nurse #1's Written Witness Statement, dated 10/18/24, indicated that on 10/17/24 around 7:00 P.M., CNA #1 told her that she went into Resident #2's room and saw a sexual act taking place. Nurse #1's Written Witness Statement indicated that Resident #1 was invited to the nurses' station and reported that he/she and Resident #2 were playing cards. Nurse #1 said that CNAs #1, #2 and #3 did not tell her that a sexual act taking place between Resident #1 and Resident #2 on 10/17/24, however when she came to the facility on [DATE] she learned that there was an allegation that there had been sexual contact between Resident #1 and Resident #2 on 10/17/24 and she wrote about that in her Written Witness Statement. Although Nurse #1 said CNAs #1, #2 and #3 did not tell her that a sexual act took place between Residents #1 and #2, her statement contradicts the statements made by CNAs #1, #2 and #3 and her (Nurse #1's) Written Witness Statement. During a telephone interview on 11/18/24 at 11:00 A.M., Nurse #2 said that on 10/17/24 around 9:00 P.M., CNA #1 told her that she had gone into Resident #2's room and seen Resident #1 performing oral sex on Resident #2. Nurse #2 said that CNA #1 told her that she had already reported the incident to Nurse #1. Nurse #2 said that she did not report CNA #1's statement to the Director of Nursing or the Administrator. During an interview on 11/06/24 at 9:30 A.M., the Director of Nursing said that around 12:00 P.M. on 10/18/24, Nurse #3 reported to her that staff members were discussing an incident (an alleged sexual act between Residents #1 and #2) which had taken place during the 3:00 P.M. to 11:00 P.M. shift on 10/17/24. The Director of Nursing said that she initiated an investigation and determined that there had been an incident in which CNA #1 observed an interaction between Residents #1 and #2 which may have been sexual in nature. The DON said that although CNAs #1 and #2 reported the incident to Nurse #1 and Nurse #2 during the 3:00 P.M. to 11:00 P.M. shift, they did not immediately notify her or the Administrator. The Director of Nursing said that when she became aware of the alleged incident more than 12 hours later, she reported it to the Administrator.

Based on observations, interviews and policy review, the facility failed to maintain professional standards for safe and sanitary food storage in the main kitchen and in two out of two kitchenettes. Findings include: Review of the facility policy titled Food Rotation Policy, dated 3/2023, indicated the following: -Label and date food items on food delivery day. Review of the 2022 United States Food and Drug Administration Food Code indicated the following: >Food shall be protected from contamination by storing the food: -In a clean, dry location. -Where it is not exposed to splash, dust, or other contamination. -At least 15 centimeters (six inches) above the floor. >Time/Temperature control for safety, cold holding: -Except during preparation, cooking, or cooling, or when time is used as the public health control, food shall be maintained at 5 Celsius (41 Fahrenheit) or less. On 9/5/23 from 7:55 A.M. to 8:15 A.M., the surveyor conducted an initial tour of the kitchen with Cook #1 and observed the following: -In the dry storage area, three bags of open pasta were undated. -In the walk-in refrigerator there were two packages of undated sliced deli cheese, and one bag of cheese with visible mold. -In the main cooking area there was a plastic container that contained flour, the cover of the container was partially open, and a radio was partially in the container and was touching the inside walls of the container. -In the main cooking area there was a reach-in refrigerator that contained an energy drink, an open bottle of water, two pieces of candy, and a half-consumed chocolate bar. -In the main cooking area there was a chest freezer containing frozen food with a significant amount of ice buildup. -In the dishwasher room there were two chest freezers containing frozen food. Both chest freezers had a significant amount of ice buildup. One had so much ice built up, the top of the freezer did not close properly. At the end of the initial kitchen tour on 9/5/23 at 8:15 A.M., Dietary Staff #1 said: -the three bags of pasta should have been labeled with the date they were opened so staff knew when to use them by, -the cheese in the walk-in refrigerator should have been labeled with a date and the moldy cheese should have been thrown away. -the three chest freezers should not have a significant amount of ice buildup in them and should be defrosted and cleaned. -the energy drink, bottle of water, candy, and half consumed chocolate bar in the reach-in refrigerator belonged to staff, and staff food and drink should not be stored in a refrigerator that was used for resident food. During an interview on 9/7/23 at 2:25 P.M., the Dietitian said all items in the kitchen should be labeled with a date when they are opened. She said the facility had labels that should be used on all food items but the staff in the kitchen were not consistent in using the labels. The Dietitian also said that staff should be monitoring that food in the kitchen was labeled weekly but when asked by the surveyor, was unable to provide any documentation that staff was completing weekly checks of the food. She additionally said there should be a schedule to clean the kitchen and that included defrosting the freezers but she was unsure when this was done last as there was no documentation to track how often the kitchen was deep cleaned. 42690 2. During a second walk through of the kitchen on 9/6/23 at 1:20 P.M., the surveyor observed one of two chest freezers (on the right) in the dishwasher room to have large amounts of ice buildup inside and around the rim of the freezer, resulting in the lid not closing tightly. It was noted that the freezer contained food. Additionally, the hinges on the freezer lid did not work properly, so when the lid was opened, it separated and fell off. On 9/6/23 at 1:45 P.M, the surveyor observed the following in the kitchenettes located on each unit: Unit One refrigerator: -Plastic milk container with a sell by date of 9/2/23 -A plastic cup with iced coffee (labeled with a name that was not a resident) -Food/drink debris on the bottom shelf, in the drawers and on the door shelves Unit Two refrigerator: -Plastic milk container with a sell by date of 9/2/23 During a follow-up observation and interview on 9/6/23 at 1:50 P.M., the Maintenance Director said that the facility used the TELS system (a program utilized for staff to communicate concerns regarding broken equipment) to communicate any issues. He said that it is checked two times a day and was unaware that the freezer needed to be addressed as he had not received a notification through the TELS system. During an interview on 9/6/23 at 1:55 P.M., Dietary Staff #1 said that the Dietary department was responsible for maintaining the two kitchenettes located on the units. She said that staff food or drinks should not be kept in the refrigerators. Together Dietary Staff #1 and the surveyor reviewed photos taken on 9/6/23 from each of the unit kitchenettes. She said that both milks (one in each refrigerator) had a sell by date of 9/2/23 and should not have been in there. She said that the dietary staff restock the refrigerators every morning, should remove items that are outdated or that do not belong and clean the refrigerators. She said that the refrigerator on Unit One needed to be cleaned as there was spillage on the bottom shelf and the shelves on the door. Lastly, she said that the plastic cup filled with iced coffee in the refrigerator on Unit One was labeled with a name that was not that of a resident in the facility and should not have been in there. During an interview on 9/7/23 at 1:05 P.M., the Administrator said that he was unable to provide a facility policy or a cleaning schedule regarding areas in the facility that the Dietary Department was responsible for, including the kitchenettes and the kitchen.

Based on observations, interviews and records reviewed, the facility failed to maintain a medication pass error rate of less than five percent (%). Specifically, the medication error rate was observed to be 31.03%, for two Residents (#34 and #18), out of three applicable residents, out of 29 opportunities. 1. For Resident #34, medication errors occurred relative to the administration of medications not given within the required timeframe. 2. For Resident #18, medication errors occurred relative to the administration of medications not given within the required timeframe and omitting a prescribed medication. Findings include: Review of the facility policy titled, General Dose Preparation and Medication Administration dated 1/1/22, indicated, but was not limited to the following: -Verify each medication administered: >is the correct medication >at the correct dose >at the correct route >at the correct rate >at the correct time >for the correct resident, as set forth in the facilities medication administration schedule. 1. Resident #34 was admitted to the facility in June 2020 with the following diagnosis: traumatic subdural hemorrhage (SDH-bleeding within layers of the brain) with loss of consciousness. On 9/6/23 at 11:00 A.M., the surveyor observed a medication administration pass for Resident #34 with Nurse #2. Nurse #2 administered the following medications: -Prilosec 20 mg (milligram), 1 capsule given -Neurontin 800 mg, 1 tablet given -Tylenol 500 mg, 2 tablets given -Baclofen 10 mg, 1 tablet given -Seroquel 100 mg, 1 tablet given Review of the September 2023 Monthly Physician's orders indicated the following: -8:00 A.M., Prilosec 20 mg, 1 capsule (give 30-60 minutes before meals) -8:00 A.M., Neurontin 800 mg, 1 tablet three times daily at (8:00 A.M., 12:00 P.M., and 4:00 P.M.) -9:00 A.M., Tylenol 1000 mg, twice daily at (9:00 A.M., 5:00 P.M.) -9:00 A.M., Baclofen 10 mg, 1 tablet twice daily at (9:00 A.M., 5:00 P.M.) -9:00 A.M., Seroquel 100 mg, 1 tablet twice daily at (9:00 A.M., 5:00 P.M.) Review of the Medication and Treatment History indicated the following: -Prilosec 20 mg was signed off as administered at 10:58 A.M. (not given before breakfast) -Neurontin 800 mg was signed off as administered at 10:58 A.M. (greater than 2 hours after the ordered time to be given) -Tylenol 500 mg was signed off as administered at 10:59 A.M. (incorrect dose documented, given almost 2 hours after the ordered time) -Baclofen 10 mg was signed off as administered at 11:00 A.M. (given 2 hours after the ordered time) -Seroquel 100 mg was signed off as administered at 11:00 A.M. (given 2 hours after the ordered time) During an interview on 9/6/23 at 11:08 A.M., Nurse #2 said that she was currently passing Resident #34's morning medications. She said that it is a heavy medication pass and she is still learning the floor. Nurse #2 said that because the Neurontin was late and it is ordered three times a day, she will give the next dose later in the afternoon around 1:00-2:00 P.M. She further said that she knows that the Prilosec should have been given before breakfast and that some of the medications were administered late. 2. Resident #18 was admitted to the facility in August 2022 with diagnoses including: Hypertension (high blood pressure), Dementia and Bipolar disorder (extreme mood changes) On 9/6/23 at approximately 11:10 A.M., the surveyor observed a medication administration pass for Resident #18 with Nurse #2. Nurse #2 administered the following medications: -Cyanocobalamin (B12) 500 mcg (microgram), 1 tablet given -Oxybutynin 5 mg, 1 tablet given -Oxcarbazepine 300 mg, 1 tablet given Review of the September 2023 Monthly Physician's orders indicated the following: -8:00 A.M., Cyanocobalamin (B12) 500 mcg 1 tablet daily -9:00 A.M., Oxybutynin Chloride 5 mg 1 tablet twice daily (9:00 A.M., and 5:00 P.M.) -9:00 A.M., Oxcarbazepine 300 mg 1 tablet twice daily (9:00 A.M., and 5:00 P.M.) -10:00 A.M., Polyethylene [sic] 3350 17 grams/1 dose in 8 ounces of liquid daily. Review of the Medication and Treatment History indicated the following: -Cyanocobalamin (B12) was signed off as administered at 11:11 A.M. (greater than 2 hours after the ordered time to be given) -Oxybutynin Chloride was signed off as administered at 11:11 A.M. (greater than 2 hours after the ordered time to be given) -Oxcarbazepine was signed off as administered at 11:12 A.M. (given greater than 2 hours after the ordered time) -Polyethylene [sic] 3350 17grams/1 dose in 8 ounces was signed off as administered at 11:21 A.M. (was not observed given during the medication pass administration) During an interview on 9/6/23 at 11:20 A.M., Nurse #2 said she administered Cyanocobalamin (B12), Oxybutynin Chloride, and Oxcarbazepine beyond the one hour required timeframe. She further said she did not administer Polyethylene [sic] 3350 17 grams as ordered. During an interview on 9/7/23 at 10:42 A.M., the Nurse/Regional Clinical Educator said that the nurses are responsible for administering medications one hour before to one hour after the scheduled time. She further said that the Nurse is responsible to reassess their workload and prioritize accordingly. She said that the Nurse should contact the Doctor if medications are not given as ordered. The Nurse/Regional Clinical Educator further said that there are no policies available but that the Nurse should use critical judgement.

Based on interviews and records reviewed for three Residents (#30, #17, and #4) out of five sampled residents for immunizations, the facility failed to offer or provide Pneumococcal Vaccinations as required. Specifically, the facility staff failed to: 1. Provide a Pneumococcal Vaccination for one Resident (#30) after the Resident's Representative requested the vaccination. 2. Provide education, assess for eligibility, and offer Pneumococcal Vaccinations per facility policy and the Centers for Disease Control and Prevention (CDC) recommendations to two Residents (#17 and #4) and/or their Representatives. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years of age (cdc.gov) dated 3/15/23, indicated the following: For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23), and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20) . Review of the facility's policy titled Vaccination of Residents, revised 8/2016, indicated but was not limited to: -All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. -Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccination. 1. Resident #30 was admitted to the facility in December 2018 and was over the age of 65. Review of the Resident's medical record included a Pneumococcal Vaccination Informed Consent for Residents form signed and dated 4/18/21, by the Resident's Representative and witnessed by a staff member that indicated the Resident's Representative requested that Resident #30 receive the Pneumococcal Vaccination. Review of the Resident's vaccination history provided by the facility indicated no evidence the Resident received the Pneumococcal Vaccination. Review of the MIIS (Massachusetts Immunization Information System) provided by the facility, indicated that no Pneumococcal Vaccines had been administered to Resident #30. Further review of the Resident's medical record indicated no evidence that the Resident ever received the vaccination. 46138 2a. Resident #17 was admitted to the facility in April 2019 and was over the age of 65. Review of the MIIS provided by the facility, indicated a PPSV23 vaccine was administered on 1/15/2019. Further review of Resident #17's clinical record indicated that there was no documented evidence that he/she had been educated, assessed for eligibility, and offered any additional Pneumococcal Vaccinations per the facility policy and CDC recommendations. 2b. Resident #4 was admitted to the facility in August 2016 and was over the age of 65. Review of the MIIS provided by the facility, indicated that no Pneumococcal Vaccines had been administered. Further review of Resident #4's clinical record indicated that Pneumonia vaccinations had been received on 9/2/09 and 2/22/16 and there was no documented evidence that he/she had been educated, assessed for eligibility, and offered any additional Pneumococcal Vaccinations per the facility policy and CDC recommendations. During an interview on 9/7/23 at 1:46 P.M., the Director of Nursing (DON) said there was no evidence that Resident #30 received the requested Pneumococcal Vaccination and no evidence that Residents #17 and #4 were educated, assessed for eligibility, and offered the Pneumococcal Vaccine.

Based on interview and records reviewed for one Resident (#7) out of a total sample of 13 residents, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment within the required 14 days. Findings include: Review of the Centers for Medicare and Medicaid (CMS), Resident Assessment Instrument Manual (RAI-dictions used to code an MDS) dated [DATE], indicated the following: -The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice elections (which can be the same or later than the date of the hospice election statement, but not earlier than.). -The MDS completion date .must be no later than 14 days from the ARD .and no later than 14 days after the determination that the criteria for a Significant Change in Status Assessment (SCSA) were met. Resident #7 was admitted to the facility in May 2022. Review of the Resident's medical record indicated the Resident elected Hospice services on 9/6/22. Review of the SCSA MDS indicated an ARD of 9/15/22 and a completion date of 9/29/22, 23 days after the ARD. During an interview on 9/6/23 at 3:29 P.M., the MDS Nurse said the SCSA MDS should have been completed within 14 days of 9/6/22 when the Resident elected Hospice services, and this was not done, as required.

Based on observation, interview, and records reviewed, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#23) out of a total sample of 13 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #23. Findings include: Resident #23 was admitted to the facility in October 2016 with diagnoses including Unspecified Dementia and Major Depressive Disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired and needed assistance with activities of daily living (ADLs- include bathing, showering, dressing, getting in and out of bed or a chair, walking, toileting and eating). Review of the most recent Activity Assessment, dated 1/9/23, indicated the Resident's current preferences for hobbies/interests included: -exercise/sports -watching TV -ball toss groups. Further review of the Activity Assessment indicated that staff will encourage and inform the Resident to participate in group activities related to music, ball toss, fishing, and reminiscing. Review of the Activities Care Plan initiated 4/7/20, indicated the following interventions initiated on 6/26/23: -Staff will provide engaging and stimulating activities of interest including relaxation music, 1:1 activities such as staff reminiscing about sports, and fishing. On 9/6/23 the surveyor made the following observations: -From 9:05 A.M. to 10:03 A.M., the surveyor observed the Resident in the day room on the 2nd floor. He/she was asleep in his/her wheelchair in the back of the day room with no other residents nearby. There were no activities occurring in the day room and the television in the day room was off. -At 10:03 A.M., an Activities staff member entered the day room and passed out the facility's newspaper, The Daily Chronicle. The Activities staff member did not provide The Daily Chronicle to the Resident and did not engage or try to interact with the Resident, who was still asleep at the time. -From 10:05 A.M. to 10:20 A.M., an Activities staff member offered refreshments to the residents in the day room. Resident #23 who remained asleep, was not offered a drink nor did the Activities staff member attempt to engage the Resident. -From 1:07 P.M. to 1:26 P.M., an Activities staff member passed out word search activities to residents in the day room. The Activities staff member did not offer a word search to the Resident, nor did they attempt to engage or talk with the Resident during the activity. At the time the Resident was awake and alert. He/she kept pushing his/her wheelchair back and forth from the table in front of him/her to the wall that was behind him/her. He/she was visibly stuck and unable to move from the small area between the wheelchair and the table and the Activities staff member did not provide any assistance or conversation to the Resident. -From 1:26 P.M. to 1:42 P.M., the Resident remained in the day room and had again fallen asleep in his/her wheelchair. -From 2:15 P.M. to 2:43 P.M., an Activities staff member engaged residents in the day room playing ball toss. Resident #23 remained asleep in the day room and the Activities staff member made no attempts to wake the Resident up or engage the Resident in the ball toss. On 9/7/23 the surveyor made the following observations: -From 7:32 A.M. to 7:58 A.M., the Resident was observed in his/her room. He/she was up in his/her wheelchair and dressed. Resident #23 repeatedly pushed his/her wheelchair back and forth in the room bumping into one wall behind him/her and then moving forward and bumping into the wall in front of him/her. There was no television, radio, or other diversional activities observed in the Resident's room. -From 7:58 A.M. to 8:40 A.M., the Resident was positioned in the hallway. He/she continually moved his/her wheelchair throughout the hallway. The Resident continuously bumped his/her wheelchair back and forth between the walls in the hallway. No staff members interacted verbally with the Resident or offered any diversional activities, the staff only assisted in moving his/her wheelchair out of their way or out of the way of other residents in the hallway. -At 8:40 A.M. the Resident was brought into the day room for breakfast. He/she was seated at a table with another resident and two staff members who were assisting the residents to eat. Resident #23 had a staff member positioned in front of him/her from 8:40 A.M. until 9:10 A.M., to assist with eating. The staff member made no attempt to provide cues, verbally encourage or engage the Resident during the entire time she was assisting Resident #23 with eating. During an interview on 9/7/23 at 9:20 A.M., Occupational Therapist (OT) #1 said the Resident benefitted from having snacks and drinks when he/she was restless. During an interview on 9/7/23 at 9:39 A.M., the Activities Director (AD) said the Resident needed 1:1 activities, which included sensory activities and reminiscing about fishing and sports. She stated he/she should have these 1:1 activities around 10:00 A.M. daily, with an Activities staff member, at the time the staff passed out The Daily Chronicle and refreshments. She further said the Resident should have been offered a refreshment during the refreshment activity and staff should have tried to engage the Resident by having a conversation with him/her. The AD also said staff should have attempted to wake the Resident up and involve him/her in ball toss. During a follow-up interview on 9/7/23 at 9:53 A.M., the AD said every time the Activities staff enter the day room where the Resident spends most of his/her time, they should attempt to engage him/her with conversation and/or explain to him/her what was happening for activities at that moment. The AD further said a care plan had not been developed for diversional activities for the Resident when he/she was in his/her room.

Based on observations, interviews and records reviewed for two residents (Residents #26 and #30) out of a total sample of 13 residents, the facility failed to ensure recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed timely and implemented as required. Specifically, 1. For Resident #26, the facility staff failed to implement recommendations for medication dosage adjustment and obtain lab work to monitor lipid levels and liver function timely. 2. For Resident #30, the facility staff failed to obtain lab work to monitor lipid levels timely. Findings include: Review of the facility's policy titled Medication Regimen Review, revised 8/17/23, indicated, but was not limited to: -The attending Physician should address the Consultant Pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. 1. Resident #26 was admitted to the facility in October 2018 with the following diagnoses: Dementia and status post Cerebral Vascular Accident (CVA-damage to the brain from interruption of its blood supply due to either a blocked artery or bursting of a blood vessel) Review of the Pharmacist's Consultation Report dated 3/9/23 indicated the following: -Resident #26 receives a statin (a type of cholesterol [a type of fat in the blood] lowering medication). -Rosuvastatin Calcium 10 milligrams (mg). Give one tablet by mouth every night at 8:00 P.M. -The Resident's serum triglycerides (a certain type of fat in the blood) concentrations are persistently high, reported as 276 mg/deciliter (dL) on 2/7/23. -Please reevaluate and consider the need to increase Rosuvastatin Calcium or decrease the Seroquel (an antipsychotic medication which may contribute to increased fat in the blood) for a trial as it (the Seroquel) may be contributing. -If therapy is changed, please monitor a fasting lipid level (a test that measures different fats in the blood) in four weeks, every year thereafter and liver function tests at baseline and clinically indicated thereafter. Further review of the Pharmacist's Consultation Report dated 3/9/23 indicated the facility's Physician's Assistant (PA) did not review and respond to the recommendations until 6/19/23, more than three months (90 days) after the MRR recommendations were made. 2. Resident #30 was admitted to the facility in December 2018 with the following diagnoses: Dementia and Hyperlipidemia (high levels of fat particles in the blood). Review of the Pharmacist's Consultation Report dated 3/9/23 indicated the following: -Resident #30 receives Olanzapine (an antipsychotic medication) and Atorvastatin (a medication used to lower cholesterol). -Please monitor fasting lipid panel on the next convenient lab day and at least annually thereafter. Further review of the Pharmacist's Consultation Report indicated the facility's PA did not review and respond to the recommendation until 6/19/23, more than three months (90 days) after the MRR recommendations were made. During an interview on 9/7/23 at 10:53 A.M., the Nurse/Regional Clinical Educator said the PA receives Consultant Pharmacist Reports directly from the Pharmacist either the same day or the day following the MRR. In addition, the Pharmacist sends the reports directly to the facility's Director of Nursing (DON), Administrator, and the Nursing Support Specialist. She further said that the Pharmacist and the facility were aware there had been delays relative to the PA responding to the Pharmacist recommendations. The Nurse/Regional Clinical Educator said the PA did not address the recommendations made for both Resident #26 and Resident #30 timely which resulted in pertinent lab work being delayed.

Based on observations, interviews and policy review, the facility failed to ensure that medications were stored in a safe and secure manner and medication storage rooms were maintained in a sanitary manner. Specifically, facility staff: -stored Heparin flushes in an unlocked drawer of a resident's nightstand with availability to any resident having access to the room. - were using and storing personal food containers in the medication storage room, with risk of spilled contents and contamination. Findings include: Review of the facility's policy titled Storage of Medications, revised April 2007, indicated, but was not limited to: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments containing drugs and biologicals shall be locked when not in use shall not be left unattended if open or otherwise potentially available to others. -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. On 9/6/23 at 2:50 P.M., the surveyor and Nurse #3 observed several 5 milliliter (ml) syringes of Heparin Lock Flush Solution (a preparation of Heparin Sodium [a blood thinning medication] mixed with Sodium Chloride [saline] intended to keep an intravenous line [IV-a soft flexible tube placed inside a vein] free from clogging) in the top drawer of a Resident's nightstand. Nurse #3 quickly removed the syringes from the Resident's room and said the medication should not have been left in the Resident's drawer because it could be dangerous for the Resident. During an inspection of the Unit 1 medication storage room on 9/7/23 at 9:50 A.M., with Nurse #1, the surveyor observed a silver travel cup containing a tea bag on the medication room shelf. Nurse #1 said the cup should not have been stored in the medication room because of risk for contamination in the medication storage area.

Based on interview and records reviewed for one Resident (#23) out of a total sample of 13 residents, the facility failed to ensure an accurate medical record was maintained relative to Physician's orders for the care and services of a Foley urinary catheter (tubing inserted into the bladder to that allows urine to drain outside the body). Findings include: Review of the facility policy titled Foley Catheter Insertion ., revised October 2010, indicated the following: -Verify there is a Physician's order in place for catheter insertion (procedure) -Document the size of the Foley catheter inserted . Resident #23 was admitted to the facility in October 2016 with a diagnosis of urinary retention (inability for the bladder to fully empty). Review of the September 2023 Physician's orders indicated the following orders: -Change Foley catheter monthly 16 French (Fr-the size of the catheter tube) 10 milliliter (ml) balloon (a device that is inflated in the urinary bladder to hold the catheter in place) with a start date of 10/18/22. Further review of the September 2023 Physician's orders indicated the following additional order: -Change 14 Fr 10ml indwelling Foley catheter monthly on the 1st .with a start date of 10/28/22. Review of the September 2023 Treatment Administration Record (TAR) indicated on 9/1/23 the Nurse signed off that the Resident's catheter was changed, and the Nurse signed off on the 14 Fr order as the size used for the catheter change. During an interview on 9/6/23 at 2:27 P.M., Unit Manager (UM) #1 said there should only be one order in place for changing the Resident's catheter monthly, but she was unsure which size Foley urinary catheter was correct and would need to investigate which was the correct size. She further said if the Resident has two orders in place this could be confusing, and the Resident could have excess catheter changes each month which would put the Resident at risk for infection. During an interview on 9/6/23 at 2:37 P.M., Nurse #1 said that she observed the Resident's catheter, and the Resident currently had a 16 Fr catheter inserted. During an interview on 9/6/23 at 3:39 P.M., the Nurse/Regional Clinical Educator said the Resident should not have had two orders in place for monthly Foley urinary catheter changes. She further said the order for the 14 Fr Foley catheter was incorrect and the Resident used a 16 Fr catheter. She additionally said when the Nurse changed the Resident's catheter on 9/1/23 the documentation was incorrect as a 16 Fr catheter was inserted and the Nurse should not have signed off on inserting a 14 Fr catheter.

Based on observation, record review and interview, the facility failed to: (1.) ensure the services of a registered nurse (RN) were used for at least 8 consecutive hours a day, 7 days a week and (2.) ensure a Director of Nurses (DON) was employed on a full time basis. Findings include: 1. The facility failed to ensure the services of an RN were used for at least 8 consecutive hours a day, 7 days a week. Review of the last two weeks of January 2022 nursing schedules indicated no RN was scheduled on 1/16/22, 1/18/22, 1/25/22, 1/29/22, and 1/30/22. During an interview on 2/02/22 at 9:56 A.M., Administrator #1 said he did not have evidence that a RN worked on 1/16/22, 1/18/22, 1/29/22, and 1/30/22, as required. He said he still needed to check on the other dates in question. During an interview on 2/02/22 at 10:38 A.M., Administrator #1 said he did not have evidence that a RN worked on 1/25/22, as required. 2. The facility failed to designate an RN to act as the DON on a full-time basis. During the entrance conference on 1/27/22 at 8:40 A.M. Administrator #2 said there were no staffing waivers in place. She further said the facility employed a consultant DON that worked two days per week. Administrator #2 said she was currently covering while Administrator #1 was out. During an interview on 1/28/22 at 10:36 A.M. the Corporate Nurse said the DON worked on Mondays and Wednesdays and was only part-time. She said it was the best coverage they could get. During a phone interview with Administrator #1 on 1/28/22 at 12:31 P.M the surveyor asked how long the facility had been without a full-time DON. Administrator #1 said there had not been a full-time DON since his start as the administrator in August 2021. He further said he could not speak to the period of time before he started.

Based on observation, interview, and policy review the facility failed: (1.) to store food in accordance with professional standards for food service safety, and (2.) to monitor temperatures in the kitchen refrigerators and freezers and the nourishment kitchen refrigerator. Findings include: Review of the facility's policy for Food Rotation, dated ,d+[DATE], indicated the following: Purpose: To ensure food is stored and rotated properly. Procedure: -Food should be stored at proper temperature. -Maintain temperature log for refrigerator and freezer -Identify the expiration date on the food -Inspect dates and labels on food weekly 1. The facility failed to ensure that staff stored food in accordance with professional standards for food service and safety. On [DATE] at 7:53 A.M., the surveyor observed the following in the kitchen walk-in refrigerator: *open bottle of hot sauce with expiration date [DATE] *open bottle of mayonnaise with expiration date [DATE] On [DATE] at 7:32 A.M., the surveyor observed the following: - In the kitchen walk-in refrigerator: *open bottle of hot sauce with expiration date [DATE] * two open bottles of mayonnaise with expiration date [DATE] * two open containers of apple sauce not labeled or dated * a bag of imitation crab meat with use by label [DATE] During an interview on [DATE] at 7:55 A.M., the Food Service Supervisor (FSS) said the crab meat won't be used and everything in the refrigerator should have been labeled and dated. She said the expired items would be thrown out. 2. The facility failed to ensure that staff monitored and recorded temperatures in the kitchen walk- in refrigerator and milk refrigerator, two kitchen freezers, and one nourishment kitchen refrigerator. On [DATE] at 8:30 A.M., the surveyor observed no thermometers in the two kitchen freezers. During an interview on [DATE] at 8:39 A.M., the FSS said she ordered thermometers for the two freezers but they weren't in yet. The surveyor requested the temperature logs for all of the freezers and refrigerators in the kitchen. During an interview on [DATE] at 8:50 A.M., the FSS said she had no temperature logs for the any of the kitchen refrigerators or freezers for [DATE]. On [DATE] at 3:00 P.M., the surveyor observed the nourishment kitchen refrigerator (located on the unit to store resident's food items) and was unable to locate a temperature log for the refrigerator. During an interview on [DATE] at 3:44 P.M., the FSS said that she has no temperature logs for the nourishment kitchen refrigerator. She said she had no temperature logs for any of the freezers or refrigerators in the facility, for the last 3 months.

Based on observation, record review and interview the facility failed to ensure staff implemented the required infection control practices to prevent and control the spread of COVID-19 during an outbreak related to (1.) proper use of personal protective equipment (PPE) on one out of one units, (2.) assessment for symptoms of COVID-19 for three residents (#4, #14, and #7), (3.) screening of individuals entering the building and, (4.) proper hand hygiene during a dressing change for one Resident (#25) in a total of 14 sampled residents. Findings include: Review of the facility policy titled Infection Prevention Control, revised October 2020, indicated the infection control guidelines of the Massachusetts Department of Public Health (DPH) and Centers for Disease Control and Prevention (CDC) are the primary source of information relied upon for guidance in preventing the transmission of any infections within the facility. During the entrance conference on 1/27/22 at 8:40 A.M., the Infection Preventionist (IP) said the facility was in the midst of a COVID-19 outbreak for staff and residents. He said the outbreak began on 12/27/21 when three staff members tested positive. He further said there were positive COVID-19 cases among residents in the facility. 1. The facility failed to implement infection control guidelines for donning (putting on) and doffing (removing) PPE between residents based on their COVID-19 status (specifically isolation gowns and N95 respirators). On 1/27/22 at 11:03 A.M. the surveyor observed Housekeeper #1 enter an isolation room (occupied by two COVID-19 positive residents) in full PPE. Housekeeper #1 emptied an overflowing bin of contaminated isolation gowns into a trash bag and exited the isolation room without removing the isolation gown, gloves or N95 mask. The housekeeper then re-entered the room to bring a clean trash bag and again exited the isolation room without removing the gown, gloves or N95 mask. The surveyor observed Housekeeper #1 remove the gloves and isolation gown in the hallway and disposed of them in her cart, she did not change the N95 mask before entering another resident's room (not marked isolation). On 1/28/22 from 9:25 A.M. through 10:00 A.M. the surveyor observed one side of the unit that was behind closed fire doors. There were stations to don and doff PPE on both sides of the doors. The surveyor observed that all staff members in the hall behind the closed doors were wearing isolation gowns, N95 masks and eye protection in the hallway. The surveyor reviewed the Resident COVID-19 Status List (provided by the IP) and the list indicated that while that section of the unit was behind closed fire doors, it was not a dedicated COVID-19 unit and housed residents that were COVID-19 positive, negative and recovered. The following observations/interviews were made by the surveyor on the portion of the unit behind closed doors: -9:29 A.M. The surveyor observed a housekeeper enter and exit resident rooms wearing the same reusable yellow gown. The Housekeeper went from an isolation room to a room occupied by COVID-19 negative residents, without changing her isolation gown or N95 mask. -9:34 A.M. The surveyor observed Activity Staff #1 pass out a newsletter and converse with residents in their rooms. She was observed going room to room while still wearing the same PPE (regardless of resident COVID-19 status). During an interview with Activity Staff #1 she said it was her understanding that it was a dedicated COVID-19 unit and that required eye protection and an N95 mask at all times. She further said she had to don an isolation gown when she entered the unit and remove it when she left the unit. She said she was not aware that she had to change PPE between residents. -9:37 A.M. The surveyor observed Certified Nurse Aide (CNA) #2 exit an isolation room without doffing the isolation gown and N95. The CNA then entered the room of a COVID-19 negative resident, while wearing the same PPE. -9:43 A.M. The surveyor observed CNA #1 document at a wall kiosk while wearing an isolation gown, eye protection and an N95. The bottom elastic of the N95 mask was not around his head, but tucked into the mask. He told the surveyor that side of the unit was a positive unit and PPE did not need to be changed from room to room. -9:47 A.M. The surveyor observed Nurse #2 enter an isolation room to provide medications. When the nurse exited the room at 9:53 A. M. he did not remove his gown or change his N95 mask before exiting the room and walked back to the medication cart at the end of the hall. Nurse #2 then entered another resident room that was not marked isolation, still wearing the same PPE. -9:57 A.M. During an interview, Nurse #2 said that all the residents behind the fire doors were either COVID-19 positive, recovered or exposed. When the surveyor asked what he meant by exposed, Nurse #2 said he considered the negative resident to be exposed because there were COVID-19 positive residents in the surrounding rooms and it was difficult to keep the residents in their rooms. He further said that was why they had implemented wearing gowns in the hall. When the surveyor asked Nurse #2 when PPE was supposed to be changed, he said the isolation gown had to be removed before exiting the fire doors. He said they did not need to change the PPE between residents unless it became soiled. He said the N95 was worn for the entire shift unless it became visibly soiled. During an interview on 1/28/22 at 11:35 A.M. the IP said the residents behind the fire doors were either COVID-19 positive or had recently recovered from COVID-19. When the surveyor asked about the status of the 6 residents (on the closed side of the unit) that were indicated as COVID-19 negative (on the list the IP provided) he said they were considered exposed. He said they were considered exposed because they were in rooms adjacent to COVID-19 isolation rooms. When the surveyor asked the IP about isolation gowns observed in the hallway, he said gowns were allowed in the hallway because many of the residents often left their rooms and came into physical contact with staff in the hallway. He further said PPE should have been changed between residents and when leaving the unit. When the surveyor inquired about the plan for cohorting the IP referred the surveyor to the administrator. During a phone interview on 1/28/22 at 12:31 P.M. Administrator #1 said the status of the residents behind the fire doors was a mix of COVID-19 positive, recovered and negative. He said the negative residents were considered exposed or somewhat exposed. When the surveyor asked the administrator what he meant by somewhat exposed he said they were on a side of the unit with COVID-19 positive residents that did not always stay in their rooms. He said multiple room changes had been made in attempt to make a dedicated COVID-19 positive unit but some residents resisted moving and they had difficulty cohorting COVID-19 positive residents due to bed limitations. He said he then decided to isolate residents in place and closed the fire doors on the side of the unit where the majority of COVID-19 positive cases were located. On 1/31/22 at 9:56 A.M., the surveyor observed the Minimum Data Set (MDS) Nurse enter a COVID-19 isolation room with an N95 mask in place and don a yellow isolation gown and gloves. Upon exiting the isolation room the MDS nurse doffed the gloves and yellow isolation gown but did not doff the N95 mask. During an interview the MDS Nurse said that she wore the same N95 mask with all residents and that she did not change her mask going in and out of COVID -19 isolation rooms. Review of a DPH circular letter titled Update to Caring for Long-Term Care Residents During the COVID-19 Response, dated 1/25/22, indicated the following guidance for the use of PPE: *COVID-19-Positive Residents: Full PPE upon room entry to include fit-tested N95 respirator or alternative, Face Shield/Goggles, Gown and Gloves. Gown and gloves must be changed between residents. *COVID-19 Negative* Residents who are not up to date with COVID-19 vaccine or recovered from COVID-19 in the last 90 days when there are resident or staff case(s) identified within the last 14 days on the unit: Facemask, Face Shield/Goggles, Gown and Gloves. Gown and glove use can be prioritized for high-contact resident care activities. Gown and gloves must be changed between residents. Review of a DPH circular letter titled Comprehensive Personal Protective Equipment (PPE) Guidance, dated 1/21/22, indicated the following guidance for the use of respirators: Health care organizations and providers that are caring for high numbers of patients with suspected or confirmed COVID-19, or confirmed exposures to COVID-19 during high rates of community transmission may choose to adopt any of the following principles when caring for patients in the same cohort (i.e. all confirmed COVID-19 cases): Utilize the same N95 respirator or other acceptable alternate product between multiple patient encounters provided that the N95 respirator or acceptable alternative is always discarded after doffing, during a break, when eating or drinking or when contaminated with blood, respiratory or nasal secretions, or other bodily fluids. Reuse the same N95 respirator or acceptable alternate product over the course of an entire shift; N95 respirators or acceptable alternative must be discarded if non-intact or contaminated with blood, respiratory or nasal secretions, or other bodily fluids. Utilize the same eye protection between multiple patient encounters provided that the eye protection is clean and disinfected after doffing, or when contaminated with blood, respiratory or nasal secretions, or other bodily fluids. During an interview on 2/2/22 at 2:35 P.M. the Director of Nurses (DON) said staff were recently educated on PPE use from the updated DPH guidance and should have been changing PPE in between residents as required. 2. The facility failed to assess Residents #4, #14 and #7 for the signs and symptoms of COVID-19 each shift as required during an outbreak. Review of a DPH circular letter titled Update to Caring for Long-Term Care Residents During the COVID-19 Response, dated 1/25/22, indicated residents should be asked about COVID-19 symptoms and must have their temperatures checked a minimum of one time per day. On unit(s) conducting outbreak testing, a long-term care facility should assess residents for symptoms of COVID-19 during each shift. Review of the CDC website, updated 2/22/21, indicated the symptoms of COVID- 19 included, but were not limited to fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. During an interview on 2/1/22 at 1:29 P.M. the DON said that all residents were assessed for the symptoms of COVID-19 every shift. She said the documentation of those assessments were on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) in each resident's record. -Resident #4: *Review of the facility Resident COVID-19 Vaccine Roster (the facility's tracking log for resident vaccination status) indicated Resident #4 was not fully vaccinated (had not received the primary series of COVID-19 vaccines). *Review of the January 2022 MAR and TAR indicated there was no evidence that Resident #4 was assessed for the symptoms of COVID-19 every shift. *Review of the facility COVID-19 resident status list (provided by the IP) indicated Resident #4 tested positive for COVID-19 on 1/12/22. -Resident #14: *Review of the facility Resident COVID-19 Vaccine Roster indicated Resident #14 was not fully vaccinated against COVID-19. *Review of the January 2022 MAR and TAR indicated there was no evidence that Resident #14 was assessed for the symptoms of COVID-19 every shift. *Review of the facility COVID-19 resident status list, indicated Resident #14 tested positive for COVID-19 on 1/21/22. -Resident #7: *Review of the January 2022 MARs and TARs indicated there was no evidence that Resident #7 was assessed for the symptoms of COVID-19 every shift. *Review of the facility COVID-19 resident status list, indicated Resident #7 tested positive for COVID-19 on 1/12/22. During an interview on 2/2/22 at 12:37 P.M., the DON said she had reviewed the records for Residents #4, #14 and #7 and had no evidence that they were assessed for the symptoms of COVID-19 every shift as required. 3. The facility failed to ensure all individuals entering the building were screened for signs and symptoms of COVID-19 as required. Review of the DPH guidance issued 1/25/22 titled Update to Caring for Long-Term Care Residents during the COVID-19 Response indicated that every facility must establish a process to ensure everyone arriving at the facility is assessed for symptoms of COVID-19 (cough, shortness of breath, or sore throat, myalgia, chills, or new onset loss of smell or taste and a fever), and exposure to others with suspected or confirmed [CONDITION(S)]-CoV-2 infection. On 1/27/22 at 7:00 A.M. the DPH surveyors arrived at the facility. The facility was locked and required a staff member to permit entrance to the building. A staff member answered the bell at 7:04 A.M. and led the surveyors to an unoccupied activity room on the first floor, without screening the surveyors for symptoms of COVID-19. At 7:34 A.M. Nurse #1 entered the building and a surveyor alerted the nurse that the surveyor team had not been screened for COVID-19. Nurse #1 said there was usually a receptionist available for screening and said the survey team should have been screened upon entrance to the facility. During the entrance conference on 1/27/22 at 8:40 A.M., Administrator #2 and the IP said that all individuals required screening for COVID-19 symptoms when entering the building. They further said there should have been someone at the reception area to provide the screening, and since there was not, the staff member that let the team into the facility should have performed the screening. 4. For Resident #25 the facility failed to provide proper hand hygiene during a dressing change. Resident #25 was admitted to the facility in September 2016. Review of the clinical record indicated that Resident #25 had an unstageable deep tissue injury (DTI), full thickness wound to the right heel. (An injury when there isn't an open wound but the tissues beneath the surface have been damaged). Review of the Physician's Order, dated January 2022, indicated the following. Treatment to the unstageable DTI of the right heel full thickness, apply skin prep (liquid film-forming dressing) followed by ABD (highly absorbent gauze pad), gauze roll, and tape, done daily at 9:00 A.M. Review of the facility policy, Dressings, Dry/Clean, dated September 2013, indicated the following: Steps in Procedure Steps 6-9 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. On 1/28/22 at 9:10 A.M. the surveyor observed the dressing change to the right heel, performed by the IP. The IP removed the old dressing, applied skin prep, followed by ABD pad and gauze roll. Hand hygiene was not performed after removal of the old dressing. During an interview on 1/28/22 at 9:25 A.M., the IP said that he should have performed hand hygiene after removal of the old dressing.

Based on record review, observation and interviews, the facility failed to ensure inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for two residents (#25, #18) out of 14 sampled residents. Findings include: Review of the facility's Bed Rail Policy, dated 11/2017, indicated: section 3, Installation and Maintenance of Bed Rails. When installing bed rails the facility should: -Ensure the bed's dimensions are appropriate for the resident. -Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed. -Install the bed rail using the manufacturer's instructions to ensure proper fit. -Inspect and regularly check the mattress and bed rails for areas of possible entrapment. -Regardless of the mattress width, length, and /or depth, the bed frame, bed rail, and mattress should leave no gap wide enough to entrap a resident's head or body. 1. Resident #25 was admitted to the facility September 2016. Review of the January 2022 Physician Orders indicated the following: -bilateral half side rails in bed for assist with mobility and transfer -Air Mattress setting at #4. Review of the progress note, dated 4/12/21, indicated the Resident received a new air mattress. Review of the Bed Rail Assessment, dated 11/10/21, indicated that one-half partial rail; upper left and upper right were recommended at all times when the Resident is in bed. On 1/27/22 at 9:55 A.M., 1/28/22 at 7:37 A.M., 1/28/22 at 11:15 A.M., 2/1/22 at 9:00 A.M., and 2/1/22 at 11:03 A.M., the surveyor observed Resident # 25 in bed with bilateral half side rails up in the raised position. An air mattress was in place. 2. Resident #18 was admitted to the facility May 2020. Review of the January 2022 Physician Orders indicated the following: - two half side rails to help aid in mobility. Review of the Bed Rail Assessment, dated 5/19/21, indicated that half partial rail; upper left and upper right were recommended at all times when the Resident is in bed. On 1/27/22 at 9:02 A.M., 1/28/22 at 7:41 A.M., 1/28/22 at 1:29 P.M., and 2/2/22 at 7:58 A.M., the surveyor observed Resident #18 in bed with bilateral half side rails up in the raised position. During an interview on 2/2/22 at 2:25 P.M., Administrator #1 provided a Bed Rail Audit binder. Review of the Bed Rail Audit Binder indicated that all bed inspections (facility wide) had been done between April 2019 and May 2019. Administrator #1 said he was unsure how often the bed inspections were done and that the maintenance department was responsible for bed inspections. He said no one from the maintenance department was available to speak with the surveyors at that time. During an interview on 2/2/22 at 2:37 P.M., the corporate nurse said she was unable to determine if the Bed Rail audits from 2019 were still applicable today. She did not know how many residents in the building had side rails. She was not aware of a system for bed or side rail inspections.

Based on observation, interview, and record review, the facility failed to document on going re-evaluation of the need for a restraint, and failed to document ongoing re-evaluation of the need for restraint reduction for one Resident (#23), out of a total of 14 sampled residents. Findings include: Resident #23 was admitted to the facility in September 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessments (dated 8/24/21 and 11/18/21) indicated a trunk restraint was used daily while in the chair. The MDS also indicated Resident #23's short-term and long-term memory were impaired and the Resident's ability to make every day decisions about tasks or activities of daily living was severely impaired. Review of the facility Device/Restraints Policy and Procedure, last revised 4/2017, indicated: - The need for continued device/restraint or restraint reduction trials will be conducted quarterly with the MDS review, while restraints are being used. - Physical restraint elimination trials will be conducted at least quarterly at the time of the MDS assessment. Review of the record indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record indicated a Device/Physical Restraint Assessment and a Restraint Reduction Form dated 5/5/2021. No subsequent Physical Restraint or Restraint Reduction Assessments were documented in the record. On 1/27/22 at 9:55 A.M., the surveyor observed Resident #23 seated in a wheelchair at the bedside with a pelvic restraint in place. On 1/31/22 at 9:41 A.M., the surveyor observed Resident #23 seated in a wheelchair in his/her room with a pelvic restraint in place. During an interview on 2/1/22 at 11:42 A.M., the Corporate Nurse said that Restraint Assessments and Restraint Reduction Forms should be done quarterly. She said that the only Restraint Assessment and Restraint Reduction Form done for Resident #23 was dated 5/5/21, but that there should have been assessments for every quarter that Resident #23 had a restraint in place.

Based on observation, record review and interview, the facility failed to determine a significant change in physical condition for one Resident (#24) out of 14 sampled residents. Findings include: Resident #24 was admitted to the facility in December 2018. Review of a progress note, dated 1/08/22, indicated the Resident returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 1/26/22, indicated the Resident's prior level of function was as follows: -toileting hygiene: independent -toilet transfers: independent -upper body dressing: set up or clean-up assistance -lower body dressing: supervision or touching assistance Review of the care plan for Self Care Deficit, with goal date 2/02/22, indicated the following interventions: -provide set-up for completion of upper body bathing and grooming -break tasks into simple steps -allow adequate time for resident to complete tasks, assist as necessary Review of the care plan for risk of falls, with goal date 2/01/22, indicated the following interventions: -Staff to assist ambulation to all meals with rolling walker. Review of the care plan for bladder incontinence, with goal date 2/01/22, indicated the following interventions: -toilet twice a shift and as needed On 1/27/22 at 4:37 P.M., the surveyor observed the Resident laying in bed with their left arm in a sling and a brace to the left shoulder. On 1/28/22 at 7:40 A.M., the surveyor observed the Resident seated at the side of his/her bed with a sling on the left arm. During an interview on 1/28/22 at 2:05 P.M., Certified Nurse Aide (CNA) #3 said she knew the Resident well and took care of him/her prior to the fracture. She said the Resident used to walk with a walker but now he/she can't. CNA #3 said the Resident used to be incontinent of urine only in the morning but then would be dry the rest of the day because he/she could take him/herself to the bathroom. CNA #3 said that the Resident now has to wait for staff to help walk him/her and so he/she is incontinent of urine most of the day. CNA #3 said she doesn't dress the Resident anymore because of the left arm sling, so she dresses the Resident in a johnny (hospital gown). During an interview on 2/01/22 at 9:28 A.M., CNA #2 said the Resident has needed more help with dressing, transfers, and ambulation. She said the Resident used to be able to do things with only minimal supervision/assist. During an interview on 2/01/22 at 2:17 P.M., the rehabilitation director said nursing was responsible to track the resident's status' and determine if they have had a decline. She said there was only one OT that can do the evaluation and he was recently out of work due to an illness so that's probably why the evaluation wasn't done until 1/26/22. During an interview on 2/01/22 at 2:30 P.M., CNA #2 said that the Resident used to be continent of urine but is now incontinent because he/she cannot ambulate him/herself to the bathroom. CNA #2 said that the Resident used his/her good hand on the walker and then the CNA gently placed the Resident's left hand on the walker for ambulation. CNA #2 said she had to provide a lot of assistance to help the Resident ambulate since his/her left arm was in a sling. During an interview on 2/01/22 at 2:43 P.M., the Infection Preventionist said that it was likely that the CNAs didn't communicate the Resident's decline to nursing. He said if nursing had known about the decline, they would have brought that information to morning meeting where all of the interdisciplinary team is, and if that had happened, the Minimum Data Set (MDS) assessment department would have gotten involved to determine if a significant change should be done. He said it was an obvious breakdown in communication and this wasn't the way things were supposed to go. During an interview on 2/01/22 at 3:13 P.M., the MDS nurse she said that if the Resident had a decline in 2 or more ADLs she would do a significant change assessment. She said she was told the Resident was more incontinent of urine. The MDS nurse said that normally there is a Director of Nurses, Assistant Director Of Nurses, or nurse manager to pull these things together. She said that the Resident's decline had not come up in morning meeting but that she isn't there every day. The Certified Occupational Therapy Assistant (COTA) was unavailable for interview. The surveyor left a voicemail on 2/02/22 at 10:49 A.M. at the number the facility provided. The phone call was not returned. Refer to F 657

Based on record review and interviews, the facility failed to ensure staff accurately coded the Minimum Data Set (MDS) assessments related to falls for one Resident (#25) out of 14 sampled residents. Findings include: Resident # 25 was admitted to the facility in September 2016. Review of the Minimum Data Set (MDS) assessment, with reference date of 8/24/21, indicated that the Resident had not fallen since the prior assessment. Review of the Interdisciplinary Progress Notes (IPN), dated 6/26/21, indicated the Resident was observed on the floor in front of the left side of his/her bed. Review of the MDS assessment, with the reference date of 11/18/21, indicated the Resident had not fallen since the prior assessment. Review of the IPN dated 10/4/21 indicated the Resident had a fall, no apparent injuries noted. Review of the IPN dated 11/6/21, indicated a staff member observed the Resident sitting on the bathroom floor. Review of the IPN dated 11/16/21 indicated the Resident attempted to self-transfer to wheelchair and slid to the floor. During an interview on 2/1/21 at 3:00 P.M., the MDS coordinator said that the MDS assessments on 8/24/21 and 11/18/21 were not coded accurately for falls.

Based on record review and interview, the facility failed to ensure one resident (#33) was free of significant medication errors prescribed to help control aggressive behavior, in a total sample of 13 residents. Findings include: Resident #33 was admitted to the facility in November of 2020. Review of the Minimum Data Set Assessment, dated 11/16/20, indicated Resident #33 had cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 9 out of 15, had exhibited verbal behaviors 4 to 6 of the 7 previous days and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a consult from a Behavioral Health Group, dated 1/19/21, indicated the following: -Resident #33 continues to exhibit aggression. He/she was recently involved in a resident to resident altercation where he/she punched another resident in the back of the head 2 times. May benefit from [MEDICATION(S)] (an anti-[CONDITION(S)] medication also used for aggressive behaviors), 200 milligram (mg) daily. Review of the February 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . daily. Review of the clinical record indicated a consent form for the use of [MEDICATION(S)] had been signed by Resident #33's responsible party on 1/25/21. The consent stated the medication was used to treat symptoms of aggression. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The remaining days from 1/25/21, when consent had been obtained from the responsible party, indicated the [MEDICATION(S)] had been held. Review of a nurse's note, dated 2/4/21, indicated that at 8:00 P.M., Resident #33 was talking to a staff member at the nurse's station. Unprovoked, the resident hit another resident twice. The nurse practitioner was notified and gave an order to Section 12 (involuntary emergency admission to a psych facility) the resident for psychiatric care. The police were called and accompanied the resident out of the unit with Emergency Medical Technicians (EMTs) at 9:46 P.M. The resident returned to the facility that evening with no new changes to his/her medication. Review of a progress note by social services, dated 2/25/21, indicated a referral was made for a psychiatric admission. Review of a nurse's note, dated 2/25/21, indicated Resident #33 appeared angry and agitated, throwing trays on the floor and attempting to hit several staff. Review of a Social Services note, dated 2/25/21, indicated the resident had been transferred again to a psychiatric facility that day. He/she remained there until 3/10/21 for inpatient treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MAR, from 2/1/21 to 2/25/21, indicated the [MEDICATION(S)] had been administered on 2/7/21 and 2/14/21. The remainder of days indicated the medication had been held. During an interview on 3/23/21 at 8:31 A.M., with Nurse #1, she said Resident #33 resided on her unit prior to his/her most recent psychiatric hospitalization . She was the full time nurse on the 7:00 A.M. to 3:00 P.M. shift. She said she did not administer the [MEDICATION(S)] because the consent for the use of the medication had not been obtained and she wasn't allowed to give it. The surveyor showed Nurse #1 the consent for [MEDICATION(S)] dated 1/25/21. Nurse #1 said she did not know the consent was in the record because no one had told her.

Based on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), the Facility failed to ensure staff provided adequate supervision to prevent a burn. When on 11/30/19, Resident #1 was left unsupervised in the unit dining room and spilled hot coffee on his/her lap, resulting in second degree burn (a partial thickness burn) on his/her right upper thigh. Findings include: The Facility's Investigation Summary, dated 12/4/19, indicated that on 11/30/19, Certified Nurse Aide (CNA) #1 was supervising residents who were eating in the dining room on the unit, had stepped out, and left the residents unsupervised. Resident #1 went across the dining room to the coffee urn, and spilled hot coffee onto his/her right upper thigh, resulting in a burn. Review of the Facility's Security Video, date stamped 11/30/19, indicated a staff member (identified as CNA #1), was the only staff member in the dining room while residents were eating. CNA #1 left the dining room, one minute and 10 seconds after CNA #1 left the dining room, Resident #1 was observed self-propelling in his/her wheelchair across the dining room over to the coffee urn. The coffee urn was a standing type unit with a spout at the bottom which the person pouring the coffee would pull down on the lever on the spout while holding a cup under the spout. Resident #1's back was turned to the camera, and he/she obscured view of the urn spout. However, Resident #1 quickly raises him/herself up from his/her wheelchair, staff entered the dining room and then assisted Resident #1 out of the dining room. The Nurse Progress Note, dated 11/30/19, indicated Resident #1 spilled hot coffee on his/her lap during breakfast, and redness was noted on his/her right thigh. The Nurse Progress Note, dated 12/2/19, indicated Resident #1 was assessed with [REDACTED]. During interview on 12/24/19 at 11:01 [NAME]M., Certified Nurse Aide (CNA) #1 said that on 11/30/19 she was monitoring the morning meal in the dining room on the unit, and was asked by a resident to heat up some food. CNA #1 said she knew she was the only staff member in the dining room at the time, and said she mentioned to another staff member who was in the hallway that she was leaving the dining room. CNA #1 said she did not see Resident #1 spill the coffee on him/herself, and said she knew there should be a staff member in the dining room at all times during meals. Resident #1 was admitted to the Facility in (MONTH) 2019, with [DIAGNOSES REDACTED]. Resident #1's Plan of Care related to Safety, dated 11/25/19, indicated Resident #1 was known to seek thin liquids to drink, was known to drink from the bathroom faucet, and staff would re-educate him/her regarding the need for honey thickened liquids. During interview on 12/20/19 at 9:52 [NAME]M., the Director of Nurses (DON) said Resident #1 was known to seek thin liquids. The DON said there should always be at least one staff member in the dining room at mealtimes, and said CNA #1 should not have left the dining room. On 12/20/19, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: [NAME] The Wound Evaluation and Management Summary, dated 12/17/19, indicated Resident #1 was assessed by the wound clinic doctor, and a treatment plan was initiated, with documented ongoing healing. B. The Quality Assurance Performance Improvement (QAPI) Worksheet, dated 12/1/19, indicated dietary staff would check the temperature of the coffee in the kitchen and on the unit to ensure the temperature is between 136 degrees Fahrenheit and 140 degrees Fahrenheit for a period of seven days. C. The Facility's Investigation Summary, dated 12/4/19, indicated the findings of the coffee temperature audits would be presented to QAPI quarterly. D. During interviews with the Administrator and the Food Service Director, they each said the temperature control checks were to be ongoing. E. The Coffee Temperature Audit Tool, dated 12/5/19 through 12/20/19, indicated dietary staff were checking the temperature of the coffee served on the units at each meal. F. The Inservice Program Attendance Sheet for coffee temperature, dated 12/5/19, indicated dietary department staff were educated to check the temperature of the coffee delivered to the units. [NAME] The Inservice Program Attendance Sheets for Mealtime Supervision, dated 12/4/19, 12/5/19 and 12/6/19, indicated nursing staff were educated that residents should not be left unattended during meals, and staff were not to allow residents to serve hot drinks at any time. H. The QAPI Meeting Minutes, dated 12/11/19, indicated the Facility discussed and implemented corrective actions related to staff supervision of residents during meal time and hot beverage service. I. During interview, the Administrator said she would be responsible for ongoing compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to prevent Resident #1 from receiving medications that were not prescribed by his/her physician, which resulted in Resident #1 to experience an overall decline in condition, and required Resident #1 to be emergently transferred to the Hospital Emergency Department (ED) for evaluation. The Emergency Medical Services (EMS) report indicated that route to the Hospital Resident #1 became unresponsive, had pinpoint pupils was given [MEDICATION NAME] (a medication used to treat narcotic overdose) with minimal and transient improvement. Upon arrival to the ED, Resident #1 was noted to be in respiratory distress. It was later determined that Resident #1 received and was somehow administered medications that were prescribed for his/her roommate (Resident #2), and were not medications presribed for him/her by his/her physician. Findings include: The Facility Policy titled, Administering Medications, revised 12/2012, indicated medications shall be administered in a safe and timely manner, and as prescribed. The Policy indicated the individual administering medications must verify the resident's identity before giving the resident his/her medications. The Policy indicated methods of identifying the resident include: a. checking identification band b. checking photograph attached to the medical record c. if necessary, verifying resident identification with other facility personnel Resident #1 was admitted to the Facility in (MONTH) 2010 with [DIAGNOSES REDACTED]. A Nurse Progress Note, dated 06/02/19, (written by Nurse #1) indicated Resident #1 was alert and verbally responsive throughout the morning shift and had meals in the dining room. The Note indicated Resident #1 refused his/her 1:00 P.M. smoke break stating he/she was tired. The Note indicated at 7:00 P.M. Resident #1 came out of his/her room to the dayroom, had a drink, was compliant with his/her medications, and sat in the dayroom for a couple of hours watching television. The Note indicated that at 9:00 P.M., she (Nurse #1) ran into the day room when she heard a Certified Nurse Aide (CNA) yell out to a resident that he/she was going to fall and found the CNA holding on to Resident #1. The Note indicated she (Nurse #1) and the CNA assisted Resident #1 back to his/her room. The Note indicated Resident #1 appeared to be sleep walking. The Note indicated Resident #1 was assessed by obtaining vital signs and auscultating his/her lung sounds. The Note indicated Resident #1 had rhonchi bilaterally in his/her lungs and Nurse #1 administered a nebulizer treatment with negative effect. The Note indicated the Nurse Practitioner was notified and ordered to send Resident #1 to the Hospital Emergency Department for evaluation. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:35 P.M. on 06/26/19. CNA #1 said on 06/02/19 Resident #1 had supper, was his/her usual self, was sitting in the day room, and at approximately 9:00 P.M. Resident #1 went to get up from his/her chair to ambulate and began to stagger. CNA #1 said he called for Nurse #1 and together, they accompanied Resident #1 back to his/her room. CNA #1 said Resident #1 began to have trouble breathing, that Nurse #1 assessed Resident #1, that 911 was called and Resident #1 was transferred to the Hospital. A Physician's Transfer Order, dated 06/02/19, indicated to transfer Resident #1 to the Hospital Emergency Department for evaluation. The Surveyor interviewed Unit Manager #1 at 11:48 [NAME]M. on 06/26/19. Unit Manager #1 said she received a telephone call from a physician at the hospital on [DATE] requesting to clarify Resident #1's medication list. Unit Manager #1 said the physician said Resident #1 had a toxicology screen performed which detected the medications [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (antipsychotic), and [MEDICATION NAME] (narcotic). Unit Manager #1 said Resident #1's medication list did not indicated Resident #1 was prescribed those medications. Review of Resident #1's clinical record and his/her physician's orders [REDACTED].#1 was not prescribed the medications [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #2's Physician Orders, dated 06/01/19 through 06/30/19, indicated Resident #2's prescribed medications included: - [MEDICATION NAME] 200 mg daily at 5:00 P.M. - [MEDICATION NAME] 175 mg daily at 9:00 [NAME]M. - [MEDICATION NAME] 50 mg every 6 hours at 12:00 [NAME]M., 6:00 [NAME]M., 12:00 P.M., and 6:00 P.M. - [MEDICATION NAME] 200 mg twice daily at 9:00 [NAME]M. and 5:00 P.M. The Facility Investigation, dated 06/07/19, indicated on 06/04/19, Unit Manager #1 received a telephone call from the Hospital requesting a clarification of Resident #1's medications. The Investigation indicated a toxicology screen was performed on Resident #1 at the Hospital and showed a positive presence of the medications [MEDICATION NAME] ([MEDICATION NAME]) (an anticonvulsant medication), [MEDICATION NAME] ([MEDICATION NAME]) (an antipsychotic medication), and [MEDICATION NAME] (a narcotic medication), which Resident #1 was not prescribed. The Investigation indicated Resident #1's roommates (Resident #2) medications were reviewed and included the detected medications in the toxicology screen. The Investigation indicated Nurse #1 did not recall administering the [MEDICATION NAME], and [MEDICATION NAME] to Resident #1, but was assigned to care for Resident #1 and Resident #2 for the shift at the time of the error. The Surveyor interviewed Nurse #1 at 4:32 P.M. on 06/26/19. Nurse #1 said on 06/02/19 she had worked the 7:00 [NAME]M. to 11:00 P.M. shift and was assigned to Resident #1 and Resident #2. Nurse #1 said Resident #1 was his/her usual self during the shift. Nurse #1 said she had last seen Resident #1 sometime after 8:00 P.M. in the day room and administered his/her medications. Nurse #1 said approximately 15 to 20 minutes later she heard CNA #1 yell, went in to the day room and observed Resident #1 trying to ambulate with his/her eyes partially closed. Nurse #1 said Resident #1 was accompanied to his/her room where she assessed him/her. Nurse #1 said Resident #1 was breathing heavy and he/she sounded like he/she had fluid in his/her lungs. Nurse #1 said she administered a nebulizer treatment with no effect. Nurse #1 said she called the Nurse Practitioner and obtained an order to send Resident #1 to the Hospital Emergency Department for evaluation. Nurse #1 said she does not recall administering Resident #1 the incorrect medications. The Surveyor interviewed the Director of Nurses (DON) at 1:36 P.M. on 06/26/19. The DON said on 06/04/19 she started the investigation regarding Resident #1 and how he/she could have been administered [MEDICATION NAME], and [MEDICATION NAME] that he/she was not prescribed. The DON said she discovered Resident #1's roommate (Resident #2) was prescribed those medications. The DON said she then reviewed staffing schedules and determined that Nurse #1 had been the assigned nurse for Resident #1 and Resident #2 on 06/01/19 during the 3:00 P.M. to 11:00 P.M. shift and on 06/02/19 for the 7:00 [NAME]M. to 11:00 P.M. shift when Resident #1 and Resident #2 would receive their medications. The Surveyor interviewed Physician #1 at 1:32 P.M. on 07/01/19. Physician #1 said the Director of Nurses informed her that she had spoken with a pharmacist and they had said for Resident #1's change in mental status to occur the incorrect medication would have had to be given on the shift he/she was sent to the Hospital Emergency Department for evaluation on. The Hospital Discharge Summary, dated 06/20/19, indicated Emergency Medical Services (EMS) had been called to the facility on [DATE] for a resident with difficulty breathing and upon arrival found Resident #1 to be in respiratory distress. The Summary indicated in route to the Hospital Resident #1 became unresponsive, had pinpoint pupils was given [MEDICATION NAME] (a medication used to treat narcotic overdose) with minimal and transient improvement. The Summary indicated EMS intubated (a tube placed in the airway to assist with breathing) Resident #1. The Summary indicated a urine drug screen was obtained on Resident #1 in the Emergency Department and was positive for [MEDICATION NAME] (a medication used for sedation; given by EMS in route to the Hospital), [MEDICATION NAME] ([MEDICATION NAME]) (an antidepressant medication), [MEDICATION NAME], and [MEDICATION NAME]. The Summary indicated per Resident #1's medication list, he/she was prescribed [MEDICATION NAME] (a statin medication), [MEDICATION NAME] (a calcium channel blocker medication), [MEDICATION NAME] (an antipsychotic medication), [MEDICATION NAME] (an antipsychotic medication), [MEDICATION NAME] (an anticonvulsant medication), [MEDICATION NAME] (a laxative medication), [MEDICATION NAME] (a hormone medication), and not [MEDICATION NAME] and [MEDICATION NAME]. The Summary indicated upon further discussion with the Facility, it was reported that Resident #1's roommate (Resident #2) received [MEDICATION NAME] 15 milligrams (mg) at bedtime, [MEDICATION NAME] 200 mg daily, [MEDICATION NAME] ([MEDICATION NAME]) 200 mg daily, and [MEDICATION NAME] 50 mg every six hours. The Summary indicated Resident #1 was admitted to the Intensive Care Unit (ICU) on a ventilator (a breathing machine) with [DIAGNOSES REDACTED]. On 06/26/19, the Facility provided the Surveyor with a plan of correction which addressed the concern as evidence by: A) Resident #1 was sent to the Hospital Emergency Department for evaluation on 06/02/19 and returned to the facility on [DATE]. B) Resident #2 was assessed and monitored for any changes in mental status. Resident #2's room was changed on 06/06/19 and he/she was placed on a different medication pass assignment from Resident #1. C) The Facility (based on chart review) did not identify any other resident that had a change in mental status that could have be related to receiving the wrong medications. D) All Medication carts were checked on 6/04/19 for any potential systemic problems. E) Room changes were made with all residents, after obtained consents, that had the same first name to separate the residents. F) Physician order [REDACTED]. G) Pharmacy Consultant completed medication administration observations on 06/10/19, 06/20/19, and 06/21/19. H) Staff education with licensed staff was completed on 06/21/19 on Medication Administration. I) Random medication pass observations will be conducted on licensed staff monthly. J) A Quality Assurance Performance Improvement (QAPI) meeting was held 06/05/19 and discussed the medication error involving Resident #1. K) Monthly random medication pass observations of licensed staff will be conducted by the Director of Nurses and/ or designee and the findings will be reported and reviewed in the quarterly QAPI meetings. L) The Director of Nurses and/or designee will be responsible for overall compliance.

Based on records reviewed and interviews, for three of three sampled discharge records (Resident #1, Resident #2, and Resident #3), the facility failed to ensure that residents were permitted to return to the facility following a hospitalization . Although these residents were unable to be interviewed, a reasonable person would suffer emotional; and psychosocial harm as a result of being suddenly displaced form their long term home. Findings include: The Facility's Bed Hold Policy, revised 01/2015, indicated that any Medicaid (MassHealth) resident hospitalized in excess of the 20 days paid bed hold period would be readmitted to the first available bed if the resident required services provided by the Facility and was eligible for Medicaid nursing facility services. Review of the Facility's weekly census reports, dated for 12/21/18 through 02/28/19, indicated that the Facility had between 28 and 35 available licensed beds. Review of documentation provided by the Facility indicated that from 12/21/18 through 01/21/19, eight residents were transferred to the hospital, including Resident #1, Resident #2, and Resident #3. The Documentation indicated that as of 03/01/19, seven of the eight residents were discharged to other skilled nursing facilities and the eighth resident (Resident #1) remained in the Hospital. The Surveyor interviewed the Business Office Manager at 8:37 A.M. and at multiple times on 03/05/19. The Business Office Manager said that all of the eight residents transferred from the Facility to the hospital between 12/21/18 and 01/21/19 were discharged , including Resident #1, Resident #2 and Resident #3. The Business Office Manager said none of the eight residents were placed on a MassHealth bed-hold at the time of their transfers out of the Facility. The Surveyor interviewed the Administrator, Director of Nurses (DON), and Director of Clinical Services at 2:24 P.M. on 03/05/19. The Administrator, DON, and Director of Clinical Services said that none of residents discharged during the Facility's finding of immediate jeopardy (defined by the Centers for Medicare and Medicaid Services (CMS) as a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) were given the opportunity to return to the Facility. Review of the Notice of Determination of Immediate Jeopardy Notice of Agency Action: Limitation on Admissions, dated 12/21/18, indicated that residents on medical leaves of absence could be readmitted with prior approval from the Department of Public Health (DPH). The Surveyor interviewed the Administrator at 8:09 A.M. on 03/01/19 and at multiple times throughout the dates of survey. The Administrator said the Facility had a finding of immediate jeopardy at the time of Resident #1's transfer to the hospital on [DATE], and so the plan for his/her re-admission was unknown. The Administrator said she was under the impression the Facility could not re-admit Resident #1 because of the Facility's finding of immediate jeopardy. The Administrator said she spoke with Guardian #1 and notified her that the Facility was closed to admissions, and said Guardian #1 said she wanted Resident #1 to return to the Facility. The Administrator said she spoke with staff from DPH on approximately 02/08/19, and said she was told there was a process for re-admitting residents from the hospital during a finding of immediate jeopardy. The Administrator said that none of the residents transferred out of the Facility during the finding of immediate jeopardy were permitted to return to the Facility. The Director of Nurses (DON) said that at the time of Resident #1's transfer to the hospital on [DATE], the Facility was unsure if or when they could re-admit him/her because of the finding of immediate jeopardy. The Surveyor interviewed the Director of Social Services at 1:02 P.M. on 03/01/19. The Director of Social Services said he was not involved in determining whether residents hospitalized during the Facility's finding of immediate jeopardy could return to the Facility. 1. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The Surveyor interviewed Guardian #1 at 8:57 A.M. on 03/01/19. Guardian #1 said that in (MONTH) 2019, administrative staff repeatedly mentioned Resident #1's expressions of wanting to leave the Facility. Guardian #1 said Resident #1's behavior was long-standing, and said she often reminded staff of Resident #1's failed attempts to live in less structured and supportive levels of care. Guardian #1 said she felt that administrative staff just wanted to get rid of Resident #1, or words to that effect, and said Resident #1's hospitalization in (MONTH) 2019 gave them that opportunity. The Administrator, DON, and Director of Social Services said Resident #1 had a long-standing behavior of wanting to leave the Facility. The Surveyor interviewed the Ombudsman Program Director at 9:43 A.M. and at multiple times on 02/28/19. The Ombudsman Program Director said she spoke with the Administrator on 01/30/19, and said the Administrator told her that the Facility could not re-admit Resident #1 from the hospital because of the finding of immediate jeopardy. The Ombudsman said she told the Administrator that the Facility could re-admit residents if they received authorization from DPH. Guardian #1 said that on a date in (MONTH) 2019 prior to 02/08/19, the Administrator told her that Resident #1 could not be readmitted to the Facility because the DPH would not let the Facility admit anyone. Guardian #1 said that at no time did Facility staff discuss the possibility of re-admitting Resident #1 to the Facility with her. Review of the Aged Ledger Report, dated 03/05/19, indicated that at the time of Resident #1's transfer to the hospital on [DATE], his/her primary payor was MassHealth, which would provide for a paid MLOA for 20 days at a time (01/21/19 to 02/10/19). Guardian #1 said Resident #1 resided at the Facility for a couple of years, and said she often told Facility staff that they provided wonderful care and attention to Resident #1, and she therefore wanted Resident #1 to remain there for the rest of his/her life. Guardian #1 said that while at the Facility, Resident #1 regularly attended religious services, went to the senior center, attended a book club, and would go out into the community with his/her friends. Guardian #1 said Resident #1 was discharged from the hospital on [DATE] to a different skilled nursing facility in a different town, and no longer had access to the people and places that he/she was familiar and comfortable with. Guardian #1 said she was concerned, given Resident #1's mental illnesses, that the change would have a significant negative impact on his/her psychosocial well-being, which would then impact his/her functional capabilities. The Administrator, DON, and Director of Social Services said Resident #1 often participated in activities out in the community. The DON and Director of Social Services said Guardian #1 had expressed wanting Resident #1 to remain at the Facility for the rest of his/her life. There was no documentation to support that Resident #1 was permitted to return to the Facility after his/her hospitalization on [DATE], despite Guardian #1's expressed wishes that he/she do so. 2. Resident #2 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the Aged Ledger Report, dated 03/05/19, indicated that: at the time of Resident #2's transfer to the hospital and subsequent discharge from the Facility on 01/07/19, his/her primary payor was MassHealth, which would provide for a paid medical leave of absence for 20 days at a time (01/07/19 to 01/27/19). There was no documentation to support that Resident #2 was evaluated for or permitted to return to the Facility after his/her hospitalization on [DATE]. 3. Resident #3 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the Aged Ledger Report, dated 03/05/19, indicated that: at the time of Resident #3's transfer to the hospital and subsequent discharge from the Facility on 01/06/19, his/her primary payor was MassHealth, which would provide for a paid medical leave of absence for 20 days at a time (01/06/19 to 01/26/19). There was no documentation to support that Resident #3 was evaluated for or permitted to return to the Facility after his/her hospitalization on [DATE].

Based on records reviewed and interviews for five of seven sampled residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5), the Facility failed to prevent Resident #1 physically abusing Resident #2, and failed to prevent Resident #4 from physically abusing Resident #3 and Resident #5). Findings include: The Behavioral Management Policy, revised 03/2017, indicated it is the policy of the facility to provide services to residents who have challenging behaviors associated with their medical needs. The Policy indicated the facility provides for a comprehensive assessment and review of all residents who are admitted to the facility, and the timely development of appropriate interventions as the individual requires. The Policy indicated behavioral management is the responsibility of all employees at all times. The Policy indicated a focused behavioral plan shall be developed and implemented as appropriate which addresses the identified behavior, a resident centered measurable goal, and specific intervention plan which addresses the problem behavior in the least intrusive manner. The Facility policy titled, Abuse Prevention Policies and Procedures, revised 04/2017, indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Policy indicated physical abuse includes hitting, slapping, pinching and kicking. The Policy indicated residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy indicated the prevention of all forms of abuse, neglect, and exploitation of our residents is the responsibility of all staff members, consultants, contractors, volunteers, and other caregivers who provide care and services on behalf of the facility. 1. The Facility Investigation, dated 07/23/18, indicated Resident #2 had bumped into Resident #1's spouse and then into Resident #1. The Investigation indicated Resident #1 and Resident #2 had a verbal altercation, were threatening each other, and staff separated them. The Investigation indicated Resident #1 then walked into the dining room and out of nowhere started to attack Resident #2 by punching him/her multiple times. The Investigation indicated the incident was caught on surveillance camera and appeared to be a violent premeditated action by Resident #1. The Investigation indicated Resident #2 sustained a three centimeter laceration on his/her left eye brow that required him/her to be transferred to the hospital for evaluation where he/she received four sutures to close the wound. The Investigation indicated Resident #1 was sent section 12 to the hospital for evaluation. Resident #1 was admitted to the Facility in (MONTH) (YEAR). A Nurse Progress Note, dated 06/27/18, indicated Resident #1 reported that another resident was in his/her room and Resident #1 pushed him/her out of his/her room. A Psychiatric Note, dated 06/30/18, indicated, Resident #1 had a confrontation with another resident that had gone into his/her room uninvited. Resident #1 said had the resident been younger and not so fragile, he/she might have led him/her out forcibly and maybe struck him/her but given the age and perceived fragility of the resident, Resident #1 said he simply took him/her by the arm gently and led him/her out of the room and told him/her not to return. A Nurse Progress Note, dated 07/10/18, indicated another resident reported that he/she was pushed by Resident #1 when he/she was coming out of the bathroom. A Psychiatric Note, dated 07/14/18, indicated Resident #1 was involved in an altercation with another resident. The Note indicated Resident #1 was in the bathroom when another resident came into the bathroom, and Resident #1 pushed the other resident. The Note indicated Resident #1 admitted that he/she was in the wrong. A Behavior Care Plan, dated 06/28/18, indicated Resident #1 had alteration in behaviors related to [DIAGNOSES REDACTED]. The Care Plan did not indicate goals or interventions. A Nurse Progress Note, dated 07/24/18, timed at 07:27 A.M., indicated at 5:$) P.M. (time illegible), Resident #1 was observed bumping into Resident #2 near the dining room door and began to yell at each other and staff separated them. The Note indicated Resident #1 was standing with his/her spouse at the elevator door when he/she went back into the dining room as if he/she was looking for something. The Note indicated Resident #1 suddenly turned around, rushed to where Resident #2 was seated eating his/her supper, and Resident #1 started to aggressively punch Resident #2 with clenched fists all over his/her face. The Note indicated Resident #1 and Resident #2 were immediately separated by staff, police were notified, and Resident #1 was sent section 12 to the hospital for evaluation. Resident #2 was admitted to the Facility in (MONTH) (YEAR). A Behavior Care Plan, dated 06/06/18, indicated Resident #2 had the inability to restrict impulsive behavior, very limited insight, verbally abusive, threatening to others and intrusive into others personal space. A Nurse Progress Note, dated 07/24/18, indicated Resident #2 was seat at the dining room table eating supper, when Resident #1, who he/she had just had a verbal altercation with, suddenly rushed Resident #2 and started aggressively punching Resident #2 with closed fists all over his/her face. The Note indicated staff immediately separated Resident #1 and Resident #2. The Note indicated Resident #2 sustained a three centimeter laceration on his/her left eyebrow. The Note indicated Resident #2 was transferred to the hospital for evaluation where he/she received four sutures to close the wound. A Psychiatric Note, dated 07/28/18, indicated Resident #2 was physically attacked by another resident that required him/her to be sent to the hospital emergency department for evaluation and required several stitches to his/her left temple area of the head. The Surveyor interviewed Certified Nurse Aide (CNA) #10 at 10:49 A.M. on 12/19/18. CNA #10 said she witnessed Resident #1 and Resident #2 bump into each other and have a verbal altercation and she said she separated them. CNA #10 said Resident #2 was seated at the table and Resident #1 was pacing back and forth into and out of the dining room. CNA #10 said when the meal truck arrived, the nurse checked the meal trays, and when she began to pass out the meal tray, Resident #1 had his/her body over Resident #attacking him/her. CNA #10 said she begged Resident #1 to stop and pulled Resident #1 off of Resident #2. The Surveyor interviewed Nurse #2 at 10:11 A.M. on 12/19/18. Nurse #2 said Resident #1 had reported to him that Resident #2 had disrespected his/her spouse. Nurse #2 said he said to Resident #1 you're not going to do anything right or words to that effect and Resident #1 laughed and responded no, no, no, I know where I live or words to that effect. Nurse #2 said they were on high alert because Resident #1 was a big dude and that they had once had a conversation about how Resident #1 had said men that disrespected women really ticked him/her off and that he/she would go after them when he/she was in prison. Nurse #2 said Resident #2 was seated in the dining room eating supper when Resident #1 entered the dining room, pretended to walk by Resident #2, was high-fiving other residents as he/she walked in and then suddenly ran over to Resident #2 and began punching Resident #2 multiple times in the face. Nurse #2 said CNA #10 yelled don't do that or words to that effect and separated Resident #1 and Resident #2. Nurse #2 said Resident #2 was laughing and told Resident #2 to go own to his/her room. Nurse #2 said Resident #2 sustained a three centimeter laceration on his/her left eyebrow and was sent to the hospital emergency department for evaluation where he/she received four sutures to close the wound. Nurse #2 said Resident #1 was sent section 12 to the hospital for evaluation. The Surveyor interviewed the Nurse Consultant at 07:20 A.M. on 12/19/18. The Nurse Consultant said the video surveillance footage of the incident on 07/23/18 between Resident #1 and Resident #2 was not saved, could not be found and that it is unable to be retrieved because the tape erases after 30 days. 2. The Facility Investigation, dated 11/18/18, indicated Resident #3 was on the elevator and told Resident #4 to get out of the way. The Investigation indicated Resident #4 began to throw punches at Resident #3 making contact on Resident #3's right side of the head near his/her ear. (It was later identified through video surveillance and interview that Resident #3 was punched on the left side of his/her head and not on the right side of his/her head). Resident #3 was admitted to the Facility in (MONTH) 2009. The Behavior Care Plan for Resident #3, dated 08/07/18, indicated peer retaliation alteration related to threatening and accusatory behavior, altercations when intrusive into others personal space, and bumps into others with his/her wheelchair, will grab and strike out at others and staff. The Care Plan indicated to encourage Resident #3 to ask staff for assist as needed when others are in his/her personal space. The Care Plan indicated staff to escort off the unit for smokes and activity and assist back to unit. A Nurse Progress Note, dated 11/18/18 and written by Nurse #3, indicated Resident #3 was involved in a resident to resident altercation. The Note indicated the elevator doors opened and Nurse #3 heard shouting, turned around and witnessed Resident #3 attempting to hit/block Resident #4, who was throwing punches at Resident #3's head. The Note indicated Resident #3 was punched on his/her right side of head near his/her ear. The Note indicated Nurse #3 shouted for the residents to stop but they continued to throw punches at each other until Nurse #3 intervened. The Note indicated Resident #3 told Resident #4 to get out of his/her way and the next thing he/she knew Resident #4 was punching him/her in the head. A Progress Note, dated 11/18/18 written by Nurse Supervisor #1, indicated Resident #3 was involved in a resident to resident altercation when Resident #3 became verbally abusive to Resident #4 and then Resident #4 struck Resident #3 on the side of his/her face. Resident #4 was admitted to the Facility in (MONTH) (YEAR). The Behavior Care Plan for Resident #4, dated 03/28/18, indicated he/she was a risk for peer retaliation due to problematic behaviors, becomes assaultive and strikes out when in personal space, intrusive into space of others, verbally abusive and verbally threatening to others. The Care Plan indicated staff to monitor behaviors, intervene at onset of behavior/increased agitation. A Nurse Progress Note, dated 11/18/18, indicated Resident #4 was involved in a resident to resident altercation. The Note indicated the elevator doors opened, Nurse #3 then heard shouting, turned around and witnessed Resident #4 throwing punches at another resident (later identified as Resident #3) who was attempting to hit/block the resident. The Note indicated Resident #4 made contact to Resident #3's right side of the head near his/her ear. The Note indicated Nurse #3 shouted for resident to stop but the residents continued to throw punches at each other until Nurse #3 intervened. Resident #4 stated he/she got mad when Resident #3 told him/her to move out of his/her way. The Surveyor interviewed Nurse #3 at 12:35 P.M. on 12/18/18. Nurse #3 said she had heard shouting, turned around and witnessed Resident #3 and Resident #4 throwing punches at each other. Nurse #3 said the only contact she witnessed between Resident #3 and Resident #4 was Resident #3 punch Resident #4 on his/her right side of the head near his/his ear. Nurse #3 said she shouted for Resident #3 and Resident #4 to stop and removed Resident #3 off the elevator. After Nurse #3 viewed the video surveillance footage of the resident to resident altercation between Resident #3 and Resident #4, Nurse #3 said Resident #3 was punched on the left side of the head and not on the right side of the head. 3. The Facility Investigation, dated 12/04/18, indicated Resident #5 backed his/her wheelchair into Resident #4 and then he/she pushed Resident #4. The Investigation indicated Resident #4 then slapped Resident #5 on the right side of his/her face. The Investigation indicated staff separated the residents. The Investigation indicated the Executive Secretary witnessed the incident. The Surveyor interviewed the Executive Secretary at 9:57 A.M. on 12/19/18. The Executive Secretary said she was standing in the doorway of the Executive Directors office when she witnessed Resident #5 push Resident #4, who was standing up against the wall, with his/her wheelchair and then swatted at Resident #4 to get out of his/her way. The Executive Secretary said Resident #4 then slapped Resident #5 across the face. The Executive Secretary said she went right over and intervened. The Executive Secretary said she did not recall if other staff members were there and said she was not assigned to provide one to one supervision to Resident #4. Resident #4 was admitted to the Facility in (MONTH) (YEAR). The Behavior Care Plan for Resident #4, dated 03/28/18, indicated he/she was a risk for peer retaliation due to problematic behaviors, becomes assaultive and strikes out when in personal space, intrusive into space of others, verbally abusive and verbally threatening to others. The Care Plan indicated staff to monitor behaviors, intervene at onset of behavior/increased agitation. The Care Plan was updated on 11/20/18 and indicated Resident #4 was placed on one to one supervision. A Nurse Progress Note, dated 12/04/18, indicated Resident #4 was involved in a resident to resident altercation. The Note indicated Resident #4 was in the basement with Resident #5 when Resident #5 backed his/her wheelchair into Resident #4 and the then pushed him/her. The Note indicated Resident #4 then slapped Resident #5 on the right side of his/her face. The Note indicated Resident #4 was brought back to the nursing unit and remained on one to one supervision on the unit. The Note indicated Resident #4 was sent to the hospital section 12 to the hospital for evaluation. The Surveyor interviewed Nurse #3 at 8:12 A.M. on 12/19/18. Nurse #3 said Resident #4 was not on one to one supervision at the time of the incident because there was not enough staff. There was no documentation in Resident #4's clinical record to indicate that at the time of the resident to resident physical altercation that Resident #4 was on a one to one supervision. The Surveyor interviewed the Director of Nurses (DON) at 3:15 P.M. on 12/18/18. The DON said Resident #4 should have been on one to one supervision when the incident occurred on 12/04/18. Resident #5 was admitted to the Facility in (MONTH) 2008. A Behavior Care Plan, dated 06/24/16, indicated Resident #5 had a behavior of bumping into others with his/her wheelchair and staff to redirect and assist him/her with wheelchair when in the hall and entering the elevator. A Behavior Care Plan, dated 12/15/16, indicated Resident #5 had the potential for combative/aggressive behavior and will strike out without warning. The Care Plan indicated to reeducate Resident #5 not touch other residents. A Nurse Progress Note, dated 12/04/18, indicated Resident #5 had a resident to resident altercation with another resident (identified as Resident #4) during lunch. The Note indicated Resident #5 was sent section 12 to the hospital for a psychiatric evaluation.

Based on records reviewed and interviews for two of seven sampled residents (Resident #1 and Resident #4) the Facility failed to implement an effective behavior care plan to prevent further resident to resident physical altercations. As a result, Resident #1 physically abused other residents. Findings include: The Behavioral Management Policy, revised 03/2017, indicated it is the policy of the facility to provide services to residents who have challenging behaviors associated with their medical needs. The Policy indicated the facility provides for a comprehensive assessment and review of all residents who are admitted to the facility, and the timely development of appropriate interventions as the individual requires. The Policy indicated behavioral management is the responsibility of all employees at all times. The Policy indicated a focused behavioral plan shall be developed and implemented as appropriate which addresses the identified behavior, a resident centered measurable goal, and specific intervention plan which addresses the problem behavior in the least intrusive manner. 1. Resident #1 was admitted to the Facility in (MONTH) (YEAR). A Nurse Progress Note, dated 06/27/18, indicated Resident #1 reported that another resident was in his/her room and Resident #1 pushed him/her out of his/her room. A Psychiatric Note, dated 06/30/18, indicated, Resident #1 had a confrontation with another resident that had gone into his/her room uninvited. Resident #1 said had the resident been younger and not so fragile, he/she might have led him/her out forcibly and maybe struck him/her but given the age and perceived fragility of the resident, Resident #1 said he simply took him/her by the arm gently and led him/her out of the room and told him/her not to return. A Nurse Progress Note, dated 07/10/18, indicated another resident reported that he/she was pushed by Resident #1 when he/she was coming out of the bathroom. A Psychiatric Note, dated 07/14/18, indicated Resident #1 was involved in an altercation with another resident. The Note indicated Resident #1 was in the bathroom when another resident came into the bathroom, and Resident #1 pushed the other resident. The Note indicated Resident #1 admitted that he/she was in the wrong. The Facility Investigation, dated 07/23/18, indicated Resident #2 had bumped into Resident #1's spouse and then into Resident #1. The Investigation indicated Resident #1 and Resident #2 had a verbal altercation, were threatening each other, and staff separated them. The Investigation indicated Resident #1 then walked into the dining room and out of nowhere started to attack Resident #2 by punching him/her multiple times. The Investigation indicated the incident was caught on surveillance camera and appeared to be a violent premeditated action by Resident #1. The Investigation indicated Resident #2 sustained a three centimeter laceration on his/her left eye brow that required him/her to be transferred to the hospital for evaluation where he/she received four sutures to close the wound. The Investigation indicated Resident #1 was sent section 12 to the hospital for evaluation. A Nurse Progress Note, dated 07/24/18, timed at 07:27 [NAME]M., indicated at 5:$) P.M. (time illegible), Resident #1 was observed bumping into Resident #2 near the dining room door and began to yell at each other and staff separated them. The Note indicated Resident #1 was standing with his/her spouse at the elevator door when he/she went back into the dining room as if he/she was looking for something. The Note indicated Resident #1 suddenly turned around, rushed to where Resident #2 was seated eating his/her supper, and Resident #1 started to aggressively punch Resident #2 with clenched fists all over his/her face. The Note indicated Resident #1 and Resident #2 were immediately separated by staff, police were notified, and Resident #1 was sent section 12 to the hospital for evaluation. The Surveyor interviewed Certified Nurse Aide (CNA) #10 at 10:49 [NAME]M. on 12/19/18. CNA #10 said she witnessed Resident #1 and Resident #2 bump into each other and have a verbal altercation and she said she separated them. CNA #10 said Resident #2 was seated at the table and Resident #1 was pacing back and forth into and out of the dining room. CNA #10 said when the meal truck arrived, the nurse checked the meal trays, and when she began to pass out the meal tray, Resident #1 had his/her body over Resident #attacking him/her. CNA #10 said she begged Resident #1 to stop and pulled Resident #1 off of Resident #2. The Surveyor interviewed Nurse #2 at 10:11 [NAME]M. on 12/19/18. Nurse #2 said Resident #1 had reported to him that Resident #2 had disrespected his/her spouse. Nurse #2 said he said to Resident #1 you're not going to do anything right or words to that effect and Resident #1 laughed and responded no, no, no, I know where I live or words to that effect. Nurse #2 said they were on high alert because Resident #1 was a big dude and that they had once had a conversation about how Resident #1 had said men that disrespected women really ticked him/her off and that he/she would go after them when he/she was in prison. Nurse #2 said Resident #2 was seated in the dining room eating supper when Resident #1 entered the dining room, pretended to walk by Resident #2, was high-fiving other residents as he/she walked in and then suddenly ran over to Resident #2 and began punching Resident #2 multiple times in the face. Nurse #2 said CNA #10 yelled don't do that or words to that effect and separated Resident #1 and Resident #2. Nurse #2 said Resident #2 was laughing and told Resident #2 to go own to his/her room. Nurse #2 said Resident #2 sustained a three centimeter laceration on his/her left eyebrow and was sent to the hospital emergency department for evaluation where he/she received four sutures to close the wound. Nurse #2 said Resident #1 was sent section 12 to the hospital for evaluation. A Behavior Care Plan, dated 06/28/18, indicated Resident #1 had alteration in behaviors related to [DIAGNOSES REDACTED]. The Care Plan did not indicate specific behaviors, goals, intervention, or revised and updated following the problem behavior. 2. Resident #4 was admitted to the Facility in (MONTH) (YEAR). The Behavior Care Plan for Resident #4, dated 03/28/18, indicated he/she was a risk for peer retaliation due to problematic behaviors, becomes assaultive and strikes out when in personal space, intrusive into space of others, verbally abusive and verbally threatening to others. The Care Plan indicated staff to monitor behaviors, intervene at onset of behavior/increased agitation. A Nurse Progress Note, dated 11/18/18, indicated Resident #4 was involved in a resident to resident altercation. The Note indicated the elevator doors opened, Nurse #3 then heard shouting, turned around and witnessed Resident #4 throwing punches at another resident (later identified as Resident #3) who was attempting to hit/block the resident. A Nurse Progress Note, dated 11/20/18, indicated Resident #4 was involved in a resident to resident altercation on 11/18/18 that is being investigated by the Police Department and Medical Examiner's office. The Behavior Care Plan, updated 11/20/18, indicated Resident #4 was placed on one to one for behavior monitoring. The Facility Investigation, dated 12/04/18, indicated Resident #5 backed his/her wheelchair into Resident #4 and then he/she pushed Resident #4. The Investigation indicated Resident #4 then slapped Resident #5 on the right side of his/her face. The Investigation indicated staff separated the residents. The Investigation indicated the Executive Secretary witnessed the incident. The Surveyor interviewed the Executive Secretary at 9:57 [NAME]M. on 12/19/18. The Executive Secretary said she was standing in the doorway of the Executive Directors office when she witnessed Resident #5 push Resident #4, who was standing up against the wall, with his/her wheelchair and then swatted at Resident #4 to get out of his/her way. The Executive Secretary said Resident #4 then slapped Resident #5 across the face. The Executive Secretary said she went right over and intervened. The Executive Secretary said she did not recall if other staff members were there and said she was not assigned to provide one to one supervision to Resident #4. A Nurse Progress Note, dated 12/04/18, indicated Resident #4 was involved in a resident to resident altercation. The Note indicated Resident #4 was in the basement with Resident #5 when Resident #5 backed his/her wheelchair into Resident #4 and the then pushed him/her. The Note indicated Resident #4 then slapped Resident #5 on the right side of his/her face. The Note indicated Resident #4 was brought back to the nursing unit and remained on one to one supervision on the unit. The Note indicated Resident #4 was sent to the hospital section 12 to the hospital for evaluation. The Surveyor interviewed Nurse #3 at 8:12 [NAME]M. on 12/19/18. Nurse #3 said Resident #4 was not on one to one supervision at the time of the incident because there was not enough staff. There was no documentation in Resident #4's clinical record to indicate that at the time of the resident to resident physical altercation that Resident #4 was on a one to one supervision. The Surveyor interviewed the Director of Nurses (DON) at 3:15 P.M. on 12/18/18. The DON said Resident #4 should have been on one to one supervision when the incident occurred on 12/04/18.

Based on records reviewed and interviews for one of seven sampled residents (Resident #3), the Facility failed to follow acceptable standards of practice when staff failed to perform a neurological assessment on Resident #3 who had been punched in the head by Resident #4. In addition, when Resident #3's condition deteriorated. the staff failed to perform cardio-pulmonary resuscitation consistent with standards of practice. - On [DATE] at approximately 7:25 [NAME]M. Resident #4 was witnessed punching Resident #3 in the head. - On [DATE] after supper Resident #3 appeared sleepy, and said to Nurse #1 to he/she would like to go to bed after going out to smoke. -On [DATE] at approximately 6:30 P.M. was observed sleeping in his/her wheelchair. -On [DATE] at approximately 9:40 P.M. Resident #3 was noted to be unresponsive with no pulse or respirations evident. - On [DATE] at 10:17 P.M. Resident #3 was transported to the Hospital by EMS. - On [DATE] at 10:24 P.M. Resident #3 arrived at the Hospital and he/she was pronounced deceased by the Physician at 10:48 P.M. from cardiopulmonary collapse. - There was no documentation in Resident #3's clinical record to indicate he/she had a complete neurological assessment performed by the Facility staff after being punched in the head by Resident #4 on [DATE]. Findings include: 1. Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.[NAME]L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility Policy titled, Neurological Assessment, revised ,[DATE], indicated neurological assessments are indicated: upon physician order, following an unwitnessed fall, following a fall or other accident/injury involving head trauma or when indicated by the resident's condition. The Policy indicated the following steps in the neurological procedure: determine resident's orientation to time, place and person; observe resident's pattern of speech and clarify; take temperature, pulse, respirations and blood pressure; check pupil reaction; determine motor ability; determine sensation in extremities; check gag reflex with tongue depressor, if safe for resident; have resident smile to determine if there is any facial drooping; check eye opening, verbal, and motor responses using the Glasgow Coma Scale (an assessment used to determine a person's level of consciousness). The Facility Form titled, Neuro Checks Flow Sheet, revised [DATE], indicated vital signs and neuro checks should be performed every 15 minutes for one hour, then every 30 minutes for one hour, then every one hour for four hours, then every four hours for 24 hours, then every six hours for three hours for an overall total for 48 hours. Resident #3 was admitted to the Facility in (MONTH) 2009 with [DIAGNOSES REDACTED]. The Facility Investigation, dated [DATE], indicated Resident #3 was on the elevator and told Resident #4 to get out of the way. The Investigation indicated Resident #4 began to throw punches at Resident #3 making contact on Resident #3's right side of the head near his/her ear. (It was later identified through video surveillance and interview that Resident #3 was punched on the left side of his/her head and not on the right side of his/her head). A Nurse Progress Note, dated [DATE] and written by Nurse #3, indicated Resident #3 was involved in a resident to resident altercation. The Note indicated the elevator doors opened and Nurse #3 heard shouting, turned around and witnessed Resident #3 attempting to hit/block Resident #4, who was throwing punches at Resident #3's head. The Note indicated Resident #3 was punched on his/her right side of head near his/her ear. The Note indicated Nurse #3 shouted for the residents to stop but they continued to throw punches at each other until Nurse #3 intervened. The Note indicated Resident #3 told Resident #4 to get out of his/her way and the next thing he/she knew Resident #4 was punching him/her in the head. The Surveyor interviewed Nurse #3 at 12:35 P.M. on [DATE]. Nurse #3 said she had heard shouting, turned around and witnessed Resident #3 and Resident #4 throwing punches at each other. Nurse #3 said the only contact she witnessed between Resident #3 and Resident #4 was Resident #3 punch Resident #4 on his/her right side of the head near his/his ear. Nurse #3 said she shouted for Resident #3 and Resident #4 to stop and removed Resident #3 off the elevator. Nurse #3 said she obtained vital signs and assessed Resident #3 for pain, and that there were no visible injuries. Nurse #3 on Resident #3 but did not do a complete neurological assessment. Nurse #3 said she then informed Nurse Supervisor #1, who was Resident #3's primary nurse. After Nurse #3 viewed the video surveillance footage of the resident to resident altercation between Resident #3 and Resident #4, Nurse #3 said Resident #3 was punched on the left side of the head and not on the right side of the head. A Progress Note, dated [DATE] written by Nurse Supervisor #1, indicated Resident #3 was involved in a resident to resident altercation when Resident #3 became verbally abusive to Resident #4 and then Resident #4 struck Resident #3 on the side of his/her face. The Surveyor interviewed Nurse Supervisor #1 at 2:24 P.M. on [DATE]. Nurse Supervisor #1. Nurse Supervisor #1 said she received report from Nurse #3 that Resident #4 had hit Resident #3 in the head. Nurse Supervisor #1 said she looked Resident #3 over and did not note any visible injuries and that he/she was his/her usual self, and was not experiencing any pain. Nurse Supervisor #1 said she did not perform a complete neurological assessment on Resident #3. There was no documentation in Resident #3's clinical record to indicate Resident #3 had a complete neurological assessment performed according to the Facility's policy. The Surveyor interviewed the Director of Nurses (DON) at 3:15 P.M. on [DATE]. The DON said a neurological assessment should be completed on any resident with a head injury. 2. On [DATE] at approximately 9:40 P.M. Resident #3 was noted to be unresponsive with no pulse or respirations evident and at 10:01 P.M. emergency medical services (EMS) received a 911 call from the Facility, approximately 21 minutes after Resident #3 was noted by Nurse #1 to be unresponsive with no pulse or respirations. Although the Facility initiated cardio-pulmonary resuscitation (CPR), during CPR the facility failed to administer Resident #3 with rescue breaths and oxygen with an Ambu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) and only administered chest compressions. On [DATE] at 10:05 P.M. EMS arrived at the Facility and was with Resident #3 at 10:06 P. M., and at 10:17 P.M. Resident #3 was transported to the Hospital. Resident #3 arrived at the Hospital and he/she was pronounced deceased by the Physician at 10:48 P.M. from cardiopulmonary collapse. The Surveyor interviewed Nurse #1 at 3:16 P.M. on [DATE]. Nurse #1 said that sometime around 9:00 P.M. to 9:30 P.M. while speaking with Resident #3's roommate, he had noticed Resident #3 appeared pale, unable to awaken, had a thready pulse and low respirations. Nurse #1 said he sent for Nurse #2, he initiated chest compressions and then Nurse #2 arrived with the code cart. Nurse #1 said he and Nurse #2 placed the board under Resident #3 and applied the AED machine, and that Nurse #2 continued with chest compressions. Nurse #1 said he left the room to call 911. Nurse #1 said he did not provide rescue breaths with the Ambu bag during CPR and did not administer Oxygen to Resident #3. Nurse #3 said he did not page an internal emergency response system. Nurse #3 said the facility does not fill out code form after a code. The Surveyor interviewed Nurse #2 at 4:59 P.M. on [DATE]. Nurse #2 said at approximately 9:30 P.M. Nurse #1 called him to Resident #3's room. Nurse #2 said Nurse #1 had assessed Resident #3 and that when he arrived at the room he started chest compressions, called for the code cart, and once the code cart arrived placed Resident #3 on the cardiac board and continued compressions. Nurse #2 said he and Nurse #1 applied the AED and no shocks were advised and then chest compressions resumed. Nurse #2 said he did not administer rescue breaths with the Ambu bag or administer oxygen to Resident #3 because the AED did not advise too or words to that effect. Nurse #2 said the facility does not complete code forms. The Surveyor interviewed the Director of Nurses (DON) at 4:46 P.M. on [DATE]. The DON said she would expect rescue breath and oxygen be administered with the Ambu bag during CPR. The DON said she did not have a code form and was not sure if the facility completed them.

Based on records reviewed and interviews for one of seven sampled residents (Resident #3), the Facility failed to provide rescue breaths and oxygen while performing Cardiopulmonary Resuscitation (CPR) and failed to promptly call Emergency Medical Services (EMS) for Resident #3 who was having a life threatening medical emergency that required transportation the hospital for evaluation. - On [DATE] at 9:40 P.M. Resident #3 was found by Nurse #1 to be unresponsive with no pulse or respirations and chest compressions were initiated. - On [DATE] at 10:01 P.M. EMS received a 911 call from the Facility, approximately 21 minutes after Resident #3 was noted by Nurse #1 to be unresponsive with no pulse or respirations. - During CPR the facility failed to administer Resident #3 with rescue breaths and oxygen with an ambu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) and only administered chest compressions. - On [DATE] at 10:05 P.M. EMS arrived at the Facility and was with Resident #3 at 10:06 P.M. - On [DATE] at 10:17 P.M. Resident #3 was transported to the Hospital by EMS. - On [DATE] at 10:24 P.M. Resident #3 arrived at the Hospital and he/she was pronounced deceased by the Physician at 10:48 P.M. from cardiopulmonary collapse. Findings include: The Facility Policy titled Automatic External Defibrillator (AED), dated ,[DATE], indicated: - The response team member responsibilities include paging the facility internal emergency response system and providing prompt basic life support including AED. - Contacting the community 911 response team, Emergency Medical Services (EMS) if required. - Following each AED response event, all key participants involved in the event including the Executive Director and Director of Nurses shall participate in a post event review. The post event review shall include identification of actions that were conducted as well as reviewing the opportunities for improvement. - The Executive Director or the Director of Nurses shall complete the AED Emergency Response Event Report. According to the American Heart Association Chain of Survival, dated (YEAR), survival chances decline with every minute that passes by ,[DATE]%, within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed. Chain of survival includes calling 911, giving immediate and effective CPR (30 compressions and 2 breaths), defibrillating (if no shock advised, continue CPR for about 2 minutes which is approximately 5 cycles of 30 compressions and 2 breaths, until prompted by AED to allow rhythm check), and providing basic life support until advanced life support and delivering post-arrest care, to minimize brain damage. CPR should be provided while the AED pads are applied and until the AED is ready to analyze the rhythm. The Facility Policy titled Cardiopulmonary Resuscitation (CPR), revised ,[DATE], indicated that cardiopulmonary resuscitation (CPR) be initiated as an emergency measure only, CPR is administered when a patient is not breathing, and oxygen is pumped into the lungs using a rubber bag and the chest is then compressed repeatedly until breathing is restored and stabilized or until it is established that breathing cannot be restored. If CPR is initiated, immediate transfer to the hospital will take place via emergency ambulance service. Resident #3 was admitted to the facility on (MONTH) 2009 with [DIAGNOSES REDACTED]. An Advanced Directive Care Plan, dated [DATE], indicated Resident #3 was a full code, that his/her wishes regarding code status, supported by staff, and would be resuscitated in the event of cardiopulmonary failure. The Care Plan indicated to initiate CPR according to facility policy and procedures in the event of cardiopulmonary failure. The Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) for Resident #3, signed and dated by the Physician on [DATE], indicated to attempt resuscitation, intubate and ventilate, use non-invasive ventilation and transfer to the hospital. The Physician Orders, dated [DATE] through [DATE], indicated Resident #3 was a full code. The Nurses Progress Note, dated [DATE], indicated the Nurse #1 noticed Resident #3 appeared pale, his/her pulse was weak and thready and he/she had low respirations. The Note indicated at approximately 9:40 P.M. Resident #3 remained unresponsive with no pulse or respirations being evident. The Note indicated team work was initiated, the Nurse Practitioner was notified and 911 was called and that the crash cart was brought into Resident #3's room. The Note indicated the cardiac board was placed under Resident #3's body, chest compressions were started, the AED was attached to Resident #3 and prompted to continue with chest compressions. The Note indicated the emergency response team immediately arrived and took over and Resident #3 was transferred to the hospital emergency department at 10:15 P.M. The Ambulance Patient Care Report for Resident #3, dated [DATE], indicated EMS received the 911 call from the Facility at 10:01 P.M. (approximately 21 minutes after Resident #3 was noted to be unresponsive with no pulse or respirations). The Report indicated EMS arrived at the Facility at 10:05 P.M. and was with Resident #3 at 10:06 P.M. The Report indicated oxygen was not being administered to Resident #3 prior to EMS's arrival. The Report indicated Resident #3 was last seen by the Facility staff at 9:50 P.M. (which is inconsistent with Nurse #1's nurse progress note) and that the AED had advised no shock twice. The Report indicated Resident #3 was transported to the Hospital at 10:17 P.M. The Hospital Report, dated [DATE], indicated the Facility had started chest compressions at 9:50 P.M., the AED machine was applied at 10:00 P.M., EMS arrived at 10:00 P.M. and that Resident #3 had last been seen well five minutes prior to EMS being called. The Report indicated Resident #3 arrived at the Hospital at 10:24 P.M. and that he/she was pronounced deceased by the Physician at 10:48 P.M. from cardiopulmonary collapse. The Surveyor interviewed Nurse #1 at 3:16 P.M. on [DATE]. Nurse #1 said that sometime around 9:00 P.M. to 9:30 P.M. while speaking with Resident #3's roommate, he had noticed Resident #3 appeared pale, unable to awaken, had a thready pulse and low respirations. Nurse #1 said he sent for Nurse #2, he initiated chest compressions and then Nurse #2 arrived with the code cart. Nurse #1 said he and Nurse #2 placed the board under Resident #3 and applied the AED machine, and that Nurse #2 continued with chest compressions. Nurse #1 said he left the room to call 911. Nurse #1 said he did not provide rescue breaths with the ambu bag during CPR and did not administer Oxygen to Resident #3. Nurse #3 said he did not page an internal emergency response system. Nurse #3 said the facility does not fill out code form after a code. The Surveyor interviewed Nurse #2 at 4:59 P.M. on [DATE]. Nurse #2 said at approximately 9:30 P.M. Nurse #1 called him to Resident #3's room. Nurse #2 said Nurse #1 had assessed Resident #3 and that when he arrived at the room he started chest compressions, called for the code cart, and once the code cart arrived placed Resident #3 on the cardiac board and continued compressions. Nurse #2 said he and Nurse #1 applied the AED and no shocks were advised and then chest compressions resumed. Nurse #2 said he did not administer rescue breaths with the ambu bag or administer oxygen to Resident #3 because the AED did not advise too or words to that effect. Nurse #2 said the facility does not complete code forms. The Surveyor interviewed the Director of Nurses (DON) at 4:46 P.M. on [DATE]. The DON said she would expect rescue breath and oxygen be administered with the ambu bag during CPR. The DON said she did not have a code form and was not sure if the facility completed them.

Based on records reviewed and interviews, for one of seven sampled residents (Resident #7), the facility failed to ensure court approved treatment plans were maintained consistent with the legal representative's wishes. This resulted in a deterioration in Resident #7's mood as ECT appointments were missed. Findings include: Resident #7 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #7's clinical record indicated a Permanent Decree of Guardianship, dated [DATE]. Review of Resident #7's Treatment Plan for Electro-Convulsive Therapy (ECT), approved by a trial court in the Commonwealth of Massachusetts on [DATE], indicated a review date of [DATE] and an expiration date of [DATE]. The Surveyor interviewed Guardian #2 at 10:11 A.M. on [DATE]. Guardian #2 said the Facility was responsible for ensuring the court mandated paperwork for Resident #7's ECT treatments was submitted to the courts as required. Guardian #2 said the Facility was aware the Treatment Plan expired on [DATE], and did not know why the Treatment Plan was allowed to expire. Guardian #2 said Resident #7 received ECT treatments to improve his/her mood, and said his/her last ECT treatment was in late (MONTH) (YEAR). Guardian #2 said she had noticed a decline in Resident #7's psychosocial well-being since his/her last ECT treatment. Guardian #2 said Resident #2 was more anxious, worried, depressed, and easily distracted. Guardian #2 said Resident #7 also began perseverating on things not going right, not smiling, and was not happy to be with his/her family for visits. Guardian #2 said the Facility was unable to tell her when Resident #7's ECT would be resumed because the necessary paperwork had not been completed as of the date of interview. The Surveyors interviewed the Director of Social Services at 11:01 A.M. on [DATE]. The Director of Social Services said Resident #7's court approved treatment plan for ECT had expired on [DATE] or [DATE]. The Director of Social Services said he was responsible for ensuring Resident #7's treatment plan did not expire. The Director of Social Services said he did not know when Resident #7's last ECT treatment had been, or when it could be expected to resume. Review of the Discharge Instruction Sheet for Patients Receiving Outpatient Electroconvulsive Therapy (ECT), dated [DATE], indicated that Resident #7 received treatment. Review of Resident #7's Patient Progress Note from the psychiatric services provider, dated [DATE], did not indicate that Resident #7 expressed any indications of depression. Review of the nursing Progress Note, dated [DATE], indicated that he/she left the Facility for an ECT treatment, but returned within an hour due to behavioral issues during transportation to the ECT site, and that the ECT appointment was canceled. The Surveyors interviewed the Director of Nurses (DON) at 1:45 P.M. on [DATE]. The DON said Resident #7's ECT provider canceled his/her appointment scheduled for [DATE] because Resident #7's court approved treatment plan had expired. The DON said Resident #7's court approved treatment plan for ECT treatments should not have been allowed to expire, and said she did not know when Resident #7's ECT treatments would be resumed. Review of Resident #7's Patient Progress Note from the psychiatric services, dated [DATE], indicated that staff were at work to have his/her ECT sessions resumed. The Note indicated that Resident #7 appeared depressed, had a sense of hopelessness, had scary feelings, admitted to morbid ideation (thoughts of or a preoccupation with death), and that he/she spoke of sadness and despair. There was no documentation to support that the Facility ensured the court approved plan for Resident #7's ECT treatments did not expire, which resulted in him/her being unable to receive treatments and a decline in his/her psychosocial well-being.

Based on records reviewed and interviews, for one of seven sampled residents (Resident #7), the facility failed to ensure the resident received electroconvulsive therapy (ECT) treatments to prevent a decline in his/her psychosocial well-being. Findings include: Resident #7 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #7's clinical record indicated a Permanent Decree of Guardianship, dated [DATE]. Review of Resident #7's Treatment Plan for Electro-Convulsive Therapy, approved by a trial court in the Commonwealth of Massachusetts on [DATE], indicated a review date of [DATE] and an expiration date of [DATE]. Review of Resident #7's care plan for ECT treatments, dated [DATE] and revised [DATE], indicated that he/she received ECT treatment for [REDACTED]. The Surveyor interviewed Guardian #2 at 10:11 A.M. on [DATE]. Guardian #2 said the Facility was responsible for ensuring the court mandated paperwork for Resident #7's ECT treatments was submitted to the courts as required, and was aware the Treatment Plan expired on [DATE]. Guardian #2 said Resident #7 had not received an ECT treatment since late-October (YEAR), and said she had noticed a decline in his/her psychosocial well-being since then. Guardian #2 said Resident #2 was more anxious, worried, depressed, and easily distracted. Guardian #2 said Resident #7 also began perseverating on things not going right, not smiling, and was not happy to be with his/her family for visits. Guardian #2 said the Facility was unable to tell her when Resident #7's ECT would be resumed because the necessary paperwork had not been completed as of the date of interview. The Surveyors interviewed the Director of Social Services at 11:01 A.M. on [DATE]. The Director of Social Services said Resident #7 could not receive ECT treatments because his/her court approved treatment plan for ECT had expired. The Director of Social Services said he did not know when Resident #7's last ECT treatment had been, how often Resident #7 received ECT treatments, or when the ECT treatments could be expected to resume. Review of Resident #7's Progress Note, dated [DATE], indicated that papers to continue his/her ECT treatments were faxed to the Nurse Practitioner, who said he would take care of the papers later. Review of the physician progress notes [REDACTED].#7 was cleared for ECT. Review of the Discharge Instruction Sheet for Patients Receiving Outpatient Electroconvulsive Therapy (ECT), dated [DATE], indicated that Resident #7 received treatment on that date. Review of Resident #7's Patient Progress Note from the psychiatric services provider, dated [DATE], did not indicate that Resident #7 expressed any indications of depression. Review of the nursing Progress Note, dated [DATE], indicated that Resident #7 left the Facility for an ECT treatment, but returned within an hour due to behavioral issues during transportation to the ECT site, and that the ECT appointment was canceled. Review of Resident #7's Progress Note from the psychiatric services provider, dated [DATE], indicated that paperwork for his/her ECT needed to be completed, and the psychiatric services provider was aware. The Surveyors interviewed the Director of Nurses (DON) at 1:45 P.M. on [DATE]. The DON said Resident #7's ECT treatment scheduled for [DATE] was canceled by the ECT provider because Resident #7's court approved treatment plan had expired. The DON said she did not know when Resident #7's ECT treatments would be resumed. Review of Resident #7's Progress Note from the psychiatric services provider, dated [DATE], indicated that the social worker was to follow up on the status of Resident #7's ECT. Review of Resident #7's Patient Progress Note from the psychiatric services, dated [DATE], indicated that staff were at work to have his/her ECT sessions resumed. The Note indicated that Resident #7 appeared depressed, had a sense of hopelessness, had scary feelings, admitted to morbid ideation (thoughts of or a preoccupation with death), and that he/she spoke of sadness and despair. There was no documentation to support that the Facility maintained Resident #7's court approved plan for ECT treatments, which prevented Resident #7 from receiving treatments and resulted in a decline in his/her psychosocial well-being.

Based on observation, record review and interview, the facility staff failed to assess 1 resident's (#15) ability to smoke safely and failed to ensure 2 residents (#35 and # 124) of 5 sampled residents (including 1 closed record) with falls, received adequate supervision and assistive devices to prevent accidents, in a total sample of 17 residents. Findings include: Review of the facility's Fall Policy and Procedure Policy, date revised 4/19/13, indicated the following; -To identify residents at risk for falls and adequately implement protocols to prevent falls. -The Licensed Nurse must implement a preventative protocol to promote resident safety based on the resident's risk factors. If identified as high risk, the resident may be place on the falling star program. Residents identified as high risk for falls will have a gold star placed on his/her door plate. -The Case Management Committee consisting of a multi-interdisciplinary team will meet to review and approve the recommended preventative protocol. -The Committee shall identify and investigate the cause of a fall, review the suggested interventions and implement individualized interventions to prevent further fall. 1. For Resident #124, the facility staff failed to ensure a fall intervention was maintained to prevent 1 fall with major injuries of 6 unwitnessed falls the resident sustained [REDACTED].>Resident #124 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the Fall Care Plan, original date 1/25/16, indicated the following interventions; -Call bell within reach. -Staff to re-approach and assist into bed for rest periods when showing signs of fatigue and/or sleeping in the wheel chair. -Staff to assist with toileting and out of bed when observed awake. Review of the Quarterly Minimal Data Set (MDS) Assessment, dated 2/27/17, indicated the resident had severe cognitive impairment as evidenced by a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance with bed mobility, transfers, dressing and hygiene, was totally dependent for toileting and bathing, did not ambulate, and had a fall with injury (not major). Review of the clinical record indicated the following; -The resident had an unwitnessed fall on 3/14/17 at 1:45 P.M. in the bedroom and was not injured. -The resident had an unwitnessed fall on 4/14/17 at 2:40 P.M. in the bedroom and was not injured. -The resident had an unwitnessed fall on 6/3/17 at 2:30 P.M. in the bedroom and was not injured. Review of the facility's Quality Assessment and Assurance Fall Audit Tools, dated 3/15/17, 4/14/17 and 6/5/17 indicated the resident was a high fall risk with a score of 10 or greater and had a star/sunburst on his/her doorway. -The Resident had an unwitnessed fall on 8/3/17 at 4:00 P.M. in the unit dining room and was not injured. The new intervention added was to discontinue the wheel chair alarm and add a seat belt restraint belt while in the wheel chair, release and reposition every 2 hours and during meals and activities. Review of the Fall Assessment Form, dated 8/3/17, indicated of score of 19. A score of 10 or greater indicated a high fall risk. Review of the Quarterly MDS Assessment, dated 8/15/17, indicated the resident had severe cognitive impairment as evidenced by a score of 3 out of 15 on the BIMS, required extensive assistance with bed mobility, transfers, dressing, eating, toileting and hygiene, required total assistance with bathing and had 1 fall with no injuries. -The resident had an unwitnessed fall on 9/8/17 at 3:45 P.M. in the bedroom and was not injured. Review of the Fall Assessment, dated 9/18/17, indicated the resident remained at a high fall risk as evidenced by a score of 20. -The resident had an unwitnessed fall on 12/10/17 at 9:20 A.M. The resident was found on the floor in the hallway with blood coming from his/her left eye brow, nose and left upper lip. The Post Fall Investigation Report, dated 12/10/17, indicated the resident had been in the wheel chair prior to the fall. The report indicated the resident's seatbelt was not buckled at the time of the fall. The resident was sent to the hospital for an evaluation. The hospital discharge summary, dated 12/10/17, indicated the resident sustained [REDACTED]. After the resident was returned to the facility, the new intervention added was to re-educate the staff on the use of the restraint. During an interview on 05/08/18 at 11:51 A.M., the Director of Nurses (DON) said that in 12/10/17 the Certified Nursing Assistant (CNA) brought the resident from the unit dining room to the hallway. She said the CNA did not reapply the seatbelt and the resident fell from the wheel chair sustaining major injuries. During an interview on 5/9/18 at 4:10 p.m., the Administrator said the CNA involved in the above incident was no longer an employee of the facility. 2. For Resident #35 the facility staff failed to ensure the resident's fall interventions were maintained for 2 of 6 falls the resident sustained [REDACTED]. Resident #35 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Review of the Fall Care Plan indicated the following; -Assist with toileting twice a shift and as needed. -Resident to utilize hand reacher for objects not within reach. -Staff to assist with non-skid socks while in bed. -Low bed and bed alarm (12/21/16). -Staff to assist with transfers in and out of bed or wheel chair (2/21/17) Review of the Quarterly MDS Assessment, dated 1/10/17, indicated the resident had moderate cognitive impairment as evidenced by a score of 12 out 15 on the BIMS, required limited assistance with bed mobility, toileting and walking in the room, required extensive assistance with transfers, dressing and hygiene, was dependent for bathing and had 2 or more falls with injuries. Review of the Fall Assessment, date 1/24/17, indicated a score of 16. A score of 10 or greater indicates a high fall risk. Review of the clinical record indicated the resident had an unwitnessed fall on 1/24/17 at 4:30 A.M. in the bedroom. The Post Fall Investigation Report, dated 1/24/17, indicated the resident was found on the floor and complained of hip pain. The resident was sent to the hospital and returned with no indication of fractures. The report indicated he/she was in bed prior to the fall and there was not an alarm in use. The new interventions added were to re-orient the resident to time of day when observed awake early in bed and Physical/Occupational Therapy. Review of the clinical record indicated the resident had an unwitnessed fall on 2/4/17 at 7:01 A.M. in the bedroom and was not injured. The Post Fall Investigation Report, dated 2/4/17, indicated the resident was found on the floor in front of a recliner and said he/she slid out of it when trying to get dressed. Further review of the report indicated the resident had been in bed prior to fall and bed alarm was in place. The report indicated the resident self transferred out of bed. The report did not indicate the bed alarm was sounding when the resident was found on the floor. The new intervention added was to move items around in the bedroom, ensure walker was within reach and do not use pink pad on the recliner. Review of the clinical record indicated the following falls; -The resident had a witnessed fall on 2/7/17 at 11:20 P.M. and was not injured. -The resident had an unwitnessed fall on 2/17/17 at 3:45 P.M. in the unit dayroom and was not injured -The resident had an unwitnessed fall on 2/23/17 at 2:15 PM in the bedroom and was not injured. -The resident had an unwitnessed fall on 3/2/18 at 6:00 P.M. in the bedroom and sustained a scratch to his/her back, new order for soft belt while up in wheel chair. During an interview on 4/24/18 at 10:20 A.M., the resident's spouse said the resident self transferred and won't always ask for help. On 4/26/18 at 10:15 A.M. the resident was observed in bed. The bed was in a low position, the side rails were up, a bed alarm was observed, there was a fall mat on floor to left side of the bed and the call bell in was in his/her hand. During an interview on 4/27/18 at 8:50 A.M., the DON said the falls that occurred early last year were prior to her being employed as the facility's DON. The DON provided the surveyor with copies of the facility's Fall Log for Resident #35 and said if the fall care plan indicated the bed alarm was an intervention (added 12/2016) then the alarm should have been on and sounding when he got out of bed and fell on [DATE] and 2/4/17. 3. For Resident #15 the facility staff failed to assess, in a timely manner, his/her ability to smoke safely. Review of the Resident Smoking Policy, dated 10/2015, indicated that nursing would complete a Smoking Assessment for all residents who smoke in accordance with the requirements on the Assessment Schedule. Review of the Assessment Schedule indicated the Smoking Assessment would be completed annually for residents who smoked. During an observation on 4/27/18 at 9:02 A.M., Resident #15 was observed smoking in the supervised smoking room. Review of the medical record indicated the last Smoking Assessment was done on 1/19/17. During an interview on 5/03/18 at 9:00 A.M., the Administrator said that the smoking assessments were done annually per their policy but this one was overdue.

Based on observation, interviews and records reviewed, for one of three sampled Residents (Resident #1) the Facility failed to prevent an incident on 2/23/17 around 11:00 P.M. in which Nurse #1 yelled at Resident #1 to shut up and shoved his/her wheelchair away from Nurse #1 down the corridor in such as manner that Resident #1's wheelchair moved freely down the corridor. Findings include: On 2/24/17, the Facility reported an allegation that, on 2/23/17, Nurse #1 abused Resident #1 when she told Resident #1 to shut up and pushed Resident #1's away from Nurse #1. Resident #1's most recent Admission Minimum Data Set Form, completed 12/23/16, indicated that his/her cognitive patterns and communication skills were impaired. The Surveyor could not interview Resident #1 about the alleged incident due to Resident #1's cognitive and communication impairments and observed him/her moving about the unit in his/her wheelchair. The Surveyor reviewed video recorded from a surveillance camera which showed Nurse #1, Nurse #2 and Resident #1 at the medication cart. The Time Stamp on the video is dated 2/23/17 at 23:03. At 23:03:28, Nurse #1 turned abruptly toward Resident #1 and said something. The Surveyor interviewed Nurse #2 at 9:00 A.M. on 4/7/17. Nurse #2 said that on 2/23/17 she arrived at 11:00 P.M. to start a shift. Nurse #2 said that Nurse #1 was finishing the 3:00 P.M. to 11:00 P.M. shift and while she and Nurse #1 counted medications, Nurse #1 yelled at Resident #1 to shut up in an aggravated and agitated tone of voice. The video recorded from the surveillance camera showed, at 23:04:25, Nurse #1 moved Resident #1's wheelchair backwards for several feet, spun the wheelchair abruptly and shoved the wheelchair away from her down the corridor in such a manner that Resident #1's wheelchair moved freely down the corridor. Nurse #2 said that she saw Nurse #1 push Resident #1's wheelchair away from her down the corridor. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 10:00 A.M. on 4/11/17. CNA #1 said that she heard Nurse #1 yell shut up in a loud and aggravated tone of voice and she later learned that Nurse #1 had been speaking to Resident #1. The Surveyor interviewed CNA #2 at 3:00 P.M. on 5/12/17. CNA #2 said that she heard Nurse #1 yell shut up in a frustrated tone of voice. CNA #2 said that she saw Nurse #1 push Resident #1's wheelchair away from her, hard enough that the wheelchair continued to move once Nurse #1 released the wheelchair handles. The Surveyor interviewed CNA #3 at 12:00 P.M. on 5/17/17. CNA #3 said that she heard Nurse #1 yell shut up in a loud and exhausted tone of voice. Nurse #1 did not respond to the Surveyor's telephone message or to a letter sent to her home address. Nurse #1's written statement indicated that she asked Resident #1 to stop interrupting medication count and pushed Resident #1's wheelchair a little way away from the medication cart. Although Resident #1's impaired mental status limited the degree to which he/she understood the alleged incident, an unimpaired individual would experience mental anguish when yelled at by a nurse to shut up and shoved down the corridor in a wheelchair.

4. For Resident #6, the Facility failed to document or rotate the injection sites of the [MEDICATION NAME] insulin. Resident #6 was admitted to the Facility in 4/2012 with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the 12/2015 MAR indicated [REDACTED]. During interview on 12/23/15 at 1:30 P.M., Nurse #2 said that the insulin injection sites were not rotated and/or documented as required. 1/23/2017: Examples 13, 15, and 17 were moved to tag 0514 per CMS due to IIDR review. Based on record review and interview the facility failed to meet professional standards of quality for 5 (#6, #8) Residents out of a total sample of 17 residents. Findings include: 1. For Resident #8, the Facility failed to ensure that the resident was correctly identified prior to receiving medication. Resident #8 was admitted to the Facility in 10/2012 with a [DIAGNOSES REDACTED]. Review of the Rights of Medication Administration, Nursing2014 Drug Handbook. (2014). Lippincott Williams & Wilkins: Philadelphia Pennsylvania., indicated, that prior to administering medication ensure: 1. Right Patient * Check the name on the order and the patient. * Use 2 identifiers. * Ask patient to identify himself/herself. * When available, use technology. Review of the Facility General Dose Preparation and Medication Administration Policy, indicated that the facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Review of the Quarterly MDS Assessment, dated 10/14/15, indicated that the resident was cognitively impaired. Review of the nurse's note, dated 12/21/15, indicated that the resident received the wrong medications at 8:00 A.M. The nurse's note indicated that the nurse confirmed the resident's identity with the overnight nurse. The nurse's note further indicated that at 8:10 A.M. the resident blood pressure was 112/50. At 8:30 A.M. the Nurse Practioner ordered that vital signs were to be taken every hour for 5 hours. The nurse's note indicated that at 9:30 A.M. the resident exhibited increased lethargy, was difficult to arouse and had a blood pressure of 89/37. The resident was sent to the Hospital. The nurse's note indicated that the resident returned from the hospital at 5:45 P.M. There was no evidence that the nurse used 2 identifiers prior to administering medication to the resident, per professional standards. The Surveyor observed Resident #8, sitting in the hallway on 12/22/15 at 9:00 A.M. Resident #8 told the Surveyor that on the day prior (12/21/15) he/she was administered another resident's medications and spent the day in the hospital. During an interview with the Administrator on 12/29/15 at 2:00 P.M. he said that the nurse did not correctly identify Resident #8 prior to the medication administration and that he/she received another resident's medication and was sent to the hospital. He said that there was no indication that the nurse used 2 identifiers prior to administering medication to the resident, per professional standards. Please refer to F333. 2. Per Nursing2014 Drug Handbook, page 750, rotation of injection sites is important to avoid lipodystrophies (abnormal or [MEDICAL CONDITION] conditions of the body's adipose {fat} tissue). Patients with [DIAGNOSES REDACTED] have a tendency to develop insulin resistance.

Based on observation, interviews, and record review for 1 of 9 sampled residents (Resident #2), the Facility failed to ensure that the nursing staff followed the plan of care for safe smoking and failed to ensure staff assigned to the smoking break monitored the residents for safety. On 4/22/15 at 3:00 P.M., Certified Nurse Aide (CNA) #3 did not monitor the 3:00 P.M. smoking break as assigned and CNA #8 and Housekeeper #1 did not remove Resident #2's oxygen prior to lighting Resident #2's cigarette which resulted in a flash fire and Resident #2 sustaining a nasal burn. Findings include: The Admission Record indicated the Facility admitted Resident #2 in November 2014. The Physician Notes, dated from 2/11/15 to 4/10/15, indicated Resident #2's [DIAGNOSES REDACTED]. The April 2015 Physician order [REDACTED]. The Surveyor interviewed Nurse #1 at 10:25 A.M. on 5/19/15 and Unit Manager #1 at 10:40 A.M. on 5/19/15. Nurse #1 and Unit Manager #1 said Resident received oxygen via a nasal cannula from a portable oxygen tank when out of bed. Nurse #1 and Unit Manager #1 said Resident #1 was easily distracted and at times confused. The Policy/Procedure titled Smoking Policy, revised May 2006 and May 2015, indicated the Facility had supervised smoking hours, 9:00 A.M., 1:00 P.M., 3:00 P.M. and 6:00 P.M., monitored by Facility staff. The Surveyor interviewed the Director of Nurses (DON) at 6:45 A.M. on 5/19/15 and throughout the survey as needed. The DON said 3 assigned staff members supervised smoking breaks. The DON said the staff members were responsible for removing oxygen from the room; issuing smoking materials and, lighting smoking materials. The Certified Nurse Aide (CNA) Assignments, dated 4/22/15, indicated CNA #3 and CNA #8 were assigned to cover the 3:00 P.M. smoking break. The DON said Housekeeper #1 was also assigned to that smoking break. The Surveyor interviewed CNA #3 at 11:40 A.M. on 5/19/15. CNA #3 said she monitored smoking breaks prior to 4/22/15 and knew that oxygen was not allowed in the smoking room while the residents smoked. The Surveyor interviewed CNA #8 at 11:00 A.M. on 5/26/15. CNA #8 said he covered several smoking breaks prior to 4/22/15. CNA #8 said Resident #1 had attended the smoking breaks and did not have oxygen on. CNA #8 said he did not work on Resident #1's unit and therefore was not familiar with the residents from that unit. The Surveyor interviewed Housekeeper #1 at 1:30 P.M. on 5/19/15. Housekeeper #1 said he covered smoking breaks prior to 4/22/15, and he knew oxygen was not allowed in the smoking room while the residents smoked. On 5/19/15, the Surveyor observed video surveillance recording of the 4/22/15, 3:00 P.M. smoking break and observed: at 3:00 P.M., Resident #2 was seated at table #1 in the smoking room with a portable oxygen tank on the back of his/her wheelchair with oxygen tubing attached to the tank and nasal cannula located in Resident #2's nares. Housekeeper #1 gave Resident #2 two cigarettes and CNA #8 lit the first cigarette without removing Resident #2's oxygen tank and tubing. The Interdisciplinary Progress Notes for 4/22/15 indicated Resident #2 sustained [MEDICAL CONDITION] to smoking with oxygen in place. CNA #3 said she did not see Resident #2 in the smoking room with his/her oxygen on because when she went to the smoking break, she thought she saw 3 staff members already in attendance and therefore she went to the elevator to assist residents attending the 3:00 P.M. smoking break off and on the elevator. The Surveyor interviewed CNA #5 at 1:15 P.M. on 5/19/15. CNA #5 said that on 4/22/15, he was going by the smoke break room when he saw a flash, opened the door to the smoke break room, and observed Resident #1 with black soot on his/her face. CNA #5 said CNA #3 was in the corridor near a kiosk and was not positioned at either of the smoking room windows where he/she could observe the residents. CNA #8 said after lighting cigarettes, he stationed himself near the first exit door of the smoking room to assist residents with entering and exiting the room. CNA #8 said he did not realize Resident #1 had his/her oxygen on. CNA #8 said there were 2 residents from his unit that required continual supervision and he kept watching them. CNA #8 said he observed CNA #3 down by the employee break room when he first entered the smoking room and each time he opened the door to let residents in or out, CNA #3 was not near the smoking room. Housekeeper #1 said he was focused on handing out the smoking materials and did not notice Resident #2 wearing oxygen during the smoking break.

Based on interviews and record review for 1 of 9 sampled residents (Resident #2), the Facility failed to ensure the nursing staff assigned to cover the smoking break, monitored the smoking break as assigned and removed Resident #2's oxygen prior to lighting his/her cigarette. On 4/22/15 at the 3:00 P.M. smoking break, Resident #2 sustained a second degree (blistering of the superficial dermis) to third degree (damage to the entire thickness of skin layers, can present as black dry skin) nasal burn because Resident #1 smoked a cigarette while receiving oxygen via a nasal cannula. In addition, the Facility failed to follow their smoking assessment policy for 4 of 9 residents who smoked. Findings include: The Policy/Procedure titled Smoking Policy, revised May 2006 and May 2015, indicated the Facility had supervised smoking hours, 9:00 A.M., 1:00 P.M., 3:00 P.M. and 6:00 P.M., monitored by Facility staff. The Surveyor interviewed the Director of Nurses (DON) at 6:45 A.M. on 5/19/15 and throughout the survey as needed. The DON said 3 assigned staff members supervised smoking breaks. The DON said the staff members were responsible for removing oxygen from the room; issuing smoking materials and, lighting smoking materials. The Surveyor observed the smoking room on 5/14/15, and observed the smoking room had 2 exits and 2 windows allowing staff stationed outside to observe residents during smoking. The Certified Nurse Aide (CNA) Assignments, dated 4/22/15, indicated CNA #3 and CNA #8 were assigned to cover the 3:00 P.M. smoking break. The DON said Housekeeper #1 was also assigned to cover that smoking break. The Interdisciplinary Progress Notes for 4/22/15 indicated Resident #2 sustained facial burns due to smoking with oxygen in place. On 5/19/15, the Surveyor observed video surveillance recording of the 4/22/15, 3:00 P.M. smoking break and observed: at 3:00 P.M., Resident #2 was seated at table #1 in the smoking room with a portable oxygen tank on the back of his/her wheelchair with oxygen tubing attached to the tank and nasal cannula located in Resident #2's nares. Housekeeper #1 gave Resident #2 two cigarettes and CNA #8 lit the first cigarette without removing Resident #2's oxygen tank and tubing. Resident #1 finished his/her first cigarette and lit his/her second cigarette using the first cigarette. Continued observation of the 4/22/15 video surveillance recording indicated that at 3:14 P.M., Resident #2 was finishing his/her second cigarette when flames ignited in the area of the nasal cannula; Resident #2 pushed him/herself away from the table and repeatedly struck his/her face dousing the flames within 5 seconds. The Surveyor interviewed CNA #3 at 11:40 A.M. on 5/19/15. CNA #3 said on 4/22/15, she did not see Resident #2 in the smoking area with his/her oxygen on because when she went to the smoking break, she thought she saw 3 staff members already in attendance and therefore she went to the elevator to assist residents attending the smoking break off and on the elevator. The Surveyor interviewed CNA #5 at 1:15 P.M. on 5/19/15. CNA #5 said that on 4/22/15, he was going by the smoke break room when he saw a flash, opened the door to the smoke break room, and observed Resident #1 with black soot on his/her face. CNA #5 said CNA #3 was in the corridor near a kiosk and was not positioned at either of the smoke break room windows where he/she could observe the residents. The Surveyor interviewed CNA #8 at 11:00 A.M. on 5/26/15. CNA #8 said after lighting cigarettes, he stationed himself near the first exit door of the smoke break room to assist residents with entering and exiting the room. CNA #8 said he did not realize Resident #1 had his/her oxygen on. CNA #8 said there were 2 residents from his unit that required continual supervision and he kept watching them. CNA #8 said he observed CNA #3 down by the employee break room when he first entered the smoke break room and each time he opened the door to let residents in or out, CNA #3 was not near the smoke break room. The Surveyor interviewed Housekeeper #1 at 1:30 P.M. on 5/19/15. Housekeeper #1 said he was focused on handing out the smoking materials and did not notice Resident #2 wearing oxygen during the smoking break. The Discharge Summary, dated 4/23/15, indicated Resident #2 sustained a burn covering 1% of his/her body involving singed nasal hair bilaterally and a second to third degree burn on his/her nose and in the right crease outside of his/her nose that was dry and intact. The burn required application of Bacitracin ointment (an antiseptic ointment and no further treatment. In addition, annual assessment schedule, revised May 2013, indicated the Facility completed smoking assessments for residents who smoked at the time of admission, annually, and with a change in condition. The policy title Resident Smoking Policy, revised April 2015, indicated the staff completed assessments for all residents who smoked in accordance with the smoking schedule. Resident #5's last completed smoking assessment was dated 3/20/14. Resident #6's last completed smoking assessment was dated 4/8/14. Resident #7's last completed smoking assessment was dated 3/5/14. Resident #8's last completed smoking assessment was dated 12/4/13.

Based on interview and record review, the Facility failed to implement the behavioral care plan for one of four sampled residents (Resident #1). On 8/6/16 at approximately 11:40 A.M., Resident #1 got into a verbal altercation with Resident #2. Although the altercation was witnessed by Nurse #1, it was not immediately reported to Resident #1's Nurse and Social Worker, in accordance with Resident #1's care plan. Ten minutes later, the conflict between Resident #1 and Resident #2 resumed in an unsupervised dining room, and Resident #2 sustained a facial laceration and a fractured left hip as a result of being knocked to the ground and repeatedly kicked and struck by Resident #1. Findings include: The most recent Quarterly Minimum Data Set (MDS) Assessment Form, completed 6/2/14, indicated Resident #1's cognitive patterns were moderately impaired and Resident #1 exhibited physically abusive behavioral symptom one to three days each week. The MDS indicated the court ordered guardianship for Resident #1. The MDS indicated Resident #1 ambulated with supervision. A care plan concern, initiated 3/10/14, indicated Resident #1 suffered from cognitive loss with poor decision making, insight and judgement. The care plan interventions included assistance with decision making and short simple instruction. Three care plan concerns, initiated 3/10/14, addressed Resident #1's behavioral symptoms which included verbal abuse (loud outbursts, racial slurs, threats, accusations and making fun of other residents), socially inappropriate behavior (intruding into the personal space of others) and aggression toward others. The care plan interventions included intervening with Resident #1 at the onset of behavioral symptoms, immediately reporting all incidents to nursing and social service, and social service follow up for any unresolved issues with other residents. The Surveyor interviewed Nurse #1 at 4:30 P.M. on 9/10/14. Nurse #1 said that he worked on Resident #2's unit during the 7:00 A.M. to 3:00 P.M. shift on 8/6/14. Nurse #1 said that around 11:40 A.M., while he was at the nurses' station across from the elevator, the elevator doors opened and he saw and heard Resident #1 and Resident #2 arguing. Nurse #1 said that he immediately responded to the elevator and separated Resident #1 and Resident #2. Nurse #1 said he did not hear the words Resident #1 and Resident #2 uttered when they argued. The Surveyor interviewed the Housekeeper at 2:30 P.M. on 8/18/14. The Housekeeper said that, on 8/6/14 around 11:40 A.M., he heard a heated verbal exchange from the elevator. The Housekeeper said he recognized the voices of Resident #1 and Resident #2 and he responded to the elevator where Nurse #1 separated Resident #1 and Resident #2. The Housekeeper said he heard Resident #1 tell Resident #2 that he/she would crack Resident #2's skull. Nurse #1 said Resident #2 exited the elevator with him and Resident #1 said he was going to go back to his/her room on the second floor. Nurse #1 said that he left Resident #2 with a certified nursing assistant who wanted to weigh Resident #2 and returned to the nurses' station. The Surveyor asked Nurse #1 whether he knew that Resident #1 and Resident #2 would be going to the unsupervised dining room for lunch shortly before 12:00 P.M., within 15 minutes of their argument, and he said that he did. The Surveyor asked Nurse #1 whether he notified Resident #1's nurse or the Social Worker of the argument and he said that he did not. The Surveyor interviewed the Social Worker at 11:00 A.M. on 9/11/14. The Social Worker said she was not notified of the argument between Resident #1 and Resident #2. The Social Worker said that the intervention for social service follow up was added to Resident #1's care plan because Resident #1 benefited from calm conversation with her or the behaviorist about interpersonal conflicts. The Social Worker said that, on occasion, Resident #1 demonstrated insight into his/her role in conflicts and would make amends with residents he/she argued with and shake their hands. The Social Worker said she was in the Facility on 8/6/14 and should have been immediately made aware of the argument between Resident #1 and Resident #2. The Facility Internal Investigation report, dated 8/8/14, indicated that about ten minutes after the argument in the elevator, Resident #1 and Resident #2 had an argument in the dining room which escalated to a physical fight. The Internal Investigation report indicated Resident #2 sustained a one centimeter laceration above his/her left eye brow and was sent to the emergency department for evaluation of back pain and diagnosed with [REDACTED].