**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop, implement and individualize a comprehensive care plan for one Resident (#137), out of a total sample of 27 residents. Specifically, the facility failed to ensure a comprehensive care plan related to Resident #137's right hand contracture (shortening/tightness to the muscle, tendons, ligaments, skin and other tissues resulting in difficulty moving the affected joint) was developed and implemented.Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, indicated but was not limited to the following:- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.- The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.- Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.Review of the facility's policy titled Resident Mobility and Range of Motion, dated July 2017, indicated but was not limited to the following:- Residents with limited range of motion (ROM) will receive treatment and services to increase and/or prevent a further decrease in ROM.- The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed.- The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.- The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives.Resident #137 was admitted to the facility in December 2022 with diagnoses including right hand contracture, cerebral infarction and muscle weakness.Review of Resident #137's Minimum Data Set (MDS) assessment, dated 6/12/25, indicated he/she had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Furthermore, the MDS assessment indicated Resident #137 had a range of motion impairment to his/her upper extremity and he/she was dependent for functional mobility tasks.On 7/30/25 at 9:30 A.M., the surveyor observed Resident #137 in bed turned onto their left side. Resident #137 was noted to have a contracture to his/her right hand.Review of Resident #137's Occupational Therapy (OT) Discharge summary, dated [DATE], indicated but was not limited to:- Resident #137 received skilled OT services from 4/17/25 to 6/10/25.- Skilled Intervention: Skilled OT focused on PROM (passive range of motion) to bilateral hands/wrists in order to prevent contracture. Addressed splint fit, tolerance and training.- Patient Progress: Resident tolerates right resting hand splint up to six hours. Recommend wear schedule on with A.M. care and off with P.M. care. Left palm pillow to be worn as tolerated. Resident agreeable with POC (plan of care) and will prevent further contracture.- Communication: Functional skills reviewed with team members and reviewed resident's plan of treatment and treatment services with interdisciplinary team members.Review of Resident #137's comprehensive care plans failed to indicate a contracture or limited ROM care plan was developed or implemented. During an interview on 8/4/25 at 2:29 P.M., Certified Nursing Assistant (CNA) #2 said Resident #137 wears a splint on her right and left hands due to contractures.During an interview on 8/4/25 at 2:30 P.M., Nurse #5 said she believed Resident #137 had contractures to his/her right hand and left hand. Nurse #5 said she was not sure if Resident #137 had a care plan related to his/her contractures. Nurse #5 said she believed the Unit Manager was responsible for updating resident care plans.During an interview on 8/4/25 at 2:37 P.M., Unit Manager (UM) #3 said care plans are minimally updated on a quarterly basis but also when a resident has a change in condition/status. UM #3 reviewed Resident #137's comprehensive care plans and said Resident #137 did not have a care plan related to his/her contractures and limited range of motion.During an interview on 8/4/25 at 4:50 P.M., the Director of Nursing (DON) said Resident #137 should have a care plan related to his/her contractures and limited ROM.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#94) was administered medications in accordance with professional standards of quality, in a total sample of 27 residents. Specifically, the facility failed to ensure that nurses administering medications ensured Resident #94 had taken the medications.Findings include:Review of the facility's policy titled Administering Medications, dated as revised in April 2019, indicated the following:-only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so-medications are administered in accordance with prescriber orders, including any required time frameResident #94 was admitted to the facility in September 2024.Review of the Minimum Data Set (MDS) assessment, dated 6/24/25, indicated Resident #94 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact.Review of the medical record indicated Resident #94 was advised of their right to self-administer medication on 9/13/24 and indicated they wished for the nursing staff to administer their medications.During an interview with observation on 7/30/25 at 11:50 A.M., the surveyor observed Resident #94 in bed and on the overbed table there was a medication cup containing at least seven medications (two red and blue capsules, two oblong tablets and three round tablets). Resident #94 said he\she was not sure what time they were provided the medication because he/she gets confused sometimes.Review of the paper and electronic medical record failed to indicate Resident #94 had been assessed to administer his/her own medications.Review of the Medication Administration Record indicated Resident #94 had an order to be administered the following medications at 9:00 A.M. (almost three hours earlier):-Lactobacillus capsule (a probiotic)-Potassium Chloride extended release 20 milliequivalent (mEq); give 2 tablets (a potassium supplement)-Sertraline 50 milligram (mg) tablet-Vitamin D3; give 2 tablets-Acetaminophen 500 mg; give 2 tablets During an interview with observation on 8/1/25 at 9:21 A.M., Resident #94 said the nurse had recently brought him/her their medication and he/she still had to take them. The surveyor observed a medication cup with five pills on the overbed table (two oblong tablets and three round tablets). During an interview on 8/1/25 at 11:25 A.M., Nurse #2 said she was normally assigned to work the unit and was familiar with the residents. She said none of the residents on her assignment were able to self-administer medications. She said Resident #94 did not have an assessment to self-administer medications. She said when she had left the Resident's room this morning the Resident was in the process of taking their medication and she had not waited until the medications had all been taken. During an interview on 8/1/25 at 11:30 A.M., Unit Manager #2 said there was a list of four residents on the unit who were able to self-administer medications and Resident #94 was not one of them. She said she would have to review the information and follow up with the surveyor. During an interview on 8/5/25 at 8:22 A.M., Unit Manager #2 said Resident #94 was not capable of self-administering medications and nurses should ensure the Resident has taken all of the medications prior to leaving the Resident.

Based on observation, document review, and interview, the facility failed to maintain complete and accurate medical records for two Residents (#2 and #10), out of a total sample of 27 residents. Specifically the facility failed to:1. Ensure Resident #2 had documentation in their medical record of their full diagnoses and psychiatric history, including a historical diagnosis of Schizoaffective disorder; and2. Ensure Resident #10's medical record contained only his/her health information.Findings include:1. Resident #2 was admitted to the facility in April 2025 with diagnoses including: Metabolic encephalopathy, bipolar disorder, anxiety disorder, and major depressive disorder recurrent. Review of the Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the Resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS indicated diagnoses of other neurological conditions, and anxiety, depression, and bipolar disorder under the psychiatric/mood disorder diagnoses section. Review of the diagnoses list for Resident #2 indicated a diagnosis of schizoaffective disorder was added to the Resident's record on 6/16/25. During an interview on 7/31/25 at 8:42 A.M., the Resident said he/she has a long history of mood and psychiatric disorders, and he/she takes medications to help him/her manage those diagnoses. The Resident said they were bipolar and said he/she does not recall anyone ever telling him/her that they had any type of schizoaffective disorder. Review of the progress notes from the Psychiatric Nurse practitioner (Psych NP) at the facility, from 5/5/25 through 6/25/25, failed to indicate the Resident was being seen or monitored for schizoaffective disorder. A telephonic follow up note, dated 5/7/25, indicated the Psych NP had received and reviewed the Resident's records from their outpatient psychiatrist but did not include any information on the schizoaffective disorder. During an interview on 7/31/25 at 4:35 P.M., the MDS Nurse said she added the diagnosis of schizoaffective disorder following a hospitalization in which it appeared the Resident had a diagnosis of schizoaffective disorder, bipolar type. She said she is aware that prior to adding a diagnosis of schizoaffective disorder the facility should do their due diligence to ensure the diagnosis is accurate, but she did not have any other information on the Resident and would have to look for some documentation to determine if it was a onetime episodic diagnosis or a long-standing history. During an interview on 8/1/25 at 12:33 P.M., the Director of Nursing (DON) said the facility found a document, that was not in the medical record, that indicated from the Resident's community provider a historic diagnosis of schizoaffective disorder, after the surveyor inquired about the new diagnosis. She said the document and the diagnosis for schizoaffective disorder should have been in the medical record to ensure the record was complete and accurate and it was not. During an interview on 8/1/25 at 1:03 P.M., the Social Worker said she found Resident #2's behavioral health document regarding their history in the community on a clipboard for the Psych NP in her office. She said the document was not in the medical record where it should have been. During an interview on 8/1/25 at 1:49 P.M., the Psych NP said she reached out to Resident #2's community psychiatric provider in May 2025 and received a copy of their history and records at that time. She said the documents indicated the Resident had a long history of schizoaffective disorder. She said she did not put the document in the medical record at the facility and did not update her progress notes to reflect the diagnosis for the Resident. She said the medical record did not reflect the diagnosis for the Resident or the Resident's history accurately, as it should. During an interview on 8/5/25 at 1:17 P.M., the Administrator said his expectation is that the medical records are complete and accurate at all times. 2. Resident #10 was admitted to the facility in October 2024 with diagnoses which included: heart failure and hypertension. Review of Resident #10’s electronic medical record, documents tab, indicated but was not limited to: -Inpatient Order (IPO), dated 10/9/24, for Resident #169, and -Provider Progress Note, dated 4/29/25, for Resident #170 During an interview on 8/5/25 at 9:29 A.M., the Director of Admissions said the liaison had uploaded the IPO for Resident #169 and it should not have been uploaded into Resident #10’s medical record. During an interview on 8/5/25 at 9:46 A.M., the Director of Nurses (DON) said she reviewed Resident #10's electronic medical record and said the documents for Residents #169 and #170 should have been uploaded into the correct residents' medical record and not Resident #10's medical record.

Based on interviews and records reviewed, the facility failed to ensure one Resident (#57), out of a total sample of 27 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #57, to implement treatments from the wound consultant physician for an unstageable pressure ulcer (wound covered with necrotic (dead) tissue making it difficult to determine stage) of the coccyx.Findings include:Resident #57 was admitted to the facility in September 2024 with diagnoses including Parkinson's Disease and muscle weakness.Review of Resident #57's Minimum Data Set (MDS) assessment, dated 7/4/25, indicated he/she had an unhealed unstageable pressure ulcer and was receiving pressure ulcer/injury care.On 7/30/25 at 9:32 A.M., Resident #57 said he/she had a wound on their buttock region and said it had been present since last fall.Review of Resident #57's care plans indicated he/she had actual skin breakdown related to an unstageable coccyx wound. The care plan interventions included but were not limited to: wound consult as needed, administer treatment per physician orders and follow-up care with physician as ordered.Review of the Consultant Wound Physician's note, dated 2/4/25, indicated the following treatment plan: cleanse with normal saline, apply calcium alginate, honey gel to base of wound, secure with superabsorbent pad and change daily and as needed (PRN) for soiling, saturation, or accidental removal.Review of the February 2025 Treatment Administration Record (TAR) indicated the following treatment was applied to Resident #57's wound from 2/4/25 through 2/11/25:- Cleanse with normal saline, pat dry, apply Santyl, calcium alginate and cover with foam dressing.Review of Resident #57's medical record failed to indicate why the Consultant Wound Physician's treatment for honey gel from 2/4/25 was not implemented.Review of the Consultant Wound Physician's note, dated 2/25/25, indicated the following treatment plan: cleanse with normal saline, apply calcium alginate, honey gel and collagen to base of the wound, secure with superabsorbent pad and change daily and PRN.Review of the February 2025 TAR indicated the following treatment was applied to Resident #57's wound from 2/25/25 through 2/28/25:- Cleanse with normal saline, apply calcium alginate, honey gel to base of the wound, secure with superabsorbent pad.Review of Resident #57's medical record failed to indicate documentation on why the treatment order from 2/25/25 through 2/28/25 did not include the Consultant Wound Physician's treatment of collagen to the base of the wound.Review of the Consultant Wound Physician's notes, dated 3/4/25, 3/11/25, 3/20/25, and 3/25/25, indicated the following treatment recommendation: cleanse with normal saline, apply calcium alginate, collagen, Santyl (honey gel ok until Santyl arrives) to base of wound, secure with superabsorbent pad and change daily and PRN.Review of the March 2025 TAR indicated the following treatments were applied to Resident #57's wound from 3/6/25 through 3/31/25:- Cleanse with normal saline, apply Santyl, followed by calcium alginate and cover with foam dressing every day shift; and- Cleanse with normal saline, pat dry, apply Santyl, calcium alginate, collagen and cover with superabsorbent dressing, may use Medi honey if Santyl is unavailable.- Both of above treatments were signed off daily.Review of Resident #57's medical record failed to indicate documentation stating the Consultant Wound Physician's treatments were clarified and/or changed as well as failed to indicate why the collagen was removed from the treatment order. Furthermore, the medical record failed to include documentation indicating the nursing staff only completed one of the coccyx treatment orders.Review of the Consultant Wound Physician's note, dated 4/15/25, indicated the following treatment recommendation: cleanse with normal saline, apply calcium alginate, crushed Flagyl to the base of the wound, secure with superabsorbent pad and change daily/PRN. This order was discontinued by the Consultant Wound Physician on 4/22/25.Review of the Consultant Wound Physician notes, dated 4/22/25 and 4/29/25, indicated the following treatment recommendation: cleanse with normal saline, apply calcium alginate, Santyl, collagen to the base of the wound, secure with superabsorbent pad and change daily and PRN.Review of the April 2025 TAR indicated the following treatment was applied to Resident #57's wound from 4/16/25 through 4/29/25:- Cleanse with normal saline, apply calcium alginate, crushed Flagyl to base of the wound, secure with superabsorbent pad.Review of Resident #57's medical record failed to indicate documentation stating why the Consultant Wound Physician's treatment was not implemented on 4/22/25 and/or 4/29/25. Furthermore, the medical record failed to indicate documentation regarding the continuation of the Flagyl treatment order.Review of the Consultant Wound Physician's note, dated 5/13/25, indicated the following treatment recommendation: cleanse with normal saline, apply calcium alginate, Gentamycin to base of the wound, secure with superabsorbent pad and change daily and PRN.Review of the May 2025 TAR indicated the following treatment was applied to Resident #57's wound from 5/1/25 through 5/31/25:- Cleanse with normal saline, apply calcium alginate, Santyl, collage to base of the wound, secure with superabsorbent pad.Review of Resident #57's medical record failed to indicate documentation stating why the Wound Consultant Physician's treatment, which included the use of gentamycin, was not implemented.Review of the Consultant Wound Physician's note, dated 6/16/25, indicated the following treatment recommendation: cleanse with normal saline, cleanse with wound cleanser, apply calcium alginate, gentamycin to wound base, secure with superabsorbent pad and change daily and PRN.Review of the June 2025 TAR indicated the following treatment were applied to Resident #57's wound from 6/17/25 through 6/22/25:- Cleanse with Vashe (wound cleanser) solution, apply gentamycin cover with superabsorbent pad; and- Soak gauze with Vashe solution and apply to wound for 5 minutes, apply calcium alginate, Santyl and collagen to base of wound, secure with superabsorbent pad.Review of Resident #57's medical record failed to indicate documentation which included why the Consultant Wound Physician's treatment was not implemented as ordered or why duplicate orders were completed. Furthermore, the medical record failed to indicate documentation stating the nursing staff only completed one of the coccyx treatment orders.Review of the Consultant Wound Physician's note, dated 7/29/25, indicated the following treatment recommendation: cleanse with Vashe, apply wound vac at 125 mmHg (millimeter of Mercury), collagen to base of the wound first, and change three times per week and PRN.Review of the July 2025 TAR indicated the following treatment was applied to Resident #57's wound from 7/29/25 through 7/31/25:- Clean wound with Vashe, pat dry and pack with green foam, place back wound vac.Review of Resident #57's medical record failed to indicate documentation regarding why the Consultant Wound Physician's treatment to apply collagen to the base of the wound was not implemented.During an interview on 8/5/25 at 10:40 A.M., Nurse #3 said Resident #57 has a chronic coccyx wound. Nurse #3 said her process would be to review treatment orders prior to completing a dressing change. Nurse #3 and the surveyor reviewed the June 2025 TAR which included two different treatment orders for Resident #57's coccyx wound. Nurse #3 said she was responsible for the Resident's dressing on 6/17/25 after reviewing the TAR. Nurse #3 said the TAR indicates two treatments were completed on 6/17/25.During an interview on 8/5/25 at 10:50 A.M., Unit Manager (UM) #3 and the surveyor reviewed Resident #57's medical record. UM #3 said if both treatments are checked off on the MAR it would indicate the nurse performed both treatment orders. UM #3 said the nurse should have indicated in their documentation that one of the treatment orders was held and clarified with the Assistant Director of Nursing (ADON) on which order to perform.During an interview at 8/5/25 at 11:02 A.M., the ADON said she completes weekly wound rounds with the Consultant Wound Physician on Tuesday. The ADON said the process was after the end of wound rounds the Consultant Wound Physician would upload her notes into the electronic medical record and the ADON would verify the information and make changes to the treatment orders. The ADON and the surveyor reviewed the treatment order documentation from February 2025 through July 2025. The ADON said the Consultant Wound Physician's recommendation from 7/29/25 included collagen and it was not initially put into the treatment order. The ADON said she clarified the order on 8/4/25 and updated it to include collagen. The ADON said the TAR for July 2025 indicates multiple treatment orders were completed for Resident #57's coccyx wound. The ADON said the Wound Consultant Physician's treatment order for Gentamycin should have been the only order completed from 6/16/25 through 6/22/25. The ADON said she is not sure why the Gentamycin order was not implemented on 5/13/25 as recommended by the Wound Consultant Physician and said there should be documentation in the medical record indicating why the order was not implemented. The ADON said she was not sure why the treatment order from 4/16/25 through 4/29/25 included Flagyl and not Santyl and collagen as recommended by the Wound Consultant Physician and said there should be documentation in the medical record if the facility's provider wanted to extend the use of the Flagyl or if the Wound Consultant Physician changed her recommendation. The ADON said there should have only been one treatment order from 3/6/25 through 3/31/25 which included collagen as recommended. The ADON said the medical record should have indicated the change from honey to Santyl from 2/4/25 through 2/11/25 and 2/25/25 through 2/29/25 order should have included collagen.During an interview on 8/5/25 at 12:50 P.M., Nurse Practitioner (NP) #2 said he accepts all Consultant Wound Physician recommendations for treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food products and maintain safe/clean equipment in three nourishment kitchenettes; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). Findings include:1. Review of the facility's policy titled Foods Brought by Family/Visitors, dated October 2017, indicated but was not limited to the following:- Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents.- Food brought by family/visitors that is left with resident to consume later will labeled (sic) and stored in a manner that is clearly distinguishable from facility-prepared food.- Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.- The nursing staff will discard perishable foods on or before the use by date.- The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). On 7/30/25 at 1:02 P.M., the surveyor made the following observations in the Acushnet Unit Kitchenette:- The freezer contained a brown paper bag dated 7/30/25 to 8/9/25 containing individual [NAME]-Dazs ice cream cups. The bag was not labeled with resident identification. On 7/30/25 at 1:12 P.M., the surveyor made the following observations in the Fairhaven Unit Kitchenette:- An individual container of Profeel Protein Pudding was located on the door of the refrigerator and had no resident identification.- A Sargento Balance Break Cheese and Cracker Snack container was located on the door of the refrigerator and had no resident identification. On 7/30/25 at 1:21 P.M., the surveyor made the following observations in the Dartmouth Unit Kitchenette:- The microwave had food splatter and residue on the top and sides. The top inside portion of the microwave had peeling/bubbling of the white plastic lining.- A package of prunes was opened and unsealed on the door of the refrigerator with a use by date of 7/31/25. There was no resident identification on the package.- The refrigerator contained an opened Thick and Easy Thickened Orange Juice (Nectar Consistency) bottle. The bottle was dated received on 6/27/25. There was no open or use by date indicated on the bottle. The manufacturer label on the bottle indicates to dispose of the bottle 10 days after being opened. On 7/31/25 at 7:28 A.M., the surveyor made the following observations in the Dartmouth Unit Kitchenette:- The microwave had food splatter and residue on the top and sides. The top inside portion of the microwave had peeling/bubbling of the white plastic lining.- A package of prunes was opened and unsealed on the door of the refrigerator with a use by date of 7/31/25. There was no resident identification on the package. On 8/4/25 at 1:12 P.M., the surveyor made the following observations in the Fairhaven Unit Kitchenette:- An individual container of Profeel Protein Pudding was located on the door of the refrigerator and had no resident identification. On 8/4/35 at 8:38 A.M., the surveyor made the following observations in the Acushnet Unit Kitchenette:- The freezer contained a brown paper bag dated 7/30/25 to 8/9/25 containing individual [NAME]-Dazs ice cream cups. The bag was not labeled with resident identification. On 8/4/25 at 8:46 A.M., the surveyor made the following observations in the Dartmouth Unit Kitchenette:- The microwave had food splatter and residue on the top and sides. The top inside portion of the microwave had peeling/bubbling of the white plastic lining. During an interview on 8/5/25 at 10:16 A.M., the Food Service Director (FSD) said the unit kitchenettes in the facility are cleaned and stocked by the dietary staff daily. The FSD said the dietary staff make sure microwaves and refrigerators/freezers are clean. The FSD and the surveyor reviewed the observations made in the unit kitchenettes throughout the survey. The FSD said all items should have proper labels including resident identification and use by dates. The FSD said the microwave on the Dartmouth Unit needed to be replaced due to the peeling/bubbling on the top inside. 2. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:- 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.- 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 7/31/25 at 11:40 A.M., the surveyor made the following observations of the lunch line service:- At 11:45 A.M.: Dietary Staff #2 leaves the tray line service to walk into the refrigerator twice to grab a premade sandwich. Dietary Staff #2 does not perform any hand hygiene prior to returning to the tray line.- At 11:46 A.M.: Dietary Staff #2 wipes their face with their ungloved hands and continues working on the tray line plating meals and drinks. Dietary Aide #2 does not perform any hand hygiene.- At 11:48 A.M.: Dietary Staff #1 picks up the phone next to the food service line and alerts the facility a meal truck is being delivered to a unit. Dietary Staff #1 continues to plate meals without changing his gloves or performing hand hygiene.- At 11:53 A.M.: Dietary Staff #1 answers the phone next to the food service line. Dietary Staff #1 hangs up the phone and continues plating meals without changing gloves or performing hand hygiene.- At 11:57 A.M.: Dietary Staff #2 leaves the tray service line and walks into the refrigerator to grab drinks twice. Dietary Staff #2 did not perform any hand hygiene before returning to the tray service line to plate food and drinks.- At 11:58 A.M.: Dietary Staff #2 pulls his shirt to his face with ungloved hands to wipe face and nose. Dietary Staff #2 does not perform any hand hygiene and continues plating food items and drinks onto meal trays.- At 12:01 P.M.: Dietary Staff #1 picks up the phone next to the service line to alert the facility a food truck is being delivered to a unit. Dietary Staff #1 continues to plate food items on the food service line without changing gloves or performing hand hygiene.- At 12:06 P.M.: Dietary Staff #2 leaves the tray service line and walks into the freezer to grab individual ice cream cups. Dietary Staff #2 returns to the tray service line and continues to plate food and drink items without performing hand hygiene.- At 12:12 P.M.: Dietary Staff #2 leaves the tray service line and walks into the refrigerator to grab sandwiches. Dietary Staff #2 returns to the tray service line without performing hand hygiene to plate food and drink items.- At 12:16 P.M.: Dietary Staff #2 brings hand to face to wipe nose and forehead. Dietary Staff #2 continues plating food and drink items on the tray service line without performing hand hygiene. During an interview on 8/5/25 at 10:16 A.M., the FSD and the surveyor reviewed the observations made during the lunch line service. The FSD said hand hygiene, including changing of gloves, should be completed each time a dietary staff member leaves their station or changes tasks. The FSD said Dietary Staff #1 should have changed their gloves and performed hand hygiene after answering or using the phone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease) and other opportunistic waterborne pathogens.Findings include: Review of the facility's policy titled Legionella Water Management Program, dated as revised September 2022, indicated but was not limited to:-As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team-The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease-The water management program includes the following elements:a. An interdisciplinary water management teamb. A detailed description and diagram of the water system in the facility, including the following1. Receiving;2. Cold water distribution;3. Heating;4. Hot water distribution; and5. Wastec. The identification of areas in the water system that could encourage the growth and spread of Legionella of other waterborne bacteriad. The identification of situations that can lead to Legionella growthe. Specific measures used to control the introduction and/or spread of Legionellaf. The control limits or parameters that are acceptable and that are monitoredg. A diagram of whether control measures are appliedh. A system to monitor control limits and the effectiveness of control measuresi. A plan for when control limits are not met and/or control measures are not effective andj. Documentation of the programReview of the Water Management Program, dated 1/6/25, indicated but was not limited to:1. Written description of building water system and devices (page 2 of 5)-Cold water systems: the cold water is dead headed at all units. It is pumped by 70-pound pressure that is supplied by the town of [NAME].-Back flow devices: All backflow devices are checked by the town of [NAME] twice a year and all necessary repairs are handled by [Name of Plumbing Company].2. Water System Flow Diagram (page 3 of 5)-includes trellis fountain-unable to distinguish areas that have been identified/classified as hazardous concerns: conditions for bacterial spread, stagnation, temperature permissive, no disinfectant, external hazardsFurther review of the Water Management Program indicated the facility failed to describe the building water systems using text and flow diagrams specific to their building and identify areas where Legionella could grow and spread.During an interview on 8/4/25 at 4:34 P.M., the Director of Maintenance said the Water Management Program and assessment is reviewed and updated annually and was last completed in January 2025. The Director of Maintenance reviewed the water management program documentation and said the written description of building water system and devices was not specific to the facility and the Water System Flow Diagram did not clearly depict the hazardous concerns. The Director of Maintenance said the facility did not receive its water from the town of [NAME] and had no trellis fountains.During an interview on 8/5/25 at 10:12 A.M., the Administrator said the Water Management Program and assessment should have been specific to the facility and should meet all criteria.

Based on records reviewed, interviews and observations for one of three nursing units (Unit #1), with two (2) medication administration carts (A & B), the facility Failed to ensure it provided a separate locked, permanently affixed compartment for storage of medications that were controlled substances and/or other drugs subject to abuse, when both medication administration carts narcotic boxes were able to be opened without the use of a key, making these medications easily accessible. Findings include: Review of the Facility Policy titled Medication Storage in the Facility, dated as last revised 2/2019, indicated that medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. The Policy indicates that Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications. The Policy further indicated that the access to system to control medications is not the same as the system giving access to other medications (the key used, the medication nurse on duty maintains possession of the key to controlled substance storage areas). During an observation on 02/03/25 at 11:15 A.M., Surveyor #2 lifted up the cover, on what appeared to be the locked narcotic box located in the A-side medication cart, however the narcotic box cover was able to easily opened without a key, so the controlled substance medications stored inside, were not secured. During an interview on 02/03/25 at 11:16 A.M., Nurse #1 said that she knew that the narcotic box on medication cart for side A would not lock properly and said that she did not have a key to the narcotic box. Nurse #1 said she does not remember telling anyone about the narcotic box being broken and said all narcotics should always be double locked. During an observation on 02/03/25 at 11:25 A.M., Surveyor #2 lifted up the cover, on what appeared to be the locked narcotic box located in the B-side medication cart, however the narcotic box cover was able to easily open without a key, so the controlled substance medications stored inside were not secured. During an interview on 02/03/25 at 11:25 A.M., Nurse #2 said that sometimes the narcotic box is easy to open without the key and said sometimes the key can get stuck when trying to open the narcotic box. Nurse #2 said that all narcotics are supposed to be double locked on all medication carts. During an interview 02/03/25 at 3:46 P.M., the Director of Nurses (DON) said that she was not aware that the two narcotic boxes in the medication carts on Unit 1 were not locking properly. The DON said that the Facility's expectation was that all narcotic boxes will be maintained under a double locked system and if any narcotic box was not opening or closing properly, nursing staff were to notify the DON and maintenance immediately.

Based on records reviewed, interviews, and observation, for one of seven (7) sampled residents (Resident #7) who should have been on Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of Multi-Drug-Resistant Organisms (MDRO) in nursing homes) related to wound care needs, the Facility failed to ensure nurses were aware of the need to use EBP's and implemented the necessary infection control practices during the provision of care. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated as last revised August 2023, indicated that EBP's are utilized to prevent the spread of multi-drug-resistant organisms (MDRO's) to residents. The Policy further indicated the following; -EBP's employ targeted gown, and gloves use during high contact resident care activities when contact precautions do not otherwise apply; -Gloves and gown are applied prior to performing the high contact resident care activity such as dressing, bathing, providing hygiene, and changing brief or assisting with toileting; -EBP's are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBP's remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk; -Staff are trained prior to caring for residents on EBP's; -Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required; -PPE is available outside of the resident room, or immediately inside the resident room; and -Residents, families and visitors are notified of the implementation of EBP's throughout the facility. Resident #7 was admitted to the Facility in January 2019, diagnoses include atrial fibrillation, malnutrition, anxiety, and dementia. Review of Resident #7's Physician's Wound Care Progress Note, dated 01/14/25, indicated that Resident #7's pressure injury was first evaluated on 11/26/24 and now appearing as a worsening Stage III (full thickness tissue loss) to his/her sacrum. Review of Resident #7's Annual MDS assessment, dated 01/24/25, indicated he/she had a Stage III pressure injury. Review of the Facility EBP listing by unit, provided by the Infection Preventionist on 02/03/25, indicated that there was no documentation to support Resident #7 required EBP's. Review of Resident #7's Physician's Orders, dated 02/03/25, indicated that there was no documentation to support a Physician's Order was obtained to maintain EBP's (until after being identified by Surveyor #2 during the survey). During an observation on 02/03/25 at 12:00 P.M., Surveyor #2 observed that there was no signage on Resident #7's room outside the doorway to indicate that he/she was on any kind of precautions and there was no Personal Protective Equipment (PPE- gowns, gloves, masks, eye protection) designated to his/her room. During an interview on 02/03/25 at 12:01 P.M., Certified Nurse Aide (CNA) 1 said that Resident #7 was not on any precautions that she was aware of, said she had provided Resident #7 personal care in the morning and had not worn PPE. During an interview on 02/03/25 at 12:11 P.M., the Unit Manager said that Resident #7 has a pressure injury and should be on EBP's. The Unit Manager said she was not sure why there was no sign for EBP's outside of his/her room. During an interview on 02/03/25 at 3:06 P.M., the Infection Preventionist (IP) said that she was not sure how it was missed that Resident #7 required EBP's to be in place and followed by staff due to his/her pressure injury. The IP said that once a resident develops a wound, requires an indwelling device of any kind, and/or has a history of an MDRO, nursing staff need to notify her and initiate EBP's (put a sign at their room door and provide PPE outside of the room) to help minimize the spread of any infection. During an interview of 02/03/25 at 3:46 P.M., the Director of Nurses (DON), said she did not know Resident #7 was not placed on EBP's said he/she should have been secondary to his/her pressure injury, wound care needs. The DON said that it was the Facility's expectation that any resident with a history of an MDRO, indwelling device, and wounds must be placed on EBP's immediately and reported to her and the IP to ensure proper infection control procedures are being followed.

Based on record review, interview, and policy review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#133), out of a total sample of 25 residents. Specifically, for Resident #133 the Pharmacist failed to review and report irregularities related to the administration of a medication. Findings include: Review of the facility's policy titled Consultant Pharmacist Reports, effective date February 2019, indicated but was not limited to: -Comments and recommendations concerning medication therapy and apparent irregularities will be reported in a timely manner to ensure the resident's safe and appropriate medication utilization. Resident #133 was admitted to the facility in April 2024 with diagnoses including chronic kidney disease and diabetes with diabetic neuropathy. Review of the Minimum Data Set (MDS) assessment, dated 4/13/24, indicated Resident #133 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #133's current Physician's Orders indicated but was not limited to: -Oxycodone (opioid used to treat pain) 5 milligrams (mg), give half a tab by mouth every 4 hours as needed for severe pain (5/6/24) -Oxycodone 5 mg, give one tablet by mouth every 4 hours as needed for severe pain (5/6/24) -Pain Score every shift 0=No Pain, 1,2,3,4= Mild Pain, 5,6,7= Moderate Pain, 8,9,10= Severe pain every shift for Pain (4/2/24) Review of the May 2024 Medication Administration Record (MAR) for Resident #133 indicated Oxycodone had been administered 34 times. Review of Resident #133's MRR, dated 5/17/24, failed to indicate any irregularities with his/her Oxycodone parameters. During an interview on 5/21/24 at 2:17 P.M., MDS Nurse #1 said Resident #133 should have a pain scale parameter for each Oxycodone order. During an interview on 5/21/24 at 2:40 P.M., Nurse #3 said Resident #133 should have had a range on his/her Oxycodone order. Nurse #3 said both orders for Oxycodone should not say for severe pain. During an interview on 5/21/24 at 2:52 P.M., Resident #133 said he/she was offered a choice between taking Oxycodone 2.5 mg and Oxycodone 5 mg. Resident #133 said he/she would request the Oxycodone 5 mg dose. During an interview on 5/21/24 at 3:53 P.M., the Director of Nursing (DON) said for Resident #133 there should not have been two orders for Oxycodone for severe pain. The DON said the order for Oxycodone 2.5 mg should have been for moderate pain and for Oxycodone 5 mg should have been for severe pain. The DON said both orders should have included a pain range. During a telephonic interview on 5/22/24 at 1:20 P.M., Pharmacist #1 said he electronically reviews each residents' medication orders monthly. Pharmacist #1 said he reviews the Resident orders for things such as the use, correct diagnosis, appropriate dose, interactions, indications for use and accurate order entry. Pharmacist #1 said when there was a recommendation to distinguish between two different doses based on a pain scale he would provide the facility with a written recommendation. Pharmacist #1 said, with his review on 5/17/24, he did not make a reference to the dose of Oxycodone for Resident #133, but he should have.

Based on interviews, record review, and policy review, the facility failed to ensure for three Residents (#11, #73, and #133), out of a total sample of 25 residents, that the Residents were free from significant medication errors. Specifically, the facility failed to ensure pain medicine was administered according to the pain scale indicated in the physician's orders. Findings include: Review of the facility's policy titled Pain - Clinical Protocol, revised October 2022, indicated but was not limited to: -Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Review of the facility's policy titled Administering Medications, revised April 2019, indicated but was not limited to: -Medications are administered in accordance with prescriber orders. -If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.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 nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice. 1. Resident #73 was admitted to the facility in May 2021 with diagnoses including morbid obesity, acute on chronic congestive heart failure, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #73, dated 2/28/24, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. Review of Resident #73's active Physician's Orders indicated the following: - Acetaminophen (pain reliever), give 30 milliliters (ml) by mouth three times a day for pain, 30 ml to equal 1000 milligrams (mg). Active 3/13/24. Discontinued 5/15/24. - Acetaminophen (pain reliever), give 30 ml by mouth three times a day for pain, 500 mg/15 ml, give 30 ml to equal 1000 mg. Active 5/15/24. - Oxycodone tablet 5 mg, give 5 mg by mouth every 6 hours as needed for moderate-severe pain. Active 6/23/21. - Pain score every shift, 0 = no pain; 1, 2, 3, 4 = mild pain; 5, 6, 7 = moderate pain; 8, 9, 10 = severe pain. Active 5/20/21. Review of Resident #73's Medical Administration Record (MAR) for the months of April and May 2024 indicated Oxycodone was administered to the Resident outside of the physician's ordered pain parameters for the following dates: 4/1/24, pain score = 4, administered by Nurse #11 4/3/24, pain score = 3, administered by Nurse #12 4/6/24, pain score = 4, administered by Nurse #12 4/6/24, pain score = 4, administered by Nurse #11 4/7/24, pain score = 4, administered by Nurse #11 4/7/24, pain score = 4, administered by Nurse #12 4/8/24, pain score = 4, administered by Nurse #11 4/11/24, pain score = 4, administered by Nurse #11 4/11/24, pain score = 4, administered by Nurse #12 4/12/24, pain score = 4, administered by Nurse #11 4/18/24, pain score = 4, administered by Nurse #11 4/19/24, pain score = 4, administered by Nurse #11 4/25/24, pain score = 4, administered by Nurse #12 5/1/24, pain score = 4, administered by Nurse #11 5/4/24, pain score = 4, administered by Nurse #12 5/5/24, pain score = 4, administered by Nurse #11 5/7/24, pain score = 4, administered by Nurse #12 5/9/24, pain score = 4, administered by Nurse #12 5/18/24, pain score = 4, administered by Nurse #13 5/21/24, pain score = 4, administered by Nurse #11 Additional review of Resident #73's MAR for the months of April and May 2024, indicated the Resident received Acetaminophen per physician's orders. During an interview on 5/22/24 at 10:38 A.M., Nurse #12 said she did not know what the pain scale was off the top of her head. Nurse #12 said on a scale from 1-10, she counts a pain rating of 4-7 as moderate. Nurse #12 said per the physician's order for pain score, pain at 5-7 is considered moderate. Nurse #12 said Resident #73 should not receive Oxycodone when the Resident reports pain of 4 or less on the pain scale. Nurse #12 said she did not contact the physician in regard to administering the Oxycodone outside of the ordered pain parameters but she should have. During an interview on 5/22/24 at 12:07 P.M., the Director of Nursing (DON) said pain levels 5-10 are considered moderate to severe. The DON said the physician should have been called when Resident #73 requested Oxycodone for a pain level of 4 or below. The DON could not provide the Surveyor documentation that the physician was specifically notified or aware of Oxycodone being administered to Resident #73 for a pain level of 4 or below.2. Resident #11 was admitted to the facility in April 2024 with diagnoses including muscle weakness and atrial fibrillation. Review of the MDS assessment, dated 4/13/24, indicated Resident #133 was cognitively intact as evidenced by a BIMS score of 13 out of 15. Review of Resident #11's current Physician's Orders indicated but was not limited to: - Acetaminophen (pain reliever) 500 mg give 2 tablets (1000 mg) by mouth every 8 hours as needed for mild pain (4/28/24) - Oxycodone 5 mg give one tab every six hours as needed for severe pain (7-10), dated 5/8/24 - Pain Score every shift 0=No Pain, 1,2,3,4= Mild Pain, 5,6,7= Moderate Pain, 8,9,10= Severe pain every shift for Pain (4/27/24) Review of Resident #11's May MAR indicated that Oxycodone was administered 21 times. Further Review of the MAR indicated that 10 out of 21 times Oxycodone had been administered out of the Physician's parameters as follows: - 5/8/24 at 8:45 P.M. Pain Score: 4 by Nurse #8 - 5/9/24 at 8:18 A.M. Pain Score: 5 by Nurse #7 - 5/9/24 at 4:50 P.M. Pain Score: 2 by Nurse #8 - 5/9/24 at 10:27 P.M. Pain Score: 3 by Nurse #8 - 5/10/24 at 8:36 A.M. Pain Score: 6 by Nurse #7 - 5/11/24 at 1:49 A.M. Pain Score: 5 by Nurse #5 - 5/11/24 at 9:29 A.M. Pain Score: 6 by Nurse #14 - 5/13/24 at 1:35 P.M. Pain Score: 5 by Nurse #1 - 5/14/24 at 9:46 A.M. Pain Score: 6 by Nurse #7 - 5/20/24 at 3:00 A.M. Pain Score: 2 by Nurse #15 Review of Resident #11's care plan titled Pain (back) related to chronic pain syndrome, last revised 4/28/24, indicated but not limited to: - Administered (sic) pain medication per physician orders (initiated 4/27/24) During an interview with medical record review on 5/20/24 at 1:43 P.M., Nurse #1 and the surveyor reviewed Resident #11's MAR. Nurse #1 said Resident #11 should have only been administered the Oxycodone for a pain score of 7 or higher. If the Oxycodone was administered for a pain score of less than 7, then the Physician/Nurse Practitioner (NP) should have been called and notified. During an interview on 5/20/24 at 1:53 P.M., Physician #1 said if a pain medication is administered for a pain level below the prescribed parameter, then, prior to administration, the Physician/NP should be called. During an interview on 5/20/24 at 4:23 P.M., Nurse #2 said pain medications should be administered per physician's orders and parameters. If a Resident requests pain medication outside of physician's orders, then the Physician/NP should be called prior to administration and a nurse's note should be written to document the conversation. During an interview on 5/21/24 at 11:28 A.M., the DON said that the nurses should have called the Physician/NP when administering a pain medication outside of the physician's orders. The DON said she could not find any documentation that the Physician/NP were notified of the Oxycodone being administered outside of the Physician's orders' parameters. 3. Resident #133 was admitted to the facility in April 2024 with diagnoses including chronic kidney disease and diabetes with diabetic neuropathy. Review of the MDS assessment, dated 4/13/24, indicated Resident #133 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of Resident #133's current Physician's Orders indicated but was not limited to: -Acetaminophen 650 mg give 2 tablets (650 mg) by mouth every 8 hours as needed for pain (4/28/24) -Oxycodone 5 mg, give half a tab by mouth every 4 hours as needed for severe pain (5/6/24) -Oxycodone 5 mg, give one tablet by mouth every 4 hours as needed for severe pain (5/6/24) -Pain Score every shift 0=No Pain, 1,2,3,4= Mild Pain, 5,6,7= Moderate Pain, 8,9,10= Severe pain every shift for Pain (4/2/24) Review of Resident #133's April and May MAR indicated that Oxycodone was administered 34 times. Further Review of the MAR for Resident #133 indicated 24 out of 34 times Oxycodone 5 mg had been administered outside of the Physician's parameters: - 5/6/24 at 6:10 P.M., Pain Score: 7 by Nurse #5 - 5/7/24 at 8:40 P.M., Pain Score: 6 by Nurse #6 - 5/8/24 at 8:55 A.M., Pain Score: 6 by Nurse #7 - 5/8/24 at 4:38 P.M., Pain Score: 4 by Nurse #8 - 5/8/24 at 9:10 P.M., Pain Score: NA (not applicable) Nurse #8 - 5/9/24 at 11:46 A.M., Pain Score: 5 by Nurse #7 - 5/9/24 at 5:03 P.M., Pain Score: 2 by Nurse #8 - 5/9/24 at 9:08 P.M., Pain Score: 3 by Nurse #8 - 5/10/24 at 12:44 P.M., Pain Score: 6 by Nurse #7 - 5/11/24 at 2:38 A.M., Pain Score: 0 by Nurse #6 - 5/14/24 at 1:54 A.M., Pain Score: 7 by Nurse #9 - 5/14/24 at 8:54 A.M., Pain Score: 6 by Nurse #7 - 5/14/24 at 9:46 P.M., Pain Score: 7 by Nurse #5 - 5/15/24 at 9:36 A.M., Pain Score: 0 by Nurse #4 - 5/15/24 at 9:10 P.M., Pain Score: 7 by Nurse #10 - 5/16/24 at 6:04 A.M., Pain Score: 7 by Nurse #17 - 5/16/24 at 8:31 P.M., Pain Score: 7 by Nurse #9 - 5/17/24 at 1:01 A.M., Pain Score: 7 by Nurse #9 - 5/17/24 at 8:00 A.M., Pain Score: 5 by Nurse #1 - 5/17/24 at 2:32 P.M., Pain Score: 6 by Nurse #1 - 5/18/24 at 5:59 A.M., Pain Score: 5 by Nurse #6 - 5/20/24 at 3:00 A.M., Pain Score: 7 by Nurse #2 - 5/21/24 at 1:05 A.M., Pain Score: 7 by Nurse #9 - 5/21/24 at 1:23 P.M., Pain Score: 7 by Nurse #9 Review of Resident #133's care plan titled Pain (generalized related to fibromyalgia (a condition that involves widespread body pain), last revised 4/8/24, indicated but was not limited to: -Administered (sic) pain medication per physician orders (initiated 4/8/24) During an interview on 5/21/24 at 2:10 P.M., Nurse #4 said, in order to give a pain medication, the nurse should have assessed the resident's pain and administered the medication per physician's order. Nurse #4 said Resident #133 would ask for Oxycodone 5 mg. Nurse #4 said the Physician/NP should have been called if Resident #133 was having less than severe pain. During an interview on 5/21/24 at 2:40 P.M., Nurse #3 said Resident #133 should have had a range on his/her Oxycodone order. Nurse #3 said if a resident rates their pain below what the physician's order says, then prior to administering the medication, the Physician/NP should be called to get clarification of the order. During an interview on 5/21/24 at 2:52 P.M., Resident #133 said he/she was offered a choice between taking Oxycodone 2.5 mg and Oxycodone 5 mg. Resident #133 said he/she would request the Oxycodone 5 mg dose. During a telephonic interview on 5/22/24 at 12:56 P.M., Nurse #2 said she had administered the Oxycodone on 5/20/24 at 17:42 (5:42 P.M.) to Resident #133 for pain of 7 out 10. Nurse #2 said she should have called the Physician to get an order to administer the Oxycodone but did not. During an interview on 5/22/24 at 1:54 P.M., the DON said the expectation was for pain medications to be administered per physician's orders and per the pain scale.

Based on observations, interviews, and policy review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of COVID-19, during a COVID-19 outbreak in the facility. Specifically, the facility failed to: 1. Ensure that healthcare personnel performed hand hygiene upon entering and exiting an isolation precaution room; donned (put on) the appropriate personal protective equipment (PPE) as indicated by posted signs outside of the resident's room and doffed (take off) all PPE as necessary; 2. Ensure that healthcare personnel cleaned and disinfected shared medical equipment in between each resident; and 3. Ensure face masks were used by staff as a method of source control during a COVID-19 outbreak as posted throughout the facility. Findings include: 1. Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions, dated as revised September 2022, indicated but was not limited to the following: - Transmission-based precautions (TBP) are initiated when a resident develops signs and symptoms of a transmissible infection, has a laboratory confirmed infection, or is at risk of transmitting the infection to others. - TBP are additional measures to protect staff, visitors and others from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. - When a resident is placed on TBP appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. - The signage informs the staff of the type of precaution, instruction for PPE use, and/or instruction to see a nurse prior to entering the room. - When TBP are in effect non-critical resident care equipment items such as a stethoscope, sphygmomanometer (blood pressure cuff device), or digital thermometer will be dedicated to a single resident, if re-use of an item is necessary then the item will be cleaned and disinfected before use with another resident. On 6/30/23 at 7:35 A.M., the surveyor observed an isolation precaution sign hanging outside of Resident #1's room on the Fairhaven unit. The precaution sign indicated the following: -In addition to standard precautions Staff and Providers must: -Clean hands when entering and exiting -Gown change between each resident -N95 Respirator (Facemask acceptable if N95 not available; fit tested N95 or higher required for aerosol-generating procedures) -Eye protection (goggles or face shield) -Gloves change between each resident -Keep door closed (Unless safety concern or not on physically separate unit) -Use patient dedicated or disposable equipment -Clean and disinfect shared equipment During an observation with interview on 6/30/23 at 7:36 A.M., the surveyor observed Certified Nurse Assistant (CNA) #1 exit Resident #1's room, and doff her gown, gloves, and face shield. She failed to doff her mask or change her mask to a new clean mask. She said she had just completed morning care on the Resident in the room and the Resident was COVID-19 positive. She said the staff are not required to change their masks in between patients, even if the Resident is COVID-19 positive. On 6/30/23 at 7:40 A.M., the surveyor observed CNA #1 enter Resident #2's room with the same mask on her face worn when she exited Resident #1's room. The sign posted outside of Resident #2's room indicated that the Resident was on enhanced barrier precautions (EBP). During an interview on 6/30/23 at 7:47 A.M., Nurse #1 said the expectation is for staff to change their N95 mask when exiting an isolation precaution room. She was made aware of the surveyor's observations and said CNA #1 should have changed her mask upon exiting Resident #1's room. On 6/30/23 at 7:59 A.M., the surveyor observed an EBP sign hanging outside of Resident #6's room on the Acushnet unit. The precaution sign indicated but was not limited to the following: Providers and staff must: -Gown for high contact care change between each resident During an observation with interview on 6/30/23 at 8:00 A.M., the surveyor observed CNA #2 assist the Resident back into bed and adjust his/her bed linens. She was not observed to be wearing a gown throughout the activity. CNA #2 doffed her gloves, performed hand hygiene and exited the room. She said she was assisting the Resident with his/her morning care in the bathroom and then changed the bed so the Resident could take a nap. She said she was not wearing a gown because she thought she only needed to wear a gown with residents who were on isolation precautions for COVID-19. She reviewed the posted sign for EBP posted on the Resident's door and said she should have been wearing a gown for the care and activities she performed and did not. During an interview on 6/30/23 at 8:17 A.M., the Director of Nurses (DON) and Infection Preventionist (IP) were made aware of the surveyor's observations and said CNA #1 should have changed her mask upon exiting a COVID-19 positive isolation precaution room and CNA #2 should have worn a gown for the care activity of assisting the Resident on EBP back to bed and adjusting his/her linens. On 6/30/23 at 7:50 A.M., the surveyor observed an isolation precaution sign hanging outside of Resident #3's room on the Dartmouth unit. The Precaution sign indicated the following: -In addition to standard precautions Staff and Providers must -Clean hands when entering and exiting -Gown change between each resident -N95 Respirator (Facemask acceptable if N95 not available; fit tested N95 or higher required for aerosol-generating procedures) -Eye protection (goggles or face shield) -Gloves change between each resident -Keep door closed (Unless safety concern or not on physically separate unit) -Use patient dedicated or disposable equipment -Clean and disinfect shared equipment On 6/30/23 at 7:50 A.M., the surveyor observed Nurse #4 outside Resident #3's room. Nurse #4 was then observed entering the Resident's room but was not observed to perform hand hygiene, or don a gown, gloves, or eye protection prior to entering, as the posted sign indicated. On 6/30/23 at 8:00 A.M., the surveyor observed Nurse #4 exiting Resident #3's room. Nurse #4 was not observed to perform hand hygiene upon exiting the room, as required per the posted sign. Nurse #4 removed her N95 mask and placed it in the basket attached to the Nurse on a stick (a machine that monitors blood pressure and pulse) which held blood pressure cuffs. During an interview on 6/30/23 at 8:00 A.M., Nurse #4 said she should be following the sign and wearing a gown, gloves, and eye protection prior to entering the room and caring for any residents with COVID-19. Nurse #4 said she should have cleaned her hands upon entering and exiting the room. Nurse #4 said she should have placed her N95 in the trash, not in the basket with common use resident equipment. 2. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised September 2022, indicated but was not limited to: -Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) -Only equipment that is designated reusable is used by more than one resident -Durable medical equipment is cleaned and disinfected before reuse by another resident On 6/30/23 at 8:10 A.M., the surveyor observed an EBP sign hanging outside of Resident #4's room on the Dartmouth Unit. The Precaution sign indicated the following: -Clean hands when entering and exiting -Gown for high contact care change between each resident -Mask N95 for aerosol-generating procedures or ongoing transmission on the unit -Eye protection (goggles or face shield for patient care encounters) -Gloves for high contact care change between each resident On 6/30/23 at 8:10 A.M., the surveyor observed Nurse #4 outside Resident #4's room. Nurse #4 was then observed entering the Resident's room, but not observed to perform hand hygiene, or don gloves or eye protection prior to entering. Nurse #4 was observed bringing the nurse on a stick, that was used immediately prior on Resident #3, into Resident #4's room without disinfecting it in between resident use. On 6/30/23 at 8:15 A.M., the surveyor observed Nurse #4 exiting Resident #4's room, but did not observe the nurse performing hand hygiene. During an interview on 6/30/23 at 8:15 A.M., Nurse #4 said she should be following the sign and wearing gloves and eye protection prior to entering the room. Nurse #4 said she should have cleaned her hands upon entering and exiting the room. Nurse #4 said she should have cleaned the nurse on a stick between residents but did not. During an interview on 6/30/23 at 2:15 P.M., the DON said she was aware that Nurse #4 did not follow the posted precaution signs outside each residents' room for the use of PPE and the signs should be followed by all staff to ensure they use PPE correctly in isolation or precaution rooms. The DON said Nurse #4 should have cleaned the Nurse on a stick in between each resident and the expectation was not met. 3. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 2022, indicated but was not limited to the following: - Source control refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. - Source control options for healthcare providers (HCP) include a well-fitting facemask. On 6/30/23 at 7:00 A.M., the surveyor observed signs posted at the entrance and at both elevators that indicated masks were to be worn in the facility for source control during the current COVID-19 outbreak. During an interview on 6/30/23 at 7:13 A.M., the DON and Administrator said the facility is enforcing that all staff wear masks at all times while in the facility as source control during the current COVID-19 outbreak. On 6/30/23 at 1:30 P.M., the surveyor observed CNA #3 coming from behind the Dartmouth unit nurses' station with her mask pulled down below her mouth. CNA #3 was holding a sandwich in a yellow wrapper and proceeded to take a bite from her sandwich. CNA #3 was observed to continue walking down the hall eating her sandwich prior to exiting the Dartmouth unit. During an interview on 6/30/23 at 1:50 P.M., CNA #3 said she should have not taken her mask off and eat her sandwich until she was off the unit and she is supposed to have her mask on at all times when on the unit. During an interview on 6/30/23 at 2:15 P.M., the DON was made aware of the surveyor's observations and said CNA #3 should not be removing her mask and eating on the unit. The DON said staff are to wear masks at all times in all resident areas and the expectation was not met.

Based on observation, record review, and interviews, the facility failed to ensure a reasonable accommodation was made for one Resident (#68), out of a total sample of 28 residents. Specifically, the facility failed to ensure the call system button was accessible to the Resident in order to summon assistance when needed. Findings include: Resident #68 was admitted to the facility in December 2022 with diagnoses including hemiplegia and hemiparesis affecting the right dominant side. On 1/26/23 at 8:47 A.M., the surveyor observed Resident #68 lying in bed resting. The Resident's right hand was contracted and resting on top of the bed sheet and his/her left hand was holding onto the side rail on the left side of the bed. Resident #68 told the surveyor that he/she wanted someone to come and get him/her cleaned and dressed for the day. The surveyor observed the Resident had no way to alert staff that he/she was in need of assistance as the call bell system controller was out of reach and tied tightly in a knot around the side rail on the Resident's right side which is paralyzed. The surveyor alerted Nurse #1 that Resident #68's call bell was inaccessible to the Resident. On 1/26/23 at 8:48 A.M., Nurse #1 said the call light should be placed on the Resident's left side so he/she can call for assistance when needed.

Based on record review, document review, and interview, the facility failed to notify the resident's representative (family member) of a room change for one Resident (#80), out of a total sample of 28 residents. Findings include: Resident #80 was admitted to the facility in December 2022 with diagnoses including dementia, complete atrioventricular (AV) heart block with the presence of a cardiac pacemaker, and congestive heart failure. During an interview on 1/24/23 at 1:47 P.M., Resident #80's spouse said the facility did not call when the Resident's room was changed and moved closer to the nurses' station following a fall last Friday night (1/20/23). The spouse said when he/she came to visit last Saturday (1/21/23) she/he went to the Resident's room and he/she was not in the room. The spouse said she/he was really nervous because she/he didn't know where the Resident was. The Resident's spouse reiterated that she/he was never called/notified about the room change following a fall. Review of the Facility Incident Report, dated 1/21/23 at 12:15 A.M., indicated the Resident's spouse was contacted on 1/20/23 at 10:48 P.M. and the physician was contacted on 1/20/23 at 10:46 P.M. Review of a Nurse's Note, dated 1/19/23 at 9:55 P.M., indicated but was not limited to the following: Resident's alarm started to sound when entering room, resident was observed attempting to stand, went to sit back down in wheelchair and slid out of the wheelchair to the floor and landed on his/her bottom. No injuries. Family, MD and management made aware of incident. The nurse's note did not indicate/reference that the Resident's room was changed following the fall to be closer to the nurses' station. During an interview on 1/30/23 at 10:05 A.M., Unit Manager #1 explained the notification process that when a resident has a room change that the family member is/should be notified. The surveyor informed Unit Manager #1 that it wasn't until the spouse arrived on the Unit on 1/21/23 that she/he was made aware of the room change.

Based on observation, record review, interview, and policy review, the facility failed to assess and re-evaluate the use of a Velcro alarmed seatbelt as a restraint for one Resident (#19), out of a total sample of 28 residents. Findings include: Review of facility's policy titled Use of Restraints, last revised April 2017, indicated but was not limited to the following: -Physical Restraints are defined as 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 restricts normal access to one's body. -The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. -Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. treat the medical symptom; b. protect the resident's safety; and c. help the resident attain the highest level of his/her physical or psychological well-being. -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. -Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. -Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. -Documentation regarding the use of restraints shall include: a. full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode b. a description of the resident's medical symptoms that warranted the use of restraints; c. how the restraint use benefits the resident by addressing the medical symptom; d. the type of the physical restraint used; e. the length of effectiveness of the restraint time; and f. observation, range of motion and repositioning flow sheets Resident #19 was admitted to the facility in September 2019 with diagnoses including major depressive disorder and dementia with behavioral disturbance. Review of the Minimum Data Set assessment, dated 12/7/22, indicated Resident #19 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 2 out of 15, received psychotropic medication daily and did not have a restraint. On 1/23/23 at 1:34 P.M., the surveyor observed Resident #19 seated in a wheelchair in the unit dayroom with a Velcro alarmed seatbelt fastened around his/her waist. The surveyor asked the Resident if he/she could demonstrate how to release the seatbelt. The Resident did not respond to the surveyor's request, and made no attempt to demonstrate releasing the seatbelt. On 1/24/23 at 10:17 A.M., the surveyor observed Resident #19 seated in a wheelchair in the unit dayroom with a Velcro alarmed seatbelt fastened around his/her waist. On 1/25/23 at 1:15 P.M., the surveyor observed Resident #19 seated in a wheelchair in the unit dayroom with a Velcro alarmed seatbelt fastened around his/her waist. The Resident was not responsive to the surveyor's request and made no attempt to demonstrate releasing the seatbelt. Review of the January 2023 Physician's Orders included but was not limited to: -self-release alarmed seatbelt to wheelchair, monitor placement and function every shift (9/19/19) -Resident to demonstrate ability to self-release seatbelt on command weekly, every day shift on Monday (9/13/21) The physician's order failed to identify the device as a restraint and failed to identify a symptom for its use. Review of the Comprehensive Care Plan for falls included but was not limited to: -Focus: At risk for falls due to impaired balance/poor coordination, medication side effects, unsteady gait, history of falls (9/19/19) -Interventions: Self-releasing alarmed seatbelt (9/6/21) -Goal: Minimize risk for injury related to falls (9/19/19); Minimize risk for falls (9/19/19); Decreased number of falls (9/19/19) Review of Licensed Nursing Summaries, dated 12/26/22 and 1/23/23, included but was not limited to: -Resident is totally dependent on staff for bathing, grooming, and dressing due to decreased attention span, decreased motivation, easily distracted, and unable to initiate or complete tasks. On 1/26/23 at 12:55 P.M., the surveyor observed Resident #19 seated in a wheelchair in the hallway outside the unit dayroom with a Velcro alarmed seatbelt fastened around his/her waist. During an interview on 1/26/23 at 12:57 P.M., Unit Manager #2 (UM #2) said that Resident #19 has an alarmed Velcro seatbelt because he/she is a fall risk and can be impulsive. She confirmed that Resident #19 is severely cognitively impaired and is dependent on staff for all activities of daily living except eating. The surveyor asked UM #2 to ask Resident #19 to release his/her seatbelt. UM #2 approached the Resident and asked him/her to release the seatbelt. The Resident did not respond and made no attempt to release the seatbelt. UM #2 asked the Resident four more times to release the seatbelt and the Resident was unable to understand and made no attempt to release the seatbelt on command. UM #2 said that the seatbelt is considered a restraint because the Resident is unable to release it on command.

Based on record review, interviews and policy review, the facility failed to ensure nutritional status was maintained for one Resident (#68), out of a total sample of 28 residents. Specifically, the facility failed to follow their policy for weight monitoring. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, last revised March 2022, indicated the following: -Residents are weighed upon admission and at intervals established by the interdisciplinary team such as weekly for four weeks, then monthly unless otherwise indicated or as ordered. -A weight change of 5 lbs. (pounds) or more in a patient weighing more than 100 lbs. or of 2 lbs. in a patient weighing less than 100 lbs. since the last weight assessment will be retaken for validation. If the weight is verified, nursing will notify the Dietitian. For non-significant weight changes either the dietitian or provider is notified upon consideration of the resident's overall clinical condition. -The Dietitian will follow-up within 1 week. -The Dietitian will discuss undesired weight changes (loss or gains) with the resident and/or family. Resident #68 was admitted to the facility in December 2022 with diagnoses including dysphagia oropharyngeal phase, hemiplegia and hemiparesis affecting the right dominant side and gastrostomy tube (an artificial external opening into the stomach for nutritional support). Review of December 2022 Physician's Orders included but was not limited to: -weekly weights (12/2/22) Review of the medical record on 1/24/23 indicated Resident #68's measured weights as follows: 12/2/22=148.8 lbs. 12/12/22=152.2 lbs. 12/23/22=151.0 lbs. 12/28/22=153.2 lbs. 1/9/23 =147.0 lbs. Further review of the medical record failed to indicate staff obtained a reweigh after a 5 lb. loss on 1/9/23 to verify the weight according to facility policy. The weight log indicated 5 weekly weights were taken out of the possible 8 weeks the Resident has been in the facility. During an interview on 1/27/23 at 1:21 P.M., the surveyor and Unit Manager #2 reviewed Resident #68's medical record. Unit Manager #2 said the weights documented in the medical record taken while the Resident was on the short-term unit and the Resident should have been re-weighed when he/she arrived on the long term unit on 1/10/23. She said the Resident is NPO (nothing by mouth) and dependent on tube feeding for all nutrition and should not lose weight. During an interview on 1/27/23 at 2:25 P.M., the surveyor and Unit Manager #1 reviewed Resident #68's medical record. She said Resident #68 resided on her unit during the time the weights were measured and recorded in the medical record. She said that residents should be re-weighed if there is a 5 lb. weight gain or loss. She reviewed the Resident's weights and said the Resident had a 6 lb. weight loss and the weight should have been validated by a re-weigh according to the facility's policy and the dietitian would follow-up with the Resident. The Unit Manager said the Resident is dependent on tube feeding, should not lose weight and should be evaluated by the Dietitian. During an interview on 1/30/23 at 1:18 P.M., the Dietitian said she was not notified at any time that Resident #68 had a weight loss of 6 lbs. She said the Resident should have been re-weighed to verify the weight loss. If the weight loss was verified, she would have followed up with the Resident within a week.

Based on observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) were provided in accordance with professional standards and physician's orders for one Resident (#100), out of 5 residents in the facility with feeding tubes, and a total sample of 28 residents. Findings include: Review of the facility's policy, Enteral Nutrition Feedings, last revised 7/26/13, included but was not limited to: -Intermittent feeding: enteral feeding delivered over a specified period of time or until a specified volume of formula is delivered. -Process: - Verify Physician's order - Review resident care plan and provide for any special needs of the resident - Ensure that equipment and devices are working properly by performing any calibrations, or checks as instructed by the manufacturer - Hold enteral feeding if gastric residual volume is 500 ml or greater (or according to order) and notify practitioner Resident #100 was admitted to the facility in December 2021 with diagnoses including frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage and moderate protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 12/31/22, indicated Resident #100 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 1 out of 15, receives more than 51% of his/her nutrition from a feeding tube and is on Hospice services. Review of the January 2023 Physician's Orders included but was not limited to: -Enteral feed order every 6 hours flush enteral tube every 6 hours with 200 milliliters (ml) (4/26/22) -Enteral feed order every shift check tube for proper placement prior to each feeding, flush or medication administration. Elevate hob [head of bed] at least 30-45 degrees during feeding and 1 hour after (4/26/22) -Enteral feed order every shift flush feeding tube with 30 ml water before and after medication administration. Flush feeding tube with 5 ml water between each medication (4/26/22) -Enteral feed order every shift PEG feeding tubes: check residual volume. If greater than 250 cubic centimeters (cc) refer to procedure. Or G/J feeding tubes: check residual volume. If greater than 60 cc refer to procedure (4/26/22) -Enteral feed in the afternoon, begin tube feed (4/26/22) -Enteral feed order one time a day intermittent gravity/pump enteral feeding: Formula: Nepro 54 ml/hr frequency: off at 10:00 A.M. on at 1400 (2:00 P.M.); Total ml/24 hrs: 1080 ml, Gtube, 16 Fr (4/26/22) On 1/24/23 at 9:19 A.M., the surveyor observed Resident #100 lying in bed sleeping. A bottle of Nepro formula was hung on a pole with tubing running through an electronic tube feeding pump. A label on the Nepro bottle indicated the feed was hung, spiked and began infusing at 15:30 (3:30 P.M.) and not 2:00 P.M. as ordered by the Physician. The control screen indicated the pump was running with a feed rate of 54 ml/hr and had so far infused a volume of 693 ml of Nepro formula. The Resident required 387 ml of Nepro to reach a total volume of 1080 ml. At a rate of 54 mL/hr, the tube feed would need to run for another 7.1 hours. Review of the January 2023 Medication Administration Record (MAR) for 1/24/23 indicated Resident #100's tube feeding was taken down at 10:00 A.M. Further review of the medical record failed to indicate the total volume of tube feeding was infused as ordered by the Physician. On 1/25/23 at 2:05 P.M., review of the January 2023 MAR indicated Nurse #2 signed off that Resident#100's Nepro tube feeding had been started at 2:00 P.M. On 1/25/23 at 2:10 P.M., the surveyor observed Resident #100 reclined in a Broda chair (positioning chair) in the hallway. There was no tube feed pump or feed being infused to the Resident. During an interview on 1/25/23 at 2:25 P.M., Nurse #2 said that she signed off in the medical record that she started Resident #100's tube feed at 2:00 P.M. when she did not. On 1/25/23 at 2:26 P.M., the surveyor and Unit Manager (UM) #2 walked past Resident #100 reclined in a Broda chair in the hallway and entered his/her room. The surveyor asked UM #2 to review the infusion history on the feeding pump. UM #2 said the readings on the pump are cumulative and represent the volume of feeding the Resident has received. The infusions displayed on the screen were as follows: -Previous 24 hours=1034 ml (and not 1080 ml per Physician's orders); -Previous 48 hours=1883 ml (and not 2181 ml per Physician's orders); -Previous 72 hours=2905 ml (and not 3240 ml per Physician's orders). UM #2 said that nursing is not doing the tube feed properly and is not confirming total volume of the feed that is infused. She said the Resident is not getting enough of the Nepro as ordered by the Physician. On 1/30/23 at 10:20 A.M., the surveyor observed Resident #100 in bed sleeping. The tube feed was hung up and the pump was running. The control screen indicated the pump was running with a feed rate of 54 ml/hr and had so far infused a volume of 1004 ml. The Resident would require 1.4 more hours of feed infusion to reach 1080 ml as ordered by the Physician. On 1/30/23 at 10:35 A.M., review of the December 2023 MAR indicated Nurse #7 signed off that Resident#100's Nepro tube feeding had been taken down. The medical record failed to indicate the total volume infused. On 1/30/23 at 10:52 A.M., the surveyor and UM #2 reviewed the infusion history on the feeding pump. The infusions displayed on the screen were as follows: -Previous 24 hours=1026 ml (and not 1080 ml per Physician's orders) -Previous 48 hours=1978 ml (and not 2160 ml per Physician's orders) -Previous 72 hours=3067 ml (and not 3240 ml per Physician's orders) UM #2 said the infusion volume readings are cumulative. She said nursing should monitor the feed to ensure it is infusing as it should and should not remove the feed until the full volume is infused as ordered. During an interview on 1/30/23 at 11:00 A.M., the Dietitian said she was not notified by staff that Resident #100 was not receiving the full volume of tube feeding as ordered. She said the Resident is on Hospice services and not weighed, so a weight loss would not have been triggered in the electronic medical record to alert her the Resident was not receiving enough nutrition.

Based on policy review, record review, and interview, the facility failed to ensure that care and treatment of a Mid-line catheter (venous access device-VAD-which is located directly in the basilic vein of the arm and terminates at the axilla) was provided in accordance with the facility's policy/protocols for one Resident (#233), out of a total sample of 28 residents. Specifically, the facility failed to ensure staff assessed/documented the condition of, and the length of, the Mid-line catheter once it was discontinued/removed, according to the facility's policy/protocols. Findings include: Review of the facility's policy titled Mid-line Catheter Removal, dated June 2016, indicated but was not limited to the following: -The nurse must verify that entire length of catheter has been removed by comparing catheter length to length recorded on insertion record or by x-ray -Examine catheter's integrity and confirm entire catheter has been removed by comparing catheter length to insertion record length. -Document in the resident's chart. Resident #233 was admitted to the facility in January 2023 with diagnoses that included liver abscess and sepsis. The Resident was admitted to the facility with a Mid-line catheter in place for the administration of intravenous (IV) antibiotics. Review of the Physician's Orders indicated that the Resident was receiving Ceftriaxone 2 grams daily IV via the Mid-line catheter with the last dose to be administered on 1/23/23. The Resident's Mid-line was discontinued per the physician's order on 1/25/23. Review of the Treatment Administration Record indicated that on 1/25/23 the nurse initialed that the Mid-line catheter was discontinued/removed. Further record review indicated no documentation/assessment of the removed Mid-line catheter (the required documentation i.e., catheter intactness or catheter length) in the medical record. During an interview on 1/26/23 at 3:00 P.M., Unit Manager #1 said that the Mid-line catheter had been removed, however the required documentation/assessment for the removal of a Mid-line catheter was not completed/performed as per the facility's policy/protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that for one Resident (#82), out of a total sample of 28 residents, that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to monitor for potential adverse consequences related to the use of an anticoagulant (blood thinner) medication. Findings include: Review of the manufacturer's (Bristol-[NAME] Squibb) website, revised September 2016, indicated Plavix (Clopidogrel) is a P2Y12 platelet inhibitor indicated for acute coronary syndrome, recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease to reduce the rate of MI and stroke. Adverse Reactions -Bleeding, including life-threatening and fatal bleeding, is the most reported adverse reaction Resident #28 was admitted to the facility with diagnoses including peripheral vascular disease, diabetes mellitus type 2, heart failure, and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Review of the current Physician's Orders indicated the following: -Plavix Tablet 75 milligrams (mg), give 1 tablet by mouth one time a day for blood thinner, monitor for bleeding, bruising, and black tarry stools, start date 11/24/19 Review of the January 2023 Medication Administration Record (MAR) indicated the following: -Plavix Tablet, administered daily from 1/1/23 through 1/30/23 Further review of the medical record failed to indicate Resident #28 was being adequately monitored for signs and symptoms of bleeding related to the use of a blood thinner. During an interview on 1/30/23 at 10:02 A.M., the surveyor reviewed the medical record with the Assistant Director of Nursing who said Resident #28 was not being monitored for signs and symptoms of bleeding but should have been. During an interview on 1/30/23 at 2:33 P.M., the Director of Nursing (DON) said the nurse who is admitting the resident should enter the anticoagulation protocol. She said the monitoring order should not have been part of the Resident's Plavix order; it should have been separated so there would be a space for staff to document if there were signs of bleeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document, and policy review, the facility failed to ensure all medications used in the facility were labeled in accordance with currently accepted professional principles. Specifically, the facility failed to ensure staff properly labeled all medications stored in 1 out of 3 medication carts reviewed and properly disposed of an outdated medication. Findings include: Review of the facility's policy titled, Storage of Medications, revised [DATE], indicated but was not limited to the following: -Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner On [DATE] at 1:51 P.M., the surveyor reviewed the Acushnet medication cart with Nurse #4 and observed the following: -One opened bottle of Brimonidine/Timolol (Combigan) 0.2/0.5% ophthalmic solution (used to treat high pressure inside the eye) inside the packaging box, seal broken, not labeled with the date when opened, not labeled with the expiration date, packaging box labeled 12/21, labeled with a resident's name -One opened bottle of Alphagan 0.1% ophthalmic solution (used to treat glaucoma or high fluid pressure in the eye) inside the packaging box, seal broken, labeled with an expiration date of [DATE]; packaging box not labeled with an open date or expiration date, labeled with a resident's name -One opened bottle of Timolol 0.5% ophthalmic solution (used to treat glaucoma) inside the packaging box, seal broken, not labeled with an open date or expiration date; packaging box labeled 1/2 and 1/3, labeled with a resident's name -One opened bottle of Hyosyne oral drops 15 milliliters (ml) (treats a variety of stomach/intestinal issues), seal broken, not labeled with an open date or expiration date, packaging box labeled as opened on 12/4 During an interview on [DATE] at 1:51 P.M., Nurse #4 said the Combigan, Timolol, and Hyosyne bottles were not labeled properly and if they got separated from the packaging box, staff would not know if they were still good. The surveyor reviewed the Meds with Short Expiration Dates document attached to Nurse #4's medication cart and she said the medications were not on it. Nurse #4 said the Alphagan eye drop expiration date should have been 2023, not 2022, but was not good anymore. She proceeded to peel off the resident label then discarded the bottle in the trash attached to the side of her medication cart without squeezing out the contents first. Residents were observed nearby. She said there were 27 residents on the unit with dementia. During an interview on [DATE] at 2:52 P.M., the Director of Nursing (DON) said she was not sure how long the bottles of Combigan, Timolol, or Hyosyne were good for and would locate the short-expiration list and get back to the surveyor. She said the expectation is that if you are the person opening the medication, then you label it with the date opened and the expiration date as well as on the actual bottles. The DON said if eye drops were expired, then staff were expected to squeeze out the contents, put the identifier label in shredding, then dispose of the bottle in the general trash. She said if this was not done, then it should not have been disposed of in the general trash where it could be accessible to residents nearby. During an interview on [DATE] at 8:04 A.M., the DON provided the surveyor with a short-term expiration document and said, per the pharmacy, the eye drops were good for 60 days and staff were to follow the manufacturer's expiration date for the Hyosyne oral drops.

Based on record review and interview, the facility failed to ensure staff maintained medical records that were accurate for one Resident (#82), out of a total sample of 28 residents. Specifically, the Resident's medical record demonstrated discrepancies with their advanced directive. Findings include: Review of the facility's policy titled, Advance Directives, revised September 2022, indicated but was not limited to the following: -The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive -Changes or revocations of a directive must be submitted in writing to the administrator. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. Resident #82 was admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies (abnormal deposits of a protein in the brain which can lead to problems with thinking, movement, behavior and mood), transient ischemic attack (TIA), legal blindness, major depressive disorder, and diabetes mellitus type 2. Review of the current Physician's Orders indicated: -Honor MOLST, 9/9/22 Review of the medical record indicated Resident #82 had a MOLST (standardized form that documents discussions about appropriate life-sustaining treatment) in place, signed and dated 9/8/22 by the physician and the Resident. The MOLST indicated Resident #82 was a Do Not Resuscitate (DNR), Do Not Intubate and Ventilate, and Do Not Use Non-Invasive Ventilation. Review of Resident #82's Advance Directive care plan, initiated 9/9/22, indicated the following: -Full Code The Advance Directive care plan failed to reflect Resident #82's current MOLST status that was dated and signed on 9/8/22. During an interview on 1/26/23 at 12:05 P.M., Nurse #4 said the MOLST and care plan were conflicting, but she always goes by the MOLST. During an interview on 1/26/23 at 1:05 P.M., the surveyor reviewed the medical record with the Director of Nursing (DON) who said the MOLST and advance directive care plan should have been matching but were not.

2. On 1/26/23 at 8:38 A.M., the surveyor observed Nurse #5 place her index finger inside a plastic pouch to add medications to be crushed without performing hand hygiene first or donning (to put on) gloves. Nurse #5 then opened a medication capsule and sprinkled the contents into a medication cup also without performing hand hygiene first or donning gloves. During an interview on 1/26/23 at 9:00 A.M., Nurse #5 said she probably should have performed hand hygiene and worn gloves prior to handling the medication and should not have touched the inside of the plastic pouch with her finger. During an interview on 1/26/23 at 2:52 P.M., the Director of Nursing said Nurse #5 should have worn gloves to handle the medication capsule and should not have put her finger inside the medication pouch. Based on observation, policy review, and interview, the facility failed to ensure infection control practices were implemented during medication pass. Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2015, indicated but was not limited to the following: -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before preparing or handling medications 1. On 1/24/23 at 9:26 A.M., the surveyor observed the following infection control breeches during Nurse #1's medication pass: -Nurse #1 accidentally knocked over a small stack of plastic medication cups. Nurse #1 picked up a medication cup which was lying on its side using her thumb (on the outside of the cup) and index finger (on the inside of the cup) to pick it up and place it on the medication cart. Nurse #1 then began pouring the medications into the medication cup. Nurse #1 brought the medications to the Resident. -Nurse #1 performed hand hygiene and continued with her medication administration. Nurse #1 touched several items within the medication cart: medication cards, pill bottles, and the drawer handles of the medication cart, as she put the medications in a cup. Nurse #1 then poured water into a plastic cup. She picked up the medication cup and water cup together with her index finger touching the inside of one cup and her thumb touching the inside of the other cup. During an interview on 1/24/23 at 9:50 A.M., Nurse #1 told the surveyor that she didn't even realize she had done this [touched the inside of the cups (water and medication)], but agreed that is was a breech in infection control.

Based on record review, policy review, and interview, the facility failed to implement the Antibiotic Stewardship protocols by not monitoring the continued/appropriate use of prophylactic antibiotics for two Residents (#80 and #11), in a total sample of 28 residents. Findings include: Antibiotic Stewardship is a program that promotes the appropriate use of antibiotics. This includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The facility is responsible for ensuring that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident, while also attempting to reduce the development of antibiotic-resistant organisms. According to the Centers for Disease Control and Prevention (CDC), the core elements of Antibiotic Stewardship included but were not limited to the following: -Facility leadership commitment to safe and appropriate antibiotic use -Implement policy(ies) or practice to improve antibiotic use -Track measures of antibiotic use in the facility Antibiotic usage/surveillance tools, referred to as a Line Listing, are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. The Line Listings will provide the Infection Preventionist (IP) with the following information: - Antibiotic usage and outcome data (documented using a facility approved antibiotic surveillance tracking form). - The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. - The IP will review all infections treated with antibiotics. - All antibiotic regimens will be documented on the surveillance tracking (Line Listings) form which includes but is not limited the following (form used by facility: - Resident name and room number - Category - Date of onset - Symptoms - Culture date - Site - Results - Treatment - Infection clear - HAI/CAI (Healthcare or Community acquired infection) - Count a. Resident #80 was admitted to the facility in July 2022 with diagnoses that included paraplegia and neuromuscular dysfunction of the bladder and had a Foley catheter in place. Review of the January 2023 Physician's Orders indicated the following: Macrodantin (antibiotic) Capsule 50 milligrams (mg) Five one capsule by mouth two times a day for prophylactic Urinary Tract Infection (UTI) (start date 9/19/22, no duration specified or resident specific rationale for the use). Review of the facility's Line Listings indicated the following: -On 10/4/22, the Resident's urine culture indicated that he/she had a UTI and was treated with Levaquin (antibiotic). -On 12/26/22, the Resident's urine culture indicated that he/she had a UTI and was treated with Bactrim DS (antibiotic) The Macrodantin continued to be administered twice a day with no oversight by the IP for the appropriate use or rationale for the continuation of the prophylactic antibiotic. b. Resident #11 was admitted to the facility in January 2022 with diagnoses including retention of urine and neuromuscular dysfunction of the bladder. Review of the Consultation Note from Resident #11's Urologist, dated 9/19/22, indicated Resident #11 had a history of urinary tract infections and ESBL colonized urine. The Urologist ordered an antibiotic (Keflex) 500 milligrams (mg) three times a day for 30 days and Hiprex (a urinary anti-infective medicine used to treat and prevent urinary tract infection) 1 gram (gm) twice daily indefinitely for UTI prophylaxis. Review of the manufacturer's instructions for use indicated unnecessary use of Hiprex can lead to its decreased effectiveness and the development of antibiotic-resistant bacteria. Review of a Nurse Practitioner's (NP) Progress Note, dated 11/28/22, indicated Resident #11 continued to receive prophylactic Hiprex and had a newly diagnosed UTI. The NP ordered the antibiotic Macrobid 100 mg twice daily for seven days. During an interview on 1/30/23 at 3:15 P.M., the IP said that she does not keep a list of residents who are receiving prophylactic antibiotics. She said that the resident information would be added to the line listing when the antibiotic was started, but she does not perform any routine monitoring/documentation/oversight for these residents after the initiation of the prophylactic antibiotic. The IP said that she has a couple of residents on prophylactic antibiotics but would have to review the line listings previous to October 2022 for the exact information related to Resident #80 and Resident #11 (surveyor reviewed the 10/2022, 11/2022 and 12/2022). The IP said that she does not review the residents on the prophylactic antibiotics routinely once the antibiotic was started. The IP had no process in place for the review of the continual need of the prophylactic antibiotic and did not routinely re-evaluate the prophylactic antibiotic for appropriate use for Resident #80 and Resident #11, according to the Antibiotic Stewardship program/protocol. The IP failed to provide the surveyor with a list of all residents receiving prophylactic antibiotics or with any supporting documentation prior to the survey team's exit.

6. Resident #28 was admitted to the facility with diagnoses including peripheral vascular disease, diabetes mellitus type 2, heart failure, and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Review of current Physician's Orders indicated the following: -Plavix (antiplatelet to prevent platelets, a type of blood cell, from sticking together and forming a dangerous blood clot) Tablet 75 milligrams (mg), give 1 tablet by mouth one time a day for blood thinner, monitor for bleeding, bruising, and black tarry stools, start date 11/24/19 Further review of Resident #28's medical record failed to indicate an interdisciplinary care plan had been developed for the use of a blood thinning medication that included measurable objectives, timeframes, and interventions. During an interview on 1/30/23 at 10:02 A.M., the Assistant Director of Nursing said Resident #28 should have a care plan for the use of Plavix but did not. During an interview on 1/30/23 at 2:33 P.M., the Director of Nursing said she must have inadvertently resolved the care plan and it should be active at this time but was not.Based on record review, interview, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#11, #19, #68, #86, #112, #28, and #80), out of 28 sampled residents. Specifically, the facility failed to: 1. For Resident #11, develop a comprehensive care plan for: a. frequent urinary tract infections, Extended Spectrum Beta-Lactamase (ESBL: enzymes that break down and destroy some commonly used antibiotics, including penicillins and cephalosporins, and make these drugs ineffective for treating infections) and prophylactic use of Hiprex (medication used to prevent or control returning urinary tract infections caused by certain bacteria), and b. the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment; 2. For Resident #19, develop a comprehensive care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment; 3. For Resident #68, develop a comprehensive care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment; 4. For Resident #86, develop a comprehensive care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment. 5. For Resident #112, develop a comprehensive care plan for: a. the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment, and b. the Resident's cardiac pacemaker; 6. For Resident #28, develop a care plan for the use of a blood thinning medication; and 7. For Resident #80, develop and implement an individualized plan of care for a pacemaker. Findings include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, last revised 4/25/22, included but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Include medical and nonmedical care that is appropriate to a resident's organs and bodily needs 1. Resident #11 was admitted to the facility in January 2022 with diagnoses including retention of urine, neuromuscular dysfunction of the bladder, psychotic disorder, major depression, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 12/12/22, indicated Resident #11 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, requires extensive assistance from two staff for all activities of daily living, is always incontinent of bowel and bladder, and received psychotropic medication daily. a. Review of the medical record indicated a 9/19/22 Consultation Note from Resident #11's Urologist. The physician indicated Resident #11 had a history of urinary tract infections and ESBL colonized urine. The Urologist ordered an antibiotic (Keflex) 500 milligrams (mg) three times a day for 30 days and Hiprex (a urinary anti-infective medicine used to treat and prevent urinary tract infection) 1 gram (gm) twice daily indefinitely for UTI prophylaxis. Review of a Nurse Practitioner's (NP) Progress Note, dated 11/28/22, indicated Resident #11 continued to receive prophylactic Hiprex and had a newly diagnosed UTI. The NP ordered the antibiotic Macrobid 100 mg twice daily for seven days. Review of the comprehensive care plans failed to indicate a care plan had been developed for the Resident's history of recurrent UTIs and prophylactic use of Hiprex. b. Review of the medical record indicated the following Physician's Orders for psychotropic medications: -Olanzapine (antipsychotic) 2.5 milligrams (mg), at bedtime every Monday, Thursday (10/24/22) -Olanzapine 5 mg, at bedtime every Tuesday, Wednesday, Friday, Saturday and Sunday (10/25/22) -Trazodone (antidepressant) 50 mg, at bedtime (2/9/22) Review of comprehensive care plans included but was not limited to: -Focus: At risk for adverse effects related to use of antipsychotic/antidepressant/hypnotic/antianxiety (1/21/22) -Interventions: AIMS testing per facility guidelines (1/24/22); evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs (1/21/22); notify MD of a decline in activity of daily living (ADL) ability or mood/behavior related to a dosage change (1/21/22); reduce environmental noise/distractions to facilitate sleep (1/24/22); report to physician signs of adverse reaction such as a decline in mental status, decline in positioning/ambulation, ability, lethargy, complaints of dizziness, tremors, etc (2/21/22) -Goal: Will show no side effects of medication use (1/21/22) Further review of the care plans failed to identify Resident specific targeted behaviors and/or signs and symptoms, non-pharmacological approaches, and measurable goals of treatment for the use of antidepressant and antipsychotic medications to meet the Resident's needs. During an interview on 1/27/23 at 1:21 P.M., the surveyor reviewed Resident #11's medical record with Unit Manager #2. She said the Resident's comprehensive care plans did not include his/her history of frequent UTIs and ongoing prophylactic use of Hiprex. She said the care plan needed to identify resident specific targeted behaviors for the use of psychotropic medications. 2. Resident #19 was admitted to the facility in September 2019 with diagnoses including type 2 diabetes mellitus, major depressive disorder, and dementia with behavioral disturbance. Review of the MDS assessment, dated 12/7/22, indicated Resident #19 had severe cognitive impairment as evidenced by a BIMS score of 2 out of 15, received insulin daily, and received psychotropic medication daily. Review of the medical record indicated the following Physician's Orders: -Depakote sprinkles (used to stabilize mood) 125 mg one time daily (1/31/20) -Gabapentin (used for anxiety) 300 mg one time daily (9/24/19) -Prozac (antidepressant) 30 mg daily in the morning (12/10/22) -Risperidone (antipsychotic) 0.25 mg three times a day (12/10/22) -Trazodone (used to treat anxiety/depression) 50 mg, give half a tablet at bedtime (7/22/21) Review of the comprehensive care plans included but was not limited to: -Focus: At risk for adverse effects related to use of antipsychotic/antidepressant/hypnotic/antianxiety (9/19/19) -Interventions: Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs (9/19/19); GDR Risperdal 10/17/19; notify MD of a decline in activity of daily living (ADL) ability or mood/behavior related to a dosage change (9/19/19); Psychiatrist consult and follow-up as needed (9/19/19); report to physician signs of adverse reaction such as a decline in mental status, decline in positioning/ambulation, ability, lethargy, complaints of dizziness, tremors, etc. (9/19/19) -Goal: Will show no side effects of medication use (9/19/19) Further review of the care plans failed to identify Resident specific targeted behaviors and/or signs and symptoms, non-pharmacological approaches, and measurable goals of treatment for the use of antidepressant and antipsychotic medications to meet the Resident's needs. During an interview on 1/27/23 at 12:20 P.M., the surveyor reviewed Resident #19's medical record with Unit Manager #2. She said the care plan needs to identify resident specific targeted behaviors for the use of antidepressant and antianxiety medications. 3. Resident #68 was admitted to the facility in December 2022 with diagnoses including major depressive disorder. Review of the MDS assessment, dated 12/9/22, indicated Resident #68 has severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and receives antidepressant medication daily. Review of the medical record indicated the following Physician's Order: -Citalopram Hydrobromide (antidepressant) 20 mg one time a day (12/2/22) Review of comprehensive care plans failed to indicate a care plan had been developed for the use of Citalopram and the diagnosis of major depression with resident specific targeted behaviors and/or signs and symptoms of depression, non-pharmacological interventions, and measurable goals of treatment for the use of the psychotropic medication. During an interview on 1/27/23 at 12:20 P.M., the surveyor and Unit Manager #2 reviewed Resident #68's medical record. She said the care plan needs to identify resident specific targeted behaviors for the use of antidepressant and antianxiety medications. 4. Resident #86 was admitted to the facility in January 2021 with diagnoses including major depressive disorder. Review of the MDS assessment, dated 1/11/23, indicated Resident #86 has severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, and received antidepressant medication daily. Review of the medical record indicated the following Physician's Orders: -Trazodone 25 mg at bedtime (7/22/22) -Zoloft (antidepressant) 50 mg at bedtime (8/22/22) Review of comprehensive care plans failed to indicate a care plan had been developed for the use of Trazodone and Zoloft and the diagnosis of major depression with resident specific targeted behaviors and/or signs and symptoms of depression, non-pharmacological interventions, and measurable goals of treatment. 5. Resident #112 was admitted to the facility in April 2022 with diagnoses including the presence of a cardiac pacemaker, psychotic disturbance, mood disturbance and anxiety. Review of the MDS assessment, dated 11/4/22, indicated Resident #112 has severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, has a cardiac pacemaker and receives antidepressant medication daily. Review of the medical record indicated the following Physician's Orders: -Trazodone 25 mg in the afternoon (10/25/22) -Trazodone 50 mg two times a day (10/25/22) -Trazodone 50 mg every 24 hours as needed (12/24/22, d/c 2/24/23) -Pacemaker check: frequency and directions. Bi-annual (11/25/22) a. Review of comprehensive care plans failed to indicate a care plan had been developed for the use of Trazodone and the diagnoses of psychotic mood disturbance, mood disturbance and anxiety with resident specific targeted behaviors and/or signs and symptoms, non-pharmacological interventions, and measurable goals of treatment. b. Review of comprehensive care plans included but was not limited to: -Focus: Cardiac disease related to hypertension, hyperlipidemia (1/7/22); -Interventions: Administer medications per physician's orders (1/7/22); obtain vital signs as indicated and report significant changes to physician (1/7/22); pacemaker checks as ordered (1/7/22) -Goal: Will remain free of complications related to pacemaker (1/7/22); will exhibit no acute cardiac distress such as complaints of chest pain, cyanosis, shortness of breath, etc. (1/7/22); blood pressure will remain within patient's normal limits (1/7/22); will experience effective symptom management (1/7/22). The care plan failed to include any information about the pacemaker device and any symptoms to monitor for pacemaker failure. During an interview on 1/26/23 at 12:35 P.M., Unit Manager #2 reviewed Residents #11, #19, #68 and #112's medical record and said the care plans for psychotropic medications did not include resident specific targeted behaviors and/or signs and symptoms to monitor, non-pharmacological interventions and measurable goals of treatment to meet the Residents' needs. She said that a pacemaker care plan should have been developed for Resident #112 that included information about the pacemaker device, symptoms for staff to monitor for pacemaker failure as well as contact information for the Resident's cardiologist. 7. Resident #80 was admitted to the facility in December 2022 with diagnoses including dementia, complete atrioventricular (AV) heart block with the presence of a cardiac pacemaker, and congestive heart failure. Review of comprehensive care plans failed to indicate that a comprehensive care plan had been developed related to the Resident's pacemaker with a focus, goal or interventions/tasks that included the following information (at a minimum but not be limited to): -The type of pacemaker, model, serial number, date of implant, the cardiologist responsible for care of the Resident's pacemaker, and frequency of the pacemaker monitoring. During an interview on 1/26/23 at 12:02 P.M., Unit Manager #1 said that Resident #80 did have a pacemaker in place and that a care plan had not been developed and implemented for the Resident's pacemaker.

Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for nine Residents (#53, #62, #112, #86, #19, #68, #63, #232, and #80), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #53, to ensure diabetic management; 2. For Resident #62, to ensure orders were in place for monitoring hyper/hypoglycemia with treatment interventions to address the potential for hyper/hypoglycemia; 3. For Resident #112, to ensure orders were in place for: a. monitoring for signs and symptoms of hyper/hypoglycemia, b. FSBS (finger stick blood sugars) to obtain blood glucose levels in order to implement a sliding scale, and c. FSBS to obtain blood glucose levels in order to implement the hypoglycemic protocol; 4. For Resident #86, to ensure orders were in place for: a. monitoring for signs and symptoms of hyper/hypoglycemia, b. FSBS to obtain blood glucose levels in order to implement a sliding scale, and c. FSBS to obtain blood glucose levels in order to implement the hypoglycemic protocol; 5. For Resident #19, to ensure orders were in place for a. monitoring for signs and symptoms of hyper/hypoglycemia, b. FSBS to obtain blood glucose levels in order to implement the hypoglycemic protocol, and c. treatment interventions for the potential of hyperglycemia; 6. For Resident #68, to ensure that medications were administered according to physician's orders; 7. For Resident #63, to administer medication as ordered by the physician resulting in a medication error; 8. For Resident #232, to ensure: a. orders were in place for FSBS to obtain capillary blood glucose levels daily, and b. wound dressing changes were completed and accurately documented according to physician's orders; and 9. For Resident #80, to ensure: a. there was information/documentation in the medical record for the care and treatment of the Resident's pacemaker, and b. a physician's order for one to one (1:1) supervision had been obtained. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website content titled, Manage Blood Sugar, last reviewed September 2022, indicated but was not limited to the following: It's important to keep your blood sugar levels in your target range as much as possible to help prevent or delay long-term, serious health problems such as heart disease, vision loss, and kidney disease. Symptoms of low blood sugar include: -shaking -sweating -nervousness or anxiety -irritability or confusion -dizziness -hunger Symptoms of high blood sugar include: -feeling very thirsty -feeling very tired -having blurry vision -needing to urinate more often -high ketones (high ketones can be an early sign of diabetic ketoacidosis, which is a medical emergency and needs to be treated immediately) A blood sugar target is the range you try to reach as much as possible. These are typical targets: -Before a meal 80-100 mg/dL (milligrams/deciliter) -Two hours after the start of a meal: less than 180 mg/dL Review of the Centers for Disease Control and Prevention (CDC) website content titled, All About Your A1C, last reviewed September 2022, indicated but was not limited to the following: The A1C test- also known as the hemoglobin A1C or HbA1c test- is a simple blood test that measures your average blood sugar levels over the past three months. It is one of the commonly used tests to diagnose prediabetes and diabetes and is also the main test to help you and your health care team manage your diabetes. Higher A1C levels are linked to diabetes complications. If you have diabetes, get an A1C test at least twice a year, more often if your medicine changes or if you have other health conditions. Your A1C Result: -Normal (below 5.7%) -Diabetes (6.5% or above) Review of the facility's policies, Blood Glucose Monitoring, last revised 6/2012 and Diabetes-Clinical Protocol, last revised 11/2020, included but was not limited to: -The Physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters such as glycosuria ( glucose, or sugar, in your urine), weight gain or loss, hypoglycemic (low blood sugar)episodes, etc. 1. Resident #53 was admitted to the facility with diagnoses including diabetes mellitus (DM) with hyperglycemia (high blood sugar). Review of the January 2023 Physician's Orders indicated the following antidiabetic medications: -Lantus SoloStar Solution Pen-injector 100 units/milliliter (ml) (Insulin Glargine), Inject 18 units subcutaneously one time a day for DM (9/20/22) -Lantus SoloStar Solution Pen-injector 100 units/ml, Inject 56 units subcutaneously at bedtime for DM (9/19/22) -Novolog PenFill Solution Cartridge 100 units/ml (Insulin Apart), Inject as per sliding scale: if 0-149 = 0 Units; 150-199 = 2 Units; 200-249 = 4 Units; 250-299 = 6 Units; 300-349 = 8 Units; 350-399 = 10 units; 400-449 = 12 Units; 450-999 = 14 Units, subcutaneously before meals and at bedtime related to DM (10/22/21) The physician's orders failed to indicate an order to monitor for signs and symptoms of hyperglycemia. Review of the facility's December 2022 and January 2023 Blood Sugar Summary indicated documented blood sugars ranging from 111.0 mg/dL (milligrams/deciliter) to 419.0 mg/dL. Of the 205 documented blood sugars, they indicated the following: -1 entry over 400 mg/dL -88 entries 300-399 mg/dL -97 entries 200-299 mg/dL -19 entries 100-199 mg/dL Further review of Resident #53's medical record indicated the last hemoglobin A1C (blood test that measures your average blood sugar levels over the past three months) test was in June 2022 and resulted as 14.0% (H) (normal lab range 4.0-6.0%). During an interview on 1/23/23 at 9:24 A.M., Resident #53 said his blood sugars were high all the time. During an interview on 1/26/23 at 3:54 P.M., the Assistant Director of Nursing (ADON) said staff typically just puts in a hypoglycemic protocol (interventions to treat) and not a hyperglycemic protocol but, with him/her, his/her sugars were so high she probably would have. The ADON said there was no physician's order to monitor and report signs and symptoms of hyperglycemia. During an interview on 1/30/23 at 9:00 A.M., the surveyor reviewed the Blood Sugar Summary with Physician #2 who said nurses should have been automatically monitoring for signs and symptoms of hyperglycemia. He said he would consider the Resident's June 2022 A1C value and, anything above 7.0%, to be uncontrolled. He said the Resident is being treated for a chronic ulcer which can increase his/her blood sugars. Physician #2 said the Resident's A1C should have been drawn every three months. During an interview on 1/30/23 at 9:06 A.M., Physician #2 said the Resident is difficult and he would refer the Resident to an endocrinologist (medical doctors who specialize in diagnosing and treating health conditions related to the body's hormones, hormonal glands, and related tissues). During an interview on 1/30/23 at 10:03 A.M., Physician #2 said Resident #53 was very non-compliant with his diet. The ADON was at the nurses' station and said if that was the case then the Resident should have been care planned for non-compliance with diet with listed interventions but was not. Physician #2 said there should have been an order for hyperglycemia monitoring. During an interview on 1/30/23 at 2:36 P.M., the surveyor reviewed the medical record with the Director of Nursing (DON) who said typically they have an order for CBG's (type of blood test) with parameters to notify the physician and obtain further insulin orders, but there was not an order to do this. She said they did not have a hyperglycemic protocol to enter for monitoring and the Resident should have had a non-compliance care plan developed to include objectives and interventions if he/she was resistive to his/her diet. 2. Resident #62 was admitted to the facility with diagnoses including type 2 diabetes mellitus with hyperglycemia and chronic kidney disease. Review of the January 2023 Physician's Orders indicated the following antidiabetic medications: -Humalog Solution 100 units/ml, inject 10 units subcutaneously one time a day related to type 2 diabetes mellitus with hyperglycemia (6/24/22) -Humalog Solution 100 units/ml, inject 6 units subcutaneously one time a day related to type 2 diabetes mellitus with hyperglycemia (6/23/22) -Humalog Solution 100 units/ml, inject 8 units subcutaneously one time a day related to type 2 diabetes mellitus with hyperglycemia (6/23/22) -Humalog Solution 100 units/ml, Inject as per sliding scale: if 0-149 = 0 Units; 150-199 = 2 Units; 200-249 = 4 Units; 250-299 = 6 Units; 300-349 = 8 Units; 350-399 = 10 units; 400-999 = 12 Units, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with hyperglycemia (2/10/22) The physician's orders failed to indicate an order to monitor for hypo/hyperglycemia and failed to include interventions to address potential serious side effects of hypo/hyperglycemia. Review of the facility's December 2022 and January 2023 Blood Sugar Summary indicated documented blood sugars ranging from 76.0 mg/dL to 365 mg/dL. The following documented blood sugars failed to indicate a corresponding nurse's note to indicate if the Resident was symptomatic or if any interventions/treatments were implemented: 1/5/23 - 76.0 mg/dL 1/11/23 - 79.0 mg/dL During an interview on 1/30/23 at 11:39 A.M., Nurse #5 said there was no order in place to monitor for signs and symptoms of hypo/hyperglycemia and, if there was no order, then it would not be on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for nurses to document. Nurse #5 said there were no orders in place for interventions to address potential serious side effects of hypo/hyperglycemia. During an interview on 1/30/23 at 2:46 P.M., the Director of Nursing (DON) reviewed the medical record and said there should have been an order to monitor for signs and symptoms of hypoglycemia, and hyperglycemia if the doctor says to. The DON further said there was no hypo/hyperglycemic protocol for Resident #62. She said if the Resident was hypoglycemic on 1/5/23 and 1/11/23 they would have notified the physician but there were no corresponding nurses' notes. She said she was unable to determine if the Resident was symptomatic or not if there were no nurses' notes. 3. Resident #19 was admitted to the facility in September 2019 with diagnoses including type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 12/7/22, indicated Resident #19 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 2 out of 15 and received insulin injections daily. Review of the January 2023 Physician's Orders included but was not limited to: -Basaglar KwikPen Solution Pen-Injector 100 unit/milliliters, inject 15 units subcutaneously ((sc)under the skin) in the morning (10/11/22) -Hypoglycemic protocol-for blood sugar less than 80 if symptomatic or blood sugar less than 70 with or without symptoms present: 1. Administer approximately 15 grams (g) of glucose by mouth or carbohydrates found in any of the following: 1/2 cup juice, 1/2 cup applesauce, 1 cup milk, 1 tube glucose gel, 3 glucose tablets; 2. Wait 15 minutes; 3. Recheck blood glucose levels. If level is still below the target, give another 15 g of glucose by mouth or follow with a meal or snack within an hour; 4. If the resident is unable to swallow administer glucagon 1 milligram (mg) intramuscularly immediately. A. Recheck blood glucose levels in 15 minutes, if no response may repeat one time. B. Notify Physician for continuing orders (9/18/19) The Physician's orders failed to include an order to monitor for signs and symptoms of hyper/hypoglycemia, failed to include an order for finger stick blood sugars to obtain blood glucose levels to implement the hypoglycemic protocol and failed to include any interventions to address potential serious side effects of hyperglycemia. 4. Resident #86 was admitted to the facility in January 2021 with diagnoses including type 2 diabetes mellitus. Review of the MDS assessment, dated 1/11/23, indicated Resident #86 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15 and received insulin injections daily. , Review of the January 2023 Physician's Orders included but was not limited to: -Lantus SoloStar Solution Pen-Injector 100 unit/ml, inject 26 units sc one time a day (3/23/22) -Metformin (diabetic treatment) HCI 1000 mg twice daily (1/3/21) -NovoLog FlexPen Solution Pen-Injector 100 unit/ml, inject 5 units sc one time a day (8/23/22) -NovoLog FlexPen Solution Pen-Injector 100 unit/ml, inject 7 units sc in the afternoon (8/23/22) -NovoLog FlexPen Solution Pen-Injector 100 unit/ml, inject 7 units sc in the evening (8/23/22) -NovoLog FlexPen Solution Pen-Injector 100 unit/ml, inject as per sliding scale sc before meals and at bedtime (3/28/22): -if 0-70=0 proceed with hypoglycemic protocol -71-150=0 -151-200=2 units -201-250=4 units -251-300=6 units -301-350=8 units -351-400=10 units -401-999=12; if over 500, notify Physician -Hypoglycemic protocol-for blood sugar less than 80 if symptomatic or blood sugar less than 70 with or without symptoms present: 1. Administer approximately 15 grams (g) of glucose by mouth or carbohydrates found in any of the following: 1/2 cup juice, 1/2 cup applesauce, 1 cup milk, 1 tube glucose gel, 3 glucose tablets; 2. Wait 15 minutes; 3. Recheck blood glucose levels. If level is still below the target, give another 15 g of glucose by mouth or follow with a meal or snack within an hour; 4. If the resident is unable to swallow administer glucagon 1 milligram (mg) intramuscularly immediately. A. Recheck blood glucose levels in 15 minutes, if no response may repeat one time. B. Notify Physician for continuing orders (1/3/21) The Physician's orders failed to include an order to monitor for signs and symptoms of hyper/hypoglycemia, failed to include an order for finger stick blood sugars to obtain blood glucose levels to implement the order for sliding scale insulin four times a day and to implement the hypoglycemic protocol. 5. Resident #112 was admitted to the facility in April 2022 with diagnoses including type 2 diabetes mellitus. a. Review of the MDS assessment, dated 11/4/22, indicated Resident #112 received insulin injections daily. Review of January 2023 Physician's Orders included but was not limited to: -CBG as needed (4/28/22) -CBG four times a day (4/28/22) -Humalog Solution 100 unit/ml, inject 5 units sc with meals (5/4/22) -Levemir FlexTouch Solution Pen-Injector 100 unit/ml, inject 12 units sc in the morning (12/11/22) -Januvia (anti-diabetic) 50 mg every morning (4/30/22) -HumaLog KwikPen Solution Pen-Injector 100 unit/ml, inject sc as per sliding scale four times a day (5/4/22): -0-149=0 -150-199=2 units -200-249=4 units -250-299=6 units -300-349=8 units -350-300=10 units -400-449=12 units -450-999=14 units, notify Physician if greater than 450 -Hypoglycemic protocol-for blood sugar less than 80 if symptomatic or blood sugar less than 70 with or without symptoms present: 1. Administer approximately 15 grams (g) of glucose by mouth or carbohydrates found in any of the following: 1/2 cup juice, 1/2 cup applesauce, 1 cup milk, 1 tube glucose gel, 3 glucose tablets; 2. Wait 15 minutes; 3. Recheck blood glucose levels. If level is still below the target, give another 15 g of glucose by mouth or follow with a meal or snack within an hour; 4. If the resident is unable to swallow administer glucagon 1 milligram (mg) intramuscularly immediately. A. Recheck blood glucose levels in 15 minutes, if no response may repeat one time. B. Notify Physician for continuing orders (1/3/21) The Physician's orders failed to include an order to monitor for signs and symptoms of hyper/hypoglycemia, failed to include an order for finger stick blood sugars to obtain blood glucose levels to implement the order for sliding scale insulin four times a day and to implement the hypoglycemic protocol. b. Review of the facility's policy, Care of a Resident with a Pacemaker, last revised December 2015 included but was not limited to: The two most common arrhythmias that require a pacemaker are sinus bradycardia and heart block -Heart block occurs when there is a slowing or complete blockage of the electrical conductivity in the heart -If the pulse generator or battery fails, or if the leads become displaced the pacemaker may not work properly, leading to bradyarrhythmia -Monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia -Symptoms associated with bradyarrhythmia may include: a. syncope (fainting) b. shortness of breath c. dizziness d. fatigue, and/or e. confusion -Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. -Pacemaker batteries and generator will be replaced by a cardiologist as needed, usually every five to eight years. -For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of the cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Pace rate. -When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, internet) b. Type of heart rhythm; c. Functioning of the leads: d. Frequency of utilization; and e. Battery life. Review of the January 2023 Physician's Orders included but was not limited to: -Pacemaker check: frequency and directions. Bi-annual (11/25/22) There was no Physician's order to monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia: syncope, shortness of breath, dizziness, fatigue and/or confusion according to facility policy and standards of practice. Review of Resident #112's comprehensive care plans included but was not limited to: -Focus: Cardiac disease related to hypertension, hyperlipidemia (1/7/22); -Interventions: Administer medications per physician's orders (1/7/22); obtain vital signs as indicated and report significant changes to physician (1/7/22); pacemaker checks as ordered (1/7/22) -Goal: Will remain free of complications related to pacemaker (1/7/22); will exhibit no acute cardiac distress such as complaints of chest pain, cyanosis, shortness of breath, etc (1/7/22); blood pressure will remain within patient's normal limits (1/7/22); will experience effective symptom management (1/7/22). The medical record failed to identify the type of pacemaker, type of leads, manufacturer and model, serial number, date of implant and pace rate. Review of a Consultation Note, dated 11/23/22, indicated Resident #112 had an appointment with his/her cardiologist on 11/23/22. The note indicated the Resident's pacemaker had normal function and had 2 to 5 years of battery life left. The note failed to indicate the type of pacemaker, type of leads, manufacturer, model, serial number, date of implant and pace rate. Further review of the medical record failed to indicate a Physician's order for Resident #112 to be evaluated by the cardiologist. During an interview on 1/26/23 at 12:35 P.M., Unit Manager #2 reviewed Resident #112's medical record and said they are not monitoring for signs and symptoms of bradyarrhythmia but should be according to the facility's policy. She said the care plan for the Resident's cardiac status was incomplete and did not include any required information about the pacemaker. She said she knows the pacemaker was implanted in 2016 but does not know much else about it except that the Resident went out to see the cardiologist a few months ago. The Unit Manager was unable to find a Physician's order for Resident #112 to be evaluated by the cardiologist. 6. Resident #68 was admitted to the facility in December 2022 with diagnoses including hypotension. Review of December 2022 and January 2023 Physician's Orders included but was not limited to: -Midodrine (anti-hypotensive) HCI 2.5 milligrams (mg) three times a day. Hold if systolic (Systolic blood pressure: the top number, measures the force the heart exerts on the walls of the arteries each time it beats) blood pressure is greater than or equal to 130. Do not administer after the evening meal or 4 hours from bedtime to avoid supine hypertension (12/2/22, discontinued 1/23/23) -Midodrine HCI 2.5 mg two times a day. Hold if systolic blood pressure is greater than or equal to 130. Do not administer after the evening meal or 4 hours from bedtime to avoid supine hypertension (1/23/23) The Physician's orders failed to include an order to monitor the Resident for signs and symptoms of hypotension. Review of December 2022 Medication Administration Record (MAR) indicated Midodrine was administered (as indicated by a check mark and staff initials in corresponding boxes) to Resident #68 on 10 occasions when the Resident's systolic blood pressure was greater than or equal to 130 and should not have been administered as follows: -12/10/22 at 11:00 A.M.=138/80 -12/12/22 at 11:00 A.M.=136/25 -12/17/22 at 11:00 A.M.=134/72 -12/18/22 at 6:00 A.M.=140/80 -12/18/22 at 11:00 A.M.=132/74 -12/19/22 at 4:00 P.M.=139/74 -12/21/22 at 4:00 P.M.=130/78 -12/28/22 at 4:00 P.M.=132/78 -12/29/22 at 4:00 P.M.= 130/74 -12/30/22 at 6:00 A.M.=134/76 Review of the January 2023 MAR indicated Midodrine was administered to Resident #68 on 17 occasions when the Resident's systolic blood pressure was greater than or equal to 130 and should not have been administered as follows: -1/1/23 at 6:00 A.M.=138/70 -1/1/23 at 4:00 P.M.=132/72 -1/6/23 at 4:00 P.M.=159/90 -1/7/23 at 11:00 A.M.=138/82 -1/7/23 at 4:00 P.M.=146/80 -1/8/23 at 6:00 A.M.=138/82 -1/8/23 at 11:00 A.M.=131/75 -1/10/23 at 4:00 P.M.=142/82 -1/11/23 at 6:00 A.M.= blank -1/12/23 at 6:00 A.M.=132/72 -1/12/23 at 4:00 P.M.=130/70 -1/13/23 at 4:00 P.M.=168/78 -1/16/23 at 11:00 A.M.=130/69 -1/16/23 at 4:00 P.M.=138/88 -1/17/23 at 4:00 P.M.=130/80 -1/18/23 at 11:00 A.M.=133/83 -1/19/23 at 11:00 A.M.=168/79 -1/19/23 at 4:00 P.M.=139/80 During interviews on 1/26/23 at 12:35 P.M. and 1/27/23 at 2:05 P.M., the surveyor and Unit Manager #2 reviewed Residents #19, #86, #112 and #68's medical records. Unit Manager #2 said nursing should be monitoring for signs and symptoms of hyper- and hypoglycemia and there has to be Physician's orders for FSBS to obtain capillary blood glucose levels before administering sliding scale insulin and to implement the hypoglycemia protocol. Unit Manager #2 said Resident #68 moved to her unit in early January 2023. Unit Manager #2 reviewed the January 2023 Medication Administration Record (MAR) and said nursing did not hold Resident #68's antihypotensive medication according to parameters ordered by the Physician. During an interview on 1/27/23 at 2:25 P.M., the surveyor and Unit Manager #1 reviewed Resident #68's medical record. She said Resident #68 resided on her unit from admission to early January 2023. Unit Manager #1 reviewed the December 2022 MAR and said nursing did not hold Resident #68's hypotensive medication according to parameters ordered by the Physician. 9. Resident #80 was admitted to the facility in December 2022 with diagnoses including Dementia, complete atrioventricular (AV) heart block with the presence of a cardiac pacemaker and congestive heart failure. Record review indicated that there was no information regarding Resident #80's pacemaker. The medical record failed to indicate any of the required documentation of the Resident's pacemaker i.e., type of pacemaker, type of leads, manufacturer and model, serial number, date of implant, and the paced rate per facility policy. The medical record also failed to include any physician's orders for monitoring/checks with a name and/or telephone number of a cardiologist responsible for care of the Resident's pacemaker, any cardiology notes for the management and frequency of the pacemaker monitoring and battery life as well as any appointment dates to ensure the implanted device was working properly. During an interview on 1/26/23 at 12:02 P.M., Unit Manager #1 said that Resident #80 did have a pacemaker in place and that none of the required information had been obtained upon admission or as of 1/26/23 for the Resident's pacemaker according to the facility policy/protocol. b. Review the facility's policy titled One to One Staff Supervision of Residents (revised 1/2013) indicated but was not limited to the following: Residents will have adequate and safe supervision according to their level of need. Continuous one to one supervision will be provided when a resident is exhibiting behaviors that put the resident at immediate risk of harm to him/herself or others. Continuous one to one supervision will be maintained until the resident is stabilized (no longer exhibiting behaviors that put him/herself at immediate risk of harm). Process -Identify the need for continuous one to one supervision as described above -The charge nurse will call the physician and notify him/her of the change in the resident's condition and assessment findings -The charge nurse will obtain an order from the physician for the continuous one to one monitoring -The charge nurse and staff members implement ongoing continuous one to one monitoring and related documentation according to the physician's order -The charge nurse updates the note, the care plan and the care card -One to one supervision may also be modified to time periods less than 24 hours a day if it is determined by the physician and collaboration with the interdisciplinary team that this is safe and appropriate for the resident Review of the facility Incident Report, dated 1/23/23, indicated that the resident was found on the floor on the 3:00 P.M. to 11:00 P.M. shift. No injury sustained. The Resident was asked if he/she fell or slid out of the chair and the Resident stated, I didn't fall. The incident report indicated Immediate action taken place as a call was placed to the family, physician and management. 1:1 monitoring on the 3:00 P.M. to 11:00 P.M. shift (The physician and family member were notified on 1/23/23 at 10:19 P.M.) Record review indicated that a physician's order for the 1:1 supervision had not been transcribed/entered into the electronic medical record as per the facility policy. During an interview on 1/30/23 at 1:05 P.M., Unit Manager #1 said that the physician's order for 1:1 supervision had not been obtained and transcribed/entered into the EMR as per the facility policy. 7. Resident #63 was admitted to the facility in January 2023 with diagnoses that included insomnia. Review of the January 2023 Physician's Orders indicated the following: -Trazodone (anti-depressant) 25 mg daily at hour of sleep (1/7/23). On hold. Review of the medical record indicated on 1/7/23, the informed consent for the Trazodone was signed. Review of the Nurse's Note, dated 1/8/23, indicated the Trazodone had been placed on hold until the consent form for psychotropic medications was signed. Review of the January 2023 Medication and Treatment Administration Records indicated the Resident was not administered the medication as ordered and after having obtained the consent. During an interview on 1/27/23 at 12:05 P.M., the Unit Manager said the medication should have been started after obtaining the consent for the psychotropic medication on 1/7/23. She said the on hold should have been removed and the medication administered. The Unit Manager said the Resident did not get the medication as ordered because the on hold had not been taken off the orders. She said this was a medication error. 8. Resident #232 was admitted to the facility in January 2023 with diagnoses that included diabetes mellitus (DM) and a below the left knee amputation. a. Review of the January 2023 Physician's Orders indicated the following: -Capillary Blood Glucose (CBG) daily for DM. Further record review did not indicate a physician's order to perform a FSBS in order to obtain a CBG. During an interview on 1/27/23 at 1:20 P.M., Nurse # 6 said she was unaware a physician's order to perform FSBS checks was required. b. Review of Resident #232's January 2023 Physician's Orders indicated the following: Left below amputation: cleanse surgical wound with normal saline, pat dry, apply gauze dressing. Review of Resident #232's, January 2023 physician's orders indicated the following: Left below knee amputation: cleanse surgical wound with normal saline, pat dry, apply gauze dressing. During an interview on 1/27/23 at 1:00 P.M., Resident #232 said that his/her dressing/treatment had not been done in two days. Review of the medical record indicated the dressing was done daily with no breaks in the treatment. On 1/27/23 at 1:15 P.M., the surveyor and Unit Manager #1 observed Resident #232's dressing, and it was dated 1/25/23. Unit Manager #1 said she had done the treatment on 1/25/23 and said it had not been done since. Unit Manager #1 said the nurse who signed the Treatment / Medication Administration Forms should not have. She said the physician's orders were not followed.

Based on observation, policy review, record review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for two Residents (#85 and #62), in a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #85, to ensure that Oxygen (O2) was administered according to physician's orders, maintain consistent documentation of Oxygen liter flow, and ensure proper care and storage of respiratory equipment; and 2. For Resident #62, to ensure proper care and storage of respiratory equipment. Findings include: Review of the facility's policy titled Oxygen Administration, revised October 2010, indicated but was not limited to the following: -Adjust the oxygen delivery device so the proper flow of oxygen is being administered -After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: the rate of oxygen flow, route, and rationale 1. Resident #85 was admitted to the facility with diagnoses including shortness of breath, chronic obstructive pulmonary disease (COPD) (group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation, pneumonia, and acute and chronic respiratory failure with hypoxia. Review of current Physician's Orders indicated the following: -Oxygen therapy 1-2 Liters (L) via nasal cannula - continuous documentation every shift related to COPD with acute exacerbation, Oxygen (O2) saturation (O2 sat) Liters O2, while on O2 (12/29/22) -Performist Nebulization Solution 20 micrograms (mcg)/2 milliliter (ml), 1 vial inhale orally via nebulizer two times a day for COPD (12/28/22) Review of the January 2023 Medication Administration Record (MAR) indicated that the Oxygen liter flow was not documented per physician's order for 19 out of 25 day shifts, 19 out of 24 evening shifts, and 19 out of 24 night shifts. During an observation with interview on 1/23/23 at 1:28 P.M., the surveyor observed Resident #85 lying in bed with a nasal cannula (lightweight tube which one end splits into two prongs which are placed in the nostrils from which a mixture of oxygen and air flows) in place attached to an O2 cylinder delivering 3L of Oxygen. A nebulizer machine was observed on top of the Resident's side table. Resident #85 said he/she used the nebulizer for his/her breathing. On 1/25/23 at 7:52 A.M., the surveyor observed Resident #85 sitting at the side of the bed with a nasal cannula in place attached to an O2 cylinder delivering 3L of Oxygen. His/her nebulizer mask and attached tubing were resting on top of the Resident's mattress, not contained, and exposed to potential environmental contaminants. A clear plastic bag was observed lying on the floor next to the bed. On 1/26/23 at 8:04 A.M., the surveyor observed Resident #85 with a nasal cannula in place attached to an O2 cylinder delivering 3L of Oxygen. During an observation with interview on 1/26/23 at 11:36 A.M., the surveyor and Nurse #4 reviewed the Resident's respiratory equipment and observed the Oxygen liter flow set at 3L. Nurse #4 said the liter flow should be 1-2 Liters per the physician's order, not 3 Liters. The surveyor then reviewed the medical record with Nurse #4 who said the O2 liter flow was not being consistently documented. During an observation with interview on 1/26/23 at 11:56 A.M., the surveyor and Nurse #4 observed the Oxygen Liter flow set at 3L and the Resident's nebulizer mask and tubing resting on top of the nebulizer machine not contained and exposed to potential environmental contaminants. Nurse #4 said the liter flow should have been set at 2 Liters and the nebulizer mask and tubing stored in a plastic bag but were not. During an interview on 1/26/23 at 12:44 P.M., the Director of Nursing (DON) said the expectation was that nebulizer equipment be stored properly in a plastic bag when not in use. During an interview on 1/26/23 at 1:49 P.M., the surveyor reviewed the Resident's medical record with the DON and Corporate Staff #1 who said the expectation is for staff to follow physician's orders for liter flow and staff should have been consistently documenting the liter flow on the MAR but were not. 2. Resident #62 was admitted to the facility with diagnoses including bronchitis, malignant neoplasm of unspecified part of right bronchus or lung, chronic obstructive pulmonary disease, and pneumonia. Review of the current Physician's Orders indicated the following: -Performist Nebulization Solution 20 micrograms (mcg)/2 milliliters (ml), 1 vial inhale orally via nebulizer two times a day for shortness of breath (6/14/22) On 1/23/23 at 9:10 A.M. and 1/25/23 at 8:15 A.M., the surveyor observed the nebulizer mouthpiece and tubing resting on top of the nebulizer machine, not contained, and exposed to potential environmental contaminants. Resident #62 said he/she used the nebulizer machine for shortness of breath and for a history of lung cancer. On 1/30/23 at 11:09 A.M., the surveyor observed Resident #62's nebulizer mask and tubing resting on top of the nebulizer machine, not contained, and exposed to potential environmental contaminants. A clear plastic bag was observed on the seat of the Resident's wheelchair next to his/her bed. During an interview on 1/30/22 at 11:36 A.M., Nurse #5 said the nebulizer mouthpiece/tubing should be stored in a protective bag. During an interview on 1/30/23 at 2:52 P.M., the DON said the expectation was when nebulizer equipment was not in use, that it be stored in a bag.

Based on document review, observation, and interview, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice set forth by the Centers for Disease Control and Prevention (CDC) and manufacturer's guidelines during a COVID-19 outbreak in the facility. Findings include: Review of the manufacturer's guidelines for the use of the Celltrion DiaTrustTM COVID-19 Ag Rapid Test indicated but was not limited to the following: Test Procedure 1. [Mid-turbinate Nasal Swab] Tilt patient's head back 70 degrees. Use a flocked tapered swab. While gently rotating the swab, insert it less than one inch (about 2 cm) into nostril parallel to the palate until resistance is met at turbinate. Rotate the swab several times against nasal wall. Remove swab, insert it into the other nostril and repeat the process. Test method 1. Prepare an aluminum pouch containing the test device and place it on the testing surface along with the test tube filled with the extraction buffer and filter cap. 2. Release the test device from the aluminum pouch and place it on a flat surface just prior to starting test. 3. Collect the buffer fluid at the bottom of the test tube by shaking it and then peel off the seal of the test tube. Insert the tip of the swab with the patient specimen and move the swab up and down more than 10 times to ensure sufficient sample extraction. 4. Remove the swab while pressing against the sides of the tube to ensure maximum amount of liquid has been squeezed from the swab. 5. Equip the filter cap on the test tube and immediately dispense three drops of sample extracts into the sample well of the device. (If you have dropped the test device after sample application, please discard the device and restart the test using new device.) 6. Read results 15 minutes after applying the sample. Do not read results after 20 minutes. -Note: Results read before 15 minutes or after 20 minutes may lead to a false positive, false negative, or invalid result. -Failure to follow the instructions can result in inaccurate results. Wash or sanitize your hands and dry them thoroughly before starting the test. Make sure they are completely dry. This test involves taking a sample from deep inside your nose. When performing the test, pay particular attention to the instructions on how to swab your nose. Testing should be completed within 30-60 minutes of opening the test pouch. -For healthcare providers who are handling specimens, but are not directly involved in collection (e.g. handling self-collected specimens) and not working within 6 feet of the patient, follow Standard Precautions. Healthcare providers should wear a form of source control (face mask) at all times while in the healthcare facility. Review of the CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings(2007-updated May 2022) indicated but was not limited to the following: Standard Precautions -Standard Precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. -Standard Precautions include a group of infection prevention practices that apply to all , regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; -hand hygiene after contact with respiratory secretions -spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. -Physical proximity of <3 feet has been associated with an increased risk for transmission of infections via the droplet route and therefore supports the practice of distancing infected persons from others who are not infected. On 1/25/23 at 8:13 A.M., the administrative team notified the survey team that six residents tested positive for COVID-19 this morning. During an interview on 1/25/23 at 9:15 A.M., the Infection Preventionist (IP) said staff will be tested every other day for seven days, if no new cases. During an interview with the IP and the Director of Nursing on 1/25/23 at 10:50 A.M., the IP said staff self-testing occurs in her office. Everything is right on the table that the staff need to perform self-testing including the step by step instructions. The staff takes the testing supplies and then leaves the completed tests on the table. The DON said that the staff also signs in a notebook that they tested. The IP said, I guess I do when asked who was responsible for timing the results. Review of the Testing Notebook indicated staff do not document the time of their test. During an interview on 1/25/23 at 2:25 P.M., the surveyor entered the IP's office and observed two test devices on the table for CNA# 3 and CNA #4. There was no time indicated on the test devices. The IP said that CNA #3 and CNA #4 tested at 2:05 P.M. and she needed to discard the tests. More than 20 minutes had passed since the testing had been performed and as per the manufacturer's guidelines, the tests were now invalid. On 1/25/23 at 2:50 P.M., the surveyor observed four staff members performing their self-testing. The staff members did not follow the testing protocol or proper infection control practices during self-testing as follows: -4 of 4 staff did not perform hand hygiene before and/or after self-testing -4 of 4 staff did not practice distancing during self-testing staff, standing shoulder to shoulder during testing -1 of 4 staff had the surgical mask doffed the entire time testing was being performed -4 of 4 staff did not perform the nasal swab correctly. Specifically, staff did not go into the nares far enough or swab several times in each nares as per the manufacturer's recommendations -4 of 4 staff members did wait for, or time, their results after the testing had been performed. Once self-testing was completed, staff proceeded to their assigned Unit. -Nurse #9 was unfamiliar with the staff testing kit as it was not the testing kit being used for the residents. Nurse #9 asked other staff at the testing table how to use the test kit and CNA #5 provided her guidance. Nurse #9 opened up the swab, attempted to perform a nasal swab with a surgical mask on, realized that she had poked her mask with the swab, pulled the mask down to expose her nose, and using the hand that she was holding the swab in, touched her hair with the swab and then proceeded to swab her nares with the same swab. Nurse #9 did not mix the swab enough in the liquid and then had to be instructed how to expel the testing liquid from the tube. After completing the testing, Nurse #9 left the testing area and did not wait for the results. The IP was in the testing room/area and did not provide oversight for the testing procedure, infection control breeches, and timing of the results which could potentially result in invalid test results. During an interview on 1/26/23 at 8:30 A.M., the IP said that it is best practice if the staff are distancing themselves (not shoulder to shoulder while testing) and should be wearing a mask.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review, and interview, the facility failed to properly store and label food in the facility kitchen and on 3 out of 3 unit nourishment kitchens in accordance with professional standards of practice to ensure food safety. Specifically, the facility failed to: a. properly label beverage items in 1 of 2 freestanding refrigerators in the kitchen, and b. ensure food and beverages were properly stored and labeled in 3 out of 3 unit nourishment kitchens. Findings include: a. On 1/23/23 at 8:20 A.M., the surveyor, with Dietary Staff #1 present, observed seven trays of hard plastic cups filled with various liquids stored on shelving inside one of two stand up refrigerators. The cups/trays were not labeled as to when they were prepared or the use by dates. Dietary Staff #1 said the cups were filled the night before with various nectar thick liquids and were good for 24 hours. She said they should have had a sticker label on them to indicate when they were filled and what the use by date was. During an interview on 1/25/23 at 11:12 A.M., the Food Service Director (FSD) said the trays should have been labeled with a sticker as to when they were prepared but were not. b. Review of the Attention Staff Nourishment Kitchens document posted on the unit refrigerators indicated the following: -All outside food for residents must be dated and labeled including resident name and room number (discard after 3 days) -All items must be dated once opened using provided labels -Juice, milk, and bread, once opened = (7 days) -Please use opened on and discard date on labels -For the safety of our residents, nourishment room door must remain closed at all times On 1/24/23 at 6:40 A.M., the surveyor reviewed the Dartmouth Unit (dementia unit) nourishment kitchen and observed the following: -nourishment room door propped open with a garbage bin -one sandwich plate in refrigerator covered with saran wrap with tuna sandwich label, not labeled with a resident's name or room number, not labeled when sandwich was prepared or a discard date During an interview on 1/24/23 at 7:25 A.M., the FSD said the sandwich should have been labeled with the resident's name and the date and would only be good for three days. The FSD said the nourishment room door should have been closed. On 1/24/23 at 6:55 A.M., the surveyor reviewed the Acushnet Unit nourishment kitchen and observed the following: -brown paper bag in the freezer with a resident's name and room number which contained a cardboard container of Blizzard ice cream with plastic lid, approximately 75% consumed, bag and ice cream container not dated -46 fluid ounce (fl. oz) bottle of cranberry juice cocktail stored in lower cabinet, approximately 90% used, labeled with a sticker as date opened 1/15/23, no discard date -46 fl. oz bottle of thickened apple juice in the refrigerator with a sticker as date opened 1/11/23, no discard date During an interview on 1/24/23 at 7:25 A.M., the FSD said if a family member brings in food it is only good for three days. He said the Blizzard ice cream bag should have been labeled with the date the family brought it in. He said he could not determine if it was still good if it was not labeled and the cranberry and apple juice bottles were no longer good. On 1/24/23 at 7:10 A.M., the surveyor reviewed the Fairhaven Unit nourishment kitchen and observed the following: -loaf of bread in upper cabinet above sink with opening tied in a knot, not labeled when opened or a discard date -five plastic bins in the cabinet above the sink with the following items: a. bin with honey maid graham crackers, individual packages, sticker indicating a date of 12/14 on the top and 12/28 on the bottom b. bin with fudge round cookies, individual packages, not labeled c. bin with oatmeal cream cookies, individually packaged, sticker open date 1/5 and discard date 1/19 d. bin with [NAME] doon cookies, individually packaged, labeled 6/25/22 -46 fl. oz bottle of thickened apple juice in refrigerator, approximately 50% used, open date sticker 1/11/23, no discard date - Chobani yogurt and ice cream sandwich in freezer, not labeled with resident name, room number, or date During an interview on 1/24/23 at 7:10 A.M., the FSD entered the Fairhaven Unit nourishment kitchen. The surveyor reviewed the observations. The FSD said the bread should have been labeled when opened but was not. He said staff should be labeling food and beverage items with the proper opened and discard dates and, whether food or liquid is opened or not, it expires seven days from when dietary staff delivers it to the unit and not per the manufacturer's expirations. The FSD further said the ice cream sandwich and yogurt should not have been stored in the freezer and were no good.

Based on interview, the facility failed to develop, implement, and maintain a comprehensive Compliance and Ethics program as required. Findings include: During an interview on 1/30/23 at 2:42 P.M., the Administrator said the facility does not have a Compliance and Ethics program or committee and was unable to provide any written standards, policies and procedures for a Compliance and Ethics program. He said if there were any ethical concerns, they would use corporate's legal department. .

Based on interview, record review, and document review, the facility failed to notify residents, resident representatives, and families of positive COVID-19 cases (staff or resident) by 5:00 P.M. the following day as required. Findings include: During an interview on 11/10/22 at 8:50 A.M., the Administrator said the facility COVID-19 outbreak started on 10/30/22 when the first resident tested positive. He said that he was responsible for notifying all the residents and the family representatives and he sent out notification of the facility COVID-19 outbreak on 10/30/22. Review of the facility's line-listing for positive COVID-19 cases indicated that a total of five staff members tested positive for COVID -19 on the following dates: 10/16/22- Certified Nursing Assistant (CNA) #1 10/19/22- Rehabilitation Staff #1 10/20/22- CNA #2 10/26/22- Director of Nurses 10/27/22- CNA #3 10/29/22- Receptionist #1 During an interview on 11/10/22 at 12:08 P.M., the Facility Administrator said that he did not send notification to resident representatives and families after identifying the first staff member positive for COVID-19 on 10/16/22. The Facility Administrator said that the notification of resident representatives and families did not occur until 10/30/22 when the first resident tested positive for COVID-19.

Based on interview and record review, the facility failed to conduct COVID-19 outbreak management in a manner consistent with professional standards of practice. Specifically, the facility failed to: 1. Perform contact tracing for six positive staff members to include all resident and staff exposure; and 2. Perform outbreak testing for COVID-19 as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. Findings include: Review of the facility's policy titled Coronavirus Disease (COVID-19) Testing Staff, revised 9/22, included but was not limited to: -Close contact refers to someone who has been within six feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. -An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. -Viral testing of all staff (regardless of vaccination status) is conducted if there is an outbreak in the facility. Testing is conducted immediately (but not earlier than 24 hours after the exposure, if known) and testing approaches may consist of contact tracing (focused testing) or broad-based (facility-wide or group-level) testing. -If there is the ability to identify close contacts of the individual with SARS-COV-2 infection, contact tracing and focused testing are conducted. Staff who have close contact are tested immediately as described in the testing protocols above. If testing of close contact reveals additional cases of SARS-COV-2 infection, contact tracing is continued to identify residents with close contact to the newly identified individual(s) with SARS-COV2 infection. If all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission, broad-based testing is conducted. -If additional cases are identified, strong consideration is given to shifting to the broad-based approach if not already being performed in implementing quarantine for residents in affected areas of the facility. -As part of the broad- based approach, testing will continue on affected unit(s) or facility- wide every three to seven days until there are no new cases for 14 days. Review of the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, revised on 9/23/22 indicated the following: -An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. -Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. 1. During an interview on 11/10/22 at 8:38 A.M., the Facility Administrator said that initially the facility was trying to manage the COVID-19 outbreak with contact tracing but moved to broad outbreak management on 10/30/22. Review of the facility's line-listing for positive COVID-19 cases indicated that a total of five staff members tested positive for COVID-19 on the following dates: a. 10/16/22- Certified Nursing Assistant (CNA) #1 b. 10/19/22- Rehabilitation (Rehab) Staff #1 c. 10/20/22- CNA #2 d. 10/26/22- Director of Nurses (DON) e. 10/27/22- CNA #3 f. 10/29/22- Receptionist #1 Review of the facility contact investigation packets for the six staff members identified above indicated the following: a. CNA #1: -Identified residents on Dartmouth Unit assignment #2, all who were tested on day 1, 3 and 5. -No staff members were identified b. Rehab Staff #1: -Identified 10 residents exposed during rehab session, all were tested on day 1,3 and 5 -No Staff members were identified c. CNA #2: -Identified residents on Acushnet, first hallway and two other rooms, all tested on day 1, 3 and 5. - No staff members were identified d. DON: No investigation packet provided for review. e. CNA #3: No investigation packet provided for review. f. Receptionist #1: No investigation packet provided for review. During an interview on 11/10/22 at 11:55 A.M., the DON said prior to 10/30/22, they were doing contact tracing testing for residents and staff exposed to positive COVID-19 staff members. The testing was basically occurring every two days and then last week we went to daily testing. During an interview on 11/10/22 at 12:53 P.M., the Infection Control Nurse (IFC) said that she conducted contact tracing of staff after becoming aware that CNA #1 tested positive for COVID-19. She provided a list of staff to the surveyor for review. Surveyor compared the list to the actual working schedule and three staff members that worked with CNA #1 were not on the list. The IFC Nurse said that the post exposure testing had not occurred for three of the staff members who worked with CNA #1 on 10/15/22, because she looked at the wrong day on the schedule and tested the wrong staff members. During an interview on 11/10/22 at 3:05 P.M., the DON said that the only close contact she had was with the Assistant Director of Nurses (ADON) and the ADON has been testing every day. DON said she had no resident contact leading up to her positive COVID-19 test. Review of the facility testing logs indicated the Assistant Director of Nurses (ADON) did not test as required per policy on day 1, day 3 and day 5, testing only on 10/27 (day 1), 10/31 (day 4), and 11/4 (day 8) after a direct exposure. During an interview with the Administrator and the DON on 11/10/22 at 3:05 P.M., the surveyor reviewed the incomplete contact tracing investigation packets and the staff testing logs. The DON said when CNA #3 tested positive, we looked at who was on her assignment and tested the residents. Review of the CNA #3 investigation packet did not indicate any residents were tested. The DON said she determined the Receptionist #1 had no exposure to resident or staff because she sits alone out front. The Administrator and DON said they do not have contact tracing for staff exposure to Rehab Staff #1, CNA #2, or CNA #3. The DON said that a lot of staff is testing on the units and not documenting it on the testing logs. She said that she understood and that if it is not documented then it did not happen. 2. Review of the facility's policy titled Coronavirus Disease (COVID-19) Testing Staff, revised 9/22, included but was not limited to: -When utilizing broad-based testing, all residents and staff identified as close contacts or on the affected unit(s) are tested, regardless of vaccination status. Testing is done immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day zero), day 3, and day 5. During an interview on 11/10/22 at 11:55 A.M., the DON said that the outbreak date we are using is 10/30/22 because that was when the first exposed resident tested positive. She said they started testing the whole facility (residents and staff) for COVID-19. Review of the facility's testing logs indicated that the facility was not testing per policy and/or current CMS guidance as indicated (on day 1, day 3, and day 5) after transitioning to outbreak testing on 10/30/22. Review of the facility testing logs indicated that facility staff continued to test once to twice weekly. During an interview on 11/10/22 at 3:05 P.M., the DON said that a lot of staff is testing on the units and not documenting it on the testing logs because they do not have logbooks on the unit. She said that she understood and that if it is not documented then it did not happen.