Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for one Resident (#19), out of a total sample of 24 residents. Specifically, the facility failed to ensure nursing staff administered medications per physician's orders and manufacturer's recommendations. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated February 2019, indicated but was not limited to the following: -Five (5) Rights - right resident, right drug, right route, and right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration; 1) when the medication is selected, 2) when the dose is removed from the container, and finally 3) just after the dose is prepared and the medication put away. a. Check #1: Select the Medication - label, container and contents are checked for integrity, and compared against the Medication Administration Record (MAR) by reviewing the five rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the five rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the five rights. -Medications are administered in accordance with written orders of the prescriber. Review of the Asmanex Twisthaler package insert, U.S. Food and Drug Administration (FDA) website: www.fda.gov/drugsatfda, revised January 2008, indicated but was not limited to the following: Indications and Usage: -Asmanex Twisthaler (mometasone furoate inhalation powder) is a corticosteroid indicated for maintenance treatment of asthma as prophylactic therapy in patients 4 years of age and older. Dosage and Administration: -For oral inhalation only -Instruct patients to inhale rapidly and deeply and to rinse mouth after inhalation. Warnings and Precautions: -Candida albicans infection of the mouth and larynx. Monitor patients periodically for signs of adverse effects in the mouth and pharynx. Advise patients to rinse mouth after inhalation. Resident #19 was admitted to the facility in August 2024 and had diagnoses including malignant neoplasm of oropharynx, chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), malignant neoplasm of laryngeal cartilage, chronic cough, malignant neoplasm of floor of mouth, and malignant neoplasm of the tongue. Review of the Minimum Data Set (MDS) assessment, dated 8/21/24, indicated Resident #19 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had a pulmonary medical condition. Review of current Physician's Orders indicated the following: -Asmanex (14 metered Doses) Inhalation Aerosol Powder Breath Activated 220 micrograms (mcg)/ACT (mometasone furoate inhalation), 2 puffs inhale orally one time a day for asthma. Rinse mouth with water after use to reduce aftertaste and incidence of candidiasis. Do not swallow, 8/15/24 On 9/5/24 at 9:27 A.M., the surveyor observed Nurse #1 administer one puff of the Asmanex Twisthaler to Resident #19. Nurse #1 did not instruct the Resident to rinse his/her mouth after inhalation per physician's orders and manufacturer's recommendation to reduce aftertaste and the incidence of candidiasis. Further, Nurse #1 did not administer the second puff per physician's orders and began to exit the room with the medication. Upon inquiry by the surveyor, Nurse #1 returned to the Resident and administered the second puff at 9:30 A.M. During an interview on 9/5/24 at 9:32 A.M., Nurse #1 said she usually gives all the medications but gets nervous when someone is watching. She said all medications should be administered per physician's orders and should have given 2 puffs of Asmanex prior to surveyor intervention. During an interview on 9/5/24 at 11:40 A.M., Nurse #1 said she should have offered water to the Resident after administering the first puff of the Asmanex but didn't. During an interview on 9/9/24 at 4:06 P.M., the Director of Nursing said nursing staff should read the doctor's orders and follow them for medication administration.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accidents and hazards for one Resident (#19), out of a total sample of 24 residents. Specifically, the facility failed to ensure unauthorized medications were not left at the bedside for the Resident, who was legally blind, to self-administer without a proper assessment of the Resident's mental and physical capabilities to reduce the risk of any potential adverse consequences. Findings include: Review of the facility's policy titled Self-Administration of Drugs, undated, indicated but was not limited to the following: -As part of their overall evaluation, the nurse will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. -In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including but not limited to the resident's: 1. Ability to read and understand medication labels; 2. Comprehension of the purpose and proper dosage and administration time for his or her medications; 3. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them; and 4. Ability to recognize risks and major adverse consequences of his or her medications. -If the staff determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. -The nurse will ask residents who are identified as being able to self-administer medications whether they wish to do so. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. -Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party. Review of Allergan, Inc. manufacturer's product insert, revised June 2022, indicated but was not limited to the following: Refresh Tears Drug Facts: Purpose - Eye lubricant Uses - For the temporary relief of burning, irritation, and discomfort due to dryness of the eye or exposure to wind or sun. May be used as a protectant against further irritation. Warnings: -For external use only. -To avoid contamination, do not touch tip of container to any surface. Replace cap after using. -If solution changes color or becomes cloudy, do not use. -Stop use and ask a doctor if you experience eye pain, changes in vision, continued redness, or irritation of the eye, or if the condition worsens or persists for more than 72 hours. Directions: -Instill 1 or 2 drops in the affected eye(s) as needed. -Use before expiration date marked on container. Resident #12 was admitted to the facility in May 2024 with diagnoses including chronic kidney disease stage 3 and chronic diastolic heart failure. Review of the Minimum Data Set (MDS) assessment, dated 6/3/24, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 and had severely impaired vision. During an observation with interview on 9/4/24 at 8:59 A.M., the surveyor observed Resident #12 lying in bed. One bottle of Refresh artificial tears lubricant, 0.5 fluid ounces (oz.),15 milliliters (ml), was observed on top of the Resident's overbed tray table not stored in the packaging box and did not have a pharmacy label on it. Also observed on top of the tray table were 8 ½ large round multicolored tablets stored inside a small white porcelain bowl. Resident #12 said the tablets were TUMS (antacids) and took them him/herself when needed. Both medications were highly visible to the surveyor. Resident #12 said the eye drop bottle was from home and used it in both eyes but did not answer as to how many drops he/she was using or how often he/she was using them and said he/she was legally blind. It was unclear if the Resident had requested to self-administer the medications. Review of current Physician's Orders indicated the following: -Calcium Carbonate (antacid) oral tablet chewable 500 milligrams (mg), give 2 tablets by mouth every 8 hours as needed for stomach upset, 5/28/24 Review of the medical record did not indicate a physician's order for the Refresh artificial tears or an order for Resident #12 to self-administer the medications or store them at the bedside. Further review of the medical record failed to indicate a proper assessment had been conducted to determine the Resident's mental and physical capabilities to self-administer medications to reduce the risk of any potential adverse consequences. During an observation with interview on 9/5/24 at 12:59 P.M. and 9/9/24 at 11:37 A.M., the surveyor observed Resident #12 sitting in a recliner chair next to the window. One bottle of Refresh artificial tears lubricant, 0.5 fluid oz., 15 ml was observed on top of the Resident's overbed tray table not stored in the packaging box and did not have a pharmacy label on it. Also observed on top of the tray table were 6 ½ large round multicolored tablets stored inside a small white porcelain bowl. Resident #12 said he/she was legally blind but just feels for the medications to use them him/herself and knew where they were. The Resident said he/she took them as needed. On 9/9/24 at 11:44 A.M., Nurse #5 entered the room with the surveyor to observe the medications stored at the bedside and self-administered by the Resident. Nurse #5 said she was not aware the medications were at the Resident's bedside. Resident #12 said he/she used the medications as needed and preferred to administer them him/herself. The Resident said he/she used the eye drops a couple times a day but did not answer as to how many drops were used or in which eye or both. During an interview with Nurse #5 and Unit Manager (UM) #2 on 9/9/24 at 11:52 A.M., the surveyor reviewed Resident #12's medical record with Nurse #5 who said there was a physician's order for the antacids but no order to self-administer them or store them at the bedside. Nurse #5 said there wasn't an order for the eye drops and no assessment was done for self-administration of medications. She said the Resident had visual impairment. UM #2 said the Resident was legally blind and probably could not self-administer medications safely due to his/her visual impairment. UM #2 said a self-administration assessment was not done for the Resident. She said the Resident's family brings in medications for the Resident from home but if staff see medications stored at the bedside, they should remove them and notify her. She said she was not aware the Resident had the medications in his/her room. UM #2 said there wasn't a care plan with interventions to address the family bringing in medications for the Resident. Nurse #5 said if a resident wants to keep medications at the bedside, they'll do an assessment for self-administration and keep them stored in a drawer. UM #2 said there would be a physician's order to self-administer each medication and to store them at the bedside but there wasn't. During an interview on 9/9/24 at 4:34 P.M., the Director of Nursing (DON) said if residents have medications with them when they're admitted staff would check to see if there's an order for them and perform a self-administration assessment to see if it's safe for them to self-administer. The DON said she didn't think it was safe for Resident #12 to self-administer as he/she could not really see and could not tell staff how much or when to take them. She said there was no specific consent upon admission to self-administer. She said this is only done if residents have medications in their room and wish to self-administer and that the medications should be stored in a lock box in the room. The DON said staff should have seen the medications in the room and taken them out and if the Resident insisted on self-administering them, then an assessment would have been done. She said there was no physician's order for the eye drops. She said staff want to make sure a resident is capable of self-administering and it's safe to do so.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services for one Resident (#12), out of a total sample of 24 residents. Specifically, the facility failed to ensure oxygen (O2) equipment was maintained to ensure sanitary conditions to help decrease the risk of potential contamination and infection. Findings include: Review of the facility's policy titled Oxygen Administration, undated, indicated but was not limited to the following: -store tubing in a plastic bag Resident #12 was admitted to the facility in May 2024 and had diagnoses including chronic kidney disease stage 3 and chronic diastolic heart failure. Review of the Minimum Data Set (MDS) assessment, dated 6/3/24, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, did not use oxygen, and had no current respiratory infection or pulmonary disease. The MDS also indicated the Resident had severely impaired vision. Review of current Physician's Orders indicated the following: -May have supplemental O2 for comfort every shift for shortness of breath, 7/30/24 During an observation with interview on 9/4/24 at 8:59 A.M., the surveyor observed Resident #12 lying in bed. His/her nasal cannula (NC) (lightweight tube which one end splits into two prongs which are placed in the nostrils from which a mixture of O2 and air flows) tubing was observed attached to an O2 concentrator which was in the off position. The remainder of the tubing was resting on the floor potentially exposing it to environmental contaminants. The tubing was not stored in the protective bag observed hanging from the concentrator. The exterior of the concentrator was laden with dust. Resident #12 said he/she used the Oxygen at night because he/she needed it. The Resident said staff turned off the Oxygen that morning and needed staff help because he/she did not know how to work it and needed help putting on and taking off the NC because he/she could not reach it. During an observation with interview on 9/9/24 at 11:32 A.M., the surveyor observed Resident #12 sitting in a recliner chair next to the window. The Resident's NC tubing was observed attached to an O2 concentrator which was in the off position. The tubing was observed hanging over the upper siderail which was in the upright position with the end of the tubing (prongs) resting on the floor potentially exposing it to environmental contaminants. The tubing was not stored in the protective bag observed hanging from the concentrator. The exterior of the concentrator was laden with dust. Resident #12 said he/she guessed the oxygen was for some sort of respiratory reason; wheezing, but only used it at night. The Resident said assistance was needed from staff because he/she could not do anything for him/herself due to being legally blind. Resident #12 said he/she couldn't see the tubing unless staff held it up close. On 9/9/24 at 11:41 A.M., Nurse #5 entered the Resident's room with the surveyor to observe the O2 equipment. Nurse #5 said the NC tubing should not have been on the floor and should have been stored in the plastic bag when not in use. She said the O2 concentrator should be wiped down in the morning when the NC tubing is removed from the Resident's nostrils and as needed when visibly dusty/soiled. During an interview on 9/9/24 at 11:45 A.M., the surveyor reviewed Resident #12's medical record with Nurse #5 who said there was no order to wipe down the concentrator, but it was a standard of practice to do so. She said the physician's order indicated the Resident used supplemental oxygen for comfort. During an interview on 9/9/24 at 4:30 P.M., the Director of Nursing said O2 tubing should be stored in a plastic bag when not in use. She said the machines do get dusty but there was no order to wipe the machines down, including on an as needed basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure medication carts were locked when not in direct supervision of the licensed nurse; and 2. Ensure staff properly labeled all medications stored in three of four medication carts reviewed once opened. Findings include: Review of the facility's policy titled Storage of Medications, dated February 2019, indicated but was not limited to the following: -Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. -Certain medications or package types such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and/or the new date of expiration. 1. On 9/5/24 at 7:59 A.M., the surveyor observed Unit Manager (UM) #1 prepare medications for a resident from the Oyster Pond [NAME] medication cart which was positioned in the hallway next to the resident's room. UM #1 left the medication cart unlocked and unattended to retrieve an over the counter (OTC) medication in the medication room at the nurses' station which was not available in the medication cart. No other staff were in direct supervision of the cart. UM #1 returned to the medication cart approximately one to two minutes later and continued to prepare the remaining seven medications for administration. During an interview on 9/5/24 at 8:31 A.M., UM #1 said she was aware she did not lock her medication cart when she went to the medication room but should have. During an interview on 9/9/24 at 4:12 P.M., the Director of Nursing (DON) said medication carts should be locked when unattended. 2. Review of a facility document titled Medications with Shortened Expiration Dates, dated July 2015, indicated but was not limited to the following: Lantus (insulin glargine, treats diabetes) - good for 28 days after opening or removing from refrigerator. Review of [NAME] Timolol (timolol maleate) manufacturer's instructions for use, dated November 2017, indicated but was not limited to the following: Stability and Storage Recommendations: -The contents of [NAME] Timolol should not be used for more than one month after the date on which the container is first opened. Review of the Arkray Assure Platinum Reference Manual, revised August 2023, indicated but was not limited to the following: Storage and Handling -When you first open the bottle, write the date on the bottle label. Use the test strips within 3 months of first opening the bottle. Oyster Pond [NAME] medication cart: On 9/5/24 at 8:21 A.M., the surveyor reviewed the Oyster Pond [NAME] medication cart with UM #1 and observed the following: -One bottle of Assure Platinum glucometer test strips (small disposable plastic strips that are used with a blood glucose meter to measure blood sugar) stored inside the cart, seal broken indicating it had been opened, bottle not labeled with the date when opened or the new date of expiration During an interview on 9/5/24 at 8:21 A.M., UM #1 said she wasn't sure if they were supposed to label the bottle once opened and wasn't sure how long it was good for once opened. Pleasant Bay East medication cart: On 9/5/24 at 9:37 A.M., the surveyor reviewed the Pleasant Bay East Unit medication cart with Nurse #1 and observed the following: -one multidose vial of Lantus 100 units/milliliter (ml) stored inside the packaging box, pop top off the vial indicating it had been opened, packaging box and vial not labeled with the date when opened or the new date of expiration, labeled with a resident's name -One bottle of Assure Platinum glucometer test strips stored inside the cart, seal broken indicating it had been opened, bottle not labeled with the date when opened or the new date of expiration During an interview on 9/5/24 at 9:37 A.M., Nurse #1 said the insulin should have been labeled with the date when opened and was only good for one month. She said it had a short expiration because of the handling things and would have to discard because she did not know when it was opened. Nurse #1 said the test strip bottle was not labeled with the date when opened or the new expiration date but said they do not usually label them. She said she wasn't sure how long it would be good for but believed it was the manufacturer's expiration date on the bottle. Pleasant Bay North medication cart: On 9/5/24 at 9:52 A.M., the surveyor reviewed the Pleasant Bay North medication cart with Nurse #2 and observed the following: -One bottle of timolol maleate (treats glaucoma in the eye) 0.5% stored inside the packaging box, seal broken indicating it had been opened, packaging box and bottle not labeled with the date when opened or the new date of expiration, labeled with a resident's name -One bottle of Assure Platinum glucometer test strips stored on top of the cart, seal broken indicating it had been opened, bottle not labeled with the date when opened or the new date of expiration During an interview on 9/5/24 at 9:52 A.M., Nurse #2 said the eye drops should have been labeled with the date when opened on the packaging box and the bottle itself and was only good for 30 days. She said they don't usually label test strip bottles once opened and wasn't sure how long it would be good for. During an interview on 9/9/24 at 4:12 P.M., the DON said the process for the test strip bottles has been to use by the manufacturer's date of expiration, but she now knew this was different. She said the bottle was only good for 90 days once opened, per manufacturer's instruction, and should have been labeled with the new date of expiration once opened. The DON said Lantus is only good for 28 days after opening and was not sure how long the eye drops were good for as they weren't listed on the pharmacy's short expiration list. She said staff should have still labeled the bottle with the date when opened. She said the purpose of short expiration dates is to maintain potency and to not let bacteria get into the eye drop bottles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to: 1. Ensure staff did not report to work or provide care to residents while acutely ill without testing to ensure they were not COVID-19 positive while in the facility; 2. Test Residents in accordance with current COVID-19 testing guidelines following a known exposure for 9 of 17 residents effected; and 3. Ensure staff properly handled medications to reduce the potential transmission of pathogens for Resident #19 during medication administration. Findings include: 1. Review of the facility's policy titled COVID-19 Test access protocol: Healthcare personnel (HCP), dated 3/14/24, indicated but was not limited to the following: - if employee presents with fever, signs/symptoms of lower respiratory illness (shortness of breath, cough, sore throat), nasal congestion, runny nose, fatigue, body aches, vomiting, diarrhea, or sudden onset of loss of taste or smell, do not report to work. - report condition to the facility, facility may test employee or employee may report to testing center/test at home - positive results should be reported by phone - if staff test is positive the facility Infection Preventionist (IP) will evaluate and conduct outbreak testing of all potentially exposed residents and staff regardless of vaccination status Review of the Centers for Disease Control and Prevention (CDC) guidance titled Infection Control Guidance: SARS-COV-2 / COVID-19, dated 6/24/24, indicated but was not limited to the following: Perform SARS-COV-2 Viral testing: - Anyone with even mild symptoms, regardless of vaccination status, should receive a viral test for SARS-COV-2 as soon as possible Review of the facility's tracking and tracing for COVID-19 positive staff member, Certified Nurse Assistant (CNA) #2 indicated but was not limited to the following: - staff member tested positive on 9/1/24 - tested at work due to headache and flu-like symptoms - was wearing a mask the entire shift - cared for seven residents who were identified in the contact tracing as having been exposed Review of the staff COVID-19 tracking log, provided by the facility, indicated but was not limited to the following: - CNA #2 came into work on 9/1/24 with symptoms including: nasal congestion, headache, shortness of breath, and achiness - CNA #2 felt progressively worse throughout their shift and took a test for COVID-19 and was found to be positive for COVID-19 and was sent home During an interview on 9/6/24 at 12:48 P.M., the IP said CNA #2 should have tested at the start of her shift if she didn't feel well and not just wore a mask. She said the expectation would be that she would not come into work if she felt sick or tested upon arrival if there were any potential signs or symptoms of a COVID-19 like illness to ensure she didn't potentially expose anyone. Review of the timecard for CNA #2, provided by the facility, indicated CNA #2 arrived to work at 7:12 A.M. and worked until 1:01 P.M., on 9/1/24. During an interview on 9/10/24 at 12:01 P.M., CNA #2 said she came into work on 9/1/24 feeling ill and said she had symptoms like the common cold or allergies but felt she was capable of working and decided to wear a surgical mask. She said she did not test for COVID-19 prior to coming into work or upon arrival to the facility prior to starting her assignment. She said as the shift went on, she began feeling worse and like she wasn't capable of continuing to work and told a nurse who told her she needed to test for COVID-19. She said she tested and was positive and went home. She said the following day the facility called her and she informed them she came in feeling sick and had nasal congestion, shortness of breath, a headache and body aches, and as the shift went on, she became very tired and found it difficult to work. She said they asked her which residents she worked with and spent 15 minutes or more with during the shift and she provided them with a list. She said she knew she was sick but felt she was still capable of working until about 1:00 P.M. During a follow up interview on 9/10/24 at 12:15 P.M., the IP said staff are informed not to come into work if they feel ill and to test at home prior to coming in or at the facility upon coming in to ensure they do not have COVID-19. She said CNA #2 should not have come to work in accordance with the guidelines. She said if she could locate any educational documents that the CNA had received this training she would provide it to the survey team. During an interview on 9/10/24 at 12:24 P.M., the Director of Nurses (DON) said staff are trained to not come into work if they are feeling sick and to either test at home or test immediately upon entering the facility if they feel ill to ensure they are not potentially exposing other staff and residents to COVID-19. She said CNA #2 did not follow the guideline and should not have come to work sick or waited until the afternoon to test herself for COVID-19 and the expectation for staff testing when symptomatic of COVID-19 was not met in this circumstance. No evidence that CNA #2 was educated to not attend work if she was ill or to test upon arriving at work could be provided to the survey team prior to exit. 2. Review of the facility's policy titled Post PHE IPC - caring for [Facility Name] Residents and Patients, dated 5/10/23, indicated but was not limited to the following: - It is the policy of the facility to follow state and federal guidance at the end of the federal health emergency, including guidelines for the management of COVID-19. TESTING: In addition to testing when symptoms are present, [Facility Name] is required to perform outbreak testing of residents and staff as soon as possible when a case is identified; if it is determined exposure occurred less than 24 hours (hrs.) ago, then testing is conducted after 24 hrs. from any exposure, if known. - Once a new case is identified the facility tests exposed residents and staff at least every 48 hrs. on the affected unit until the facility goes 7 days without a new case, unless otherwise directed by epidemiology. - In addition, the facility should immediately test any symptomatic residents or staff members. Review of the CDC guidance titled Infection Control Guidance: SARS-COV-2 (COVID-19), dated 6/24/24, indicated but was not limited to the following: Perform COVID-19 Viral testing: - Anyone with even mild symptoms, regardless of vaccination status, should receive a viral test for SARS-COV-2 (COVID-19) as soon as possible - asymptomatic patients with close contact with someone with COVID-19 infection should have a series of three viral tests for COVID-19 infection - testing is recommended immediately (but not sooner than 24 hrs. after the exposure) and, if negative again 48 hrs. (2 days) after the first negative and, if negative again 48 hrs. (2 days) after the second negative test (this is typically day 1, 3, and 5 - with the day of exposure being day zero) During an interview on 9/6/24 at 12:43 P.M., the IP said the facility is using contact tracing for positive COVID-19 staff or residents and testing those who are known to be exposed in accordance with the guidance. She said the residents who are known to be exposed are tested about 24 hrs. after a known exposure and then every two days until they are negative for seven days total. She said the information for resident testing is on the medication administration records (MAR) and/or in the progress notes for each affected resident. She said the facility is using an exposure time of 15 minutes or more within a 24-hr. period to determine if a resident or staff member has potentially been exposed to COVID-19 after having contact with a known positive case. Review of the staff COVID-19 tracking log, provided by the facility, indicated but was not limited to the following: - CNA #2 worked on 9/1/24 with symptoms and tested positive on 9/1/24 while at the facility for COVID-19 - Activity Assistant (AA) #1 was last in the workplace on 9/1/24 and tested positive for COVID-19 at this time (this is the date the facility became aware of the known confirmed exposure from 8/30/24), symptoms started on 8/31/24 in the evening (employee last worked on 8/30/24) Review of the facility's tracking and tracing for COVID-19 positive staff member, AA #1, indicated but was not limited to the following: - staff member experienced nasal congestion, shortness of breath, body aches, and headache on 8/31/24 and tested at the facility on 9/1/24 and was positive for COVID-19 - five Residents (#95, #28, #75, #109, #15) and two additional residents were exposed to AA #1 within the 48-hour look back timeframe (8/30/24), for a total of seven exposed residents on 8/30/24 Review of the facility's tracking and tracing for COVID-19 positive staff member, CNA #2, indicated but was not limited to the following: - staff member tested positive on 9/1/24 after working on that day - four Residents (#278, #427, #43, #87) and three additional residents were exposed to CNA#2 and required COVID-19 testing, for a total of seven exposed residents on 9/1/24 The following five Residents (#95, #28, #75, #109, and #15) were all exposed to AA #1 on 8/30/24, who developed symptoms of COVID-19 on 8/31/24 and notified the facility of a positive COVID-19 test on 9/1/24, prompting outbreak testing to be initiated with a first test date of 9/1/24 expected, in accordance with the guidance. Review of the MAR for Resident #95 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test scheduled to be done, but no documentation the testing was completed 9/8/24 - COVID-19 antigen test completed and negative on 9/9/24 (3 days after the second negative test) Review of the Progress notes for Resident #95 from 9/1/24 through 9/10/24 indicated but were not limited to: - resident was on antibiotic treatment for pneumonia prior to his/her COVID-19 exposure on 8/30/24 - tested negative for COVID-19 on 9/3/24, there were no other progress notes that indicated the Resident had been COVID-19 tested The medical record for Resident #95 failed to indicate the Resident was tested for COVID-19 exposure, as soon as possible following the known exposure, and was not initially tested until 9/2/24. In addition, the record failed to indicate the Resident was tested 2 days (48 hrs) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #28 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed on 9/8/24 and completed and negative on 9/9/24 Review of the Progress notes for Resident #95 from 9/1/24 through 9/10/24 failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #75 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/8/24 Review of the Progress notes for Resident #75 from 9/1/24 through 9/10/24 failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #109 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test scheduled to be done, but no documentation the testing was completed on 9/8/24 Review of the Progress notes for Resident #109 from 9/1/24 through 9/10/24 indicated a COVID-19 test was completed and negative on 9/8/24, however it failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #15 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test was completed on 9/8/24 (no documented results) Review of the Progress notes for Resident #15 from 9/1/24 through 9/10/24 failed to indicate a COVID-19 test was completed on 9/1/24 or the Resident was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. During an interview on 9/6/24 at 12:46 P.M., the IP said it appeared the Residents involved in this particular exposure for outbreak testing were not being tested as they should have been in accordance with the current guidance and could not explain the three-day timeframe following the 9/3/24 negative COVID-19 tests for all five residents involved. The following four Residents (#278, #427, #43 and #87) were all exposed to CNA #2 on 9/1/24, who had symptoms of COVID-19 on 9/1/24 and notified the facility of a positive COVID-19 test on 9/1/24, prompting outbreak testing to be initiated with a first test date of 9/2/24 expected, in accordance with the guidance. Review of the MAR for Resident #278 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/7/24 (4 days after the previous negative test) Review of the Progress notes for Resident #278 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested 2 days (48 hrs.) after a negative COVID-19 test or tested at all after 9/7/24 in accordance with the guidance. Review of the MAR for Resident #427 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/7/24 Review of the Progress notes for Resident #427 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested or attempted to be tested on [DATE] (the timeframe for the initial test following a known exposure), or was tested 2 days (48 hrs.) after the subsequent negative COVID-19 tests in accordance with the guidance. Review of the MAR for Resident #43 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/7/24 Review of the Progress notes for Resident #43 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested 2 days (48 hrs.) after a negative COVID-19 test or tested at all after 9/7/24 in accordance with the guidance. Review of the MAR for Resident #87 from 9/1/24 through 9/10/24 indicated but was not limited to the following: - COVID-19 antigen test completed and negative on 9/2/24 - COVID-19 antigen test completed and negative on 9/3/24 - COVID-19 antigen test completed and negative on 9/6/24 (3 days after the previous negative test) - COVID-19 antigen test completed and negative on 9/7/24 Review of the Progress notes for Resident #87 from 9/1/24 through 9/10/24 failed to indicate the Resident was tested 2 days (48 hrs.) after a negative COVID-19 test or tested at all after 9/7/24 in accordance with the guidance. During an interview on 9/6/24 at 12:46 P.M., the IP said the guidance indicates the testing is within 24 hours of known exposure and then every two days after each negative test after that for a total of three tests or seven days. She said viewing the documentation it appears that the testing was not completed correctly and the guidance was not followed as it should have been. During an interview on 9/10/24 at 8:45 A.M., the Administrator said the facility had reviewed the testing concerns brought to their attention and the testing guidance was not followed as it should have been. During an interview on 9/10/24 at 3:25 P.M., the DON reviewed the MAR and progress note documentation for the referenced residents. She said the residents should have been tested 24 hours after the facility was aware of their exposure to a confirmed case of COVID-19 and then if negative every 48 hrs. or two days after that for a total of three negative tests until the facility went seven days without a new case. She said the testing for the nine Residents exposed to a known positive case of COVID-19 reviewed does not appear to have met the guidance as it should have. 3. Review of the World Health Organization Glove Use Information Leaflet, revised August 2009, indicated but was not limited to the following: Rationale for using medical gloves: Medical gloves are recommended to be worn for two main reasons: 1. To reduce the risk of contamination of health-care workers hands with blood and other body fluids. 2. To reduce the risk of germ dissemination to the environment and of transmission from the health-care worker to the patient and vice versa, as well as from one patient to another. On 9/5/24 at 9:02 A.M., the surveyor observed Nurse #1 prepare nine oral medications (12 pills total) and place them into a medication cup to be administered to Resident #19. At 9:23 A.M., as Nurse #1 began to administer the medications, Resident #19's left hand accidentally made contact with the medication cup causing approximately 5-6 pills to fall out onto the disposable absorbent pad underneath the Resident's buttocks and the mattress's fitted sheet. Nurse #1 picked up the pills with her bare hand, placed them back into the medication cup, and proceeded to administer them to the Resident. Nurse #1 did not perform hand hygiene or don (put on) gloves prior to handling the medications or dispose of them due to potential environmental contamination and to avoid the potential transfer of pathogens from Nurse #1's hand to the medications being administered. During an interview on 9/5/24 at 9:32 A.M., Nurse #1 said she shouldn't have picked up the medications with her bare hand and should have worn gloves. She said she would have only disposed of them if they had fallen onto the floor. During an interview on 9/9/24 at 4:06 P.M., the DON said anything that falls out of the medication cup should have been identified and disposed of and replaced. She said Nurse #1 should not have picked the pills up without a glove.

Based on document review, policy review, and interview, the facility failed to maintain professional standards for administering pain medication as ordered by a physician for one Resident (#265), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled Physician Medication Orders, dated as reviewed 2021, indicated but was not limited to the following: - No drugs shall be administered except upon the order of a person lawfully authorized to prescribe. - Orders for medications must include: name and strength of drug; dosage and frequency of administration; route of administration; reason or problem for which given. Resident #265 was admitted to the facility in June 2023 with diagnoses which included left femur (upper leg) fracture, osteoporosis, and chronic kidney disease. Review of the current Physician's Orders for Resident #265 included but was not limited to the following: - 6/21/23: Oxycodone HCL (narcotic pain medication) 5 milligram (mg) tablet. Give 0.5 tablet by mouth every 12 hours as needed (PRN) for pain 7-10; total dose 2.5 mg. Review of the Medication Administration Record (MAR) for June 2023 for Resident #265 indicated the following: - 6/22/23 at 6:02 A.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 4 - 6/22/23 at 7:02 P.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 5 - 6/23/23 at 8:43 A.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 3 - 6/24/23 at 10:52 A.M., Resident received 2.5 mg of Oxycodone HCL PRN for pain level of 4 During an interview on 6/27/23 at 10:56 A.M., Nurse #3 said the Resident rarely complains of pain and she herself has only provided one dose of Oxycodone to the Resident (on 6/24/23). Upon review of the MAR and physician's orders for the Resident, she said the Resident is only supposed to be receiving Oxycodone for a pain level of 7 or above, on a 0-10 pain scale and the medication should not have been administered to the Resident on 6/22, 6/23, and 6/24/23 because the pain rating was below the ordered rating for the medication parameters. During an interview on 6/27/23 at 11:14 A.M., Unit Manager #2 reviewed Resident #265's MAR and could not explain why the Resident was administered the PRN Oxycodone outside of the physician ordered parameters. During an interview on 06/27/23 at 2:43 P.M., the Assistant Director of Nurses said she was made aware of the concerns brought forward regarding Resident #265 receiving pain medication outside of the physician's ordered parameters and said the medication should not have been given and the administration of the Oxycodone was an error. She said the nurses should be following the physician's orders and parameters for pain medication and did not.

Based on document review, policy review, and interview, the facility failed to maintain and consistently implement an infection prevention and control program for the surveillance of potential illnesses based on the facility identified McGeer criteria. Findings include: Review of the facility's policy titled Infection Prevention and Control Programs, dated as revised October 2018, indicated but was not limited to the following: - Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring adherence to the infection prevention and control practices and detecting unusual pathogens with infectious implications. - Data gathered during surveillance is used to oversee infections and spot trends. Review of the March 2023 Facility Identified Surveillance Line Listing, indicated 30 different potential illness entries. Only 5 of the 30 separate entries included symptoms which was the facility's method to determine infection, and 13 separate entries were counted as infections in the facility. Review of the April 2023 Facility Identified Surveillance Line Listing indicated 36 different potential illness entries. Only 4 of the 36 separate entries included symptoms which was the facility's method to determine infection, and 12 separate entries were counted as infections in the facility. Review of the May 2023 Facility Identified Surveillance Line listing indicated 54 different potential illness entries. Only 2 of the 54 separate entries included symptoms which was the facility's method to determine infection, and 31 separate entries were counted as infections in the facility. During an interview on 6/27/23 at 3:39 P.M., the Infection Preventionist (IP) said the facility used a line listing surveillance form provided by their laboratory to monitor, track and trend illnesses in the facility which resulted in treatments with antibiotics. She said the facility used McGeer criteria (a widely accepted symptomology driven criteria to determine if an illness is at the level of infection) to complete infection surveillance. She said she did not monitor or place residents on surveillance who experienced potential signs and symptoms of an illness and did not begin some type of antibiotic or antimicrobial treatment. She said she was not trained to monitor or place residents on surveillance who were not actively being treated with antibiotics and was unaware the surveillance of all potential illnesses and infections was necessary. She said the nurses documented any resident changes in condition in the medical record, including potential signs and symptoms of an illness. The IP said she would have no way of identifying a trend or possible outbreak without reviewing individual medical records if those symptoms or illnesses did not result in antibiotic treatment. She said she did not document signs and symptoms of an illness consistently on her surveillance line listings for any residents. She reviewed the March through June line listings with the surveyor and said the line listings were incomplete and did not include symptoms for most residents on the surveillance forms. She said she felt she was still learning the process and needed to adjust her practice to meet the guidelines for surveillance of all potential resident illness and be able to identify potential trends of symptoms and illness in the facility. During an interview on 6/27/23 at 4:46 P.M., the Director of Nurses and Administrator were made aware of the surveyor's concerns regarding the missing information on the facility surveillance line listings. The Director of Nurses and the Administrator said they did not realize the surveillance documents required the symptom category to be completed if the symptoms were documented in the individual resident's medical records. During a follow up interview on 6/28/23 at 8:09 A.M., the Administrator said he reviewed the facility's surveillance line listings with the IP and agreed the surveillance could not be effectively accomplished without the symptom column of the line listings being completed for analyzing data and identifying potential infections in the facility and the forms should have been completed. He said it was not practical or the expectation for the IP to review every resident medical record daily for surveillance and the facility will be adjusting the process to complete the symptoms column on the surveillance sheets and ensuring they match the medical records for continuity. Review of the Facility Surveillance Listings for March 2023 indicated, but was not limited to the following for Resident #25: - an illness categorized as a skin problem with a date of onset of 3/4/23 - the section for symptoms indicated only one symptom of swelling - the form indicated the Resident had a healthcare acquired infection (HAI) and was being treated with Keflex (an antibiotic) - the form indicated the illness did count as an infection within the facility The facility line listing failed to indicate Resident #25's symptoms met McGeer criteria for a skin infection. Review of the medical record for Resident #25 indicated, but was not limited to the following: - the skin area was identified by the nurse practitioner (NP) on 3/3/23 and determined to be a possible ingrown toenail of the left great toe - 3/8/23: an infection note indicated the skin area was self-inflicted accidentally while Resident #25 was trimming his/her toenails independently - 3/8/23: a treatment of Keflex (an antibiotic) was ordered and initiated - 3/10/23: an infection note indicating 2 symptoms of potential infection including redness and tenderness - 3/21/23: a completed infection report indicating the following: a. date of onset 3/4/23 (one day after the documented date of onset) b. type of infection: skin, soft tissue c. two symptoms were identified as: swelling at affected site and tenderness or pain at affected site d. evaluation of infection: Criteria was not met for infection: only two of four criteria met; area improved after treatment The documentation in the medical record for Resident #25 did not match the information on the facility surveillance of the potential infection and discrepancies were not explained or resolved. The record indicated the area did not meet infection criteria to count as an infection and the facility surveillance list did count the area as an infection within the facility. Review of the Facility Surveillance Line Listings for April 2023 indicated, but was not limited to the following for Resident #7: - an illness categorized as a skin problem with a date of onset of 4/6/23 - the section for symptoms was left blank - the form indicated the Resident had a healthcare acquired infection (HAI) and was being treated with Diflucan (an antifungal) - the form indicated the illness did count as an infection within the facility Review of the medical record for Resident #7 indicated, but was not limited to the following: - 4/8/23: a nursing note indicating a bright red rash with itch and new order received for treatment with Diflucan - 4/25/23: a completed infection report indicating the following: a. date of onset 4/8/23 (2 days after the surveillance date of onset) b. type of infection: other c. two symptoms were identified as: red rash, itching d. evaluation of infection: criteria met The documentation in the medical record for Resident #7 did not match the information on the facility surveillance of potential infection and discrepancies were not explained or resolved. The date of onset was different by two days, all symptoms documented in the medical record were not documented on the surveillance and the type of infection in the medical record indicated other, while on the surveillance forms in use by the facility indicated skin. Review of the Facility Surveillance Line Listings for April 2023 indicated, but was not limited to the following for Resident #63: - an illness categorized as lower respiratory infection (LRI) with a date of onset of 4/11/23 - the section for symptoms was left blank - the form indicated a chest x-ray (CXR) was completed on 4/11/23, the results section of the form was blank - the form indicated the Resident had a HAI and was being treated with Azithromycin (an antibiotic) - the form indicated the illness did count as an infection within the facility Review of the medical record for Resident #63 indicated, but was not limited to the following: - 4/10/23 at 2:37 P.M., a nursing note indicating nonproductive cough, expiratory wheezes, decreased lung sounds - 4/10/23 at 8:48 P.M., a nursing note indicating moist nonproductive cough and notification of the physician with orders for CXR - 4/11/23: CXR results with findings of: no acute cardiopulmonary process - 4/12/23 at 10:49 P.M., a nursing note indicating congested cough - 4/13/23 at 10:23 P.M., a nursing note indicating low oxygen saturation of 88% earlier in the shift at 5:30 P.M., and treatment with Azithromycin and respiratory inhalers - 4/19/23; a completed infection report indicating the following: a. date of onset 4/11/23 (the day after the documented day of onset in the nursing notes) b. type of infection: lower respiratory c. four symptoms were identified as: new or increase cough, oxygen saturation of less than 94% on room air, new or change lung exam abnormalities, respiratory rate greater than 25 d. evaluation of infection: McGeer criteria was not met; symptoms improved with antibiotics The documentation in the medical record for Resident #63 did not match the information on the facility surveillance sheet, and discrepancies were not explained or resolved. The onset date was different, all symptoms were not documented on the surveillance and the surveillance form indicated the infection would be counted as meeting criteria, as the medical record indicated it did not meet criteria. Review of the facility surveillance line listings for May 2023 indicated, but was not limited to the following for Resident #269: - an illness categorized as urinary tract infection (UTI) with an onset date of 4/27/23 (not previously identified or documented on the April facility surveillance) - the section for symptoms was left blank - the form indicated a urine culture was completed on 4/27/23 and grew the organism Proteus - the form indicated the Resident had a HAI and was being treated with Monurol (an antibiotic) - the form indicated the illness did count as an infection in the facility Review of the medical record for Resident #269 indicated, but was not limited to the following: - 4/27/23: Nurse Practitioner (NP) encounter note indicating Resident self-report of increase urinary frequency, dysuria (painful urination) and incontinence and order for urinalysis and culture to be completed - 4/27/23: UTI SBAR note indicating new or worsening incontinence with frequency and dysuria; section A2 indicated criteria not met - 5/2/23: urinalysis and culture result report from the urine indicated the urine sample was cloudy and contained bacteria with two biotypes of the organism Proteus of counts exceeding 100,000 - 5/4/23: a completed infection report indicating the following: a. date of onset: 4/27/23 b. type of infection: urinary without a catheter c. symptom of acute dysuria d. evaluation of infection: criteria met The documentation in the medical record for Resident #269 did not match the facility surveillance information and discrepancies were not explained or resolved. The medical record reflected symptoms that the facility surveillance form lacked. Review of the Facility Surveillance Line Listings for May 2023 indicated, but was not limited to the following for Resident #268: - an illness categorized as PNU (pneumonia) with an onset date of 5/3/23 - the section for symptoms was left blank - the form indicated a CXR was completed on 5/2/23 and was positive (but specifics were not indicated) - the form indicated the Resident had an HAI and was being treated with Augmentin (a combination antibiotic) - the form indicated the illness did count as an infection in the facility Review of the medical record for Resident #268 indicated, but was not limited to the following: - 5/2/23: NP encounter note indicated: low oxygen saturations during skilled therapy without the use of supplemental oxygen, 79% at rest and 73% while walking (the American lung association indicates good oxygen saturation levels at over 90%); a CXR was ordered - 5/3/23 NP encounter note indicated: CXR of bilateral airspace opacities, patchy modest bilateral airspace disease; and to start antibiotics; resident must pause while speaking to catch his/her breath - 5/5/23: NP encounter note indicated: Resident complaint of catching a good breath and decreased oxygen saturations during skilled therapy, history of atrial flutter and history of pneumonia and respiratory failure with raised concern for possible pulmonary embolism (PE); transfer to emergency room to rule out the possibility of PE - 5/5/23: a completed infection report indicated the following: a. date of onset: 5/2/23 b. type of infection: lower respiratory c. symptoms of oxygen saturations less than 94% on room air and positive CXR d. evaluation of infection: criteria not met The documentation in the medical record for Resident #268 did not match the facility surveillance information and discrepancies were not explained or resolved. The medical record indicated symptoms that the surveillance lacked and the medical record indicated the illness did not meet infection criteria, however, the facility surveillance indicated the illness did meet criteria. During an interview on 6/28/23 at 10:25 A.M., the IP reviewed the records and surveillance line listings of the sampled Residents. She said the surveillance for Resident #25 was incomplete and lacked the documentation of symptoms on the surveillance monitoring tool in use by the facility and the determination of illness versus infection was not clarified as it should have been and the surveillance sheets were inaccurate. She said for Resident #7, the surveillance sheets were inaccurate for the onset date of illness and the record was inaccurate for category type, which should have been skin. She said for Resident #63, the surveillance monitoring tool used by the facility was incomplete and inaccurate as it lacked the necessary symptom documentation and the illness should not have been counted as an infection on surveillance as it did not meet criteria for an infection. She said for Resident #269, the surveillance tool in use by the facility was incomplete and did not reflect the symptoms the resident was experiencing and it should have. She said for Resident #268, the surveillance form was incomplete as it did not reflect the symptoms documented in the medical record and should have and the surveillance was inaccurate in its determination of category of illness as PNU, as it should have been an LRI with a note indicating the possibility of a PE (which is a non-infectious process) and because of the miscategorization of the illness it should not have been counted on the surveillance as an infection and was done so in error. She said she needs to adjust her process for surveillance and monitoring of illnesses for all residents, not just residents on antibiotic treatment. The IP said she needed to work on completing the surveillance sheets with accurate information documented in each section of the form that matches the information in the resident records. The IP said the current process does not enable her to identify trends or potential infections for analysis because the process is incomplete and inaccurate.

Based on observation and staff interview, the facility failed to ensure that for one Resident (#85), of a total sample of 23 residents, that the facility assessed the Resident to be able to safely self-administer medication prior to the nurse leaving the medication at the bedside. Findings include: On the Pleasant Bay Unit, on 10/22/20 at 8:00 A.M., the surveyor observed Nurse #1 administering medications to Resident #85 during the Medication Pass observation. Nurse #1 poured the following medications to administer to the Resident: -Atenolol 50 mg (milligrams) by mouth twice daily -treats high blood pressure -Cetirizine 10 mg by mouth daily -treats allergy symptoms -Ferrous Gluconate 324 mg, two tablets by mouth daily - treats or prevents iron deficiency -Miralax, 17 grams, by mouth daily with 8 ounces of fluid of choice -treats constipation Nurse #1 proceeded to the Resident's bedside, informed the Resident that she had the Resident's medications and handed the Resident the Atenolol, Cetirizine, and Ferrous Gluconate, which the Resident proceeded to take. Nurse #1 said to the Resident that she had his/her Miralax that was mixed in liquid. The Resident said to Nurse #1 that he/she didn't think he/she needed the Miralax. The Resident then said to Nurse #1, I'll think about it, and instructed Nurse #1 to leave the medication on the nightstand, which the nurse did. The nurse then left the room with the Resident's Miralax mixed in liquid on the nightstand without observing the Resident take the medication. After exiting the room, the surveyor questioned Nurse #1 as to why she left the Miralax at the Resident's bedside, Nurse #1 said, I never leave medication at the bedside. The surveyor said to Nurse #1 that Miralax is considered a medication and asked her what the facility's policy was on residents administering their own medication. Nurse #1 proceeded to go back to the Resident's room, removed the Miralax, and said to the surveyor that she would check with the nursing supervisor as she was not sure if she should have left the medication with the Resident to self-administer. Nurse #1 provided no evidence that a self-administration of medication assessment was available that determined that the Resident was assessed to administer his/her own medication. During interview on 10/22/20 at 1:45 P.M., the DON (Director of Nursing) said that nurses are required to observe Residents taking all medications prescribed by the physician and are not allowed to leave any medication at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #72 was admitted to the facility in March 2018 with diagnoses including multiple sclerosis and quadriplegia (paralysis of all four limbs). Review of the most recent Minimum Data Set (MDS) assessment with a reference date of 9/2/20, indicated that Resident #72 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15, was dependent on staff for all activities of daily living including bed mobility, was incontinent of both bowel and bladder, and was at risk for developing pressure ulcers. The assessment indicated that Resident #72 had a pressure reducing device for their bed and chair. Review of the medical record indicated that Resident #72 had been treated for multiple open areas on his/her skin, ranging from stage 3 (lesion extends into the dermis and forms a crater) to stage 4 (muscle and bone are exposed). Review of the interdisciplinary care plan for potential for pressure ulcer development related to a history of ulcers, immobility, incontinence, indicated that by 5/20/20, all wounds had been resolved. Preventative interventions included the use of a pressure relieving air mattress, set at 120 pounds (lbs), implemented on 3/2/2020. On 10/20/20 at 10:59 A.M., the surveyor observed Resident #72 lying in his/her bed awake. An air mattress was in place, functioning, and the dial was set at 160 lbs. On 10/21/20 at 8:47 A.M., the surveyor observed Resident #72 sitting upright in bed. The air mattress was in place, functioning, and the dial was set at 160 lbs. During interview with Unit Manager #3 on 10/22/20 at 10:23 A.M., she said that Resident #72 had an air mattress as a pressure relieving intervention because he/she is at high risk for developing pressure areas due to his/her bed bound status. The Unit Manager said that air mattresses are to be set according to the Resident's weight. The surveyor and Unit Manager reviewed Resident #72's care plan and the Unit Manager confirmed that the air mattress was to be set at 120 lbs. At 10:25 A.M the surveyor and Unit Manager #3 observed Resident #72 lying in bed awake. The air mattress was in place and functioning. The Unit Manager confirmed that the dial was set to 160 lbs, and not 120 lbs as care planned. The Unit Manager reviewed Resident #72's medical record and was unable to find documentation that proper inflation was checked or monitored on a regular basis. Based on observation, record review, policy review and staff interview, the facility failed to ensure that staff implemented a comprehensive, person centered care plan for two of three (#101 & #72) residents for prevention of impairment of their skin integrity related to pressure sore prevention, including monitoring the setting of a pressure relieving mattress. Findings include: Review of the facility policy for Use of Pressure Relieving Devices (undated), indicated the following: -the purpose and objective of the policy is to provide equipment the clinical team feels is necessary to prevent development of pressure injury and/or aid in healing process -air mattress is designed to decrease pressure on the bony prominences that come in contact with the bed. -air mattress initial inflation of the device is weight dependent -proper inflation is checked on a regular basis by wound team during wound rounds 1. For Resident #101, the facility staff failed to ensure that the pressure relieving mattress was set to the correct pressure as identified in the plan of care and failed to document the settings. Resident #101 was admitted in January 2020 with diagnoses that included protein calorie malnutrition, anemia, and Cauda Equina Syndrome (effecting the motor function of lower extremities and bladder). After a brief hospitalization, Resident #101 was readmitted to the facility on [DATE] with a Stage 2 pressure injury (partial thickness skin loss). Review of the most recent quarterly Minimum Data Set, completed on 9/30/20, indicated the Resident had a Stage 2 pressure ulcer and was receiving skin ulcer treatments, including a pressure reducing device while in bed. Review of the medical record indicated that Resident #101 had a medical decline and was evaluated and began to receive hospice service starting in October 2020. Further review of the medical record indicated that on 10/22/20 the Resident's Stage 2 pressure ulcer measured 2.26 cm (centimeter) X 1.53 cm. and was located on the Resident's coccyx. Review of the Resident's care plan indicated that the Resident has potential/actual impairment of skin integrity related to pressure area-Stage 2 located on the coccyx. One of the intervention indicated to have the pressure relieving air mattress set at 110. On 10/22/20 at 8:25 A.M. the surveyor observed Resident #101 in bed and the air mattress dial was set to 160 lbs. On 10/27/20 at 1:22 P.M. the Wound Care Specialist and the Director of Nurses were interviewed via phone and said it is the responsibility of the CNA staff to ensure that the pressure relieving mattress is set correctly as identified on the Resident's care card that the CNAs use to provide care. Review of the Resident's care card indicated that the pressure relieving air mattress should be set to 110 lbs. The Wound Care Specialist said that she checks all air mattress setting as she conducts her weekly wound rounds. The Wound Care Specials said that she last checked Resident #101's air mattress on 10/22/20, however there was no documented evidence that Resident's air mattress was set at 110 lbs.

Based on observation and staff interview, the facility failed to ensure that medications were labeled and stored in accordance with currently accepted professional principles and medications accurately labeled with the expiration date, during an inspection of 1 of 3 medication storage rooms and the inspection of 3 of 7 medication carts. Findings include: On 10/22/20 the surveyor observed, during an inspection of the facility's medication storage rooms: MEDICATION STORAGE ROOMS PLEASANT BAY UNIT MEDICATION ROOM On 10/22/20 at 12:35 P.M., the medication storage room on the Pleasant Bay Unit was inspected with UM#1 (Unit Manager #1). The medication storage refrigerator thermometer indicated that the temperature was between 31-32 degrees Fahrenheit. Multiple medications were stored in the refrigerator, to include multiple unopened vials of insulin and and IV (intravenous) bags of the antibiotic Ceftriaxone 2 grams. One IV bag of Ceftriaxone was observed to be partially frozen. The USP (United States Pharmacopoeia and National Formulary (NF) guidance from April 28, 2017 indicated that the refrigerator temperature for medication storage should be controlled between 36 degrees and 46 degrees Fahrenheit. Additionally, the U.S. FDA (Food and Drug Administration) publication dated 9/19/2017, indicated, According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator temperature at approximately 36 degrees Fahrenheit to 46 degrees Fahrenheit. Unopened and stored in this manner, these products maintain potency until the expiration date on the package. During interview at this time UM #1 said that the refrigerator temperature was not at the correct temperature range. She said that the bag of IV antibiotic should not be partially frozen. MEDICATION CART: Stage Harbor Unit-North On 10/22/20 at 10:20 A.M., the Oyster Pond medication cart was inspected with Nurse #3. The medication cart was observed to have a bottle of artificial tears in the top drawer with a resident's name on it. The artificial tears were not dated as to when the medication container was first opened. The policy from the facility's consultant pharmacy for eye drops, such as artificial tears indicated, All ophthalmic medications in vials are to be dated when opened and expire in 60 days except those meds listed above. (Artificial Tears were not listed). During interview Nurse #3 acknowledged the risk for contamination and infection with the use of eye drops past the recommended discard date.