2. Resident #2 was admitted to the facility in January 2025 with diagnoses including pneumonia, sepsis, and atrial fibrillation (an irregular heart rhythm). Review of Resident #2's medical record included Baseline Care Plan and Baseline Care Plan Summary documents, both documents were labeled with the Resident's name, room number, and attending physician, but failed to include any other information. During a telephonic interview on 2/12/25 at 4:36 P.M., Resident Representative #2 said the beginning of Resident #2's stay was a very hard transition. Resident Representative #2 said initially the communication could have been better and that things were difficult because the facility did not know Resident #2 and Resident #2 did not know them; nobody knew what to expect. Resident Representative #2 said there was no meeting within 72 hours of admission, and she had not been provided a summary of the baseline care plan. During an interview on 2/13/25 at 10:45 A.M., Nurse #1 said the baseline care plan meetings were completed by the Social Service Department, the Director of Nurses (DON) and sometimes the Minimum Data Set (MDS) department within a few days of the resident's admission. During an interview on 2/18/25 at 1:14 P.M., Nurse #2 said when a resident was admitted , there was a paper baseline care plan packet in the chart that the nurse starts. Nurse #2 said nursing management then initiates the care plan in the electronic medical record. Nurse #2 said that she was not sure if the care plan was provided to the resident/resident representative. During an interview on 2/18/25 at 11:28 A.M., the Director of Social Services said the MDS Nurse, who had recently retired, had been handling the baseline care plan meetings. The Director of Social Services said the review of the baseline care plan should include a meeting with the resident or resident representative and a copy of the plan of care should be provided. During an interview on 2/13/25 at 3:08 P.M., the DON said typically the baseline care plan would be reviewed with the resident and/or resident representative at a plan of care meeting 48 to 72 hours after admission. The DON was not sure if Residents #327 and #2 had plan of care meetings. He said he did not think the initial post-admission meetings were occurring as they were supposed to and did not think copies of the plan of care were being provided. Based on interview and document review, the facility failed to ensure two Residents (#327, #2) were informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 12 residents. Findings include: Review of the facility's policy titled Baseline Care Plans, undated, indicated but was not limited to the following: (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: -be developed 48-72 hours of a resident's admission [sic] to the facility -include the minimum healthcare information necessary to properly care for a resident (2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission. (3) The facility must offer the resident and their representative a copy with a summary of the baseline care plan that includes but is not limited to: -The initial goals of the resident. -A summary of the resident's medications and dietary instructions. -Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 1. Resident #327 was admitted to the facility in January 2025 with diagnoses including Influenza A with pneumonia and chronic kidney disease. Review of Resident #327's current Physician's Orders indicated his/her Health Care Proxy was activated. Review of Resident #327's Care Plan indicated the comprehensive care plan was initiated on 1/30/25. Resident #327's medical record included Baseline Care Plan and Baseline Care Plan Summary documents. Both documents were labeled with the Resident's name, room number, and attending physician, but failed to include any other information. During an interview on 2/12/25 at 4:10 P.M., Resident Representative #1 said she had spoken with the facility Social Worker that day to discuss discharge planning but had not had any prior meetings at the facility. Resident Representative #1 said that she did not receive a summary of Resident #327's baseline care plan.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice. Specifically, the facility failed to ensure a treatment order was in place for a dressing to Resident #327's left lower extremity. Findings include: Review of Lippincott Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #327 was admitted to the facility in January 2025 with diagnoses including Influenza A with pneumonia and chronic pedal edema (swelling of the ankles and feet). On 2/12/25 at 9:16 A.M., the surveyor observed a foam dressing on Resident #327's left lower shin. On 2/13/25 at 9:40 A.M., the surveyor observed a foam dressing marked 2/13 on Resident #327's left lower shin. Resident #327 said the nurse had changed the dressing that morning. Review of Resident #327's hospital discharge referral, dated 1/29/25, indicated Resident #327 was noted to have a skin tear on his/her left lower shin. Review of Resident #327's Physician's Orders failed to include an order for a dressing to Resident #327's left shin. Review of Resident #327's February 2025 Medication, Treatment, and Task Administration Record Report failed to include documentation indicating a dressing was applied to the Resident's left shin. Review of Resident #327's Progress Notes indicated but were not limited to the following: -2/2/25: All dressings cleansed and changed. -2/5/25: Dressing to left ankle change (cleanse, xeroform applied f/b (followed by) DCD (dry clean dressing)) and skin prep applied to bilateral heels. -2/6/25: Dressing to left ankle change (cleanse, xeroform applied f/b DCD) and skin prep applied to bilateral heels. During an interview on 2/13/25 at 11:54 A.M., Nurse #1 said Resident #327 had a skin tear on his/her left leg when he/she was admitted to the facility. Nurse #1 said that the skin tear was not healed on 2/13/25 and still required a dressing. During an interview on 2/13/25 at 3:08 P.M., the Director of Nurses said it is his expectation that an order should be obtained from the physician or nurse practitioner for any treatments and that nurses should indicate the treatment was completed on the Medication, Treatment, and Task Administration Record.

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#10), in a total sample of 12 residents. Specifically, the facility failed to ensure nail care was performed for Resident #10. Findings include: Review of the facility's policy titled Care of Nails, undated, indicated but was not limited to: -Objective: 1. to provide cleanliness 2. to prevent infection -Procedure: 1. Trim Nails Resident #10 was admitted to the facility in February 2024 with diagnoses that included peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 11/24/24, indicated Resident #10 required substantial/ maximal assistance (helper does more than half the effort) for personal hygiene and that he/she scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Review of the care plans indicated Resident #10 was totally dependent with ADLs and would not initiate or follow through due to cognitive deficits and staff would provide assistance with ADLs as needed. On the following dates and times, the surveyor observed Resident #10's fingernails on both hands to be grown past the tips of his/her fingertips and at varying lengths: -2/12/25 at 10:46 A.M., -2/13/25 at 9:08 A.M., and -2/13/25 at 1:14 P.M. During an interview on 2/13/25 at 9:08 A.M., Resident #10 said his/her fingernails had been growing for a while and were overdue to be trimmed. Resident #10 said he/she required help from the staff to cut his/her nails and was not sure why they had not been done. During an interview on 2/13/25 at 1:30 P.M., Certified Nursing Assistant (CNA) #1 said she was aware Resident #10's fingernails were long but she had not had a chance to cut them in a while. CNA #1 said she would cut his/her nails on 2/14/25. CNA #1 said Resident #10 was cooperative with care when it was being provided. During an interview on 2/13/25 at 1:35 P.M., Nurse #1 said the expectation was for the CNAs to provide nail care to residents when the nails were long and overgrown. During an interview on 2/13/25 at 3:11 P.M., the Director of Nurses (DON) said the fingernails of the residents should be trimmed by the CNAs when providing ADL care as needed.

2. Resident #23 was admitted to the facility in May 2024 with diagnoses that included depressive episodes, moderate dementia with mood disturbance, and unspecified psychosis. Review of Resident #23's Physician's Orders indicated but was not limited to the following: -Clozapine 25 mg. Give one tablet by mouth twice a day at 12 P.M. and 6 P.M. (5/20/24); -Clozapine 12.5 mg. Give one tablet by mouth every day at 8 A.M. (5/20/24). Review of Resident #23's medical record indicated the Consultant Pharmacist had completed a MRR which indicated but was not limited to the following: -12/17/24: prescriber recommendation made to consider a trial GDR of Clozapine treatment; -1/23/25: prescriber recommendation made to consider a trial GDR of Clozapine treatment. Further review of Resident #23's medical record failed to include the prescriber's signature or response to the Pharmacist's recommendations. During an interview on 2/18/25 at 1:29 P.M., the DON said the facility's process for reviewing the Consultant Pharmacist's MRRs is as follows: the Consultant Pharmacist reviews the residents' records and makes recommendations when needed, the recommendation forms are sent to the DON or their designee, and the forms are then given to the prescribers to sign and indicate whether they agree or disagree with the recommendations, and the completed forms are kept in the residents' medical records. The DON said he was not employed at the facility at the time the recommendations were made and did not know why the facility's process was not followed. During an interview on 2/18/25 at 2:26 P.M., Nurse #1 and the surveyor reviewed Resident #23's medical record and the Pharmacist's MRR. Nurse #1 said she did not know the Pharmacist's MRRs were being filed in the paper charts and was not aware of the Pharmacist's recommendation for a trial GDR of Resident #23's Clozapine. Nurse #1 said the DON oversaw pharmacy recommendations. When the former DON left the facility, the MDS nurse managed pharmacy recommendations. However, when the MDS nurse left, there was no process for pharmacy recommendations that Nurse #1 was aware of. Based on record review and interview, the facility failed to ensure that the monthly Medication Regimen Review (MRR) reports for two Residents (#9, #23), out of a total sample of 12 residents, were included in the medical record and acted upon in a timely manner. Specifically, the facility failed: 1. For Resident #9, to ensure the monthly MRR reports were included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Consultant Pharmacist; and 2. For Resident #23, to act promptly upon recommendations made by the Consultant Pharmacist during the monthly MRR for consideration of a gradual dose reduction (GDR) of Clozapine (an antipsychotic medication). Findings include: 1. Resident #9 was admitted to the facility in October 2019 with diagnoses including cerebral infarction (stroke) and depression. Review of Resident #9's Physician's Orders indicated but was not limited to the following: -Amitriptyline (antidepressant) 25 milligrams (mg) Give 2 tabs (50 mg) by mouth at bedtime (8/13/24) Review of the medical record for Resident #9 indicated the Consultant Pharmacist had completed a MRR which indicated but was not limited to the following: -7/25/24: prescriber recommendation made to evaluate the risk/benefit of Amitriptyline and consider a trial tapering dose reduction -8/26/24: prescriber recommendation made to evaluate the risk/benefit of Amitriptyline and consider a trial tapering dose reduction Further review of the Resident's medical record failed to include the Consultant Pharmacist's Note to Attending Physician/Prescriber forms, indicating the recommendations made and the Physician's response to the recommendations made, following the July 2024 and August 2024 MRRs. A copy of one form, indicating it was printed 7/30/24, was provided to the surveyor by the Director of Nursing (DON). The copy did not include the prescriber's response to the recommendation or signature. During an interview on 2/13/25 at 3:08 P.M., the DON said the original Consultant Pharmacist's Note to Attending Physician/Prescriber forms from the July 2024 and August 2024 MRRs were missing, but he was able to obtain copies of some of the original recommendations. The DON said the original forms with the prescriber's signature should be available in the medical record. During an interview on 2/18/25 at 1:29 P.M., the DON said the facility's process for reviewing the Consultant Pharmacist's MRRs is as follows: the Consultant Pharmacist reviews the residents' records and makes recommendations when needed, the recommendation forms are sent to the DON or their designee, and the forms are then given to the prescribers to sign and indicate whether they agree or disagree with the recommendations, and the completed forms are kept in the residents' medical records. The DON said he was not employed at the facility at the time the recommendations were made and did not know why the facility's process was not followed.

Based on record review and interview, the facility failed to ensure one Resident's (#23) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 12 residents. Specifically, the facility failed to ensure a gradual dose reduction (GDR) of the antipsychotic medication Clozapine was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, revised 2/24/24, included but was not limited to the following: -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Resident #23 was admitted to the facility in May 2024 with diagnoses that included depressive episodes, moderate dementia with mood disturbance, and unspecified psychosis. Review of Resident #23's Physician's Orders indicated but was not limited to the following: -Clozapine 25 milligrams (mg). Give one tablet by mouth twice a day at 12 P.M. and 6 P.M. (5/20/24); -Clozapine 12.5mg. Give one tablet by mouth every day at 8 A.M. (5/20/24). Review of Resident #23's Medication Administration Records for December 2024 through February 2025 indicated the Resident was receiving Clozapine as ordered. Review of Resident #23's medical record indicated the Consultant Pharmacist had completed a MRR which indicated but was not limited to the following: -12/17/24: prescriber recommendation made to consider a trial GDR of Clozapine treatment; -1/23/25: prescriber recommendation made to consider a trial GDR of Clozapine treatment. Review of the Minimum Data Set (MDS) assessment, dated 11/24/24, indicated but was not limited to the following: -the Resident did not have any symptoms of psychosis including delusions or hallucinations. -Date of last attempted GDR: 5/17/24; -GDR has not been documented by a physician as clinically contraindicated. Further review of Resident #23's medical record failed to indicate the prescriber's signature or response to the Pharmacist's GDR recommendations on 12/17/24 and 1/23/25, and failed to indicate any recent GDR trial for Clozapine. During an interview on 2/18/25 at 2:26 P.M., Nurse #1 said Resident #23 had been receiving Clozapine regularly as ordered by the Physician, with labs every two weeks to monitor the side effects of the medication. Nurse #1 said she was unsure of any recommendations or plans for a GDR of Clozapine. During an interview on 2/18/25 at 1:29 P.M., the Director of Nurses (DON) said he was unsure why there was no GDR of Clozapine implemented for Resident #23.

Based on observation and interviews, the facility failed to ensure that all drugs were labeled in accordance with currently accepted professional principles. Specifically, medications were stored, unlabeled, in a small box in the top right-hand side of the top drawer of the facility's only medication cart. Findings include: On 2/12/25 at 2:57 P.M., the surveyor inspected the medication cart, located on the first floor, with Nurse #3. The surveyor observed multiple unit dose medications in the top drawer, on the right side, of the medication cart. The medications were observed to be loose and sitting in a small cardboard box. There was no label or identifying information to indicate that it had come from the facility's pharmacy, they lacked resident names, and there was no administering/cautionary information or directions for administering the medication. The unit dose medications observed unlabeled in the medication cart were as follows: -Cefpodoxime (antibiotic) 100 milligrams (mg) #6 -Carbamazepine (anticonvulsant) 100 mg chewable tabs #2 -Doxycycline (antibiotic) 100 mg #2 -Prednisone (corticosteroid) 20 mg #7 -Carbamazepine (anticonvulsant) 100 mg #2 -Loperamide (anti-diarrheal) 2 mg #2 -Sinemet (treats Parkinson's disease) 25 mg/250 mg #1 During an interview on 2/12/25 at 3:34 P.M., Nurse #3 said that the storage of unlabeled medications mixed together in a cardboard box, without the proper cautionary and administration information that comes from the pharmacy was not acceptable. Nurse #3 said that the risk for a medication error existed by having medications stored and unlabeled in that manner. Nurse #3 did not know what residents the medications were for or where they came from. She said that she would contact the Director of Nursing (DON) for guidance on an acceptable way to store and label the medications as she was not sure of how that should be done. During an interview on 2/12/25 at 3:43 P.M., the DON said that medications should not be stored loosely in the top drawer of the medication cart and that it created a risk for medication errors. He said that he did not have a policy for drug storage and labeling of loose, unit dose medications at that time.

3. Review of the Center for Disease Control and Prevention (CDC) guidelines titled Infection Control in Health Care: An Overview, dated 2/7/24, included but was not limited to Pathways of spread for dry surfaces include: Touch, hands can pick up germs from dry surfaces and can then spread those germs to other surfaces, devices and people. Standard Precautions are the things you do every day . to keep germs from spreading. Standard Precautions include: Hand hygiene and based on your assessment of the situation and the risk for germs to spread, choosing the right personal protective equipment (PPE) and using it the right way, at the right time, for the right task. On 2/12/25 at 8:59 A.M., the surveyor observed Nurse #3 administering medications to residents. Nurse #3 had poured eight medications into the medication cup. After realizing she had poured the wrong dose of Omega 3, she stuck her ungloved fingers into the medication cup and removed the Omega capsule. On 2/12/25 at 9:50 A.M., Nurse #3, in preparation of pouring another resident's medications, removed two plastic medication cups from the stack of med cups on the medication cart. In the process, Nurse #3 touched the inside of the med cups with her ungloved fingers. On 2/12/25 at 10:00 A.M., Nurse #3 had poured two medications into a med cup including Eliquis and Escitalopram. After pouring the Escitalopram, Nurse #3 put her finger inside the med cup with an ungloved hand prior to pouring the last two medications. During an interview on 2/12/25 at 10:02 A.M., Nurse #3 said that she was not aware that she was putting her fingers into the med cups during the Medication Pass. During an interview on 2/18/25 at 1:39 P.M., the DON said that Nurse #3 should not have placed her fingers into the medication cups while pouring resident medications. The DON said that Nurse #3's practice posed a risk for contamination. Based on record review, observation, and interviews, the facility failed to ensure that infection control measures were implemented in order to prevent the potential development and spread of disease for two Residents (#1, #9), out of a total sample of 12 residents and three Residents during medication administration. Specifically, the facility failed: 1. For Resident #1, to ensure that transmission-based precautions (TBP) were implemented when the Resident was suspected to have a contagious respiratory illness; 2. For Resident #9, to ensure that TBP were implemented when the Resident refused COVID-19 testing during facility outbreak testing; and 3. To ensure staff donned gloves when touching the inside of the medication cup and/or its contents during medication administration. Findings include: Review of the facility's policy titled Staff and Resident Testing Procedures, undated, indicated but was not limited to the following: -Outbreak testing: Test all staff and residents in response to an outbreak (any single new infection). Continue to test all staff and residents that tested negative every 3 days until 7 days since the most recent positive result had passed. -Residents with symptoms must be placed on transmission-based precautions (TBP) in accordance with CDC guidance. Review of the facility's policy titled Procedures for Refusal of Staff and Resident Testing, undated, indicated but was not limited to the following: -Residents with symptoms who refuse testing are placed on TBP until the criteria for discontinuation are met. -Outbreak testing: Asymptomatic residents who refuse are placed on TBP until the criteria for discontinuation are met. Review of the facility's policy titled Policy for Isolation Precautions, undated, indicated but was not limited to the following: -It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. -Isolation precautions may be instituted by a physician, the infection preventionist, the director of nurses, nurse manager or charge nurse. -A resident may be placed in Isolation Precautions without a physician's order. -Use Droplet Precautions for a resident known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the resident sneezing, coughing, talking, etc., and drop from the air. This includes bacterial infections and some viral infections, including influenza. -Obtain table/cart for 24-hour supply of masks, gowns, etc. needed to maintain Isolation precautions. -Obtain appropriate signage and post outside the doorframe (no resident name or organism name should appear on the signage). Review of the Massachusetts Department of Public Health Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, dated 5/10/23, indicated the following: -Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case, unless a DPH Epidemiologist directs otherwise. 1. Resident #1 was admitted to the facility in April 2023 with diagnoses including atrial fibrillation and heart failure. Review of Resident #1's Physician's Orders indicated but was not limited to the following: -Please obtain 4 Plex swab and send out to lab for testing of COVID, flu, RSV (Respiratory Syncytial Virus, a virus affecting the respiratory tract) (order date: 2/12/25) Review of Resident #1's Progress Notes indicated but was not limited to the following: -2/12/25 at 7:39 A.M.: During 11-7 shift, the Resident had a congested cough productive of sputum followed by vomiting of blood-tinged/brownish fluid and a short period of shortness of breath. The Nurse Practitioner was contacted and a new order for chest x-ray and a 4-Plex swab (a test for flu, COVID, and RSV) was obtained. -2/12/25 at 3:17 P.M.: Resident's chest x-ray showed no acute pulmonary findings. The Nurse Practitioner was notified of the results and no new orders were given. Review of Resident #1's medical record failed to indicate that Isolation Precautions were implemented when the Resident became symptomatic or while results of the Resident's respiratory virus testing were pending. On 2/12/25 at 9:01 A.M., the surveyor observed the Resident in his/her room. No signage was posted outside the Resident's room and no cart with a supply of personal protective equipment was located nearby. During an interview on 2/18/25 at 1:42 P.M., the Director of Nurses (DON) said that when a resident is suspected to have a communicable illness requiring precautions, isolation precautions should be initiated and a sign indicating precautions were in place should be located on the doorframe outside the resident's room. The DON said it is his expectation that isolation precautions be implemented when a symptomatic resident is being tested for COVID-19 or influenza. 2. Resident #9 was admitted to the facility in October 2019 with diagnoses including cerebral infarction (stroke) and depression. Review of Resident #9's Progress Notes indicated but was not limited to the following: -8/30/24 at 8:40 P.M.: Secondary to a positive case in the facility, the Resident was tested for COVID-19 and the result was negative. -9/3/24 at 1:47 P.M.: A staff member tested positive for COVID-19 and the Resident's Health Care Proxy was notified. COVID-19 testing will continue every other day until seven days have passed without a new case. -9/5/24 at 3:13 P.M.: Resident refused COVID-19 testing on two attempts. -9/7/24 at 2:27 P.M.: Resident tested for COVID-19 and result was negative. -9/9/24 at 4:36 P.M.: Resident refused COVID-19 testing on two attempts. Review of Resident #9's medical record failed to indicate that Isolation Precautions were implemented when the Resident refused COVID-19 testing on two occasions during the facility's COVID-19 outbreak testing. During an interview on 2/18/25 at 1:42 P.M., the DON said that if a resident refuses COVID testing during outbreak testing, TBP should be implemented as a precaution for other residents/staff that may be at risk. If the resident continues to refuse testing, TBP should remain in place for five days per quarantine rules.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offer and administer the influenza and pneumococcal immunizations in a timely manner for two Residents (#3, #10), out of five sampled residents. Specifically, the facility failed: 1. For Resident #3, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the influenza vaccine, offer the immunization, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccine and place in the Resident's medical record; 2. For Resident #10, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the influenza and pneumococcal vaccines, offer the immunizations, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccines and place in the Resident's medical record; Findings include: Review of the facility's policy titled Policy for Influenza Vaccination for Residents, undated, indicated but was not limited to the following: -It is the policy of this facility that annually, in the fall, residents will be offered immunization against influenza. The time for immunization will follow the recommendations of the CDC (Centers for Disease Control and Prevention) and the state department of health. -Residents or their responsible party will be educated about the risk/benefit of the influenza vaccine on an annual basis. -Residents or their responsible party have a right to refuse vaccination and sign a declination form. They will be reapproached twice before the end of the vaccination time frame. Review of the facility's policy titled Policy for Pneumococcal Vaccination of Residents, undated, indicated but was not limited to the following: -It is the policy of this facility that each resident or their responsible party will be asked on admission if the resident previously had the pneumococcal vaccination and their age at the time of vaccination. The records may be requested from the resident's community PCP (primary care provider). If there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time. -If an immunocompetent resident was [AGE] years of age or less at the time of initial vaccination and more than five years have elapsed since initial vaccination, one booster dose of vaccine will be offered. -If an immunocompromised resident, the vaccination should be repeated once if five years have elapsed since initial vaccination, regardless of age at the time of initial vaccination. -Pneumococcal candidates for vaccination: a) 65 years or older b) Serious long-term health problem such as heart disease, sickle cell disease, alcoholism, leaks of cerebrospinal fluid, lung disease, diabetes, or liver cirrhosis c) Resistance to infection is lowered due to Hodgkin disease; multiple myeloma; cancer treatment with x-rays or drugs; treatment with long-term steroids; bone marrow or organ transplant; kidney failure; HIV/AIDS; lymphoma, leukemia, or other cancers; nephritic syndrome; damage spleen or no spleen d) Alaskan Native or certain American populations -If the resident had PCV 23 prior to admission, then the resident may have Prevnar 13 one year later from time of PCV 23 administration. -If the resident had Prevnar 13 (PCV13, a pneumococcal conjugate vaccine), then the resident may have PCV 23 one year later from the time of Prevnar 13 administration. -if the resident did not have any pneumococcal vaccines, then the resident should have Prevnar 13 followed by PCV 23 one year later after administration of Prevnar 13. *Note: There exists no PCV 23 (pneumococcal conjugate vaccine), this abbreviation most likely refers to the Pneumococcal Polysaccharide Vaccine (PPSV23)) Review of the Centers for Disease Control (CDC) guidance Flu and People 65 Years and Older, undated, indicated but was not limited to, the following: -Higher dose and adjuvanted flu vaccines are potentially more effective than standard dose unadjuvanted flu vaccines for people in this age group and are therefore recommended preferentially over a regular dose flu vaccine. -For most people who need only one dose of influenza vaccine for the season, September and October are generally good times to be vaccinated against influenza. Ideally, everyone should be vaccinated by the end of October. Review of the CDC guidance Pneumococcal Vaccine Timing for Adults, dated 10/2024, indicated but was not limited to the following: For Adults [AGE] years old or older, vaccine recommendations are as follows: -Unvaccinated adults should receive: a) PCV20 (Prevnar 20, a pneumococcal conjugate vaccine) or PCV21 vaccine (Capvaxive, a pneumococcal conjugate vaccine) or b) PCV15 followed by PPSV23 at least one year later -Adults who have received PPSV23 vaccine only (at any age): a) PCV20 or PCV21 vaccine administered at least one year after PPSV23 was received -Adults who have received PCV13 vaccine at any age: a) PCV20 or PCV21 vaccine administered at least one year after PCV13 was received -Adults who have received PCV13 at any age and PPSV23 when younger than age [AGE]: a) PCV20 or PCV21 at least 5 years after PCV13 or PPSV20 vaccine was received 1. Resident #3 was admitted to the facility in November 2022 and was over [AGE] years old. Review of the Consent for Immunizations, signed by the Resident's Representative on 11/28/22, indicated the Resident's Representative consented to the Resident receiving the PPSV23 and PCV13 vaccines and that the Resident had already received the influenza vaccine in October 2022. There was no seasonal 2024-2025 influenza vaccine consent form completed and available for surveyor review in the medical record. Review of the Minimum Data Set (MDS) assessment, dated 1/7/25, indicated Resident #3 last received the influenza vaccine on 3/27/24. Review of Resident #3's medical record failed to indicate the Resident was screened and assessed for eligibility for the vaccine, the Resident/Resident's Representative had been educated on the benefits and potential side effects of the influenza vaccine, the 2024-2025 influenza vaccine had been offered, and consent or refusal was documented and in place in the Resident's medical record. Review of the facility's Resident Vaccine Log, updated 1/24/25, provided to the surveyor by the Director of Nurses (DON) on 2/18/25, failed to indicate that the Resident had received the 2024-2025 influenza vaccine or that the vaccine had been refused by the Resident/Resident's Representative. During an interview on 2/18/25 at 1:42 P.M., the DON said the facility offers the seasonal influenza vaccine to all residents on admission if admitted during influenza season, annually, and throughout the influenza season and the vaccine is obtained from the facility's contracted pharmacy and available. The DON said that all residents should have completed Consent for Immunization forms and vaccine administration records in their medical record. The DON said that the residents' medical records should include documentation indicating whether the resident/resident's representative consents to or declines a vaccine. 2. Resident #10 was admitted to the facility in February 2024 and was over [AGE] years old. Resident #10's Consent for Immunizations was blank and failed to indicate whether Resident #10 consented, refused, or had already received the influenza, PPSV23, and PCV13 vaccines. Review of Resident #10's Vaccine Administration Record for Adults indicated Resident #10 had received a pneumococcal vaccination on 9/23/20, prior to admission to the facility. Review of Resident #10's Physician's Orders from an outside facility indicated the Resident had received the PPSV23 vaccine on 9/23/20. Review of Resident #10's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated Resident #10 had received an influenza vaccine on 10/12/23. The MIIS record did not include any pneumococcal immunization information. Review of the facility's Resident Vaccine Log, updated 1/24/25, provided to the surveyor by the DON on 2/18/25, failed to indicate that the Resident had received the 2024-2025 influenza vaccine or subsequent pneumococcal conjugate vaccine. Review of the MDS assessment, dated 11/24/24, indicated Resident #10 was offered and declined the seasonal influenza vaccine and was up to date with pneumococcal vaccination. Review of Resident #10's medical record failed to indicate the Resident was screened and assessed for eligibility for the influenza and pneumococcal conjugate vaccines, the Resident/Resident's Representative had been educated on the benefits and potential side effects of the vaccines, the 2024-2025 influenza vaccine had been offered, further pneumococcal vaccination had been offered, and consent or refusal of the vaccines were documented and in place in the Resident's medical record. During an interview on 2/18/25 at 1:42 P.M., the DON said the facility offers influenza and pneumococcal vaccines to all residents on admission, annually, and throughout the influenza season and the vaccines are obtained from the facility's contracted pharmacy and available. The DON said that all residents should have completed Consent for Immunization forms and vaccine administration records in their medical record. The DON said that the residents' medical records should include documentation indicating whether the resident/resident's representative consents to or declines a vaccine. No further immunization documentation for Residents #3 or #10 was provided to the survey team prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for five Residents (#1, #3, #10, #23, #327), out of a total sample of five residents reviewed for immunizations. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with COVID-19 Vaccines, revised 1/7/25, indicated but was not limited to the following: -Everyone ages 6 months and older should get the 2024-2025 COVID-19 vaccine. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID. -People ages 65 years and older: You are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. 1. Resident #1 was admitted to the facility in April 2023 and was over [AGE] years old. Review of the Consent for Immunizations, signed by the Resident on 4/16/23, failed to include any information regarding the COVID-19 vaccine. Review of the facility's Resident Vaccine Log indicated the Resident had last received the COVID vaccine on 3/25/22, but failed to indicate the Resident received the updated 2024-2025 COVID vaccine per CDC guidance. Review of a second Resident Vaccine Log, updated 1/24/25, failed to indicate the Resident had received the updated 2024-2025 COVID vaccine per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine. 2. Resident #3 was admitted to the facility in November 2022 and was [AGE] years old. Review of the Universal Vaccine Consent and Administration Record, undated, for Resident #3 indicated the Resident's Representative consented for the Resident to receive COVID vaccines. Review of the Vaccination Administration Record for Adults indicated Resident #3 had last received a COVID-19 vaccination on 2/25/22, but failed to indicate the Resident received the updated 2024-2025 COVID vaccine per CDC guidance. Review of the facility's Resident Vaccine Log failed to indicate the Resident had received the updated 2024-2025 COVID vaccine per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine. 3. Resident #10 was admitted to the facility in February 2024 and was over [AGE] years old. Review of Resident #10's Consent for Immunizations was blank and not signed by the Resident/Resident's Representative and failed to include any information regarding the Resident's COVID-19 vaccination status. Review of Resident #10's Vaccine Administration Record for Adults failed to include any information pertaining to COVID vaccination status. Review of the facility's Resident Vaccine Log failed to indicate the Resident had received the updated 2024-2025 COVID vaccine per CDC guidance. Review of Resident #10's Massachusetts Immunization Information System Vaccine Administration Record indicated the Resident had last received the COVID vaccine on 12/16/22, but failed to indicate the Resident received the updated 2024-2025 COVID vaccine per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine. 4. Resident #23 was admitted to the facility in May 2024 and was over [AGE] years old. Review of Resident #23's Universal Vaccine Consent Administration Record was blank and not signed by the Resident/Resident's Representative and failed to include any information regarding the Resident's COVID-19 vaccination status. Review of the facility's Resident Vaccine Log indicated the Resident had last received the COVID vaccine on 10/19/23, but failed to indicate the Resident received the updated 2024-2025 COVID vaccine per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine. 5. Resident #327 was admitted to the facility in January 2025 and was over [AGE] years old. Review of Resident #327's Consent for Immunizations failed to include any information pertaining to the Resident's COVID vaccination status. Review of Resident #327's Universal Vaccine Consent and Administration Record, undated, was blank and not signed by the Resident/Resident's Representative and failed to include any information regarding the Resident's COVID-19 vaccination status. Review of the facility's Resident Vaccine Log failed to indicate the Resident had received the updated 2024-2025 COVID vaccine per CDC guidance. During an interview on 2/18/25 at 1:42 P.M., the Director of Nurses (DON) said the facility offers COVID vaccination to all residents on admission, annually, and as needed and the vaccine is obtained from the facility's contracted pharmacy and available. The DON said that all residents should have completed Consent for Immunization forms and vaccine administration records in their medical record. The DON said that the residents' medical records, including Residents #1, #3, #10, #23, and #327, should include documentation indicating whether the resident/resident's representative consents to or declines a vaccine. No further immunization documentation for Residents #1, #3, #10, #23, and #327 was provided to the survey team prior to exit.

Based on observation, interview, policy review, and record review, the facility failed for two Residents (#2 and #11) to develop and implement comprehensive care plans to reflect the individual needs of the Residents, out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #2, to develop and implement a genitourinary system care plan related to urinary incontinence, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, chronic kidney disease stage three (CKD-Stage 3), and hyperkalemia (high potassium); and 2. For Resident #11, to develop and implement a genitourinary system care plan related to chronic urinary tract infections (UTIs), history of extended spectrum beta lactamase (ESBL) resistance, chronic obstructive pyelonephritis (kidney infection), and calculus of the kidney (kidney stone). Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised December 2016, 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 will: a. Describe the services that are to be furnished to attain or maintain the highest practicable physical, mental, a psychosocial well-being. b. Incorporate identified problem areas. c. Incorporate risk factors associated with identified problems. d. Reflect treatment goals, timetables, and objectives in measurable outcomes. e. Aid in preventing or reducing decline in resident's functional status or functional levels. f. Reflect currently recognized standards of practice for the problem areas and conditions. -Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 1. Resident #2 was admitted to the facility in April 2023 with diagnoses which included BPH with lower urinary tract symptoms, benign neoplasm of prostate, CKD-Stage 3, and hyperkalemia. Review of the Minimum Data Set (MDS) assessment, dated 1/24/24, indicated Resident #2 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Further review of the MDS indicated the Resident was incontinent of urine. Review of Resident #2's care plans failed to indicate a care plan had been developed related to his/her identified genitourinary conditions/problems including: incontinence, BPH, CKD-Stage 3, and hyperkalemia. During an interview on 2/27/24 at 2:36 P.M., Resident #2 said sometimes it is hard to get to the bathroom due to call light wait times. During an interview on 2/29/24 at 8:53 A.M., Nurse #2 said Resident #2 is always incontinent of urine but is continent of his/her bowels. She said there should be a urinary care plan in place for incontinence and there is not. During an interview on 2/29/24 at 11:37 A.M., the Director of Nurses (DON) said there should be a care plan in place for his/her incontinence care and management and there was not. 2. Resident #11 was admitted to the facility in October 2019 with diagnoses which included aphasia (impaired ability to communicate) following cerebrovascular disease (stroke), hemiplegia and hemiparesis (weakness/paralysis) following cerebrovascular disease affecting right side, UTI, ESBL resistance, acute pyelonephritis, chronic obstructive pyelonephritis, calculus of the kidney, and sepsis (life threatening complication of an infection). Review of the MDS assessment, dated 1/24/24, indicated Resident #11 was unable to complete the BIMS because the Resident was rarely or never understood. Further review of the MDS indicated the Resident was incontinent of urine, had unclear speech (slurred or mumbled words) and was sometimes understood (responds adequately to simple, direct communication only). Review of Resident #11's care plans failed to indicate a care plan had been developed related to his/her identified genitourinary conditions/problems including: UTIs, pyelonephritis, and calculus of the kidney. During an interview on 2/29/24 at 8:53 A.M., Nurse #2 said when Resident #11 is weepy, has increased yelling out and increased behaviors his/her daughter always thinks he/she has a UTI. Nurse #2 said she did not know if these behaviors increased with a change in condition or infection because the Resident is always like this and has chronic UTIs. She said when the Resident escalates, we usually get an order for a urine, because the daughter wants it, and we will monitor behaviors, temperature, and the urine for color/odor/frequency changes. Nurse #2 said he/she should have a urinary system care plan with triggered symptoms and behaviors he/she presents with but he/she does not. During an interview on 2/29/24 at 11:37 A.M., the DON said Resident #11 has staghorn calculi (large kidney stones which are linked to recurrent UTIs). She said Resident #11 should have a care plan related to this diagnosis and symptoms and she was unsure why there was not one. Additionally, she said Resident #11 usually presents with decreased appetite/fluid intake, increased signs/symptoms of pain (usually rubs legs, back/flank area), increased behaviors and is more resistant to care. The DON said the Resident is prone to UTIs, and we must ask simple questions to investigate what is going on. She said he/she should have a care plan with this information on it and probably an order for daily monitoring because he/she cannot communicate very well. She said the symptoms usually progress for a few days and since there was no monitoring for symptoms/behaviors on a care plan or in the orders other staff would not know how a UTI presents for Resident #11.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when one of one nurse made two errors in 29 opportunities, totaling a medication error rate of 6.9%. These errors impacted two Residents (#11 and #6), out of seven residents observed. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated February 2019, indicated but was not limited to the following: Preparation: -Five (5) Rights - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three (3) steps of 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. -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 (5) Rights. -Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the Five (5) Rights. -Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the Five (5) Rights. 1. On 2/28/24 at 8:35 A.M., the surveyor observed Nurse #1 prepare and administer one Aspirin (ASA) 81 milligrams (mg) chewable tablet along with eight other medications scheduled for 8:00 A.M. to Resident #11. The ASA chewable tablet was placed in the same plastic medication cup as the other eight medications. Nurse #1 did not separate the ASA from the rest of the medications or instruct the Resident to chew the ASA instead of swallowing it. Resident #11 swallowed all the pills whole with water. Review of current Physician's Orders indicated the following: -Aspirin 81 mg tablet chewable, one tablet by mouth daily, 5/8/23 Nurse #1 failed to administer the ASA via the prescribed route of administration per physician's orders. You may rely on your health professional to provide the correct information on dose and directions for use. Using aspirin correctly gives you the best chance of getting the greatest benefits with the fewest unwanted side effects. (U.S. Department of Health and Human Services Food and Drug Administration (FDA)) During an interview on 2/28/24 at 8:30 A.M., Nurse #1 said she should have separated the Resident's ASA and prompted him/her to chew it instead of swallowing it whole as that was what the order indicated but did not. During an interview on 2/28/24 at 1:16 P.M., the Director of Nursing (DON) said the ASA should have been separated to direct the resident to chew it, not swallow it. 2. On 2/27/24 at 10:05 A.M., the surveyor observed Nurse #1 administer medications to Resident #6. Nurse #1 prepared the Resident's morning medications, which included the medication artificial tears. Nurse #1 administered the oral medications and then informed the Resident that she was going to give him/her his/her eye drops and obtained a tissue from the medication cart. The nurse instilled one drop in the right eye, wiped the excess medication, and then immediately instilled one drop in the left eye, wiping the excess medication. Review of the Physician's Orders indicated to instill artificial tears, 1 drop in the right eye 4 times daily. During an interview on 2/27/24 at 11:15 A.M., Nurse #1 reviewed the artificial tears order and said that she should not have instilled the artificial tears drop in the Resident's left eye as the order was to instill only in the right eye.

Based on observation, interview, and policy review, the facility failed to develop a policy to ensure safe and sanitary storage, handling, and reheating of food brought to the facility for residents from family and visitors. Findings include: Review of the facility's policy titled Food Storage Second Floor Refrigerator, undated, indicated there were identified procedures for storage of food items. Further review of the policy indicated an absence of procedures or directions for reheating food to ensure safe consumption by the resident. During an observation of the 2nd floor nourishment kitchen/dining area on 2/28/24 at 1:45 P.M., the surveyor observed a piece of tattered and torn paper taped to the top of the microwave which indicated foods must be reheated to a minimum internal temperature of 165 degrees and maximum of 180 degrees. There were no further reheating instructions or procedures posted for staff. During an interview on 2/28/24 at 1:44 P.M., Certified Nurse Assistant (CNA) #1 said she was unaware of any procedure or guidelines for reheating of resident food. CNA #1 said she just puts the food in the microwave and pushes the button to start heating the food. CNA #1 said she did not test the food temperature and heated the food until she believed it was hot enough. During an interview on 2/28/24 at 1:48 P.M., CNA #2 said she would reheat resident food until she thought it was hot. She said she was unaware of any guidelines for reheating food. During an interview on 2/28/24 at 1:50 P.M., the Food Service Director (FSD) and Dietary Staff #2 reviewed the Food Storage policy provided to the surveyor on entrance from the Administrator. The FSD said there was a microwave on the second floor for staff and family to reheat resident food. The FSD and Dietary Staff #2 said there was no process in place for staff to determine if food temperatures were safe for residents. Dietary Staff #2 said if the kitchen was still open, kitchen staff could reheat food, but if not, staff would need to reheat resident food in the 2nd floor nourishment kitchen. The FSD said the policy the surveyor was provided with was the only policy she was aware of and there was no procedure in place for reheating food brought in from outside sources.

Based on observation, record review, policy review, and interview, the facility failed for one Resident (#11), out of a total sample of 12 residents, to maintain an accurate medical record in accordance with accepted professional standards and practices. Specifically, the facility failed to ensure Resident #11's refusal to wear a splint and sling to their right arm was documented accurately. Findings include: Review of the facility's policy titled Assistive Devices and Equipment, undated, indicated but was not limited to the following: -Assistive devices are provided by the facility (including splints and braces) -Staff don (put on) and doff (take off) equipment and devices according to MD orders. -The care plan will reflect use of device/equipment. Review of the facility's policy titled Preferred Therapy Solutions: Splinting, dated as last revised January 2018, indicated but was not limited to the following: -Splints are used to provide proper support, prevent unwanted motion, contracture management, or reduction, pain management, and to facilitate motor activity. -Therapists coordinate with the interdisciplinary team to determine splinting needs and to monitor for appropriate use and fit on a regular basis. -Once the wearing schedule is established, the physician clarification order should specify the type of splint, where it is to be applied, and the wearing schedule. Resident #11 was admitted to the facility in October 2019 with diagnoses which included aphasia (impaired ability to communicate) following cerebrovascular disease (stroke), hemiplegia and hemiparesis (weakness/paralysis) following cerebrovascular disease (stroke) affecting right side. Review of the Minimum Data Set (MDS) assessment, dated 1/24/24, indicated Resident #11 was unable to complete the Brief Interview for Mental Status (BIMS) because the Resident was rarely or never understood. Review of Resident #11's current Physician's Orders indicated but were not limited to the following: -Right upper extremity (RUE)-Sling to RUE (arm) on in the AM and off in the PM daily (6/10/22). -Splint right wrist for pain. May remove for care (6/7/22). Review of the Care Plans failed to indicate Resident #11 had a sling or splint. The surveyor made the following observations: -2/27/24 at 9:20 A.M., Resident #11 was in bed with no sling or splint on. -2/27/24 at 11:00 A.M., Resident #11 was in day room with no sling or splint on. -2/28/24 at 11:14 A.M., Resident #11 was in day room with no sling or sling on. -2/29/24 at 8:45 A.M., Resident #11 was in bed with no sling or splint on. Review of the February 2024 Treatment Administration Record (TAR) indicated but was not limited to the following: -2/27/24 and 2/28/24 during the 7:00 A.M. - 3:00 P.M. shift the sling was signed off as administered. -2/27/24 and 2/28/24 during the 7:00 A.M. - 3:00 P.M. shift the splint was signed off as administered. Review of the medical record, including nursing documentation, failed to indicate refusal to wear the sling or splint by Resident #11 during these shifts. During an interview on 2/29/24 at 8:53 A.M., Nurse #2 said Resident #11 refuses the splint and sling sometimes. She said the nurses sign it off on the TAR and the certified nurse aides (CNA) don't always tell us if he/she refuses it. She said the documentation on the TAR may not always be accurate if they forget to tell us and we don't go back in to change the documentation. Additionally, she said she was not sure the last time Resident #11 actually wore the splint or sling and she would have to check with CNA #2. During an interview on 2/29/24 at 10:10 A.M., CNA #2 said Resident #11 frequently refuses to wear the splint and sling. She said the Resident has a couple different ones in his/her room, but he/she hardly wears them. She said Resident #11 hadn't worn them in a while and she could only recall one day a couple weeks ago that he/she wore the brace. Additionally, she said the splint and sling were not on the Resident on 2/27/24, 2/28/24 or 2/29/24. During an interview on 2/29/24 at 11:37 A.M., the DON said Resident #11 does not wear the splint or sling. She said she thinks they bother him/her, but the nurses should be documenting that on the TAR and notify the physician for an alternate plan of care. During an interview on 2/29/24 at 12:31 P.M., Resident #11's Daughter said he/she does not like the splint or sling and does not wear them. She said they have tried several different ones, but he/she will not wear them, but she did not feel the contracture was any worse from not wearing them.

Based on observations, record review, and interview, the facility failed to provide care in accordance with professional standards of practice for three Residents (#1, #3, and #14), out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #1, to schedule a cardiology appointment as ordered after hospitalization for heart failure; 2. For Resident #3, to obtain a speech therapy evaluation as ordered; and 3. For Resident #14, to follow physician's orders for the daily use of a splint to the right arm with geri sleeve (stocking sleeves that protect from friction and shearing). Findings include: 1. Review of the facility's policy titled Medical Appointment Guideline, undated, indicated but was not limited to the following: -It is the policy of the facility to assist with appointment making with outside consultants. Resident #1 was admitted to the facility in August 2020 with diagnoses which included heart failure, chronic kidney disease, and asthma. Review of the Minimum Data Set (MDS) assessment, dated 11/26/23, indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. Review of Resident #1's hospital discharge paperwork from September 2023 indicated but was not limited to the following: -Resident #1 was treated for heart failure, hypoxic respiratory failure, and fluid overload. -Follow up with Cardiologist for further evaluation. Review of the current Physician's Orders indicated but were not limited to the following: -Cardiologist (9/26/23). Review of the Nursing progress notes indicated but were not limited to the following: -9/20/23 transferred to hospital for evaluation to rule out respiratory / heart failure. -9/23/23 returned from hospital, was seen by hospital cardiologist, to be followed up at facility for personal cardiologist appointment. -9/27/23 faxed over a request to a local cardiologist, followed by a phone call to confirm receipt of requested documents. Further review of the progress notes failed to indicate a cardiology appointment had been scheduled or any further attempts to schedule the appointment had been made, or any alternative treatment plan was made. Review of the Physician/Nurse Practitioner Progress notes indicated but were not limited to the following: -9/26/23 readmission: follow up with cardiology. -10/11/23 still needs follow up with cardiology. Further review of the progress notes failed to indicate a cardiology appointment had been scheduled or any alternative treatment plans were made. Review of the medical record including Consults section of the paper chart indicated Resident #1 needed a cardiology appointment, however it failed to indicate the appointment had been scheduled. During an interview on 2/29/24 at 8:53 A.M., Nurse #2 said the cardiology appointment was never scheduled and she was unsure why it was not done. Additionally, she said if unable to schedule an appointment, the physician should be notified and she did not know if the physician was ever notified. During an interview on 2/29/24 at 11:37 A.M., the Director of Nurses (DON) said when a resident needs to see an outside provider we make the appointment and write it on the calendar. Additionally, she said it is hard to follow up if waiting for a call back because we only note it on the calendar for a couple days, so things could get missed if not flipping back through the calendar and she was unsure why Resident #1 did not have a cardiology appointment scheduled or how it was missed. 2. Resident #3 was admitted to the facility in November 2022 with diagnoses which included repeated falls, dysphagia (difficulty swallowing), dementia, essential tremor, and arthritis. Review of the MDS assessment, dated 12/6/23, indicated Resident #3 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment. Review of Resident #3's current Physician's Orders indicated but were not limited to the following: -Speech Evaluation (12/6/23). Review of the progress notes indicated but were not limited to the following: -12/5/23 Resident was coughing at lunch today, recommend a SLP screen (speech language pathologist). -12/6/23 Resident seen by dietician, new recommendation to be evaluated by speech due to coughing while eating lunch, approved by MD. Further review of the progress notes failed to indicate a speech evaluation had been completed. Review of the Physician/Nurse Practitioner notes failed to indicate a speech evaluation had been completed. Review of the Care Plans failed to indicate a speech evaluation had been completed. Review of the Speech Therapy notes failed to indicate a speech evaluation had been completed since it was ordered on 12/6/23. During an interview on 2/29/24 at 8:53 A.M., Nurse #2 said when a resident has an order for an evaluation we complete the Rehab Communication form, put it in the binder, and notify the rehab director. Additionally, she said this evaluation was not done and she did not know how it was missed. During an interview on 2/29/24 at 10:00 A.M., the Rehab Director said she was not employed at the facility at the time this speech evaluation order was written and could not speak to why it was not done. During an interview on 2/29/24 at 11:37 A.M., the DON said typically the turnaround time for an evaluation is less than a week and she did not know why this evaluation was not done. 3. Review of the facility's policy titled Assistive Devices and Equipment, undated, indicated but was not limited to: - Assistive devices and equipment are provided by the facility. These include but not limited to: wheelchair, canes, splints and braces. - Staff [NAME] (put on) and Doff (remove) equipment and devices according to physician orders. Resident #14 was admitted to the facility in April 2018 with diagnoses which included cerebral infarction (stroke) with right side hemiplegia (paralysis). Review of the MDS assessment, dated 11/16/23, indicated Resident #14 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. Review of Resident #14's current Physician's Orders indicated: - Splint to right arm with geri sleeve on in the A.M. and off in the P.M., date initiated, 5/8/2020 On 2/27/24 at 11:06 A.M. and 3:42 P.M., the surveyor observed Resident #14 seated in a recliner chair with no splint or geri sleeve on the right arm. On 2/28/24 at 11:12 A.M. and 3:05 P.M., the surveyor observed Resident #14 seated in a recliner chair with no splint or geri sleeve on the right arm. During an interview and observation on 2/29/24 at 11:11 A.M., the surveyor observed Resident #14 seated in a recliner with no splint or geri sleeve to the right arm. Resident #14 said he/she did not have the splint on today and had not worn the splint on his/her right arm in a very long time. Resident #14 said he/she had not refused to put the splint on as the nurses don't offer to put the splint on. During an interview on 2/29/24 at 11:13 A.M., Certified Nurse Aide (CNA) #1 said it was not her task to put the splint on for Resident #14 and she was unsure if or when Resident #14 had a splint in place. Review of the current Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated the splint to right arm with geri sleeve on in the A.M. and off in the P.M., was administered to the Resident on 2/27/24, 2/28/24, and 2/29/24 for all shifts. Review of the medical record, including nursing documentation, did not indicate refusal to wear the splint by Resident #14. During an interview on 2/29/24 at 11:21 A.M., Nurse #2 said Resident #14 requested the splint be removed to go to the bathroom and during all meals. Nurse #2 said it was the responsibility of the nurse to place the splint on. Nurse #2 said she sometimes got busy and was unable to get back upstairs to reapply the splint. The surveyor shared the observations made on all days of survey and reviewed the MAR and TAR documentation. Nurse #2 said she was busy and was unable to go back upstairs to reapply the splint today. During an interview on 2/29/24 at 1:34 P.M., Resident #14 said shortly after the surveyor interviewed him/her earlier in the day, the nurse came in and placed the splint on. Resident #14 said he/she had not had this thing on for quite a while. During an interview on 2/29/24 at 2:05 P.M., the DON was made aware of the observations. The DON said staff should not be documenting placement of splints if not actually placed on a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy titled Storage of Medications, dated February 2019, indicated but was not limited to the following: -Certain medications or package types, such as multiple dose injectable vials and ophthalmics, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -When the original seal of a 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. -The nurse will check the expiration date of each medication before administering it to a resident. -Disposal of any medications prior to the expiration date will be required if contamination or decomposition is apparent. On [DATE] at 7:55 A.M., the surveyor reviewed the Floor 1 medication cart with Nurse #1 and observed the following in the top drawer: -One opened bottle of Brimonidine Tartrate ophthalmic solution (treats glaucoma or high pressure in the eye) 0.2% labeled with a resident's name inside the packaging box with the seal broken indicating it had been opened, bottle and packaging box not labeled with the date when opened and/or the new date of expiration -One opened bottle of Brimonidine Tartrate ophthalmic solution 0.2%, without, at a minimum, the resident's name, bottle not stored in its packaging container, bottle not labeled with the date when opened and/or the new date of expiration During an interview on [DATE] at 7:55 A.M., Nurse #1 said the medication cart was the only one used in the facility. She said the eye drop packaging box and medication bottle should have been labeled with the date when opened and the expiration date. Nurse #1 said the second bottle should have also been labeled and included at least a resident's name as it was loosely stored without its packaging box. She said without a resident's name labeled on the bottle she could not be sure of who it belonged to and would not use it. Nurse #1 said eye drops had a shortened expiration once opened per their policy, prior to the manufacturer's expiration, but wasn't sure how long they would be good for, maybe 28-30 days. She further said she wasn't sure if the eye drops were good anymore because they weren't labeled when opened and the purpose of a shortened expiration was because the medication may become less effective. On [DATE] at 8:32 A.M., the surveyor resumed the medication cart storage review with Nurse #1 and observed the following medications stored inside two resident large Ziploc bags: -One opened bottle of mometasone furoate (Asmanex, prevents and treats seasonal allergies) nasal spray 50 micrograms (mcg) inside the packaging box, seal broken indicating it had been opened, bottle and packaging box not labeled with the date when opened and/or new expiration date, labeled with a resident's name -One Levalbuterol Tartrate HFA inhaler (to prevent and treat wheezing and shortness of breath) 45 mcg, 200 meter dose, 160 meter doses remaining, inhaler not stored in its packaging container, inhaler not labeled with, at a minimum, the resident's name, inhaler not labeled with the date when opened and/or new expiration date - One Levalbuterol Tartrate HFA inhaler 45 mcg, 200 meter dose, 80 meter doses remaining, inhaler not stored in its packaging box, inhaler not labeled with, at a minimum, the resident's name, inhaler not labeled with the date when opened and/or new expiration date -Two opened bottles of sodium chloride hypertonicity ophthalmic solution 2% (used to draw water out of a swollen cornea) inside their packaging box, seals broken indicating they were opened, bottles and packaging boxes not labeled with the dates when opened and/or new expiration dates, labeled with a resident's name -One opened bottle of Brimonidine Tartrate ophthalmic solution 2% inside the packaging box, bottle's seal broken indicating it was opened, bottle not labeled with the date when opened and/or new expiration date -One opened bottle of Lumigan (bimatoprost) ophthalmic solution (treats glaucoma) 0.01% inside the packaging box, bottle's seal broken indicating it was opened, bottle and packaging box not labeled with the date when opened and/or the new expiration date Review of the facility document titled Medications with Shortened Expiration Dates, dated [DATE], indicated but was not limited to the following: -Asmanex (mometasone) nasal spray, expires 45 days after opening -Levalbuterol, use within 14 days of opening pouch: 12 months During an interview on [DATE] at 8:39 A.M., Nurse #1 said the nasal spray had been used and both the bottle and packaging box should have been labeled with the open date and expiration date but weren't. She said she thought the nasal spray would be good for 30 days. Nurse #1 said she wasn't sure how long inhalers were good for but thought 60 days. She further said the inhalers and eye drops should have been labeled with the open dates and expiration dates but were not. During an interview on [DATE] at 1:24 P.M., the Director of Nursing (DON) said the eye drop bottle and inhalers should have been stored inside their packaging box and not loose or unlabeled in the medication cart due to the potential for cross-contamination. The DON said the expectation was that staff would write the expiration date and the date opened on the medications once opened and thought on the packaging containers as well. She said the medications with shortened expiration document did not include the Lumigan and sodium chloride eye drops but they had shortened expiration dates per facility policy and should have been labeled properly. She said the purpose of shortened expiration dates is because they don't last, the quality isn't as good. The DON said the Brimonidine was only good for 30 days after being opened and the mometasone only good for 12 months. She said she could not determine if the observed medications were good anymore if they were not labeled. Based on observation, interview, and facility policy, the facility failed to ensure that drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, 1. The facility failed to ensure that medications stored in the medication storage room, including but not limited to, single-use parenteral medications, were labeled with the appropriate information including the resident's name, dose, route, time and frequency of administrations, when dispensed by the pharmacy; and 2. The facility failed to ensure staff properly labeled all medications stored in one of one medication cart reviewed. Findings include: 1. Review of the facility's policy titled IIA3 Vials and Ampules of Injectable Medications, effective date February 2019, indicated but was not limited to the following: -Vials and ampules dispensed by the pharmacy are maintained in the box or container, with the pharmacy label, in which they are dispensed. -Ampules and single use vials (containing no preservative) are discarded immediately after use. On [DATE] at 1:56 P.M., the surveyor, with Nurse #2 present, inspected the medication storage room and observed the following medication concerns: -An open, unlabeled vial of Arexvy (Respiratory Syncitial Virus) vaccine was observed in the medication refrigerator. The single-dose vial of vaccine was observed to have a small amount of liquid vaccine in it. -An open, unlabeled, undated, single dose vial of Tuberculin PPD (protein purified derivative) solution (skin test for Tuberculosis) was observed in the medication refrigerator. A small amount of the solution was observed in the open vial. During an interview on [DATE] at 1:59 P.M., Nurse #2 said that the Arexvy vial was not labeled with the date it was opened, what resident it was prescribed for, or any pharmacy instructions, and should have been discarded as it was a single-dose vial not intended for reuse. Nurse #2 said that the vial of Tuberculin PPD solution was not labeled with the date it was opened, the resident it was prescribed for, or any pharmacy instructions. Nurse #2 said that the vial of Tuberculin solution should have been discarded as it was single-dose and not intended for reuse. During an interview on [DATE] at 8:45 A.M., the Director of Nursing (DON) and Administrator said they understood the concerns identified in the medication storage room regarding medications not labeled, and/or expired and in need of discarding/destroying. The DON said, There needs to be accountability by licensed staff regarding medication storage, labeling, and following facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offer and administer the influenza and pneumococcal immunizations in a timely manner for 5 out of 5 Residents sampled (#1, #3, #8, #11, and #14). Specifically, the facility failed: 1. For Resident #1, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the pneumococcal vaccine, offer the immunization, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccine and place in the Resident's medical record; 2. For Resident #3, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the influenza and pneumococcal vaccines, offer the immunizations, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccines and place in the Resident's medical record; 3. For Resident #8, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the pneumococcal vaccine, offer the immunization, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccine and place in the Resident's medical record; 4. For Resident #11, to document the Resident's refusal of the influenza and pneumococcal vaccines on the Informed Consent and place in the Resident's medical record; and 5. For Resident #14, to ensure the resident received the requested Pneumococcal (PPV23) vaccine immunization as consented by the Resident's representative and properly document administration of the influenza vaccine in the medical record per facility policy. Findings include: Review of the facility's policy titled Vaccine Guidelines, undated, indicated but was not limited to the following: -Facility will offer all current recommended vaccines to residents as recommended by the Centers for Disease Control and Prevention (CDC). Residents/responsible parties will be provided with a VIS form for each vaccine that is offered. -Upon receipt of acknowledgement of VIS and consent for vaccine it will be administered per MD order. -Vaccine administration will be documented in the Medication Administration Record (MAR) and electronic record. This should include Lot # and administration site. Review of the facility's policy titled Influenza Vaccine, revised August 2016, indicted but was not limited to the following: -All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. -The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. -Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated, or the resident has already been immunized. -Residents admitted between October 1st ad March 31st shall be offered the vaccine within five days of the resident's admission to the facility. -For those who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's medical record. -A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. -The Infection Preventionist will maintain surveillance data on influenza vaccine coverage. Review of the facility's policy titled Policy for Pneumococcal Vaccination of Residents, undated, indicated but was not limited to the following: -It is the policy of this facility that each resident or their responsible party will be asked on admission if the resident previously had the pneumococcal vaccination and their age at the time of vaccination. If there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time. Pneumococcal candidates for vaccination: -65 or older -Serious long-term health problems such as heart disease, sickle cell disease, alcoholism, leaks of cerebrospinal fluid, lung disease (including asthma), diabetes, or liver cirrhosis -Resistance to infection is lowered -If the resident had PCV23 prior to admission, then the resident may have Prevnar13 one year later from time of PCV23 administration -If the resident had Prevnar13, then the resident may have PCV23 one year later from the time of Prevnar13 administration -If the resident did not have any pneumococcal vaccines, then the resident should have Prevnar13, followed by PCV23 one year later after administration of Prevnar13. 1. Resident #1 was admitted to the facility in August 2020 and was [AGE] years old. Review of the Vaccination Administration Record for Adults indicated Resident #1 had not received any pneumococcal vaccinations. Resident #1's Consent for Immunization form, dated and signed by the Resident on 8/10/20, was blank. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose, the provision of education related to the pneumococcal vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine in accordance with facility policy since admission, over three years prior. During an interview on 2/28/24 at 4:21 P.M., the Director of Nursing (DON)/Infection Preventionist (IP) said the Resident's medical record did not indicate he/she received the pneumococcal vaccine and there was no completed consent form maintained in the record that indicated the Resident had received education related to the vaccine and had either consented to receive it or refused. 2. Resident #3 was admitted to the facility in November 2022 and was [AGE] years old. Review of the Vaccination Administration Record for Adults indicated Resident #3 had not received the seasonal 2023-2024 influenza or any pneumococcal vaccinations. Review of Resident #3's Consent for Immunization form, dated and signed by the Resident's representative on 11/28/22, indicated consent for the Resident to receive either the Pneumococcal (PCV23) vaccine or the Pneumococcal (PCV13) immunization. There was no seasonal 2023-2024 influenza vaccine consent form completed and available for surveyor review in the medical record. Further review of the medical record failed to indicate documentation of offering or administration of the pneumococcal vaccine and failed to indicate documentation of an assessment for eligibility to receive the recommended 2023-2024 influenza vaccine dose, the provision of education related to the influenza vaccine, completed consent to either receive or refuse the vaccine, and documentation of offering or administration of the vaccine in accordance with facility policy. During an interview on 2/28/24 at 4:07 P.M., the DON said there was no evidence in the medical record that the 2023-2024 influenza vaccine was offered and either administered or declined. She said she could not locate the consent form in the record for the current flu season. The DON said the pneumococcal consent form indicated that the Resident wished to receive it but there was no documentation that he/she had. 3. Resident #8 was admitted to the facility in September 2023 and was [AGE] years old. Review of the Vaccination Administration Record for Adults form indicated Resident #8 had not received any type of vaccination as the form was not completed. Resident #8's Consent for Immunization form, dated 9/2023, was blank. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose, the provision of education related to the pneumococcal vaccine, completed consent to either receive or refuse the vaccine, and documentation of offering or administration of the vaccine in accordance with facility policy. During an interview on 2/28/24 at 3:46 P.M., the DON said when a resident is first admitted to the facility, the person responsible for doing the paperwork should meet with the resident and family and ask if the resident had a history of receiving the pneumococcal vaccination. She said the consent for immunizations and vaccination administration record should have been completed for Resident #8 but was not. The DON declined to review the Resident's medical paper record with the surveyor and said she would look after in the electronic record. She said the immunizations probably were not addressed and said if the documents were blank, then they probably weren't. On 2/28/24 at 4:31 P.M., no further documentation was provided to the surveyor regarding the Resident's pneumococcal vaccination status. 4. Resident #11 was admitted to the facility in October 2019 and was [AGE] years old. Review of the Vaccination Administration Record for Adults form indicated Resident #11 had not received the annual 2023-2024 influenza vaccine or any pneumococcal vaccines. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the annual influenza vaccine and pneumococcal vaccine, the provision of education related to the vaccines, completed consent to either receive or refuse the vaccines, and documentation of offering or administration of the vaccines in accordance with facility policy. During an interview on 2/28/24 at 3:50 P.M., the surveyor reviewed the medical record with the DON who said there was no documentation of flu or pneumonia education, no completed consent to receive or refuse the vaccinations, and no documentation of offering or administration of the vaccinations. The DON said she could not locate any notes pertaining to the flu or pneumonia vaccines but said the Resident had refused both. She said she would need to review the medical record further to provide evidence to the surveyor. She said she did not have a good tracking system for resident immunizations. On 2/29/24 at 11:22 A.M., no further documentation had been provided to the surveyor upon request. 5. Resident #14 was admitted to the facility in April 2018 and was [AGE] years old. Review of the Vaccination Administration Record for Adults form indicated Resident #11 had refused the Pneumococcal (PCV23) vaccine on 4/30/18, upon admission. Review of the Consent for Immunization form, dated 11/7/23 and signed by the Resident's representative, indicated Resident #14 consented to receiving the annual influenza and Pneumococcal (PPV23) vaccinations. Review of Nurse Progress Notes indicated the following: 11/22/23 - Resident received influenza vaccine in L deltoid. Temp 97.5, e-signed by a licensed social worker 11/27/23 - Resident did not received vaccine on 11/22/23 received today lot #AU4542C, e-signed by Consulting Staff #1 The Nurse Progress Notes failed to indicate documentation of the influenza vaccine's expiration date and clear documentation of the site of administration. Review of the November 2023 Medication Administration Record (MAR) did not indicate documentation that the influenza and pneumococcal vaccinations were administered. Further review of the medical record failed to indicate Resident #14 received the requested Pneumococcal (PPV23) vaccine immunization as consented by the Resident's representative. During an interview on 2/28/24 at 3:31 P.M., the DON said if a resident needed the influenza or pneumococcal vaccines, there would be no reason why they would not be offered or given. During an interview on 2/28/24 at 4:27 P.M., Consulting Staff #1 said she did a flu clinic at the facility in November 2023 and administered the vaccine to only those residents who had completed flu consent forms. She said she was waiting to administer the pneumonia vaccine until after the 2023-2024 flu season was over. She said the flu and pneumonia vaccines, if administered, would be documented on the Medication Administration Record (MAR) or in a nurse's note. She said when she conducted the flu clinic in November, she did not have a tracking system, she just administered it to those who had completed consents, but the goal was for 100% compliance. During an interview on 2/29/24 at 10:22 A.M., Consulting Staff #1 said there was no system in place at the facility for tracking resident immunization status. During an interview on 2/29/24 at 1:22 P.M., the DON said immunizations were tracked by documenting in the electronic Medication Administration Record or vaccination record in the paper chart which would show all the flu, pneumonia, and COVID-19 vaccinations all in one area. She said there was a tracking system, but it was tough getting everyone on the same page. The DON said for residents who receive the flu and pneumonia vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination should be documented in the resident's medical record. She further said if a resident refuses a vaccine, the refusal should be documented on the informed consent for Influenza Vaccine form or Immunization Consent form and placed in the medical record. She said all residents should have received the flu and pneumonia vaccines at the facility if indicated. No further immunization documentation for Residents #1, #3, #8, #11, and #14 was provided to the survey team upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for five residents (#1, #3, #8, #11, and #14), out of a total sample of five residents reviewed for immunizations. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with COVID-19 Vaccines, revised January 2024, indicated but was not limited to the following: People aged 12 years and older who are unvaccinated should get either: -1 updated Pfizer-BioNTech or updated Moderna COVID-19 vaccine, OR 2 doses of updated Novavax COVID-19 vaccine. People aged 12 years and older who got previous COVID-19 vaccine(s): -People aged 12 years and older who got COVID-19 vaccines before September 12, 2023, should get 1 updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine. Review of the facility's policy titled Vaccine Guidelines, undated, indicated but was not limited to the following: -Facility will offer all current recommended vaccines to residents as recommended by the Centers for Disease Control and Prevention (CDC). Residents/responsible parties will be provided with a VIS form for each vaccine that is offered. -Upon receipt of acknowledgement of VIS and consent for vaccine it will be administered per MD order. -Vaccine administration will be documented in the Medication Administration Record (MAR) and electronic record. This should include Lot # and administration site. Review of the facility's policy titled Policy for COVID-19 Vaccination of Employees/Residents during COVID, undated, indicated but was not limited to the following: -It is the policy of this facility to encourage residents to get immunization against COVID-19 either in-house or at a designated vaccination site. This is consistent with recommendations from the CDC and state and local health departments. Procedure: -Provide current vaccine information sheet (VIS) with education regarding the benefits and potential side effects. -Obtain written/verbal, informed consent from each resident. -Any resident who has had a severe allergic reaction in the past to any ingredients contained in the vaccine should not take the vaccine and should discuss with physician. -Give the vaccine as per facility policy. Review of the facility's policy titled COVID-19 Vaccination Policy for Residents and Staff, revised September 2022, indicated but was not limited to the following: If the facility has residents who require a Bivalent booster dose of COVID-19 vaccine the long-term care facility should obtain the vaccine by: -Contacting the facility's long-term care pharmacy to provide the necessary COVID-19 vaccine to the long-term care facility. -The vaccine would be administered by the pharmacist or nursing staff. -Residents are considered to be eligible to receive the booster vaccine two months after completion of the primary COVID-19 series and must not have received any other COVID-19 vaccine in the last two months. 1. Resident #1 was admitted to the facility in August 2020 and was [AGE] years old. Review of the Vaccination Administration Record for Adults indicated Resident #1 had last received a COVID-19 vaccination on 5/1/22, before September 12, 2023, but did not receive an updated dose of the Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine, if indicated, since then per CDC guidance and facility policy. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine. During an interview on 2/28/24 at 4:21 P.M., the Director of Nursing (DON)/Infection Preventionist (IP) said the Resident's medical record did not indicate he/she received an updated dose of the COVID-19 vaccine and there was no completed consent form maintained in the record that indicated the Resident had received education related to the vaccine and had either consented to receive it or refused. During an interview on 2/28/24 at 4:27 P.M., Consulting Staff #1 said she held a flu clinic in September 2023 but had not held any COVID-19 vaccine clinics or administered any COVID-19 vaccines to residents at the facility. 2. Resident #3 was admitted to the facility in November 2022 and was [AGE] years old. Review of the Vaccination Administration Record for Adults indicated Resident #3 had last received a COVID-19 vaccination on 2/25/22, before September 12, 2023, but did not receive an updated dose of the Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine, if indicated, since then per CDC guidance and facility policy. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine. 3. Resident #8 was admitted to the facility in September 2023 and was [AGE] years old. Review of the Vaccination Administration Record for Adults form indicated Resident #8 had not received any type of vaccination as the form was not completed. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and offering or administration of the vaccine to ensure the Resident was up to date with his/her COVID-19 vaccinations per CDC guidance and facility policy. During an interview on 2/28/24 at 3:46 P.M., the DON said when a resident is first admitted to the facility, the person responsible for doing the paperwork should meet with the resident and family and ask if the resident had a history of receiving vaccinations. She said the consent for immunizations and vaccination administration record should have been completed for Resident #8 but were not. The DON declined to review the Resident's medical paper record with the surveyor and said she would look after in the electronic record. She said the COVID-19 vaccine probably was not addressed upon admission and said if the vaccination record document was blank, then it probably wasn't. 4. Resident #11 was admitted to the facility in October 2019 and was [AGE] years old. Review of the Vaccination Administration Record for Adults form indicated Resident #11 had last refused the COVID-19 vaccination on 10/31/22, before September 12, 2023, but did not receive an updated dose of the Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine, if indicated, since then per CDC guidance and facility policy. Further review of the medical record failed to indicate documentation of follow up screening, a re-assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and re-offering or administration of the vaccine since the last refusal on 10/31/22. During an interview on 2/28/24 at 3:50 P.M., the surveyor reviewed the medical record with the DON who said there was no immunization documentation in the Resident's chart other than the vaccine administration form. She said she would need to review the medical record further to provide evidence to the surveyor. She said she did not have a good tracking system for resident immunizations. On 2/29/24 at 11:22 A.M., no further immunization documentation had been provided to the surveyor upon request. 5. Resident #14 was admitted to the facility in April 2018 and was [AGE] years old. Review of the Vaccination Administration Record for Adults form indicated Resident #14 had last refused the COVID-19 vaccination on 5/1/22, before September 12,2023, but did not receive an updated dose of the Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine, if indicated, since then per CDC guidance and facility policy. Further review of the medical record failed to indicate documentation of follow up screening, a re-assessment for eligibility to receive the recommended COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine, and re-offering or administration of the vaccine since the last refusal almost two years prior. During an interview on 2/28/24 at 3:31 P.M., the DON said if a resident needed the COVID-19 vaccine, there would be no reason it would not be offered or given. During an interview on 2/29/24 at 10:22 A.M., Consulting Staff #1 said there was no system in place at the facility for tracking resident immunization status. During an interview on 2/29/24 at 1:22 P.M., the DON said immunizations were tracked by documenting in the electronic Medication Administration Record or vaccination record in the paper chart which would show all the flu, pneumonia, and COVID-19 vaccinations all in one area. She said there was a tracking system, but it was tough getting everyone on the same page. The DON said there was no evidence that Resident #14 was reapproached regarding COVID-19 vaccine offering and/or administration, education, or further documentation of refusal to receive the vaccine. She further said if a resident refuses a vaccine, the refusal should be documented on the informed consent and placed in the medical record. She said all residents should have received the COVID-19 most up to date vaccinations at the facility if indicated. No further immunization documentation for Residents #1, #3, #8, #11, and #14 was provided to the survey team upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to allow one Resident (#11) the right to participate in their goals and outcomes of their stay, including their right to return to the community, in a total sample of 12 residents. Findings include: Resident # 11 was admitted to the facility in August 2020. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated Resident #11 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicates the Resident was cognitively intact. Section S of the MDS indicated Resident #11 had a Health Care Proxy (HCP), the HCP had not been invoked and that there was documentation in the medical record that a discussion of goals of care with the resident or legal healthcare representative occurred. During an interview on 10/18/22 at 10:34 A.M. Resident #11 said he/she wished to return to the community. Review of the medical record, including care plans, nursing progress notes, social service progress notes, and physician progress notes failed to include any documentation to indicate the goal regarding the stay at the facility (long term care, short term rehabilitation or plan to return to the community). Review of the medical record included one note from a Social Worker regarding the admission for Resident #11 in August 2020 which indicated the Resident felt he/she was dumped here. There were no further notes from any Social Workers for Resident #11 for the next two years. Review of the Care Plan Meeting Signature Page indicated the last Care Plan meeting for Resident #11 was held in November 2021 (11 months prior) with only the Activity Director in attendance. Review of a physician progress note, dated 9/18/21 indicated Resident #11 was not happy at the facility and wanted to get out of here. During an interview on 10/20/22 at 1:30 P.M. the Director of Nurses said she was responsible for coordinating Care Plan meetings and had not set specific dates for Care Plan meetings and had not been inviting residents or their representatives to the meetings. During an interview on 10/20/22 at 2:23 P.M. Resident #11 said he/she felt like a prisoner who had been locked up at the facility for the previous two years. Resident #11 said he/she did not understand why the staff were listening to his/her son about the Resident needing to live in the facility and no staff had spoken with him/her about the goal of returning to the community. During an interview on 10/21/22 at 9:08 A.M. the Director of Nurses said the facility and the family had felt Resident #11 could not return to the community, but had not discussed this with the Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the right to formulate advanced directives was maintained for one Resident (#11) in a total sample of 12 residents. Findings include: Resident # 11 was admitted to the facility in August, 2020. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated Resident #11 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicates the Resident was cognitively intact. Section S of the MDS indicated Resident #11 had a Health Care Proxy (HCP) and the HCP had not been invoked. Review of the medical record for Resident #11 indicated the Resident had previously formulated a Health Care Proxy, prior to admission. Further review indicated the Resident continued to be capable of making their own medical decisions, and the HCP had not been activated. Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) signed by Resident #11 on 8/6/20 indicated Resident #11 requested to be a Full Code (attempt resuscitation, intubate, ventilate, transfer to hospital, and use artificial nutrition). Further review of the medical record included a MOLST form signed by a family member of Resident #11 on 10/12/22 for the Resident to be a Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Transfer to Hospital (DNH), no artificial nutrition. Review of the Nursing Progress Notes, dated 9/21/22 indicated the Director of Nurses contacted the HCP of Resident #11, which was not invoked at this time, to review advanced directives and the HCP wished to change the advanced directives of Resident #11. During an interview on 10/20/22 at 1:05 P.M. the Director of Nurses said she had thought the HCP for Resident #11 had been activated earlier this month. She said if the HCP had been activated, to make medical decisions, than the physician would have completed a HCP activation form and placed it in the medical record. During an interview on 10/20/22 at 1:30 P.M. the Director of Nurses reviewed the medical record with the surveyor. The Director of Nurses said she was unable to locate any documentation in the medical record to indicate Resident #11 was not capable of making his/her own medical decisions.

Based on observation, record review, policy review and interview the facility failed to follow professional standards for medication reconciliation and administration. Specifically, the facility failed to: 1. Consistently document a physical inventory of all controlled substances signed by two licensed nurses as required; and 2. Ensure unlabeled pre-poured medications were not left open in the medication cart for later administration. Findings include: 1. Review of the facility policy titled: Controlled Substance storage, dated February 2019, indicated but was not limited to the following: - At each shift change or when the keys are transferred, a physical inventory of all controlled substances is conducted by two licensed nurses and is documented. During an observation with interview on 10/19/22 at 9:27 A.M., the surveyor observed the current narcotic book with Nurse #1 and identified three missing signatures. One on 8/28/22 at 7:00 A.M., for the nurse going off duty, another on 9/26/22 at 3:00 P.M. for the nurse going off duty, and 9/26/22 at 11:00 P.M., for the nurse going off duty. Nurse #1 said the process is for two nurses to complete narcotic count and sign the book for the date and time it is complete. She said missing signatures in the narcotic book means the process for completing narcotic count was not followed. During an interview on 10/19/22 at 11:08 A.M., the Director of Nurses (DON) was made aware of the surveyor's observations of missing signatures in the narcotic book and said there should be no missing signatures per the facility process and her expectation. 2. Review of the facility policy titled: Medication administration general guidelines, dated: February 2019, indicated but was not limited to the following: - medications are administered at the time they are prepared - medications are not pre-poured in advance of medication pass or for more than one resident at a time During an observation with interview on 10/19/22 at 8:44 A.M., the surveyor observed Nurse #1 open her medication cart to begin the morning medication pass. In the top drawer of the medication cart was an unlabeled cup containing eight pills of varying color and shape. Nurse #1 said the medications were pre-poured and belonged to Resident #224 and she had started preparing the medications for the Resident prior to breakfast but then was called away and did not finish the process. She said pre-pouring medications is not allowed and medications are to be administered at the time they are prepared. She said having the medications saved in the drawer in that manner did not meet the standard of practice for medication administration. During an interview on 10/19/22 at 11:08 A.M., the DON was made aware of the surveyor's observations of pre-poured medications and said pre-pouring medications is not best practice and should not be occurring.

Based on observations, interview and record review the facility failed to ensure the physician ordered therapeutic diet was followed for one Resident (#11), in a total sample of 12 residents. Findings include: Resident #11 was admitted to the facility in August 2020. Review of the Care Plans for Resident #11 indicated the Resident required supplements and increased fluid intake due to poor intake with an approach to provide a diet and supplements as ordered. Review of the medical record indicated on 10/3/22 Resident #11 weighed 77.75 pounds. Review of the current Physician Orders indicated the following orders: 12/23/21: low potassium diet (no banana, no orange juice) 5/16/22: fortified juice at breakfast 5/16/22: fortified pudding at 2:00 P.M. daily Resident #11 was observed to be having breakfast on 10/20/22 at 8:36 A.M. Review of the meal ticket on the tray indicated restrictions of no tomato, no orange juice, no banana, prefers English muffin, hot cereal, hot coffee, cold milk. The Resident's breakfast tray had an English muffin, an egg, orange juice, coffee and hot cereal. There was no fortified juice on the breakfast tray. Resident #11 was observed to be in his/her room on 10/20/22 at 2:10 P.M. During an interview at this time, Resident #11 said he/she had not received any pudding and was willing to try some pudding. At 3:18 P.M. Resident #11 said he/she had not gotten any pudding this afternoon. During an interview on 10/20/22 at 3:20 P.M. Nurse #1 said there was no order to give Resident #11 pudding at 2:00 P.M. Nurse #1 and the surveyor reviewed the Physician Orders and Nurse #1 said the order for pudding had not been entered in to the electronic medical record as an order that the nurse would see and sign off daily and therefore, the nurses did not know to make sure Resident #11 was getting pudding. Resident #11 was observed to be in his/her room on 10/21/22 at 8:19 A.M. having breakfast. The breakfast tray had a banana and orange juice and no fortified juice. During an interview on 10/21/22 at 9:50 A.M. the Director of Nurses said the Physician Orders for therapeutic diet and supplements should be followed. The Director of Nurses said the fortified juice should come from the kitchen on the breakfast tray. She said the fortified pudding should also come from the kitchen at 2:00 P.M. She said there should not have been orange juice or a banana on the meal trays when there was an order for a low potassium diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Social Services to one Resident (#11), from a total sample of 12 residents, who exhibited difficulty adjusting to the facility and had requested to return to the community. Findings include: Resident # 11 was admitted to the facility in August 2020. Resident #11 voiced the wish to return to the community on every day of survey (10/18, 10/19, 10/20 and 10/21/22) to three surveyors. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated Resident #11 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicates the Resident was cognitively intact. Section S of the MDS indicated Resident #11 had a Health Care Proxy (HCP) and the HCP had not been invoked and that there was documentation in the medical record that a discussion of goals of care with the resident or legal healthcare representative occurred. During an interview on 10/18/22 at 10:34 A.M. Resident #11 said he/she wished to return to the community. Review of the medical record included one note from a Social Worker regarding the admission for Resident #11 in August 2020 which indicated the Resident felt he/she was dumped here. There were no further notes from any Social Workers for Resident #11 for the next two years. Review of the Care Plans for Resident #11 failed to include a plan of care for the stay at the facility (short term, long term, adjustment interventions.) Review of a physician progress note, dated 9/18/21 indicated Resident #11 was not happy at the facility and wanted to get out of here. On 10/18/22 at 2:00 P.M., Resident #11 participated in the Group interview with six other residents. Resident #11 said he/she did not want to be at the facility and that he/she wanted to go home. Resident #11 said his/her son locked him/her up here and felt like a prisoner. Resident #11 said the facility had not helped him/her. The six residents participating in the group interview said Resident #11 often voiced feelings about not wanting to live at the facility and of feeling like a prisoner. One alert and oriented resident said Resident #11 had not adjusted to living in the facility. During an interview on 10/19/22 at 1:30 P.M. Resident #11 said he/she had two children and one of them put him/her in this facility and the Resident was unable to return to the community. During an interview on 10/20/22 at 2:23 P.M. Resident #11 said he/she felt like a prisoner who had been locked up at the facility for the previous two years and this made him/her feel terrible. The Resident further said he/she wanted to climb out the window just to be able to go for a walk. Resident #11 said he/she did not understand why the staff were listening to his/her son about the Resident needing to live in the facility and the staff had not spoken to the Resident about it. During an interview on 10/20/22 at 10:40 A.M. the Administrator said the facility previously had a part time Social Worker, approximately one to two days per week until July 2022. He said the Social Worker was responsible for documenting in the medical record the status of each resident at least quarterly and with any changes. During an interview on 10/21/22 at 9:08 A.M. the Director of Nurses said Resident #11 had requested to go home, but when he/she does this he/she was demonstrating that they were missing some one in their life. She said the Resident had experienced the loss of his/her son who had moved out of state and a grandchild who had moved out of the country. She said she was not sure who was working with the Resident on these losses and coping skills or why it was not part of the medical record. During an interview on 10/21/22 at 10:15 A.M. the Social Worker said she worked at the facility two days a week from approximately January 2021 through June 2022 and would be returning as the facility Social Worker. She said as the facility Social Worker she worked on a lot of financial matters like Medicaid applications or screenings (referrals for payment of stay). She said she was familiar with Resident #11 but had never talked with the Resident about adjusting to the facility, what the goals of stay were or adjusting to recent changes in family members moving away. She said she did not know Resident #11 had wanted to return to the community. She reviewed the Care Plan Meeting Signature Page with the surveyor and said she was not sure why the last care plan meeting was held in November 2021 (11 months prior) and could not say why she had not attended any of the care plan meetings from February 2021 through November 2021.

Based on record review and staff interviews, the facility staff failed to ensure that for one Residents (#18), from a total sample of 12 Residents, that each Resident's drug regimen was free of unnecessary medications. Specifically, the facility failed to ensure that orders for psychotropic drugs, as needed (PRN), are limited to 14 days, and failed to ensure the physician or prescribing practitioner reviewed and determined it is appropriate to extend the PRN order beyond 14 days and he/she document their rationale in the Resident's medical record and indicate the duration for the PRN order. Findings include: Resident #18 was admitted to the facility in September 2021 with a diagnosis of anxiety. A). Review of current Physician Orders for Resident #18 indicated an order, dated 2/17/22, for Buspirone (anti-anxiety medication) 5 mg (milligrams), every six hours, as needed. The order indicated to evaluate the use on 2/28/22. A Consultant Pharmacist Recommendation to Physician, dated 3/15/22 indicated the as needed Buspirone must be re-assessed every 14 days, a rational if longer than 14 days and an order must contain an appropriate stop date. The form indicated the re-evaluation date of 2/28/22 had passed. The physician indicated a response of disagreeing with recommendation to follow the regulation and wrote patient needs it. A Consultant Pharmacist Recommendation to Physician, dated 4/19/22 indicated the as needed Buspirone must be re-assessed every 14 days, a rational if longer than 14 days and an order must contain an appropriate stop date. The form indicated the re-evaluation date of 2/28/22 had passed and to consider extending the order. The physician did not indicate a response on the form, wrote the Resident used the medication six times in April 2022 and signed the form. The order was not re-written with a new evaluation date and an evaluation was not included in the medical record. A Consultant Pharmacist Recommendation to Physician, dated 6/10/22 indicated the same information from 4/19/22. The physician indicated a response of disagreeing with the recommendation to follow the regulation and wrote patient needs it to maintain stability, well being and quality of life. The order was not re-written with a new evaluation date and still listed a stop date of 2/28/22. A Consultant Pharmacist Recommendation to Physician, dated 7/18/22 indicated the as needed Buspirone should be re-assessed every 14 days and have clinical rational documented with an appropriate stop date. The physician indicated a response of disagreeing with the recommendation and that the medication was warranted to maintain stability and over all well being. The order was not re-written with a new evaluation date and continued to list a stop date of 2/28/22. B). Review of current Physician Orders for Resident #18 indicated an order, dated 7/15/22, for Lorazepam (anti-anxiety medication) 1 mg, daily, as needed. The order did not include a date for re-evaluation. A Consultant Pharmacist Recommendation to Physician, dated 7/18/22 indicated the as needed Lorazepam should be re-assessed every 14 days and have clinical rational documented with an appropriate stop date. The physician indicated a response of disagreeing with the recommendation and that the medication was warranted to maintain stability and over all well being. The order was not re-written with a new evaluation date and continued without a stop date. During an interview on 10/21/22 at 8:44 A.M. the Director of Nurses said the as needed psychotropic medications needed to have an identified stop date in order to be re-evaluated and the physician should be updating the orders and the writing the clinical rational in the medical record.

Based on observations and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1. Ensure staff wear face masks for source control based on facility practice while in resident areas of the facility; 2. Implement and utilize a system of surveillance for staff symptomatic or positive for COVID-19, to include return to work criteria; 3. Utilize and implement a system of surveillance of resident respiratory symptoms that is current to help identify potential active clusters of illness; and 4. Identify and respond to an outbreak of COVID-19 on 10/05/22. Findings include: 1. 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 10/19/22 at 7:00 A.M., the surveyor observed a sign posted on the front door of the facility indicating masks need to be kept on at all times while inside. During an observation with interview on 10/19/22 at 8:06 A.M., the surveyor observed the Activity Director in the hallways outside of resident rooms on the second floor, her face mask was pulled low exposing her nose and she adjusted the mask upon seeing the surveyor. She said she is suppose to wear the face mask covering both her nose and mouth at all times while in the facility. During an observation with interview on 10/19/22 at 8:08 A.M., the surveyor observed Nurse #1 in the hallway of the second floor with her mask pulled down exposing her nose. She said the mask should cover both her nose and her mouth at all times while in the facility. During an observation with interview on 10/19/22 at 8:16 A.M., the surveyor observed Nurse #3 in the first floor dining room with her mask pulled down exposing her nose. She said she is suppose to have her mask covering her nose and mouth at all times while in the facility. During an observation on 10/20/22 at 3:15 P.M., the surveyor observed the Activity Director in the first floor dining room with six residents. She was observed to be seated at a table and wearing her mask on her chin, not covering either her nose or mouth. During an interview at this time, the Activity Director said she knows she is supposed to wear her mask around residents, but was having a drink. During an observation on 10/20/22 at 3:30 P.M. the surveyor observed two staff members sitting in the second floor day room with three residents. One staff member was observed to be wearing her mask on her chin, not covering her nose or mouth. The other staff member was not wearing a mask. During an interview on 10/19/22 at 3:18 P.M., the Infection preventionist (IP) said the staff and visitors are all required to wear a face mask for source control at all times while in the facility. 2. Review of the Centers for Disease Control and Prevention (CDC) guidance titled: Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated: September 2022, indicated criteria to determine when healthcare personnel (HCP) with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. It further indicated but was not limited to the following: - HCP with mild to moderate illness could return to work after the following criteria have been met: - At least 7 days have passed since symptoms first appeared, if a negative viral test is obtained within 48 hours prior to returning to work or 10 days if testing is not performed or if a positive test at day 5-7) and; - At least 24 hours have passed since last fever without the use of fever-reducing medications, and; - Symptoms (e.g., cough, shortness of breath, etc.) have improved. Review of the facility policy titled: Procedures for staff and resident testing, undated, indicated but was not limited to the following - staff with symptoms must be restricted from work pending testing results - staff with confirmed cases of COVID-19 must follow CDC return to work restrictions During an interview on 10/19/22 at 3:18 P.M., the IP nurse stated the facility had one dietary staff member with COVID-19 at this time. She said she does contact tracing on all positive COVID-19 cases including a 48 hour look back. A report referred to as contact tracing was provided to the surveyor for review and indicated Dietary staff (DS) #1 was previously positive in the last 3 month for COVID-19 infection. The IP said DS #1 was previously positive on 10/5/22 and tested positive a second time on 10/13/22 which this document was attempting to reflect. The document contained no information on signs and symptoms of COVID-19 for the staff member, however the IP said she recalled DS#1 had body aches during the first test and body aches and headache prompting the second test on 10/13/22. She said there is no line listing of staff symptoms of COVID-19 or respiratory line listing of staff illnesses to track the staff symptoms of illness. She said the staff member returned to work 5 days after the first positive test, but symptoms were unknown at that time. She said she retested DS #1 on 10/13/22 when they complained of not feeling well again. She said she didn't know what guidance was used for the employee to return to work but thought they just needed to be out for 5 days, she said the employee may have tested to return to work but she does not have any evidence of that. She said staff and visitors complete a screening log each day when coming into the facility which may indicate signs and symptoms of illness. Review of the timecard for DS #1 indicated the following: - Pay period 10/2/22 - 10/8/22: worked for 8 hours on 10/3/22 and 10/4/22; was sick on 10/5/22 and did not work the remainder of the pay period - Pay period 10/9/22 - 10/15/22: worked for at least 8 hours on 10/10/22, 10/11/22, 10/12/22, 10/13/22, and 10/14/22 - Pay period 10/16/22 - current date (10/19/22): worked at least 7 hours on 10/17/22, 10/18/22, and 10/19/22 During a follow up interview on 10/19/22 at 3:45 P.M., the IP said she does not have any documentation of DS #1 testing negative prior to returning to work. She said she could not find any signs and symptoms identified on the facility screening tool, which is used on all staff and visitors daily at the start of their shifts. She said she does not keep a line listing of staff respiratory illness symptoms or symptoms for staff who may present with a positive COVID-19 test. Review of the staff and visitor screening tool in use by the facility has the following questions on it: - date - time - name - resident room # you are visiting for contact tracing - do you have any of the following symptoms: fever, sore throat, shortness of breathe (SOB), myalgia (muscle pain), chills, or new onset of loss of taste or smell - have you been fully vaccinated - have you been diagnosed with COVID-19 in the prior 10 days or recently exposed to anyone suspected or confirmed with COVID-19 in the prior 14 days - do you agree to notify the facility if you develop any signs or symptoms of COVID-19 in the next 2 days and whom you were in contact with in the facility Further review of the staff and visitor screening tools dated from 10/1/22 through 10/19/22 indicated DS #1 signed into the log on the following days and at no time indicated any symptoms or COVID positive status: 10/2/22, 10/3/22, 10/4/22, 10/5/22, 10/12/22, 10/13/22, 10/14/22, 10/15/22. During an interview on 10/20/22 at 8:53 A.M., DS #1 said that she had not been feeling well since 10/4/22 and informed the IP on 10/5/22 of the symptoms she was experiencing which included: a headache, body and joint pain and a cough. She said she tested positive for COVID-19 at that time and was told that she could not work for 5 days and left the facility. She said she returned on 10/10/22 and was told she just needed to wear the regular mask that is required for all staff in the facility. She said she continued to have symptoms that included: continued body aches and joint pain, cough, and shortness of breath on exertion and was retested by the facility on 10/13/22. She said she felt she was not getting better and saw her personal physician in the community on 10/18/22. We reviewed the screening tool in use by the facility and she said she tries to remember to complete it everyday she works, but she doesn't always have her glasses on and she just copies the answers of the person above her since she cannot read the print without them, which is why she did not indicate symptoms or that she was positive in the last 10 days on some of the lines. During an interview on 10/20/22 at 9:19 A.M., the IP nurse said she was confused in reporting one positive case of staff with COVID-19, and in fact there are two staff members who have tested positive for COVID-19. DS #1 on 10/5/22 and DS #2 on 10/13/22, who was asymptomatic. Review of the Centers for Disease Control and Prevention (CDC) guidance titled: Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated: September 2022, indicated criteria to determine when healthcare personnel (HCP) with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. It further indicated but was not limited to the following: - HCP who were asymptomatic throughout their infection, could return to work after the following criteria have been met: - At least 7 days have passed since the date of their first positive viral test, if a negative viral test is obtained within 48 hours prior to returning to work; or - 10 days, if testing is not performed or if a positive test at day 5-7. Review of the timecard for DS #2 indicated the following: - Pay period 10/9/22 - 10/15/22: worked for only 3.5 hours on 10/13/22 (test positive date) - Pay period 10/16/22 - current date (10/19/22): worked 6 hours on 10/18/22 (returned to work) During an interview on 10/20/22 at 10:08 A.M., IP and Regional Nurse said the guidance they used to allow positive staff to return to work included staff could return to work after they tested positive, using the positive test day as day zero in the counting of days, on day 6 if they had a negative test on day 5 or return to work on day 11 without symptoms. Neither could provide any insight as to why DS #1 returned to work on 10/10/22 (5 days after the initial positive test), while still symptomatic and without a negative test, or why DS #2 returned to work on 10/17/22, 4 days after a positive test on 10/13/22. The regional nurse said the guidance wasn't followed for the staff to return to work. 3. Review of the facility policy titled: Infection prevention and control program, undated, indicated the facility will develop and maintain an infection prevention and control program that provides a safe, sanitary and comfortable environment to help prevent the development and transmission of infections. Further review indicated, but was not limited to the following: - perform surveillance activities to monitor and investigate causes of infection and a manner of spread in order to prevent infections in the facility - analyze in a timely manner, clusters or trends of infection, changes in prevalent organisms, and any increase in the rate of infection During an interview on 10/19/22 at 3:18 P.M., the IP said she tracks respiratory symptoms of illness, including COVID-19, for residents through the use of symptom tracking on the treatment administration record (TAR) for each resident in the facility. She said she does not always have time to review these sheets daily, as she should, and relies heavily on staff providing her with verbal notification should any respiratory symptoms be developed by a resident. Resident #8 was admitted to the facility in April 2018. Review of the TARs for Resident #8 indicated the Resident had not exhibited any symptoms of a respiratory illness including COVID-19 from October 1, 2022 through October 20, 2022. Review of the facility nursing report book indicated Resident #8 began exhibiting respiratory symptoms on 10/14/22, during the 7:00 A.M. to 11:00 P.M. shift. The following symptoms were documented as effecting the Resident on the following days: - 10/14/22: congestion, non-productive cough, scattered wheezing (a high-pitched sound made when breathing, associated with difficulty breathing) - 10/15/22: congestion - 10/16/22: cold symptoms - 10/17/22: cold symptoms - 10/18/22: cough, wheezing and congestion - 10/19/22: cold symptoms Resident #6 was admitted to the facility in October 2019. Review of the TARs for Resident #6 indicated the Resident had not exhibited any symptoms of a respiratory illness including COVID-19 from October 1, 2022 through October 20, 2022. Review of the facility nursing report book indicated Resident #6 began exhibiting respiratory symptoms on 10/16/22, during the 7:00 A.M. to 3:00 P.M. shift. The following symptoms were documented as effecting the Resident on the following days: - 10/16/22: cold symptoms - 10/17/22: cold symptoms, dry cough, congestion - 10/18/22: congested non-productive cough - 10/19/22: cold symptoms and expectorating (coughing out) yellow sputum Resident #2 was admitted to the facility in October 2017. Review of the TARs for Resident #2 indicated the Resident had not exhibited any symptoms of a respiratory illness including COVID-19 from October 1, 2022 through October 20, 2022. Review of the facility nursing report book indicated Resident #2 began exhibiting respiratory symptoms on 10/19/22, during the 7:00 A.M. to 11:00 P.M. shift. The following symptoms were documented as effecting the Resident on the following days: - 10/19/22: cold symptoms Resident #22 was admitted to the facility in June 2022. Review of the TARs for Resident #22 indicated the Resident had not exhibited any symptoms of a respiratory illness including COVID-19 from October 1, 2022 through October 20, 2022. Review of the facility nursing report book indicated Resident #22 began exhibiting respiratory symptoms on 10/19/22, during the 7:00 A.M. to 11:00 P.M. shift. The following symptoms were documented as effecting the Resident on the following days: - 10/19/22: cold symptoms, congestion, wheeze - 10/20/22: shortness of breath, congested cough During an interview on 10/20/22 at 3:52 P.M., IP said she does not have any line listings that indicate respiratory symptoms for the four reviewed Residents (#8, #6, #2 and #22) currently being treated for respiratory symptoms. she could not explain the discrepancy in documentation for Residents #8, #6, #2, and #22 between the TAR symptom monitoring and the report book. She said she gets information on a look back basis to complete her monthly line listings. 4. Review of the Centers for Medicare and Medicaid Services guidance titled: 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, dated September 2022, indicated but was not limited to 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 - Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately - If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level. During an interview on 10/19/22 at 3:18 P.M., IP said the facility had a staff member test positive for COVID-19 on 10/5/22 and again on 10/13/22. She said the facility was not in an outbreak because it was not a resident who tested positive. She said DS #1 was positive no 10/13/22 and previously positive on 10/5/22, she said the dietary department staff were tested as a precaution. She said DS #1 was known to have some exposure to two residents, she said the residents were not tested as a result of the contact tracing as she assumed their exposure was limited but couldn't identify a time frame that would meet that presumed definition, and she said none of the residents in the facility wear a face mask for source control. She said she may have tested more people but takes things like community transmission into consideration and she is not aware of any local outbreaks. She said her current community transmission level is substantial, but it has been for a long time so she doesn't consider that a change or reason to consider switching from contact tracing to broad based outbreak investigating. She said contact tracing is extremely challenging and she does not always get the fine details of the tracing until after the fact. Review of the CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, dated September 2022, indicated but was not limited to the following in regards to exposure time guidance: - an exposure of 15 minutes or more is considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period - being within 6 feet of a person with confirmed SARS-CoV-2 (COVID-19) infection, distances of more than 6 feet might also be of concern, particularly when exposures occur over long periods of time in indoor areas with poor ventilation - For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset During an interview on 10/20/22 at 8:53 A.M., DS #1 said that she had not been feeling well since 10/4/22 and informed the IP on 10/5/22 of the symptoms she was experiencing which included: a headache, body and joint pain and a cough. She said she tested positive for COVID-19 at that time. She said she continued to have symptoms that included: continued body aches and joint pain, cough, and shortness of breath on exertion and was retested by the facility on 10/13/22. She said she felt she was not getting better and saw her personal physician in the community on 10/18/22. She said she does have contact and conversations with residents while she is in the facility and spends time every day she works with Resident #10 and Resident #6. She said she meets with them and talks to them both twice a day for about 20 minutes at a time totaling close to 40 minutes each day that she works. She said a few days a week she also visits with Resident #11, who sits with Resident #6 in the dining room. She said she spends approximately 15 to 20 minutes speaking with Resident #11, but is unsure if she met with Resident #11 on her test positive day for COVID or within the two prior days. During an interview on 10/20/22 at 9:19 A.M., the IP nurse said she was confused in reporting one positive case of staff with COVID-19, and in fact there are two staff members who have tested positive for COVID-19. The last positive staff member was identified on 10/13/22. During an interview on 10/20/22 at 10:08 A.M., the IP and the Regional Nurse both said that although they had staff that tested positive for COVID-19 in the last week, they were not in an outbreak because no residents were involved.

Based on document review, policy review and interview the facility failed to notify residents, staff, and family members of a confirmed COVID-19 infection by 5:00 P.M., the next business day. Findings include: Review of the facility policy titled: COVID-19 communication, undated, indicated the facility would communicate with staff, residents, and their families regarding the status and impact of COVID-19. Review of the facility staff testing logs indicated the facility had a staff member test positive for COVID-19 on 10/13/22. Review of the nursing progress notes for Residents' #8, #22, #6, #2, #10 and #11 failed to indicate the Residents of their families had been notified of a recent positive case of COVID-19 in the facility. During an interview on 10/19/22 at 5:00 P.M., the Administrator said the residents, families and staff are notified by email, telephone call or verbally of any change in the facilities COVID-19 status. During an interview on 10/20/22 at 9:15 A.M., Nurse #4 said she was notified this morning upon reporting to work that there were two dietary staff members positive for COVID-19. During an interview on 10/20/22 at 9:19 A.M., Director of nurses said she notified the staff working today of two positive COVID-19 cases of staff from 10/5/22 and 10/13/22. \ During an interview on 10/22/22 at 11:22 A.M., the Regional nurse said the facility has no documentation or evidence of resident, staff or family notification for either of the two recent COVID-19 positive cases among staff on 10/5/22 and 10/13/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, policy review and interview the facility failed to conduct COVID-19 testing as required based on Centers for Disease Control and Prevention (CDC) and/or Centers for Medicare and Medicaid Services (CMS) guidance. Specifically the facility failed to: 1. Test all people exposed to or in contact with a person known to be COVID-19 positive within the required time frame for investigational purposes in alignment with CMS guidance; and 2. Ensure employees who have returned to work have a negative COVID-19 test on file or logged with the facility as required in alignment with CDC guidance. Findings include: 1. Review of the CMS guidance titled: 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, dated September 2022, indicated but was not limited to 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 - Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately, (but not earlier than 24 hours after the exposure, if known - If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level. During an interview on 10/19/22 at 3:18 P.M., the Infection preventionist (IP) nurse stated the facility had one dietary staff (DS) member with COVID-19 at this time. She said she does contact tracing on all positive COVID-19 cases including a 48 hour look back. A report referred to as contact tracing was provided to the surveyor for review and indicated Dietary staff (DS) #1 was previously positive in the last 3 month for COVID-19 infection. The IP said DS #1 was previously positive on 10/5/22 and tested positive a second time on 10/13/22 which this document was attempting to reflect. She said she retested DS #1 on 10/13/22 when they complained of not feeling well again. She said DS #1 was known to have some exposure to two Residents (#10 and #14), she said the residents were not tested as a result of the contact tracing as she assumed their exposure was limited but couldn't identify a time frame that would meet that presumed definition, and she said none of the residents in the facility wear a face mask for source control. She said she may have tested more people but takes things like community transmission into consideration and she is not aware of any local outbreaks. She said her current community transmission level is substantial, but it has been for a long time so she doesn't consider that a change or reason to consider switching from contact tracing to broad based outbreak investigating. She said contact tracing is extremely challenging and she does not always get the fine details of the tracing until after the fact. She said should residents develop signs and symptoms of COVID-19, they would be tested at that time. Review of the facility staff COVID-19 testing log indicated DS #1 tested positive for COVID-19 on 10/5/22. Further review of the facility staff testing log indicated the following tests for dietary staff: - 10/6/22: Two dietary staff (DS #2 and #3) were tested and negative; - 10/10/22: DS #3, who previously tested on [DATE], was tested and negative - 10/11/22: DS #2, who previously tested on [DATE], was tested and negative - 10/13/22: DS #3 and #2, were both tested with DS #3 negative and DS #2 positive - 10/17/22: DS #4, tested and was negative; DS #2 was tested and remained positive for COVID-19 - 10/18/22: DS #5, tested and was negative - 10/19/22: DS #3 and DS #4, tested and were negative Review of the facility policy titled: Procedures for staff and Resident testing, undated, indicated but was not limited to the following: - Test all staff and residents in response to an outbreak (any single new infection) - Test staff and residents that tested negative every 3 days until 7 days since the most recent positive result has passed and then weekly until 14 days with no new cases During an interview on 10/20/22 at 10:08 A.M., the IP and Regional nurse stated the testing log does not reflect the frequency of staff testing for the dietary department as required in response to the positive dietary member and the guidance was not met. Review of the CDC guidance titled: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated September 2022, indicated but was not limited to the following: - asymptomatic patients (residents) with close contact with someone with SARS-CoV-2 (COVID-19) infection, should have a series of three tests for SARS-CoV-2 infection. - 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 testing is typically done at day 1, day 3, and day 5 (where day zero is exposure day) During an interview on 10/20/22 at 8:53 A.M., DS #1 said that she had not been feeling well since 10/4/22 and informed the IP on 10/5/22 of the symptoms she was experiencing which included: a headache, body and joint pain and a cough. She said she tested positive for COVID-19 at that time. She said she continued to have symptoms that included: continued body aches and joint pain, cough, and shortness of breath on exertion and was retested by the facility on 10/13/22. She said she felt she was not getting better and saw her personal physician in the community on 10/18/22. She said she did have exposure to residents when she was symptomatic prior to and at the time of her positive COVID-19 test and visits two Residents (#10 and #6) about twice a day for about 20 minutes each time and another Resident (#11) a few times a week for about 15 to 20 minutes at a time. Review of the CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, dated September 2022, indicated but was not limited to the following in regards to exposure time guidance: - An exposure of 15 minutes or more is considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period - Being within 6 feet of a person with confirmed SARS-CoV-2 (COVID-19) infection, distances of more than 6 feet might also be of concern, particularly when exposures occur over long periods of time in indoor areas with poor ventilation - For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset Review of the medical record for Residents #10, #6 and #11 failed to indicate testing had been completed in response to the exposure to the COVID-19 positive DS #1. Per the previous conversation and interview with the IP on 10/19/22 at 3:18 P.M., the Residents had not been tested in response to the COVID-19 positive staff member on 10/5/22 or 10/13/22. During an interview on 10/20/22 at 2:32 P.M., Epidemiologist #1 said the Regional nurse had contacted her for testing guidance related to the dietary employee testing positive for COVID-19. She said she was not made aware that there were any residents exposed to the positive staff member, but in the event that residents were exposed her guidance to them would have been different and the exposed residents should have been tested on day 1, day 3, and day 5, even if asymptomatic. She said the facility was not following the current guidance. 2. Review of the Centers for Disease Control and Prevention (CDC) guidance titled: Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated: September 2022, indicated criteria to determine when healthcare personnel (HCP) with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. It further indicated but was not limited to the following: HCP with mild to moderate illness could return to work after the following criteria have been met: - At least 7 days have passed since symptoms first appeared, if a negative viral test is obtained within 48 hours prior to returning to work or 10 days if testing is not performed or if a positive test at day 5-7) and; - At least 24 hours have passed since last fever without the use of fever-reducing medications, and; - Symptoms (e.g., cough, shortness of breath, etc.) have improved. Review of the facility policy titled: Procedures for staff and resident testing, undated, indicated but was not limited to the following - Staff with symptoms must be restricted from work pending testing results - Staff with confirmed cases of COVID-19 must follow CDC return to work restrictions During an interview on 10/19/22 at 3:18 P.M., the IP nurse stated the facility had one dietary staff member with COVID-19 at this time. She said she does contact tracing on all positive COVID-19 cases including a 48 hour look back. A report referred to as contact tracing was provided to the surveyor for review and indicated Dietary staff (DS) #1 was previously positive in the last 3 month for COVID-19 infection. The IP said DS #1 was previously positive on 10/5/22 and tested positive a second time on 10/13/22 which this document was attempting to reflect. The document contained no information on signs and symptoms of COVID-19 for the staff member, however the IP said she recalled DS#1 had body aches during the first test and body aches and headache prompting the second test on 10/13/22. She said there is no line listing of staff symptoms of COVID-19 or respiratory line listing of staff illnesses to track the staff symptoms of illness. She said the staff member returned to work 5 days after the first positive test, but symptoms were unknown at that time. She said she retested DS #1 on 10/13/22 when they complained of not feeling well again. She said she didn't know what guidance was used for the employee to return to work but thought they just needed to be out for 5 days, she said the employee may have tested to return to work but she does not have any evidence of that. She said staff and visitors complete a screening log each day when coming into the facility which may indicate signs and symptoms of illness. Review of the timecard for DS #1 indicated the following: - Pay period 10/2/22 - 10/8/22: worked for 8 hours on 10/3/22 and 10/4/22; was sick on 10/5/22 and did not work the remainder of the pay period - Pay period 10/9/22 - 10/15/22: worked for at least 8 hours on 10/10/22, 10/11/22, 10/12/22, 10/13/22, and 10/14/22 - Pay period 10/16/22 - current date (10/19/22): worked at least 7 hours on 10/17/22, 10/18/22, and 10/19/22 The timecard and testing log review indicated DS #1 tested positive for COVID-19 on 10/5/22 and returned to work on 10/10/22 During a follow up interview on 10/19/22 at 3:45 P.M., the IP said she does not have any documentation of DS #1 testing negative prior to returning to work. She said she could not find any signs and symptoms identified on the facility screening tool, which is used on all staff and visitors daily at the start of their shifts. She said she does not keep a line listing of staff respiratory illness symptoms or symptoms for staff who may present with a positive COVID-19 test. Review of the staff and visitor screening tools dated from 10/1/22 through 10/19/22 indicated DS #1 signed into the log on the following days and at no time indicated any symptoms or COVID positive status: 10/2/22, 10/3/22, 10/4/22, 10/5/22, 10/12/22, 10/13/22, 10/14/22, 10/15/22. During an interview on 10/20/22 at 8:53 A.M., DS #1 said that she had not been feeling well since 10/4/22 and informed the IP on 10/5/22 of the symptoms she was experiencing which included: a headache, body and joint pain and a cough. She said she tested positive for COVID-19 at that time and was told that she could not work for 5 days and left the facility. She said she returned on 10/10/22 and was told she just needed to wear the regular mask that is required for all staff in the facility. She said she continued to have symptoms that included: continued body aches and joint pain, cough, and shortness of breath on exertion and was retested by the facility on 10/13/22. She said she felt she was not getting better and saw her personal physician in the community on 10/18/22. We reviewed the screening tool in use by the facility and she said she tries to remember to complete it everyday she works, but she doesn't always have her glasses on and she just copies the answers of the person above her since she cannot read the print without them, which is why she did not indicate symptoms or that she was positive in the last 10 days on some of the lines. During an interview on 10/20/22 at 9:19 A.M., the IP nurse said she was confused in reporting one positive case of staff with COVID-19, and in fact there are two staff members who have tested positive for COVID-19. DS #1 on 10/5/22 and DS #2 on 10/13/22, who was asymptomatic. Review of the Centers for Disease Control and Prevention (CDC) guidance titled: Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated: September 2022, indicated criteria to determine when healthcare personnel (HCP) with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. It further indicated but was not limited to the following: HCP who were asymptomatic throughout their infection, could return to work after the following criteria have been met: - At least 7 days have passed since the date of their first positive viral test, if a negative viral test is obtained within 48 hours prior to returning to work; or - 10 days, if testing is not performed or if a positive test at day 5-7. Review of the timecard for DS #2 indicated the following: - Pay period 10/9/22 - 10/15/22: worked for only 3.5 hours on 10/13/22 (test positive date) - Pay period 10/16/22 - current date (10/19/22): worked 6 hours on 10/18/22 (returned to work). The timecard and testing log review indicated DS #2 tested positive for COVID-19 on 10/13/22 and returned to work on 10/18/22 During an interview on 10/20/22 at 10:08 A.M., IP and Regional Nurse said the guidance they used to allow positive staff to return to work included staff could return to work after they tested positive, using the positive test day as day zero in the counting of days, on day 6 if they had a negative test on day 5 or return to work on day 11 without symptoms. Neither could provide any insight as to why DS #1 returned to work on 10/10/22 (5 days after the initial positive test), while still symptomatic and without a negative test, or why DS #2 returned to work on 10/17/22, 4 days after a positive test on 10/13/22. The regional nurse said the guidance wasn't followed for the staff to return to work.