Does PLYMOUTH HARBORSIDE HEALTHCARE have any serious inspection findings?

Yes, PLYMOUTH HARBORSIDE HEALTHCARE has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 64 total deficiencies from recent inspections.

What are the staffing levels at PLYMOUTH HARBORSIDE HEALTHCARE?

PLYMOUTH HARBORSIDE HEALTHCARE has a two-star staffing rating from CMS with 0.67 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is PLYMOUTH HARBORSIDE HEALTHCARE located?

PLYMOUTH HARBORSIDE HEALTHCARE is located in PLYMOUTH, MA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does PLYMOUTH HARBORSIDE HEALTHCARE have?

PLYMOUTH HARBORSIDE HEALTHCARE has 101 certified beds.

Who owns PLYMOUTH HARBORSIDE HEALTHCARE?

PLYMOUTH HARBORSIDE HEALTHCARE is a for profit - corporation facility and is part of the NEXT STEP HEALTHCARE chain.

How does PLYMOUTH HARBORSIDE HEALTHCARE compare to other nursing homes?

PLYMOUTH HARBORSIDE HEALTHCARE has a 1-star overall rating, which is below average compared to other nursing homes in MA. Families should carefully review inspection findings and consider alternatives.

PLYMOUTH HARBORSIDE HEALTHCARE

Name: PLYMOUTH HARBORSIDE HEALTHCARE
Address: 19 OBERY STREET, PLYMOUTH, MA, 02360, US
Telephone: (508) 747-4790
Rating: 1.0

19 OBERY STREET, PLYMOUTH, MA 02360 · (508) 747-4790

For profit - Corporation 101 Beds NEXT STEP HEALTHCARE Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

0/100

#311 of 338 in MA

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Photo by Plymouth Harborside HealthCare

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Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Plymouth Harborside Healthcare has a Trust Grade of F, indicating significant concerns about the quality of care, as this is the lowest rating possible. It ranks #311 out of 338 facilities in Massachusetts, placing it in the bottom half of nursing homes statewide, and #23 out of 27 in Plymouth County, suggesting that only a few local options are better. While the facility shows a trend of improvement with the number of issues dropping from 14 in 2024 to 5 in 2025, it still faces serious challenges, including $42,254 in fines, which is higher than 75% of Massachusetts facilities, pointing to repeated compliance problems. Staffing is rated below average at 2 out of 5 stars, with a turnover rate of 48%, which is concerning as it is close to the state average. There have been critical incidents, including failure to perform life-saving measures for an unresponsive resident and reports of physical altercations between residents, highlighting serious safety and emergency response issues. Overall, while there are some improvements in certain areas, the facility's weaknesses raise significant concerns for prospective residents and their families.

Trust Score: F
In Massachusetts: #311/338
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $42,254 in fines. Lower than most Massachusetts facilities. Relatively clean record.
Skilled Nurses: Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for Massachusetts. RNs are the most trained staff who monitor for health changes.
Violations: 64 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 14 issues

2025: 5 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Massachusetts average (2.9)

Significant quality concerns identified by CMS

Staff Turnover: 48%

Near Massachusetts avg (46%)

Higher turnover may affect care consistency

Federal Fines: $42,254

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: NEXT STEP HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 64 deficiencies on record

2 life-threatening 6 actual harm

Sept 2025 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of four sampled residents (Resident #2), who was known to exhibit intrusive, combative and aggressive behaviors towards staff, residents, and visitors, the Facility failed to ensure that other residents residing on his/her unit were free from physical abuse, when between May 2025 and August 2025, Resident #2 was involved in several altercations, which included being witnessed by staff as he/she punched a resident in the stomach, climbed into another residents bed and became combative with attempts to be redirected, and it was alleged that he/she punched a resident on the arm and in the face during an unwitnessed altercation. Resident #2's combative and aggressive behaviors place other residents on his/her unit at increased risk for physical abuse.Findings Include:Review of the Facility Policy titled Abuse Investigation and Reporting, dated as last revised 02/2024, indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Every resident in the Facility will be treated with respect and dignity. The Policy further indicated that physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, and so on. Resident #2 was admitted to the Facility in April 2025, diagnoses include Alzheimer's Disease, dementia with behavioral disturbances, and anxiety.Review of Resident #2's admission Minimum Data Set (MDS) dated [DATE], indicated that he/she exhibited both long- and short-term memory loss, severely impaired decision-making abilities, was sometimes understood and was rarely able to understand what was being said by others.The MDS indicated he/she exhibited physical behaviors, (hitting, kicking, pushing, scratching) one (1) to three (3) days per week, verbal behaviors (threatening, screaming, or cursing at others) one (1 ) to three (3) days a week, and other behaviors (hitting or scratching self, pacing, rummaging, disrobing) four (4) to six (6) days per week. The MDS further indicated that Resident #2 rejected care one (1) to three (3) times weekly and wandered four (4 ) to six (6) days per week. 1) Review of the report submitted by the facility via Health Care Facility Reporting System (HCFRS), dated 05/02/25, indicated that at 7:28 P.M., a Certified Nurse Aide (CNA) witnessed Resident #2 punched Non-Sampled Resident (NSR) A in the stomach/chest several times. The Report indicated that Resident #2 was standing in NSR A's doorway and when NSR A attempted to enter his/her room, Resident #2 hit NSR A in the stomach/chest with a closed fist several times.Further review of the Report indicated that the plan for Resident #2 was for staff to monitor him/her while ambulating on the unit and redirect him/her out of other residents' rooms. The Report indicated that staff had identified that Resident #2 had no interest in activities and was essentially non-verbal.2) Review of a Report filed with the Department of Public Health (DPH), dated 07/22/25, indicated that on 05/31/25 Resident #2 had been observed in Resident #3's bed (roommate of Resident #1) by Resident #1's Family Member.The Report indicated that Family Member #2 had gone into Resident #1's room and found Resident #2 sleeping in Resident #3's bed. The Report indicated that Family Member #2 had called out for help, and a CNA (later identified as CNA #1) went to get Resident #2 out of Resident #3's bed.The Report further indicated Family Member #2 said that when CNA #1 woke Resident #2 up from sleeping, he/she displayed aggression and was combative with CNA #1.During an interview on 09/16/25 at 1:43 P.M., CNA #1 said that she has found Resident #2 in other residents' beds multiple times. CNA #1 said that she has assisted with getting Resident #2 out of other resident's rooms, including Resident #1 and Resident #3's room. CNA #1 said Resident #2 has punched her and been combative towards her many times.During an interview on 09/16/25 at 11:03 A.M., Resident #3 said that there is an older resident (later identified as Resident #2) that comes into their room all the time. Resident #3 said that he/she will ask him/her to leave, but that staff usually have to escort him/her out of the room. Resident #3 said that Resident #2 has been found in his/her bed sleeping and said Resident #2 had hit him/her in the past.3) Review of the report submitted by the facility via the Health Care Facility Reporting System (HCFRS) Report, dated 08/25/25, indicated that at 5:15 P.M., yelling was heard coming from a resident's room (identified as Resident #4) and upon entering the room, Resident #4 was observed holding Resident #2's hands (trying to prevent Resident #2 from hitting him/her). The Report also indicated, that although unwitnessed, Resident #4 said that Resident #2 had grabbed his/her arm and punched him/her on his/her right arm and right cheek.Further review of the Report and Facility Investigative Findings indicated that Resident #4 told staff that Resident #2 had wandered into his/her room, picked up his/her lunch tray, removed some clothing from his/her bed and then Resident #2 laid down on his/her (Resident #4's) bed.Review of Resident #4's Behavior Health Group Note, dated 08/26/25, indicated that he/she spoke of an incident involving Resident #2, and that Resident #4 said that he/she was shocked by the incident and said he/she has never been popped in the face before.Review of Resident #4's Behavior Health Group Note, dated 09/03/25, indicated he/she again discussed a recent incident where he/she alleged another resident (Resident #2) struck him/her in the face.During interviews throughout the day of the survey, dated 09/16/25, CNA s #1, #2, #4, #5, and #7 said they have witnessed and have been the recipient of Resident #2's aggressive and combative behaviors. All the CNA's said they were familiar with Resident #2's wandering behaviors and acknowledged that he/she requires supervision and constant redirection.During an interview on 09/16/25 at 12:10 P.M., Nurse #1 said that she was aware that Resident #2 can be very aggressive and combative with staff. Nurse #1 said that she was also aware that Resident #2 wandered throughout the day into other residents' rooms and has a history of being combative with other residents. During a telephone interview on 09/24/25 at 10:52 A.M., Nurse #2 said that she was aware that Resident #2 has been combative with staff and other residents.During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that Resident #2 was known to wander throughout the hallways of his/her unit and has been observed many times in multiple residents' rooms. Unit Manager #1 said that she was aware of Resident #2's aggressive and combative behavior towards staff and other residents. Unit Manager #1 said interventions such as magnetic stop signs and redirection were being implemented to decrease the risk for Resident #2 entering other residents' rooms. Unit Manager #1 said that the staff are aware of Resident #2's behaviors, and they continue to supervise and redirect Resident #2, as needed, when he/she was seen wandering around the unit.During an interview on 06/16/25, the Executive Director (ED) said that she was aware of Resident #2's behaviors, including his/her wandering and being combative with other residents and staff. The ED said that it is the Facility's expectation to maintain the safety of all residents, to accurately report and document behaviors for all residents and follow the plan of care for each resident to ensure a safe environment.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of four sampled residents (Resident #2) the Facility failed to ensure they reported and/or investigated incidents/allegations of abuse when 1) a family member reported that he attempted to redirect Resident #2 out of his family members room by pushing on Resident #2 and 2) Resident #2 punched a staff member in the face, neither of which were reported or investigated by the Facility.Findings include:Review of the Facility Policy titled Abuse Investigation and Reporting, dated as last revised 02/2024, indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Every resident in the Facility will be treated with respect and dignity. The Policy indicated the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical hurt or pain or mental anguish to a resident.The Policy further indicated that physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, and so on. Resident #2 was admitted to the Facility in April 2025, diagnoses include Alzheimer's Disease, dementia with behavioral disturbances, and anxiety.Review of Resident #2's admission Minimum Data Set (MDS) dated [DATE], indicated that he/she exhibited both long- and short-term memory loss, severely impaired decision-making abilities, was sometimes understood, and was rarely able to understand what is being said.The MDS indicated he/she exhibited physical behaviors, (hitting, kicking, pushing, scratching) one (1) to three (3) days per week, verbal behaviors (threating, screaming, or cursing at others) 1 to 3 days a week, and other behaviors (hitting or scratching self, pacing, rummaging, disrobing) four (4) to six (6) days per week and Resident #2 rejected care 1 to 3 times weekly and wandered 4 to 6 days per week. 1) Review of Resident #2's Nurse Progress Note (written by Unit Manager #1), dated 06/18/25, indicated that Resident #1's son (Family Member #2), informed Unit Manager #1 that Resident #2 wandered into Resident #1's room and Family Member #2 asked Resident #2 to leave. The Note indicated that Family Member #2 said that he pushed Resident #2 with his fingers to direct him/her out of the room and Resident #2 tried to grab him.Review of Resident #2's medical record indicated that there was no documentation to support that the facility initiated an investigation or reported the incident involving a visitor to resident altercation.During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that there was no incident report completed, or report filed to the Department of Public Health (DPH) after the documented incident.Unit Manager #1 said she thought the incident should have been a reportable event, however, said that after the management team discussed the incident with the Corporate Team, it was decided not to investigate the incident or report it.During an interview on 09/16/25 at 3:53 P.M., the Executive Director (ED) said that on 06/18/25 (day of the Incident), Family Member #2 stormed into her office telling her that Resident #2 wandered into Resident #1's room and Family Member #2 said that he pushed Resident #2 out of the room.2) During an interview on 09/16/25 at 11:16 A.M., Certified Nurse Aide (CNA) #4 said that on 08/28/25, during the evening shift (3:00 P.M. to 11:00 P.M.), she was assisting Resident #2 with evening care, that she was standing in front of Resident #2, went to lower his/her pants to get him/her changed into sleep wear and Resident #2 took both of his/her hands, made a fist with each hand and punched her on each side of her face very hard.CNA#4 said that she reported the incident to the nurse on the unit but said she was never asked to write a statement. During a telephone interview on 09/24/25 at 10:52 A.M., Nurse #2 said that she was aware of the incident that had occurred between CNA #4 and Resident #2 on 08/28/25, Nurse #4 said that she had reported it to Unit Manager #2.Nurse #2 said that Unit Manager #2 told her that if CNA #4 did not want to write a statement, then she did not have to.Nurse #2 said she did not know why an incident report wasn't completed and said she just followed what Unit Manager #2 told her and said she never asked CNA #4 for a statement.During a telephone interview on 09/24/25 at 11:20 A.M., Unit Manager #2 said that he does not recall anyone reporting a resident to staff member altercation on 08/28/25.Unit Manager #2 said that if a staff member had reported a resident to staff altercation, he was not certain that he would have initiated an incident report. The Executive Director said that she was not made aware of the 08/28/25 incident involving Resident #2 and CNA #4. The Executive Director said that she does not know why they did not do an incident report for either of these two incidents. The ED said that it was the Facility's expectation that all altercations that occur in the Facility be followed by an incident report and properly reported.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews and observation, for two of four sampled residents (Resident #1 and #4), the Facility failed to ensure they developed and/or consistently implemented and followed interventions identified in their plan of care related to the placement and use of a magnetic stop sign across their doorways to minimize the risk of other residents wandering into their rooms. Findings include: Review of the facility Policy titled Care Plans, Comprehensive Person Centered, dated as last revised 01/2024, indicted that a comprehensive, person-centered care plan will be developed for each resident and include objectives that meet the resident's physical, psychosocial and functional needs for each resident.1) Resident #1 was admitted to the Facility in February 2024, diagnoses include legal blindness, history of falls with vertebral fractures, and dementia.Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she scored a six (6) out of 15 on his/her Brief Interview for Mental Status (BIMS, evaluates cognitive impairment and can help dementia diagnosis) (0-7 indicates severe cognitive impairment).Review of Resident #1's Physician's Orders, dated as of 09/16/25, indicated that his/her Health Care Proxy (HCP) was activated and his/her Health Care Agent (HCA) had been invoked since 02/16/24.During a telephone interview on 09/15/25 at 1:42 P.M., Family Member #1 said that she had been in contact with the Facility multiple times in regard to her concerns of maintaining Resident #1's safety from another resident (identified as Resident #2) who had been wandering in and out of his/her room. Family Member #1 said she was concerned because Resident #2 exhibited aggressive and combative behaviors at times. Review of Resident #1's Nurse Progress Note, dated 06/18/25, indicated that Resident #2 had wandered into his/her room and required staff redirection to escort him/her out of Resident #1's room.Review of Resident #1's Nurse Progress Note, also dated 06/18/25, indicated that Unit Manager #1 spoke with Family Member #1 and discussed interventions that the Facility had put into place to help prevent further episodes of intrusive wandering.The Note further indicated that the interventions that had already been in place were redirecting Resident #2 out of other resident's rooms and placing a magnetic stop sign across the doorway of Resident #1's room to inhibit Resident #2 from entering.Review of Resident #1's care plans indicated that although Nursing told Family Member #1 that they had implemented the use of a magnetic stop sign across his/her doorway as an intervention to maintain his/her safety, there was no documentation to support that the intervention was added to his/her care plan.During an interview on 09/16/25 at 10:51 A.M., with Resident #1, the surveyor noted that upon arrival to his/her room, there was no stop sign across the doorway. Resident #1 said that there was a resident here (identified as Resident #2) that walks into his/her room all of the time. Resident #1 said that he/she (Resident #2) will come to the window, look out and then will he/she would sit on his/her (Resident #1's) bed. During interview with Resident #1 (at 11:06 A.M.), the Surveyor observed as Resident #2 wander into Resident #1's room and walk towards his/her bed. The Surveyor stayed with Resident #1 and a CNA then entered Resident #1's room and redirected Resident #2 out of the room.During three observations on 09/16/25 at 9:36 A.M., 10:51 A.M. and 2:47 A.M., the Surveyor observed the magnetic stop sign that should have been secured in place across Resident #1's door, was left hanging off to one side of the doorway and therefore would not stop or inhibit any one from entering his/her room.During an interview on 09/16/25 at 1:43 P.M., Certified Nurse Aide (CNA) #1 said that she does not know why the stop sign was not across Resident #1's doorway and said Resident #1 has had a stop sign across his/her doorway for a while to help prevent Resident #2 from wandering into his/her room.During an interview on 09/16/25 at 1:32 P.M., CNA #2 said that Resident #1 has had a stop sign across his/her doorway for quite some time and that sometimes she finds it hanging on the side of the door and not properly attached.During an interview on 09/16/25 at 1:21 P.M., CNA #3 said that Resident #1 has had a stop sign at his/her door for about 6 months and said it is now broken and does not always stay in place properly,During an interview on 09/16/25 at 12 :10 P.M., Nurse #1 said that she does not know why Resident #1's stop sign was not across his/her doorway during surveyor observations.During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that it was her responsibility to ensure each resident's care plan includes all identified interventions and goals. Unit Manager #1 said she thought she added the intervention of the stop sign to Resident #1's care plan. Unit Manager #1 said she did not know that Resident #1's stop sign was not being consistently utilized.2) Resident #4 was admitted to the Facility in March 2024, diagnoses include dementia with psychotic disturbances, major depression, and anxiety.Review of Resident #4's Physician's Orders, dated 09/16/25, indicated that his/her HCA had been invoked since 03/09/24.Review of the Health Care Facility Reporting System (HCFRS) Report, dated 08/25/25, indicated that at 5:15 P.M., a yell was heard coming from a resident's room (Resident #4) and upon entering the room, Resident #4 was observed holding Resident #2's hands (trying to prevent Resident #2 from hitting him/her). The Report further indicated that staff had provided a magnetic stop sign across Resident #4's doorway in hopes to deter Resident #2 from wandering into his/her room. Review of Resident #4's Care Plan titled Activities of Daily Living (ADL), dated as last revised 08/25/25, indicated that a magnetic stop sign was to be placed across his/her doorway as an intervention to maintain his/her safety.During multiple observations of Resident #4's room, on 09/16/25 throughout the day of the survey, the Surveyor did not observe a magnetic stop sign across Resident #4's doorway at any time that day.Therefore, although Resident #4's care plan indicated he/she required the use of a magnetic stop sign across his/her doorway as an intervention to maintain his/her safety, based on the Surveyor observations the intervention was not consistently implemented by staff.During an interview on 09/16/25 at 1:43 P.M., CNA #1 said she thinks that Resident #4 had a stop sign across his/her doorway but does not know what happened to it. During an interview on 09/16/25 at 1:21 P.M., CNA #3 said that Resident #4 has never had a stop sign going across his/her doorway that she was aware of.During an interview on 09/16/25 at 12 :10 P.M., Nurse #1 said that she thought Resident #4's stop sign was to be placed across his/her doorway, only a temporary intervention and does not know what happened to it. During multiple observations on Resident #2's unit, throughout the day of the survey, the Surveyor frequently observed Resident #2 wandering the unit without purpose or direction. During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that she was aware that Resident #2 wandered around on the unit and that Resident #1 and Resident #4 were to have magnetic stop signs going across their doorways to help prevent Resident #2 from wandering into their rooms.During an interview on 09/16/25 at 2:57 P.M., the Executive Director said that she was not aware that Resident #1 and Resident #4's care plans were missing interventions or that interventions were not consistently being implemented and followed accordingly.The ED said that the Facility's expectation is that nurses are to develop care plans for all residents and the staff are to implement and follow interventions per the residents' care plan as indicated.

Aug 2025 2 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Comprehensive Care Plan (Tag F0656)

A resident was harmed · This affected 1 resident

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Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) whose Plan of Care related to Activities of Daily living (ADLs) indicated that he/she required continual supervision (staff member to be with him/her during entire task) with meals, the facility failed to ensure that staff consistently implemented and followed his/her care plan interventions, when on 05/13/25, Resident #1 was served his/her breakfast tray, then left unsupervised in his/her room with his/her meal, he/she spilled a hot beverage on his/her upper legs, and sustained second-degree burns (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the front side of his/her left thigh, which required treatment.Findings Include: Review of the Facility's Policy titled, Care Plans, Comprehensive Person-Centered, dated as revised 01/2024, indicated the following:-A comprehensive, person-centered care plan will be developed for each resident; the care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident.-The resident comprehensive care plan will identify problem areas, and their causes as warranted and developing interventions that are targeted and meaningful to the resident.-Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident's condition changes.-The Interdisciplinary Team (IDT) reviews and updates the care plan when there has been a significant change in the resident's conditions, when there is a change and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Resident #1 was admitted to the Facility in August 2019, diagnoses included dementia, legal blindness, severe stage glaucoma right eye, muscle weakness, atrial fibrillation (irregular heartbeat) and hypertension. Review of Resident #1's Annual Minimum Data Set (MDS) assessment, dated 05/02/25, indicated that he/she had severe cognitive impairment, and required supervision with touch assistance when eating.Review of Resident #1's ADL Deficit Care Plan, renewed and reviewed with his/her May 2025 MDS, indicated that he/she required continual supervision with meals.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/20/25, indicated that on 05/13/25, a Certified Nurse Aide (CNA) observed Resident #1 had spilled coffee on him/herself, he/she was washed, assisted back to bed, he/she did not complain of pain and there were no discolorations on his/her left thigh. The Report indicated that on 05/14/25 at approximately 8:00 A.M. while giving care to Resident #1 a CNA observed blisters on his/her left thigh and told the Nurse who was taking care of him/her. Review of Resident #1's Nurse Progress Note, dated 05/14/25, (written by the Unit Manager), indicated that at approximately 8:00 A.M. a CNA called this writer to Resident #1's room, where she observed three blisters on his/her thigh (left or right side not indicated). The Note indicated that while speaking to staff, they stated a CNA told them yesterday (05/13/25) that Resident #1 spilled coffee on him/herself. The Note further indicated that first aid was performed, the Nurse Practitioner (NP) was notified, and a new order was placed for Bactroban (topical antibiotic) ointment.During an interview on 08/05/25 at 1:10 P.M., (which included review of her written statement) CNA #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 05/13/25 and was assigned to provide care to Resident #1. CNA #1 said she has worked at the Facility for more than a year and said Resident #1 is on her assignment the days she works. CNA #1 said residents' care Kardex's are in Point Click Care (PCC, electronic medical record (EMR) system) under Point of Care (POC) and said she knew how to look at a resident's care Kardex.CNA #1 said Resident #1 was blind and required set-up with continual supervision for meals. CNA #1 said when she provided care for Resident #1 she would set-up Resident #1's meal tray, then leave to continue passing meal trays to other residents and then go back to Resident #1's room. CNA #1 said she could not remember if she gave Resident #1 his/her breakfast meal tray on 05/13/25, but said she might have. CNA #1 said she heard someone yell Ow, from Resident #1's room, ran to his/her room, saw Resident #1's coffee mug on the floor and that there was coffee on his/her upper pants area that was dripping onto the floor. CNA #1 said she asked Resident #1 what happened and he/she told her that his/her hand was shaking, and the cup slipped out of his/her hand. CNA #1 said Resident #1's meal tray was still in his/her room, and he/she was by him/herself that morning (05/13/25), with his/her meal tray.CNA #1 said she brought Resident #1 into the bathroom to wash and dress him/her and when she removed his/her pants she saw a dime size red spot on his/her left thigh. CNA #1 said that Resident #1 said, my legs feel very, very hot. CNA #1 said she put Resident #1 back into bed, then informed a nurse (thinks it was Nurse #2) that he/she had spilled hot coffee on him/herself and had a small red area on his/her left thigh.During interviews throughout the day of the survey, on 08/05/25 with CNA #2, CNA #4, and CNA #5, who all worked on Resident #1's unit, said that Resident #1 ate his/her breakfast meal in his/her room and required continual supervision with eating. CNA #2, CNA #4, and CNA #5 said that they knew where and how to look at a resident's care Kardex on the computer.During an interview on 08/12/25 at 12:16 P.M., the Former Director of Nursing (DON) said on 05/14/25 the Unit Manager informed her that Resident #1 had spilled hot coffee on his/her leg (could not recall which leg) and that he/she had sustained a burn. The Former DON said she started her investigation which determined that Resident #1 was a set-up with continual supervision for meals and he/she was left unsupervised, as well as unassisted with his/her breakfast meal on 05/13/25. The Former DON said that staff did not follow Resident #1's plan of care.During an interview on 08/05/25 at 4:25 P.M., the Director of Nursing (DON) said it is her expectation that if a resident requires continual supervision with meals that staff must stay with the resident for the entire time during their meal. The DON said all CNA's are trained on how to document care provided in the POC EMR system and how to access residents' care Kardex's, that it is part of their orientation after hire.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required continual supervision (staff member to stay with resident during entire task) during meals, the Facility failed to ensure that he/she was provided with the necessary level of staff supervision during meals in an effort to prevent an incident resulting in an injury. On 05/13/25, Resident #1 was served his/her breakfast tray, left unsupervised in his/her room with his/her meal, spilled a hot beverage on his/her upper legs, and sustained second-degree burns (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the front side of his/her left thigh and required daily treatment to the areas for around four weeks.Findings Include: Review of the Facility's Policy tilted, Activities of Daily Living (ADLs), Supporting, dated as revised 11/2024 indicated the following:-residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living.-appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with: dining (meals and snacks). Resident #1 was admitted to the Facility in August 2019, diagnoses included Dementia, legal blindness, severe stage glaucoma right eye, muscle weakness, atrial fibrillation (irregular heartbeat) and hypertension. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, and required supervision with touching assistance with eating.Review of Resident #1's ADL Deficit Care Plan, renewed and reviewed with his/her May 2025 MDS, indicated that he/she required continual supervision with meals.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/20/25, indicated that on 05/13/25 a Certified Nurse Aide (CNA) observed Resident #1 had spilled coffee on him/herself, he/she was washed, assisted back to bed, did not complain of pain and there were no discolorations on his/her left thigh. The Report indicated that on 05/14/25 at approximately 8:00 A.M. while giving care to Resident #1 a CNA observed blisters on his/her left thigh and told the Nurse who was taking care of him/her. The Report further indicated that Resident #1's Primary Care Provider (PCP) was notified, treatment was ordered for mupirocin (Bactroban) 2% ointment (a topical antibiotic used to treat and/or prevent bacterial skin infections) to the area three times a day.Review of Resident #1's Nurse Progress Note, dated 05/14/25, (written by the Unit Manager), indicated that at approximately 8:00 A.M. a CNA called this writer to Resident #1's room, where she observed three blisters on his/her thigh (left or right side not indicated). The Note indicated that while speaking to staff, they stated a CNA told them yesterday (05/13/25) Resident #1 spilled coffee on him/herself. The Note further indicated that first aid was performed, the Nurse Practitioner (NP) was notified, and a new order was placed for Bactroban (topical antibiotic) ointment.Review of Resident #1's Weekly Skin Evaluation, dated 05/14/25, indicated that Resident #1 had three blisters on the front of his/her left thigh, measuring 7.0 centimeters (cm) by 3.0 cm, 4.0 cm by 2.5 cm and 1.5 cm by 2.5 cm.During an interview on 08/05/25 at 2:24 P.M., CNA #3 said she worked the 7:00 A.M. to 3:00 P.M. shift on 05/13/25 and said she did not give Resident #1 his/her breakfast tray that morning. CNA #3 said the CNA that is assigned to Resident #1 would give his/her breakfast tray to him/her after getting him/her out of bed into his/her wheelchair.During an interview on 08/05/25 at 1:10 P.M., (which included review of her written statement) CNA #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 05/13/25 and was assigned to provide care to Resident #1. CNA #1 said Resident #1 was blind and required set-up with continual supervision for meals. CNA #1 said she would set-up Resident #1's meal tray, then leave to continue passing meal trays to other residents then go back to Resident #1's room. CNA #1 said she could not remember if she gave Resident #1 his/her breakfast meal tray on 05/13/25, but said she might have. CNA #1 said she heard someone yell Ow, from Resident #1's room, ran to his/her room, saw Resident #1's coffee mug on the floor and that there was coffee on his/her upper pants area that was dripping onto the floor. CNA #1 said she asked Resident #1 what happened and he/she told her that his/her hand was shaking, and the cup slipped out of his/her hand. CNA #1 said Resident #1's meal tray was still in his/her room, and he/she was by him/herself that morning (05/13/25), with his/her meal.CNA #1 said she brought Resident #1 into the bathroom to wash and dress him/her and when she removed his/her pants she saw a dime size red spot on his/her left thigh. CNA #1 said that Resident #1 said, my legs feel very, very hot. CNA #1 said she put Resident #1 back into bed, then informed nursing (believed it was Nurse #2) that he/she had spilled hot coffee on him/herself and had a small red area on his/her left thigh.During an interview on 08/05/25 at 3:55 P.M., Nurse #2 said she worked from 7:00 A.M. to 11:00 P.M. on 05/13/25 and was assigned to Resident #1. Nurse #2 said she was not aware that Resident #1 had spilled hot coffee on him/herself that morning and said that the CNA (later identified as CNA #1) that was assigned to Resident #1 did not tell her about the incident.During an interview on 08/06/25 at 11:22 A.M., (which included review of her written statement) Nurse #3 said she worked from 7:00 A.M. to 11:00 P.M. on 05/13/25, on Resident #1's unit. Nurse #3 said she was passing medications in the opposite hallway when CNA #1 walked by her and said Resident #1 had spilled coffee on him/herself. Nurse #3 said she did not tell or ask Nurse #2 (Resident #1's primary nurse) or the Unit Manager if they knew about the incident, because she thought CNA #1 had told them.During an interview on 08/05/25 at 4:11 P.M., (which included review of her written statement) CNA #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on 05/13/25 and the 7:00 A.M. to 3:00 P.M. shift on 05/14/25 and was assigned to Resident #1 on both shifts. CNA #6 said on 05/14/25 she was providing morning care to Resident #1 and saw three blisters with redness on his/her left thigh and immediately informed the Unit Manager.During an interview on 08/05/25 at 3:06 P.M., the Unit Manager said on 05/14/25 CNA #6 called her to Resident #1's room to look at his/her left thigh. The Unit Manager said when she looked at Resident #1's left thigh she saw three blisters, said she cleansed them with normal saline, then notified the Nurse Practitioner (NP) and obtained an order for Bactroban (mupirocin) ointment. The Unit Manager said Nurse #3 told her that on 05/13/25 that CNA #1 had mentioned to her (Nurse #3) that Resident #1 had spilled hot coffee on him/herself. The Unit Manager said that on 05/13/25, she had not been informed that Resident #1 had spilled hot coffee on him/herself. The Unit Manager said she notified the Director of Nursing that Resident #1 had blisters on his/her left thigh, and that he/she had spilled hot coffee on him/herself the day before (05/13/25). During an interview on 08/06/25 at 12:48 P.M., the Nurse Practitioner (NP) said she could not recall the date she was notified that Resident #1 had spilled hot coffee, and that he/she was found with blisters. The NP said if a resident develops blisters after spilling a hot beverage on their self it is considered a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering).Review of Resident #1's Treatment Administration Records (TARs), dated May 2025 and June 2025, indicated that Bactroban (mupirocin) 2% ointment was applied to Resident #1's left thigh topically three times a day to promote healing from 05/15/2025 through 06/17/25 (for 34 days).During an interview on 08/12/25 at 12:16 P.M., the Former Director of Nursing (DON) said on 05/14/25 the Unit Manager informed her that Resident #1 had spilled hot coffee on his/her leg (could not recall which leg) and that he/she had sustained a burn. The Former DON said she started her investigation which determined that Resident #1 was a set-up with continual supervision for meals and he/she was left unsupervised and unassisted with his/her breakfast meal on 05/13/25. The Former DON said the CNA (later identified as CNA #1) who was assigned to Resident #1 had not informed the Nurse on duty (Resident #1's primary nurse) that he/she spilled hot coffee on his/her legs.During an interview on 08/05/25 at 4:25 P.M., the Director of Nursing (DON) said it is her expectation if a resident requires continual supervision with meals staff must stay with the resident for the entire time during their meal and that staff reports all incidents immediately to the nurse on duty or the Unit Manager.

Oct 2024 14 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on document review and interview, the facility failed to ensure one Resident (#279) was provided a summary of their baseline care plan meeting, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Care Plans-Baseline, dated November 2017, indicated but was not limited to the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; and c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary. Resident #279 was admitted to the facility in October 2024 and had diagnoses including atrial fibrillation, dementia, neuropathy (weakness, numbness, and pain from nerve damage), cerebrovascular accident (stroke), and coronary artery disease. Review of the Minimum Data Set (MDS) assessment, dated 10/17/24, indicated Resident #279 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. During an interview on 10/17/24 at 9:35 A.M., Resident #279 said he/she was new to the facility, about a week ago, but did not know what the plan of care was and did not receive a copy of anything. During an interview on 10/21/24 at 12:46 P.M., Resident #279 said he/she had still not received a copy of their baseline care plan since admission and only knew he/she was working with physical therapy. Review of the admission 72-Hour Meeting Form, dated 10/15/24, indicated but was not limited to the following: -Attendees: Resident, Rehab/Therapy, and Social Services -Objective: To identify the patient/health care proxy (HCP)/family expectations of the care provided during the stay. Care will be based upon the patient's nursing and therapy goals. -Process: After the patient is admitted : (1.) It is recommended that the IDT (interdisciplinary team) meets with the patient/HCP/family within 72 hours. (2.) The Post admission Conference Information obtained is used to determine the patient's goals for discharge. Further review of the form failed to indicate a copy of the baseline care plan was provided to the resident and/or resident representative. The section was not completed (box not checked). Review of the medical record failed to indicate documentation that a copy of the baseline care plan was provided to the resident and/or resident representative. During an interview on 10/22/24 at 1:14 P.M. with Unit Manager (UM) #1 and Social Worker (SW) #1, SW #1 said she had a meeting with the Resident but was not sure if she provided a copy of the baseline care plan to him/her. She said she doesn't usually check off the box on the form that indicates a copy was provided. SW #1 said she's only been at the facility for a very short time and is agency, so she wasn't sure who provides a copy of the baseline care plan to the residents. She said she just does the assessment form and does not write a separate note. UM #1 said a baseline care plan is completed within 48 hours of admission and a copy should be provided to the residents. SW #1 said there was no documentation to indicate the baseline care plan was provided. During an interview on 10/23/24 at 3:40 P.M., the Director of Nursing (DON) said the baseline care plan should be developed within 48 hours after admission and the resident or resident's representative should receive a copy of it.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure professional standards of practice were maintained during medication administration. Specifically, the facility failed to ensure three medications ordered by the physician were available and administered as ordered to one Resident (#66), out of a total of six residents observed during medication administration. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling 9324 titled Accepting, Transcribing, and Implementing Prescriber Orders, dated as last revised April 11, 2018, indicated but was not limited to the following: -It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication. -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Administering Medications, dated as last revised 2/2020, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber's orders. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #66 was admitted to the facility in October 2022 with diagnoses including wedge compression fracture and dementia. On 10/18/24 at 9:10 A.M., the surveyor observed Nurse #1 administer medications to Resident #66 which included but were not limited to the following: - High Potency Slow-Release Iron 45 milligrams (mg) of elemental iron equivalent to 142 mg of Ferrous Sulfate (one tab) - Fish Oil 1200 mg (one capsule) - Vitamin D3 25 micrograms (mcg) equivalent to 1000 international units (IU) (one tab) Review of the Physician's Orders for Resident #66 indicated but were not limited to the following: -Ferrous Sulfate tablet 325 mg give one tablet by mouth one time a day for supplementation (1/11/2023) -Fish Oil Oral Capsule 1000 mg give one capsule by mouth one time a day for supplement (1/13/2023) -Vitamin D3 125 mcg (5000 IU) give one tablet by mouth one time a day for supplement (5/29/24) During reconciliation of the medication administered and medications ordered it was determined that Nurse #1 failed to administer the correct medications as ordered by the provider. During an interview on 10/18/24 at 11:03 A.M., Nurse #1 said she administered the High Potency Slow-Release Iron 45 mg and the Fish Oil 1200 mg because that is all they have in the medication cart, so that is what he/she always gets. She said they are not the same as the orders, but it is all we have, so that is what was administered. Additionally, she said the Vitamin D3 order is for 125 mcg/5000 IU one tab and the highest dose available is 25 mcg/1000 IU, so that is what he/she always gets. She said there is not a 125 mcg/5000 IU tablet in the medication cart and the pharmacy doesn't send anything else so 25 mcg is what was administered not 125mcg as ordered. During an interview on 10/18/24 at 11:07 A.M., Unit Manager (UM) #1 said High Potency Slow-Release Iron 45mg is not the same as Ferrous Sulfate 325 mg, Fish Oil 1200 mg is not the same as Fish Oil 1000 mg, and Vitamin D3 25 mcg is not the same as Vitamin D3 125 mcg. He said all three medications administered were not what was ordered by the physician. He said the facility should have the correct doses or should order them if not in stock. Review of the medication storage room on 10/18/24 at 11:20 A.M. failed to indicate the correct medication was on hand. During an interview on 10/18/24 at 11:30 A.M., the Director of Nurses (DON) said those are all the wrong doses and medication errors. She said if the correct medication and/or dose is not available, then the nurse should notify the physician for a new order and/or request the correct medication/dose be obtained by the facility and not administer whatever is on hand. Refer to F759

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for the care of an indwelling suprapubic cystostomy catheter (surgical procedure that creates a connection between the bladder and the skin to drain urine) for one Resident (#24), out of a total sample of 18 residents. Specifically, the facility failed to ensure the Resident's urinary collection bag was kept below the level of the bladder and not in contact with the floor to help prevent catheter-related urinary tract infections and any related problems. Findings include: During an interview on 10/22/24 at 10:53 A.M., the Director of Nursing (DON) said the facility did not have a policy on Foley catheter care, only the insertion of. Review of Centers for Disease Control and Prevention (CDC) guidance titled Summary of Recommendations: Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 3/25/24, indicated but was not limited to the following: III. Proper Techniques for Urinary Catheter Maintenance: -Keep the collection bag below the level of the bladder at all times. -Do not rest the bag on the floor. Resident #24 was re-admitted to the facility in May 2024 and had diagnoses including neuromuscular dysfunction of the bladder, spastic hemiplegic cerebral palsy (type of cerebral palsy that causes a person to have involuntary muscle contractions and tightness on one side of their body), and infection and inflammatory reaction due to cystostomy catheter. Review of the Minimum Data Set (MDS) assessment, dated 7/19/24, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had an indwelling catheter. Review of current Physician's Orders indicated the following: -Ensure suprapubic catheter securement device is in place and catheter is secured on right leg every shift and prn (as needed), 6/25/24 -Suprapubic catheter 18 Fr (French), 10 cc (cubic centimeter) Foley catheter bag every shift, 1/16/24 Review of the Suprapubic Catheter care plan, initiated 3/25/22, indicated the following: -Keep drainage bag below level of bladder, 3/25/22 -Secure catheter, 3/25/22 During an observation with interview on 10/17/24 at 2:31 P.M., the surveyor observed Resident #24 sitting in a wheelchair in their room. A urinary catheter collection bag was observed hooked onto the waist band of the Resident's sweatpants draining yellow urine. The collection bag was not properly secured and was not hanging below the level of the Resident's bladder. Resident #24 said it was not supposed to be there, it was supposed to be below the seat of the wheelchair. Resident #24 said he/she had cerebral palsy, and a neurogenic bladder (bladder dysfunction caused by nervous system conditions) so he/she had a suprapubic catheter. During observations with an interview on 10/21/24 at 10:58 A.M. and 2:48 P.M., the surveyor observed Resident #24 sitting in a wheelchair in their room. A urinary catheter collection bag was observed hanging from a rod underneath the wheelchair draining yellow urine. The bag was in contact with the floor and had no barrier underneath potentially exposing it to environmental contaminants. Resident #24 said he/she had frequent urinary tract infections (UTIs) but denied any current symptoms or treatment. During an observation with interview on 10/21/24 at 3:40 P.M., the surveyor and Nurse #4 entered Resident #24's room and observed the Resident sitting in a wheelchair in their room. A urinary catheter collection bag was observed hanging from a rod underneath the wheelchair draining yellow urine. The bag was in contact with the floor and had no barrier underneath potentially exposing it to environmental contaminants. Nurse #4 said the Resident had a suprapubic catheter for urinary retention and the collection bag should not be in contact with the floor because where the drainage opening was, it could become contaminated and said the Resident could run over it with his/her wheelchair causing the bag to potentially rip. Nurse #4 said it should not have been hooked on his/her pants as it needed to be below the level of the bladder so urine could empty out of the bladder into it as efficiently as it should, or it could cause infection or bladder spasms which is one of the Resident's issues. During an interview on 10/22/24 at 1:43 P.M., Unit Manager (UM) #1 said the Resident had a neurogenic bladder and had a suprapubic catheter. He said the urinary collection bag should be positioned below the level of the bladder and should not have been resting on the floor or attached to the Resident's waist band. UM #1 said if the bag is above the bladder it puts the Resident at risk for UTIs and he/she is already at risk for UTIs. He said if it is on the floor, bacteria can get in or the Resident could run it over with his/her wheelchair and pull it out. During an interview on 10/23/24 at 3:18 P.M., the DON said the urinary collection bag should be below the level of the bladder and should not be in contact with the floor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to maintain the necessary respiratory care and services for one Resident (#57), out of a total sample of 18 residents. Specifically, the facility failed to maintain sanitary conditions of bilevel positive airway pressure (BiPAP - non-invasive breathing machine that helps people breathe when they're having trouble) mask and tubing and oxygen (O2) concentrator (medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) equipment to help decrease the risk of potential contamination and exposure of infection to the resident. Findings include: Review of the facility's policy titled CPAP/BiPAP S/T/Support, revised January 2018, indicated but was not limited to the following: -CPAP (continuous positive airway pressure) and BiPAP can be used in conjunction with ventilation to improve oxygenation. -BiPAP delivers separate pressure settings for expiration (EPAP) and inspiration (IPAP). -CPAP/BiPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. During an interview on 10/22/24 at 12:02 P.M., the Director of Nursing (DON) said there was no policy for the care and storage of respiratory equipment, but staff follow professional standards of practice. Review of the PerfectO2 Series Oxygen Concentrator User Manual, revised November 2009, indicated but was not limited to the following: Section 6 - Maintenance -Note: At a minimum, preventive maintenance MUST be performed according to maintenance record guidelines. Cleaning the Cabinet Filter: -There is one cabinet filter located on the back of the cabinet. -Remove the filter and clean at least once a week depending on environmental conditions. -Clean the cabinet with a mild household cleaner and non-abrasive cloth or sponge. Resident #57 was admitted to the facility in June 2024 and had diagnoses including chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure with hypercapnia (carbon dioxide retention), pulmonary hypertension, obstructive sleep apnea (OSA-sleep related breathing disorder), dependence on enabling machines and devices, dependence on supplemental Oxygen, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 8/29/24, indicated Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, received oxygen therapy, and used a non-invasive mechanical ventilator. Review of current Physician's Orders indicated the following: -Administer Oxygen at 3 Liters (L)/minute (LPM) continuous via nasal cannula, every shift monitor, 6/13/24 -BiPAP: 14 cm (centimeters) H20 (inhalation); 6 cm H2O (exhalation) every evening and night shift, 6/13/24 On 10/17/24 at 9:31 A.M., the surveyor observed a BiPAP device resting on top of Resident #57's side table. The mask and tubing were resting on top of the device and were not stored in a plastic bag when not in use potentially exposing them to environmental contaminants. During an observation with interview on 10/17/24 at 11:44 A.M., the surveyor observed Resident #57 in a wheelchair in their room with nasal cannula (NC -device that delivers extra Oxygen through a tube and into your nose) tubing inserted into the Resident's nostrils with the other end attached to an O2 concentrator which was delivering 3 L of Oxygen. The exterior of the concentrator, including the rear filter storage cabinet, was laden with dust and debris. The rear filter was laden with dark brown matter. A BiPAP device was observed resting on top of Resident #57's side table. The mask and tubing were resting on top of the device and were not stored in a plastic bag when not in use potentially exposing them to environmental contaminants. Resident #57 said he/she used the BiPAP machine every night for OSA and used Oxygen for a tentative diagnosis of COPD and occasional shortness of breath. The Resident said he/she used Oxygen continuously during the day and with the BiPAP machine at night. On 10/21/24 at 11:14 A.M., the surveyor observed Resident #57 in a wheelchair in their room with NC tubing inserted into the Resident's nostrils with the other end attached to an O2 concentrator which was delivering 3 L of Oxygen. The exterior of the concentrator including the rear filter storage cabinet was laden with dust and debris. The rear filter was laden with dark brown matter. A BiPAP device was observed resting on top of Resident #57's side table. The mask and tubing were resting on top of the device and were not stored in a plastic bag when not in use potentially exposing them to environmental contaminants. During an observation with interview on 10/21/24 at 3:56 P.M., the surveyor and Nurse #4 entered the Resident's room and observed Resident #57 in a wheelchair in their room with NC tubing inserted into the Resident's nostrils with the other end attached to an O2 concentrator which was delivering 3 L of Oxygen. The exterior of the concentrator including the rear filter storage cabinet was laden with dust and debris. The rear filter was laden with dark brown matter. A BiPAP device was observed resting on top of Resident #57's side table. The mask and tubing were resting on top of the device and were not stored in a plastic bag when not in use potentially exposing them to environmental contaminants. Nurse #4 said the Resident used BiPAP for OSA and said the mask/tubing should have been stored in a plastic bag when not in use. He said the O2 concentrator should be cleaned when dusty or dirty as needed. Nurse #4 said he saw some black/dark stains on the filter and said it's changed maybe every week but wasn't sure as he doesn't change them and wouldn't know how. During an interview on 10/21/24 at 4:09 P.M., the surveyor reviewed the medical record with Nurse #4 who said there was no order to clean the O2 concentrator, change the filter, or to store the respiratory equipment in a plastic bag when not in use. During an interview on 10/21/24 at 4:24 P.M., the surveyor reviewed the O2 concentrator with Unit Manager (UM) #1 who said it should have been wiped down and the filter cleaned weekly. He said the BiPAP equipment should have been stored in a plastic bag when not in use. During an interview on 10/23/24 at 3:55 P.M., the DON said the BiPAP equipment should be stored in a plastic bag when not in use and the O2 concentrator wiped down as needed. She said she wasn't sure how often the filter should be cleaned and wasn't sure of what the process was at the facility. The DON said there was no order for the filter to be changed but wasn't sure if there had to be as maintenance may do it. She said the expectation is that residents should have clean, safe, and operational respiratory equipment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure for one Resident (#65), out of five residents selected for unnecessary medication review, that their medication regimen was free from unnecessary psychotropic medications (drugs that affect the brain and nervous system including but not limited to antidepressants, antianxiety, antipsychotics, and sedatives). Specifically, the facility failed to ensure an as needed (PRN) psychotropic medication order for Ativan (anti-anxiety) was limited to 14 days unless the provider documented a rational to extend the PRN and the order was written for a specific longer duration. Findings include: Review of the facility's policy titled Psychotropic Medication, dated as last revised 7/2023, indicated but was not limited to the following: -Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition or diagnosis and that is documented in the clinical record. -The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rational for the order. The duration of the PRN order will be indicated in the order. -The Consultant Pharmacist reviews the appropriateness of the psychotropic medication order as part of each drug regimen review and monitors for appropriateness of psychotropic administration based on diagnosis, clinical indications, and prescribing guidelines. Review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, dated 8/2020, indicated but was not limited to the following: -Consultant Pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes providing oversight on regulatory compliance issues. -Reviewing the medication regimen of each resident at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standard, and documenting the review and findings. -The facility has a process to ensure that findings are acted upon. Resident #65 was admitted to the facility in March 2024 with diagnoses which included depression, dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 9/22/24, indicated he/she was taking anti-anxiety medication. Review of the medial record indicated he/she was taking Ativan (anti-anxiety medication). Review of the Consultant Pharmacy Recommendations, dated 4/26/24, indicated Resident #65 was taking Lorazepam (Ativan) 0.5 milligrams (mg) as needed four times a day. Additionally, the recommendation indicated The Centers for Medicare and Medicaid Services (CMS) recently updated guidelines to include the following limitations on this medication: PRN orders for psychotropic medications are limited to 14 days. If the prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, they must document their rationale in the resident's medical record and indicate the duration for the PRN order and give the order a specific stop date. PRN orders cannot be open-ended. The PRN medication must be reassessed at the end of that time frame for further need. Please review this PRN order and consider discontinuing if appropriate or document continued need for therapy and specify a stop date. Further review of the report indicated the physician reviewed the recommendation on 4/29/24 and indicated the following: marked other and wrote continue patient may be transitioned to comfort measures only (CMO) status will monitor. The recommendation was noted by nursing on 5/1/24. Review of the Physician's Orders for April and May 2024 indicated the following: -Ativan oral tablet 0.5 mg as needed for anxiety four times a day (Start Date: 4/16/24 Discontinue Date: 5/1/24) -Ativan oral tablet 0.5 mg as needed for anxiety four times a day, may have for extended time. (Start Date: 5/1/24) The order for PRN Ativan was rewritten on 5/1/24 and failed to indicate a stop date. Review of the Consultant Pharmacy Recommendations, dated 5/18/24, indicated Resident #65 was currently ordered Lorazepam (Ativan) 0.5 mg as needed four times a day, may have for an extended time. Additionally, the recommendation indicated order may continue for more than 14 days, however, you must specify reevaluation date (cannot be open ended) Please add a stop date. Further review of the report failed to indicate the physician had addressed the recommendation to add a stop date and the order remained in effect for greater than 14 days with no reevaluation/stop date. Review of the Medication Administration Record (MAR) for May and June 2024 indicated the following: -Resident #65 was administered Ativan 13 times. Further review indicated 11 of the 13 administrations were after the initial 14 days (between 5/15/24 and 5/31/24). -Resident #65 was administered Ativan three times between 6/1/24 and 6/5/24. The order was discontinued on 6/5/24 and scheduled twice daily. Review of physician's progress notes for May and June 2024 failed to indicate a rational and stop date for extending the PRN Ativan. Review of the nursing progress note, dated 6/5/24, indicated Hospice recommended to discontinue PRN Ativan and start Ativan scheduled due to increased agitation. Nurse Practitioner (NP) approved recommendation. New order to start Ativan 0.5 mg twice daily. During an interview on 10/23/24 at 9:57 A.M., Nurse #7 said she did not know the process for addressing the pharmacy recommendation but said they should be in the medical record. During an interview on 10/23/24 at 9:59 A.M., Unit Manager (UM) #2 said after the recommendation is addressed, the order is written, the form goes back to the Director of Nurses (DON) and should be scanned into the medical record. During an interview on 10/23/24 at 10:32 A.M., the DON said she located the April recommendation and reached out to the pharmacist for the May recommendation because she could not locate it. The blank May recommendation was provided to the surveyor by the DON on 10/23/24 at 2:31 P.M. During an interview at that time the DON said she did not know if the recommendation had been addressed as she was not employed at the facility at that time and could not locate a pharmacy book or anything that the previous DON may have used to keep track of the recommendations. During an interview on 10/23/24 at 2:51 P.M., UM #1 said all psychotropic PRN meds must be limited to 14 days. Additionally, she said if the physician wants to extend it longer, they can if they document the reason and for how long, but it still needs a stop date. During an interview on 10/23/24 at 3:28 P.M., the Staff Development Coordinator (SDC) said PRN psychotropics must be limited to 14 days unless the physician wants it longer, and if that is the case they would need to document why they want it longer and for how long. She said the orders must have a stop date. During an interview on 10/23/24 at 4:28 P.M., the DON said PRN psychotropics are limited it 14 days. She said if the physician wants it longer, they must follow the regulation and this order was active for more than 14 days and did not have a stop date.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure a resident with a wound received necessary treatment and services to promote healing for one Resident (#32), out of a total sample of 18 residents. Specifically, the facility failed to address the wound physician's recommendations and accurately implement care and treatment of a non-pressure wound to the Resident's right first toe. Findings include: Review of the facility's policy titled Prevention and Management of Pressure Ulcers/Injuries, dated as last revised 8/2024, indicated but was not limited to the following: -Ensure a resident receives care consistent with professional standards of practice to prevent pressure ulcers and/or residents with pressure ulcer receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcer from developing. The facility failed to provide a policy for general skin care and/or non-pressure injuries. The Director of Nurses (DON) said the policy provided was the only skin policy they had. Review of the Service Agreement between the facility and the Wound Care Provider, dated 12/19/23, indicated but was not limited to the following: The facility agrees to support delivery of wound care services and commits to: -Provide a dedicated nurse to round and communicate with the Provider. -Inform the primary care provider of recommendations within 24 hours. -Discuss recommendations/wound care plan with the provider on day of rounds. Resident #32 was admitted to the facility in December 2021 with diagnoses which included heart disease and diabetes mellitus with neuropathy (nerve damage). Review of the Minimum Data Set (MDS) assessment, dated 8/2/24, indicated he/she scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating he/she had moderate cognitive impairment, was dependent for dressing and bathing, required assistance for turning, was at risk for pressure ulcer development, and had a lesion on his/her foot requiring a dressing. Review of the medical record indicated Resident #32 was followed by the Wound Doctor. Review of the Wound Evaluation and Management Summary, dated 7/24/24, indicated but was not limited to the following: -Focused Exam (site #6) non-pressure wound of the right first toe. -Duration greater than 264 days. -Wound measured 1 x 0.9 x 0.3 centimeters (cm), had moderate serous exudate (drainage), and had 30% thick adherent black necrotic eschar (dead tissue) and 15% thick adherent devitalized necrotic tissue. -Treatment Plan: Calcium Alginate (absorbent wound dressing to help with debridement) and Santyl (debriding ointment) once daily and wrap in kerlix. Review of the Physician's Orders indicated the following: -Right great first toe-Normal Saline wash, pat dry, apply calcium alginate, and cover with gauze roll every day shift. (7/24/24) The treatment order failed to include the Santyl ointment as recommended by the wound doctor. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound doctor. Review of the Wound Evaluation and Management Summary, dated 7/31/24, indicated but was not limited to the following: -Focused Exam (site #6) non-pressure wound of the right first toe. -Treatment Plan: Honey hydrogel sheet with border apply three times per week, cover with gauze roll. Review of the Physician's Orders indicated the following: -Right great first toe-Normal Saline wash, pat dry, apply Medhoney hydrogel and cover with gauze roll every day shift. (7/31/24) The treatment order failed to include the dressing change frequency as recommended by the wound doctor. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound doctor. Review of the Wound Evaluation and Management Summary, dated 8/7/24, indicated but was not limited to the following: -Focused Exam (site #6) non-pressure wound of the right first toe. -Treatment Plan: Honey hydrogel sheet with border apply three times per week, cover with gauze roll. Review of the Physician's Orders indicated the following: -Right great first toe-Normal Saline wash, pat dry, apply Medhoney hydrogel and cover with gauze roll every day shift. (7/31/24) The treatment order failed to include the dressing change frequency as recommended by the wound doctor. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound doctor. Review of the Wound Evaluation and Management Summary, dated 9/11/24, indicated but was not limited to the following: -Focused Exam (site #6) non-pressure wound of the right first toe. -Treatment Plan: alginate calcium once daily and cover with gauze roll. Review of the Physician's Orders indicated the following: -Right great first toe-Normal Saline wash, pat dry, apply Santyl and cover with gauze roll every day shift. (8/21/24) The treatment order failed to be discontinued and a new treatment initiated as recommended by the wound doctor. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound doctor. Review of the Wound Evaluation and Management Summary, dated 9/17/24, indicated but was not limited to the following: -Focused Exam (site #6) non-pressure wound of the right first toe. -Treatment Plan: (area left blank) Review of the Physician's Orders indicated the following: -Right great first toe-Normal Saline wash, pat dry, apply Santyl and cover with gauze roll every day shift. (8/21/24 Discontinue Date: 9/17/24) The previous treatment order was discontinued, and a new treatment was not implemented. Review of the nursing and physician progress notes failed to indicate the facility had reached out to the Wound Doctor to clarify treatment recommendations. Additionally, the notes failed to indicate the physician wanted the treatment discontinued and no treatment implemented for the wound. Review of the Wound Evaluation and Management Summary, dated 9/24/24, indicated but was not limited to the following: -Focused Exam (site #6) non-pressure wound of the right first toe. -Treatment Plan: Apply betadine once daily -Wound progress: not at goal. Review of the Physician's Orders indicated the following: -Right great first toe-Apply betadine once daily for 30 days to the right first toe. (9/25/24) During an interview on 10/18/24 at 3:50 P.M., Nurse #13 said she was new and not sure who did wound rounds, but Resident #32's wound is almost resolved and only gets betadine applied to it. During an interview on 10/23/24 at 2:51 P.M., Unit Manager (UM) #2 said the Staff Development Coordinator (SDC) does wound rounds and writes the orders. She did not know why these orders did not match the recommendations or why on 9/17/24 one treatment was discontinued and nothing else ordered. During an interview on 10/23/24 at 3:28 P.M., the SDC said she does wound rounds and writes the orders. She said the old physician would always say okay, but sometimes the new physician wants to do his own thing. She said if the physician wants something different than the recommendation there should be a note stating that. Additionally, the SDC said she did not know why the orders did not match the recommendation of the wound doctor or why on 9/17/24 one treatment was discontinued and nothing else ordered. She said it was hard to follow with the lack of documentation and that is part of the reason she had to take over wound rounds in September. During an interview on 10/23/24 at 4:30 P.M., the Director of Nurses (DON) said the orders should match the wound physician recommendations and if the physician wanted to do something different then there should be a progress note indicating such.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record review, the facility failed to ensure one Resident (#42), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to accurately transcribe and implement orders for changes in treatments for the care of a stage four pressure ulcer injury (full thickness extending tissue loss that exposes bone, muscle, or tendon) to the left heel. Findings include: Review of the facility's policy titled Prevention and Management of Pressure Ulcers/Injuries, dated as last revised 8/2024, indicated but was not limited to the following: -Residents with pressure ulcer receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing -Conduct risk assessment upon admission, quarterly and with change in condition as warranted -Licensed nurse conducts a weekly skin evaluation -Develop the resident-centered care plan and interventions based on the risk factors identified, the condition of the skin, the resident's overall clinical condition Review of the wound clinic Services Agreement, dated March of 2015, indicated but was not limited to the following: Facility Responsibilities: -Provide a dedicated nurse to round and communicate with the Provider. -Inform the resident's primary care provider of Provider's recommendation within 24 hours. -Discuss recommendations/wound care plan with the Provider on the day of rounds. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling 9324 titled Accepting, Transcribing, and Implementing Prescriber Orders, dated as last revised April 11, 2018, indicated but was not limited to the following: -It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication. -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Resident #42 was admitted to the facility in April 2024 with diagnoses including Type II diabetes mellitus with diabetic neuropathy (symptoms of numbness, weakness, and decreased sensation usually starting in feet/hands). Review of the Minimum Data Set (MDS) assessment, dated 7/24/24, indicated Resident #42 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, Resident #42 had skin treatments and was dependent on staff for assistance with bed mobility. Review of Resident #42's comprehensive care plan indicated but was not limited to the following: -Resident has a left heel pressure wound -Utilize wound MD for assessment -Notify MD/NP and obtain treatment Review of the medical record indicated Resident #42 was followed by a Wound Care Physician at the facility. Review of the Wound Evaluation and Management Summary, dated 9/17/24, indicated but was not limited to the following: -Stage 4 Pressure Wound of the Left Heel measured 0.2 x 0.3 x not measurable centimeters (cm) depth was not measurable due to presence of thick adherent black necrotic (dead) tissue. -Recommendation: Hydrocolloid sheet (thin) (a self-adhesive dressing that consists of two layers and is used to treat wounds with low to moderate amounts of drainage) apply three times per week for 30 days. -Discontinue: Gauze Island with border and Alginate Calcium dressing Review of the September 2024 Physician's Orders/Treatment Administration Record (TAR) indicated an order was implemented on 9/18/24 as follows: Left heel: Normal Saline (NS) wash, pat dry, apply hydrocolloid sheet, cover with gauze island dressing every day shift. The order failed to discontinue the gauze island with border dressing and continued to be changed daily instead of three times a week per the wound physician's recommendation. Review of the skin/wound note, dated 9/17/24, indicated Resident #42 was seen by the Wound MD, and orders were updated to reflect changes. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound physician. Review of the Wound Evaluation and Management Summary, dated 9/24/24, indicated but was not limited to the following: -Stage 4 Pressure Wound of the Left Heel measured 0.3 x 0.5 x not measurable cm, depth was not measurable due to presence of thick adherent black necrotic tissue. -Recommendation: Hydrocolloid sheet (thin) apply three times per week for 23 days Review of the September 2024 Physician's Orders/TAR failed to indicate the order was obtained. The previous order for Hydrocolloid, cover with gauze island dressing change daily remained in effect. Review of the skin/wound note, dated 9/24/24, indicated Resident #42 was seen by Wound MD and orders were updated to reflect changes. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound physician. Review of the Wound Evaluation and Management Summary, dated 10/1/24, indicated but was not limited to the following: -Stage 4 Pressure Wound of the Left Heel measured 0.3 x 0.5 x not measurable cm, depth was not measurable due to presence of thick adherent black necrotic tissue. -Recommendation: Hydrocolloid sheet (thin) apply three times per week for 16 days Review of the October 2024 Physician's Orders/TAR indicated the order for left heel NS wash, pat dry, apply hydrocolloid sheet, cover with gauze island dressing every day shift was discontinued on 10/1/24. New order implemented on 10/1/24 for the following: Left heel, NS wash, pat dry, apply hydrocolloid sheet, cover with gauze island dressing, change every three days. The order failed to discontinue the gauze island with border dressing and continued to be changed every three days, instead of three times a week per the wound physician's recommendation. Review of the skin/wound note, dated 10/1/24, indicated Resident #42 was seen by Wound MD and orders were updated to reflect changes. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound physician. Review of the Wound Evaluation and Management Summary, dated 10/8/24, indicated but was not limited to the following: -Stage 4 Pressure Wound of the Left Heel measured 0.2 x 0.3 x 0.05 cm, with 100% granulation tissue. -Recommendation: Hydrocolloid sheet (thin) apply three times per week for 9 days Review of the October 2024 Physician's Orders/TAR failed to indicate the order was obtained. The previous order for Hydrocolloid, cover with gauze island dressing, change every three days remained in effect. Review of the skin/wound note, dated 10/8/24, indicated Resident #42 was seen by wound MD and orders were updated to reflect changes. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound physician. Review of the Wound Evaluation and Management Summary, dated 10/15/24, indicated but was not limited to the following: -Stage 4 Pressure Wound of the Left Heel measured 0.2 x 0.3 x not measurable cm, depth was not measurable due to presence of thick adherent black necrotic tissue. -Recommendation: Hydrocolloid sheet (thin) apply three times per week for 30 days Review of the October 2024 Physician's Orders/TAR failed to indicate the order was obtained. The previous order for Hydrocolloid, cover with gauze island dressing, change every three days remained in effect. Review of the skin/wound note, dated 10/15/24, indicated Resident #42 was seen by wound MD and no change in orders. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound physician. Further review of the October 2024 Physician's Orders/TAR indicated the treatment order had been discontinued on 10/21/24. New treatment order dated 10/21/24 for Resident #42's as follows: Left heel, NS wash, pat dry, apply hydrocolloid sheet, change every 3 days. During an interview on 10/17/24 at 2:43 P.M., Resident #42 said he/she developed the wound on his left heel at the facility. He/she said the wound doctor has been coming in to see him/her weekly. During an interview on 10/21/24 at 4:41 P.M., Unit Manager (UM) #1 said he completes rounds with the wound doctor and the wound nurse weekly. He said he removes the dressings, takes measurements of the wound, and replaces the dressings. UM#1 said the wound nurse receives the recommendations, notifies the physician, and updates the orders accordingly. During an interview on 10/22/24 at 10:26 A.M., the Wound Physician said he recommended the use of the hydrocolloid dressing to be applied three times a week. He said the dressing works best if it is not covered with another dressing. The Wound Physician said he is going to continue to recommend the hydrocolloid dressing for another week, and then re-assess the treatment recommendation at that time. During an interview on 10/22/24 at 1:47 P.M., the Wound Nurse said she rounds with the wound physician weekly. The wound doctor provides verbal recommendations and then sends them over to the facility electronically. She said she or Unit Manager #1 notifies the in-house provider of the recommendations. The Wound Nurse said she enters the orders into the chart and writes a skin/wound note. The Wound Nurse reviewed the recommendations from 9/17, 9/24, 10/1, 10/8, and 10/15 with the surveyor. She said she did notify the in-house physician of the recommendations, and she updated the treatment order. The Wound Nurse said the order in the chart does not match the wound physician's recommendations for those dates, because she entered the order incorrectly. During an interview on 10/22/24 at 2:12 P.M., UM #1 said he noticed yesterday that the order was incorrect, he notified the physician and changed the order to discontinue the gauze border dressing. UM #1 said he forgot to write a nursing note regarding updating the order, as he should have. The surveyor and UM #1 reviewed the order together, and UM #1 said the order is still incorrect, being completed every three days, instead of three times a week, per the wound physician's recommendation. During an interview on 10/22/24 at 2:18 P.M., the Director of Nursing (DON) said her expectations are for the wound physician's recommendations to be reviewed timely and transcribed correctly in the resident record. She said administering the wrong treatment is considered a medication error.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a person-centered plan of care accounting for the Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#24), with a history of trauma, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, revised October 2019, included but was not limited to the following: -Policy: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -Trauma informed care is culturally sensitive and person-centered. -Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. -Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. -Include trauma-informed care as part of the QAPI plan, so that needs, and problem areas are identified and addressed. Resident Care Strategies: -Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.) as able. Resident #24 was re-admitted to the facility in May 2024 and had diagnoses including spastic hemiplegic cerebral palsy (type of cerebral palsy that causes a person to have involuntary muscle contractions and tightness on one side of their body), anxiety disorder, bipolar disorder, and post-traumatic stress disorder (PTSD- occurs in some individuals who have encountered a shocking, scary, or dangerous situation). Review of the Minimum Data Set (MDS) assessment, dated 7/19/24, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had PTSD. Review of the Social Service admission Assessment & Notes, dated 11/3/23, indicated but was not limited to the following: Psychosocial Well-Being/Trauma Informed Care: -Psychiatric Diagnoses: PTSD, Bipolar, Anxiety Psychiatric/Psychological Services: -PRN (as needed) Trauma Informed Care: -Have you ever had an experience so upsetting that you think it changed you emotionally, spiritually, physically, or behaviorally? (symptoms of irritability, disturbed sleep, flashbacks, racing thoughts, memory difficulties, feeling emotionally numb, etc.) - yes -Do you think any of these problems bother you now? - yes -Would you be interested in discussing these problems? - yes -Resident feels uncomfortable around men and would not want a male therapist. -Trauma Informed Care Plan generated Review of the Trauma Informed care plan, initiated 11/8/23, indicated the following: -Resident has PTSD related to history of witnessing violence and being sexually and physically abused Goal: -Resident will have diminished risk for re-traumatization of past trauma through next review. Interventions: -Determine best coping strategies that has worked in the past to help the resident cope with traumatic event, 11/8/23 -Encourage resident to use a calm quiet area to foster positive self-reflection, 11/8/23 -Observe resident's sleep pattern and provide non-pharmacological interventions such as warm tea, soft music, or warm milk to aid with sleep, 11/8/23 -Refer the resident to psychiatric services for added psycho-social support, 11/8/23 Further review of the care plan indicated it was a template generated from the 11/3/23 Social Services evaluation. The care plan failed to include interventions that were person-centered to include the Resident's preferences and coping strategies to eliminate or mitigate triggers that may cause re-traumatization. Review of Resident #24's Certified Nursing Assistant (CNA) [NAME] (gives a brief overview of each resident to include activities, safety, eating/nutrition, resident care, bathing, behavior/mood, monitoring, and transferring) did not indicate Resident #24 had a history of trauma or identify any identified triggers or coping strategies. During an interview on 10/21/24 at 11:03 A.M., Resident #24 said he/she had PTSD and was seeing a female psychologist every week and that it could not be a male. Resident #24 said his/her triggers for PTSD included certain noises and smells that freak him/her out, babies crying, things like that. The Resident said when the ambulance door alarm goes off in the facility it's also a trigger. Resident #24 said no one at the facility asked him/her what his/her triggers were and would keep it to him/herself unless someone asks. The Resident said facility staff have not incorporated any of it in his/her plan of care that he/she knows of, and pain sets it off too, about what he did to us and did not feel his/her pain was being managed. During an interview on 10/21/24 at 3:46 P.M., Nurse #4 said he was assigned to the Resident and the Resident had no history like PTSD or bipolar disorder and was not sure if the Resident was being seen by psych services, but the Unit Manager (UM) might know. Nurse #4 said there weren't any triggers he was aware of that would upset the Resident other than pain. During an interview on 10/21/24 at 4:16 P.M., the surveyor reviewed the medical record with Nurse #4 who said Resident #24 had a history of PTSD and bipolar disorder but there was nowhere in the record where it identified any PTSD triggers. He said if there were, it would be carried over to the Medication Administration Record (MAR) where staff could monitor for specific PTSD related behaviors but there wasn't. Nurse #4 said there was no order to monitor PTSD related behaviors. During an interview on 10/22/24 at 12:00 P.M., CNA #5 said she was familiar with the Resident, but he/she had not any previous trauma that she knew of. During an interview on 10/22/24 at 12:08 P.M., CNA #6 said she was aware the Resident had a history of trauma but didn't know all the details or what triggers may re-traumatize the Resident. During an interview on 10/22/24 at 12:15 P.M., Nurse #2 said he was assigned to the Resident that day and was not aware of any history of trauma. Nurse #2 said the aides would know more as they spend more time with the Resident. During an interview with Social Worker (SW) #1 and UM #1 on 10/22/24 at 1:21 P.M., SW #1 said she started in August and is agency but said the Resident had a history of trauma, she thought sexual and physical abuse. UM #1 said the Resident doesn't like a male psychiatrist but other than that was not sure of any other triggers. SW #1 and UM #1 said they weren't aware of any other triggers, and none were documented on the care plan including the need for a female psychiatrist. SW #1 said the care plan was not person-centered to meet the Resident's trauma informed care needs and the goal was to try and prevent or mitigate triggers which could cause re-traumatization but didn't know what they were. SW #1 and UM #1 said there was a care planned intervention to determine what the Resident's coping strategies were, but they were not listed, and they didn't know what they were. SW #1 said she could read the psych notes to find out. UM #1 said they should have been listed on the care plan and said there was nothing in the record to monitor for PTSD symptoms but wasn't sure if they do that. During an interview on 10/23/24 at 9:34 A.M., Resident #24 said sometimes he/she gets flashbacks at night of him and calls out to staff but they don't respond sometimes. The Resident said he/she doesn't mind having a male nurse but there has to be a female present when providing wound care or personal hygiene though said there are a few male nurses that he/she feels comfortable with. The Resident said it's happened when it's just been a male nurse or aide and had to ask for a female to be present. Resident #24 said certain sounds also trigger his/her PTSD such as the ambulance door alarm because the sound of the alarm brings back memories for him/her. He/she said staff usually turn it off but there are times when it goes off for about half an hour which sets me off and wished staff were more diligent with this. The Resident said no one has asked him/her about his triggers until SW #1 did yesterday, after surveyor intervention. The Resident said he/she feels safe at the facility but doesn't feel staff are doing what they should to help him/her with his/her PTSD. Review of a Behavioral Health note, dated 9/18/24, indicated the Resident was having increased nightmares, two that were recurrent and brutal, based on incidents from the past that they wake him/her up at night and is disoriented, unable to turn a light on or take a drink of water or to do anything to orient him/herself. During an interview on 10/23/24 at 9:47 A.M., CNA #7 said he was assigned to the Resident this day and said the Resident had no history of trauma that he knew of and was getting ready to provide personal care to the Resident and that he would clean the front, then ask for assistance to clean the back. Resident #24 told the surveyor he was comfortable with CNA #7 providing personal care without a female present. During an observation with interview on 10/23/24 at 11:27 A.M., Resident #24 said he/she doesn't like to initiate conversation about his/her PTSD and hasn't said anything to anyone but would be okay talking about it if asked as he/she would like staff to know what triggers him/her, but no one has asked until yesterday. The Resident said he/she was comfortable speaking with the surveyor and SW #1 to help him/her and said the goal would be for staff to know what his/her triggers are so they can help prevent re-traumatization. Resident #24 said coping strategies included listening to music, writing, reading, painting, and 54321 (grounding exercise designed to manage acute stress and reduce anxiety). During an interview on 10/23/24 at 11:38 A.M., Nurse #5 said she was assigned to the Resident this day and knew the Resident had a history of trauma but didn't know the details. She said there were no triggers she was aware of. The surveyor and Nurse #5 reviewed the Resident's medical record. Nurse #5 said the Resident had a history of PTSD, anxiety, and bipolar disorder. She said she just started in August and did not know what the Resident's coping strategies were but knew he/she saw a counselor. During an interview on 10/23/24 at 3:20 P.M., the Director of Nursing (DON) said she would need to refer to the policy but said patients with PTSD would have a social services evaluation for trauma and a trauma informed care plan developed that should be person-centered and discussed at quarterly care plan meetings. She said the patient would also be referred to psych for ongoing support. The DON said the trauma informed care plan should include areas of the cause of the PTSD, the history of the resident, PTSD triggers and interventions specific to the resident. She said if a resident refuses services or does not wish to discuss their past trauma then that should be care planned as well as the resident has the right to decline services. The DON said she depends on the social services department to find out what the triggers are and individualize the care plan. She said she had only been at the facility since 10/3/24 and was not aware of any of this but said staff should have been aware of the Resident's history of trauma and potential triggers. She said the goal is for residents to be healthy physically, emotionally, and feel secure and to prevent or mitigate re-traumatization. She said staff should also have been aware of what the Resident's coping strategies were.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to maintain a medication error rate of less than 5%. Specifically, one of two nurses made three errors during the medication pass out of a total of 26 opportunities, resulting in a medication error rate of 11.54%. Findings include: Review of the facility's policy titled Administering Medications, dated as last revised 2/2020, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber's orders. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #66 was admitted to the facility in October 2022 with diagnoses including wedge compression fracture and dementia. On 10/18/24 at 9:10 A.M., the surveyor observed Nurse #1 administer medications to Resident #66 which included but were not limited to the following: - High Potency Slow-Release Iron 45 milligrams (mg) of elemental iron equivalent to 142 mg of Ferrous Sulfate (one tab) - Fish Oil 1200 mg (one capsule) - Vitamin D3 25 micrograms (mcg) equivalent to 1000 international units (IU) (one tab) Review of the Physician's Orders for Resident #66 indicated but were not limited to the following: -Ferrous Sulfate tablet 325 mg give one tablet by mouth one time a day for supplementation (1/11/2023) -Fish Oil Oral Capsule 1000 mg give one capsule by mouth one time a day for supplement (1/13/2023) -Vitamin D3 12 5mcg (5000 IU) give one tablet by mouth one time a day for supplement (5/29/24) During reconciliation of the medication administered and medications ordered it was determined that Nurse #1 failed to administer the correct medications as ordered by the provider. During an interview on 10/18/24 at 11:03 A.M., Nurse #1 said she administered the High Potency Slow-Release Iron 45 mg and the Fish Oil 1200 mg because that is all they have in the medication cart, so that is what he/she always gets. She said they are not the same as the orders, but it is all we have, so that is what was administered. Additionally, she said the Vitamin D3 order is for 125 mcg/5000 IU one tab and the highest dose available in the medication cart is 25 mcg/1000 IU, so that is what he/she always gets. She said there is not a 125 mcg/5000 IU tablet in the medication cart and the pharmacy doesn't send anything else, so 25 mcg is what was administered not 125 mcg as ordered. During an interview on 10/18/24 at 11:07 A.M., Unit Manager (UM) #1 said High Potency Slow-Release Iron 45 mg is not the same as Ferrous Sulfate 325mg, Fish Oil 1200 mg is not the same as Fish Oil 1000 mg, and Vitamin D3 25 mcg is not the same as Vitamin D3 125mcg. He said all three medications administered were not what was ordered by the physician. During an interview on 10/18/24 at 11:30 A.M., the Director of Nurses (DON) said those are all the wrong doses and are medication errors. She said if the correct medication and/or dose is not available the nurse should not administer whatever is on hand.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Properly label and date food products stored in the walk-in refrigerator in the main kitchen and discard prepared food when past their use by date; 2. Ensure staff did not store personal food items in one of two resident nourishment kitchen refrigerators/freezers reviewed; and 3. Ensure staff performed proper hand hygiene when serving afternoon snacks to residents on the 2nd Floor Unit, blue hallway, and ensure the snack cart did not enter resident rooms. Findings include: Review of a facility document titled Label and Dating for Leftovers and Food Being Prepped for Later Use, undated, indicated but was not limited to the following: -Sandwich spreads must be marked with a 3-day discard. -Trays of drinks and plated desserts must be labeled with the date and meal they are for. -Meat pulled from the freezer must be dated with a date it was pulled and the date/meal that it's for. -Product that is prepared is good for 3 days and must be discarded on day 3. -Refer to the Food Storage Reference Guide for additional information regarding discard dates. Review of the facility's policy titled Food and Supply Storage, revised June 2018, indicated but was not limited to the following: Labeling and rotating food supply: -Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. -Store food removed from its original package in containers or food-grade storage bags intended for food that is durable, leak-proof, and able to be sealed or covered. -Discard food that exceeds their use-by date or expiration date, is damaged, is spoiled, has the time and temperature danger zone requirements, or incorrectly stored such that it is unsafe, or its safety is uncertain. 1. On 10/17/24 at 8:11 A.M., the surveyor reviewed the main kitchen walk-in refrigerator and observed the following inside: -One 16.0 ounce (oz.) Polar Spring water bottle, approximately ¼ full, not labeled -One 20 oz. blue Gatorade bottle, approximately ¾ full, not labeled -One tray consisting of six plates of white cakelike desserts with brown drizzle and two bowls of a light brown textured item with whipped cream, not covered, not labeled with the food item, not dated when prepared or use by date -One tray of 13 covered glass bowls with unknown food substance, six bowls of diced fruit, uncovered, four bowls of pureed fruit, uncovered, tray not labeled with item description, date prepared, or use by date -Three isolated plastic cups with lids, one white liquid, one yellow liquid, one semi-opaque liquid, not labeled with item description, date prepared, or use by date -One loaf of pound cake stored in plastic wrapper, not labeled with item description, date illegible, no use by date -One square metal tin of salami wrapped in plastic wrap, labeled with preparation date of 10/3, use by date 10/10, not discarded by use by date -One large metal rectangular tin with individual large plastic bags of chicken breasts, one plastic bag ripped open, bag not sealed, contents inside potentially exposed to environmental contaminants -One tray of 24 plastic cups with lids, 23 semi-opaque liquids, one white liquid, not labeled with item descriptions, the preparation date, or use by date -One package of Swiss cheese slices, package opened, wrapped in saran wrap, not labeled with item description, date when opened, or use by date -Two turkey and cheese sandwiches on white bread, wrapped in saran wrap, preparation date 10/13, use by date 10/16, not discarded by use by date -One push rolling cart with one large rectangular metal tin on top with chopped broccoli inside, wrapped in saran wrap, not labeled with preparation date, or use by date -One square plastic container full of jelly, preparation date 10/10, use by date 10/14, not discarded by use by date -One square plastic container 1/4 full of applesauce, preparation date 10/10, use by date 10/14, not discarded by use by date -One large plastic container of ham slices, preparation date 10/12, use by date 10/15, not discarded by use by date -One small plastic container of potato salad, preparation date 10/11, use by date 10/14, not discarded by use by date On 10/17/24 at 8:49 A.M., the surveyor reviewed the findings with the Certified Dietary Manager (CDM) who said the water and Gatorade bottles were for general resident use, were not labeled, but should have been. She said the trays of prepared foods and liquids including the isolated plastic cups should have been covered and labeled but weren't. She said the pound cake should have been labeled with the use by date but wasn't and was only good for one month, so she disposed of it. The CDM said the salami was no longer good and the chicken breast bag was not closed properly and was potentially exposed to the environment. She said it should have been sealed properly and would need to dispose of it. The CDM said the cheese package was not labeled properly once opened and the sandwiches were no longer good and disposed of them. She said the broccoli should have been labeled with the date when prepared and the use by date but wasn't, and the jelly, applesauce, and ham slices were no longer good and should have been disposed of. During an interview on 10/17/24 at 8:56 A.M., the CDM said food items when prepped are only good for three days and the cooks or dietary aides, whoever preps, are responsible for labeling the item with the item description, the date when opened/prepped, and labeled three days out as the use by date. She said the food is no longer good after that time. 2. On 10/22/24 at 6:33 A.M., the surveyor reviewed the 2nd Floor Unit nourishment kitchen and observed a plastic bag in the freezer with two large frozen items stored inside, contents unknown, wrapped in saran wrap, labeled with a first name only, no item description labeled, resident's full name and room number, preparation date, or use by date. During an interview on 10/2224 at 6:38 A.M., Nurse #3 said she had no idea what was in the plastic bag or who it belonged to. She said there were no residents on that unit with that first name. During an interview on 10/22/24 at 3:09 P.M., the CDM was made aware of the food items stored in the freezer and said it was a staff member's food. She said staff should not be storing personal food in the resident's refrigerators or freezers. 3. Review of the facility policy titled Resident Meal Service and Dining, dated June 2018, indicated but was not limited to the following: -Appropriate hand hygiene is completed before distributing meals, after collecting soil dishware, and as needed during the mail service. Review of the facility's policy titled Hand Washing/Hand Hygiene, dated July 2024, indicated but was not limited to the following: -The facility considers hand hygiene the primary means to prevent the spread of infections. -All staff shall follow the hand washing hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. -Hand hygiene products and supplies (Sinks, soap, towels, alcohol-based hand rub etc.) shall be readily accessible and convenient for staff used to encourage compliance with hand hygiene policies. -Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap and water for the following situations: -Before and after eating or handling food -Before and after assisting a resident with meals On 10/17/24 at 2:19 P.M., the surveyor observed two Certified Nursing Assistants (CNAs) serving afternoon snacks on the second floor, blue hallway and made the following observations: -CNA #3 brought the snack cart into resident room [ROOM NUMBER] and assisted the resident in the A bed with choosing a snack. The resident picked a snack off the tray, handling multiple snacks before making his/her final selection. CNA #3 left the room without performing hand hygiene. -CNA #3 and CNA #4 then brought the snack cart into resident room [ROOM NUMBER] and offered snacks to both residents. CNA #3 or #4 did not perform hand hygiene. -CNA #3 brought the snack cart into resident room [ROOM NUMBER] and assisted the resident in the A bed (door) by uncovering the residents' hands form underneath the blanket. CNA #3 assisted the resident with choosing a snack and opened the snack for the resident. CNA #3 did not perform hand hygiene. -CNA #4 entered resident room [ROOM NUMBER] after CNA #3 served the resident in #203 A bed, and asked CNA #3 for a glass of juice. CNA #3 while still in room [ROOM NUMBER], handled the cups, poured a glass of juice, and handed it to CNA #4 who was leaving the room to serve to another resident not in room [ROOM NUMBER]. CNA #3 and CNA #4 did not perform hand hygiene. During an interview on 10/17/24 at 2:25 P.M., CNA #3 said she brings the whole cart of food into each resident's room to choose a snack because they change their minds. CNA #3 said she should be sanitizing her hands between each resident. CNA #4 agreed and said they should be sanitizing their hands and probably have a bottle of hand sanitizer on the cart. During an interview on 10/18/24 at 12:15 P.M., the Director of Nurses (DON) said the CNAs should not be bringing the whole cart of snacks into the resident rooms, it is an infection control issue. She said they should be performing hand sanitization in between each resident served.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, document review, and interviews, the facility failed to maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections, within the facility using their predetermined infection definition criteria. Findings include: Review of the facility's policy titled Surveillance for Infections, dated as revised July 2024, indicated but was not limited to the following: - The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections to guide appropriate interventions and prevent future infections. - Criteria for infections are based on current standard definitions of infections. - In addition to collecting data on incidents of infections the surveillance system is designated to capture certain epidemiologically important data that may influence how overall surveillance data is interpreted, for example: surveillance data gathered for residents with a recent hospital stay. During an interview on 10/22/24 at 12:54 P.M., the Infection Preventionist (IP) said the facility uses the laboratory supplied surveillance sheet to document the surveillance of illnesses in the facility, and McGeer Criteria to identify and define whether an illness is an infection by the criteria protocol. Review of the McGeer Criteria for Infection, in use by the facility, indicated but was not limited to the following: Syndrome: Cellulitis (bacterial skin infection), soft tissue, or wound infection Must fulfill at least one criteria. 1. Pus at wound, skin, or soft tissue site 2. At least four of the following new or increasing sign or symptom: -Heat (warmth) at affected site, redness (erythema) at affected site, swelling at affected site, tenderness, or pain at affected site, serous (clear fluid) drainage at the affected site 3. At least one of the following: -Fever, leukocytosis (elevated white blood cell count), acute change in mental status, acute functional decline Syndrome: Urinary tract infection (UTI) without indwelling catheter Must fulfill both one and two criteria. 1. At least one of the following sign or symptoms: -Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate -Fever or leukocytosis (a high level of white blood cells), and one or more of the following: -Acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency, or frequency. -If no fever or leukocytosis, then two or more of the following: -Suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency, and frequency. 2. At least one of the following microbiologic criteria - greater than or equal to 100,000 count of no more than two species of organisms in a voided urine sample, OR - greater than or equal to 50,000 count of any organism(s) in a specimen collected by an in-and-out catheterization Review of the laboratory surveillance sheet key in use by the facility: -Categories: Skin, Mucosal, Soft Tissue = S; Urinary tract = UTI; Urinary tract Catheter = UTC; Other = O -Count: Yes = Y; No = N Review of the facility provided surveillance listings indicated the following: July 2024: -14 out of 14 residents met McGeer Criteria for infection and 14 out of 14 residents were started on antibiotics. -Resident #12 Category: UTI; date of onset: 7/7/24; symptoms: Hx; results: Positive; count: Yes The surveillance listing for Resident #53 failed to indicate all criteria was met for this illness to be counted as an infection, and did not include any symptoms, making the surveillance sheet incomplete. August 2024 -11 out of 17 residents met McGeer criteria for infection and 17 out of 17 residents were started on antibiotics. September 2024 -11 out of 13 residents met McGeer criteria for infection and 13 out of 13 residents were started on antibiotics. -Resident #53 category: O; date of onset: 9/25/24; symptoms: redness, swelling; results: MD DX; count: Yes The surveillance listing for Resident #53 failed to indicate that all criteria was met for this illness to be counted as an infection, and never defined the other category, making the surveillance sheet inaccurate, incomplete, and undefined. Review of the McGeer criteria documents completed by the facility for Residents #12 and #53 indicated criteria was not met for an actual infection and the count of the infection inaccurate on the surveillance listing in accordance with the facility's use of McGeer criteria. During an interview on 10/22/24 at 1:18 P.M., the IP said she does not track any residents who have symptoms of an illness that do not require the use of an antibiotic. She said she would only track a gastrointestinal or COVID outbreak if warranted. The IP said she reviews the 24-hour nursing report and progress notes to see if any new antibiotics have been started and will track antibiotic use on the line listings. She said she is new to this position and was not educated on tracking and trending illnesses. The IP said for Residents #12 and #53, the McGeer criteria was filled out inaccurately and it should not have counted as an infection. She said she does not complete all the McGeer criteria documents. She said the nurse taking the order for the antibiotics completes the McGeer criteria in the chart. The IP said the symptoms did not meet the criteria to count the infection, although she did, and the surveillance was inaccurate. During an interview on 10/22/24 at 2:18 P.M., the Director of Nursing (DON) said her expectation is for the IP to track all illnesses to identify any trends in the facility. She said improvements are needed to ensure McGeer criteria is completed accurately, so they will have an accurate reflection of all infections within the facility.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program, last revised 1/24, indicated but was not limited to the following: -The antibiotic stewardship program establishes antibiotic treatment recommendations to optimize antibiotic prescribing, monitoring, and communication of resident changes in condition(s) to improve resident outcomes related to antibiotic use. -Appropriate indications for use of antibiotics include Criteria met for clinical definition of active infection: McGeer Criteria (a set of guidelines used to help identify infections in long-term care facilities). -As part of the facility antibiotic stewardship program, clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. -The infection preventionist, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. -At the conclusion of the review, the provider will be notified of the review findings. Review of the facility's policy titled Antibiotic Stewardship Review and surveillance of Antibiotic use and Outcomes, last revised 10/22, indicated but was not limited to the following: -Antibiotic usage and outcome data will be collected and documented -The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. -All clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee -The provider will be notified of the review findings. -All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form During an interview on 10/22/24 at 12:54 P.M., the Infection Preventionist (IP) said the facility uses the laboratory supplied surveillance sheet to document the surveillance of illnesses in the facility, and McGeer Criteria to identify and define whether an illness is an infection by the criteria protocol. Review of the facility surveillance sheets for July, August and September 2024 indicated but was not limited to the following: July: Resident #12 had a urinary issue with an onset date of 7/7/24, the surveillance indicated the issue did rise to the level of an infection, and Resident #12 was treated with an antibiotic for seven administrations. Review of the McGeer Criteria dated 7/9/24 for Resident #12 indicated the illness did not rise to the level of an infection, per the facility identified criteria, and the surveillance listing was inaccurate. Review of the progress notes, including physician and nurse practitioner notes for Resident #12 from 7/7/24 through 7/30/24, failed to indicate the provider was made aware of Resident #12's continued antibiotic use when the symptoms did not meet infection criteria. August: Resident #58 had a urinary issue with an onset date of 8/23/24 and had a catheter in place. The surveillance indicated the issue did not rise to the level of an infection as determined by the facility criteria, however an antibiotic was prescribed for seven days. Review of the progress notes, including physician and nurse practitioner notes for Resident #58 from 8/23/24 through 9/5/24 failed to indicate the provider was made aware of Resident #58's continued antibiotic use when the symptoms did not meet infection criteria. September: Resident #51 had a lower respiratory issue with an onset date of 9/17/24, the surveillance indicated the issue did not rise to the level of an infection as determined by the facility criteria, however an antibiotic was prescribed for five days. Review of the progress notes, including physician and nurse practitioner notes for Resident #51 from 9/17/24 through 10/22/24 failed to indicate the provider was made aware of Resident #51's continued antibiotic use when the symptoms did not meet infection criteria. During an interview on 10/22/24 at 1:18 P.M., the IP said, for Resident #12, she documented incorrectly on the surveillance listing, and she should have documented it did not count. She said when a resident is utilizing an antibiotic that does not meet criteria, she notifies the physician or nurse practitioner, and documents in a nursing note. The IP reviewed the nursing progress notes for Residents #12, #58 and #51 and could not locate any evidence the physician or NP were notified of the continued antibiotic usage. During an interview on 10/22/24 at 2:18 P.M., the Director of Nursing (DON) said her expectation is for the IP to notify the physician when an antibiotic is ordered that does not meet McGeer criteria, and document the notification and physician response in a nursing progress note.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and test tray results, the facility failed to serve food that was palatable and at appetizing temperatures for two out of two test trays conducted on two of two units. Findings include: Review of the facility's policy titled Trayline and Meal Delivery, revised June 2018, indicated but was not limited to the following: -Meals are assembled attractively based on the planned menu and resident diet orders, food allergens, and preferences; and delivered within established mealtimes in a manner to maintain palatability and food safety. On 10/18/24 at 1:30 P.M., the surveyor held a Resident Group meeting with 19 residents in attendance, five of which had the following food complaints: -food distribution is slow, the foods sits around in the cart and that is probably when it's not as hot -food sits on the unit -the food is not hot enough -the food is salty -the food is ice cold all the time. On 10/21/24 at 12:02 P.M., the surveyor requested a lunch test tray for the 1st Floor Unit (truck 4). The test tray was placed on the food truck at 12:16 P.M., left the kitchen, and arrived on the 1st Floor Unit at 12:17 P.M. The test tray was conducted at 12:24 P.M. with the Certified Dietary Manager (CDM) with the following results: -The milk registered at 45.1 degrees Fahrenheit (F) and was cool to taste -The chicken parmesan was 128.5 degrees F, lukewarm, tasted salty, rubbery texture -Pasta 125.4 degrees F, lukewarm -Ground chicken 122.9 degrees F, lukewarm -Pureed chicken 126.0 degrees F, lukewarm -Mashed potatoes 118.0 degrees F, lukewarm, bland tasting On 10/22/24 at 7:33 A.M., the surveyor requested a breakfast tray for the 2nd Floor Unit (truck 2). The test tray was placed on the food truck at 7:41 A.M., left the kitchen, and arrived on the 2nd Floor Unit at 7:44 A.M. The test tray was conducted at 7:53 A.M. with the CDM with the following results: -The milk registered at 44.8 degrees F, cool to taste -Apple juice 50.6 degrees F, slightly cool -Scrambled eggs 121.0 degrees F, lukewarm, bland tasting -Waffle 94.8 degrees F, cold tasting, rubbery, required the use of a knife and fork with pulling motion to cut and sample -Ground meat sausage 98.0 degrees F, slightly warm, appetizing taste -Pureed bread 110.0 degrees F, lukewarm -Pureed eggs 101.7 degrees F, tasted cold and gritty in texture, no flavor The results of the test trays validated the residents' concerns of unpalatable food served at unappetizing food temperatures. During an interview on 10/22/24 at 8:05 A.M., the CDM said she agreed there was no taste to the scrambled eggs, the waffle was cold, the pureed bread did not taste hot, and said she agreed with the surveyor's findings regarding the pureed eggs. She said ideally cold temperatures, once the trays get to the unit, should be between 42.0 degrees F and 43.0 degrees F, realistically, and said overall the hot temperatures should have been between 125.0 degrees F and 135.0 degrees F once arriving to the units.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0645 (Tag F0645)

Minor procedural issue · This affected multiple residents

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Based on record review and interview, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness (ID/DD/SMI) and needed further evaluation) for one Resident (#25), out of a total sample of 18 residents, who transferred to the facility in 2019. Findings include: Review of the MassHealth Nursing Facility Bulletin 169 titled Updates to Nursing Facility Regulations: preadmission screening and resident review (PASARR) for intellectual disability, developmental disability, and serious mental illness, dated June 2024, indicated but was not limited to the following: - Level II Evaluation. A comprehensive independent evaluation that is consistent with federal PASARR regulations at 42 CFR 483.134, and conducted on individuals that have positive Level I Screenings. The Level II Evaluation is a person-centered assessment taking into account all relevant information, including the individual's or individual's authorized representative's goals and preferences for the individual's care. It is required to ascertain: 1) whether the referred individual has ID/DD, SMI, or both; and 2) if so, whether community-based services, admission to a nursing facility or other setting is appropriate; and 3) if a nursing facility is appropriate, whether Specialized Services are required. - When an individual is transferred from one nursing facility (transferring facility) to another nursing facility (receiving facility), with or without an intervening hospital stay, the individual is not considered a new admission, and does not require preadmission screening (but may require a Resident Review, depending on the circumstances, such as a Significant Change). The transferring facility must ensure that it transfers all copies of the resident's PASARR paperwork, including the Level I Screening form and, if applicable, the Determination Notices and CERs, to the receiving facility. This transfer must be documented in the PASARR Portal. If the Level I Screening form is not available in the PASARR Portal, then the transferring facility must submit a new Level I Screening form via the PASARR Portal before transferring the individual. The receiving facility must not admit such an individual without receiving all PASARR-related documentation from the transferring facility. The receiving facility must inform the appropriate PASARR Authority within 48 hours of the transfer that the individual has been transferred to the receiving facility, in the same manner as described in Section 2.A.3, above. Resident #25 was admitted to the facility in July 2019 with diagnoses which included major depressive disorder, paranoid schizophrenia, and dementia with mood disturbances. Review of the Level l PASARR indicated but was not limited to the following: -Level ll PASARR is indicated and must be completed before admission. Date of completion 7/31/12. Further review of the medical record indicated a Level ll PASARR was not present in the medical record. During an interview on 10/22/24 at 5:12 P.M., the Director of Nursing (DON) said Resident #25 was a transfer from another facility. She said she could not find the Level ll PASARR and will reach out to the previous facility to see if they have the completed Level ll PASARR. The DON said she does not know if Resident #25 required any additional services for his/her mental illness. During an interview on 10/23/24 at 1:52 P.M., the DON said she called the MassHealth PASARR office, and they have no record of a Level ll PASARR ever being completed. She said when Resident #25 transferred to this facility and did not have the Level ll paperwork, they should have requested a Level ll PASARR be completed.

Nov 2023 2 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Comprehensive Care Plan (Tag F0656)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, was essentially helpless, unable to participate in care due to left sided hemiparesis (partial paralysis on one side of the body) and had been assessed by nursing as being at high risk for falls, the Facility failed to ensure that his/her care plan related to activities of daily living was updated and accurately identified his/her individual care needs that he/she required two staff members to assist at all times during the provision of care, due to impaired mobility and safety concerns. Although staff consistently documented that Resident #1 required two staff persons for assistance with care, his/her Care Plan and Resident Care Card, both indicated he/she required one or two staff persons for assistance and on 10/13/23, Certified Nurse Aide (CNA) #1 provided personal care to Resident #1 in bed without another staff member present to assist her, when CNA #1 turned Resident #1 onto his/her side, he/she fell out of bed and landed on the floor on his/her right side. As a result of the fall Resident #1 sustained a laceration to the back of his/her head, was transferred to the Hospital Emergency Department for further evaluation, he/her received seven staples to close the laceration and was also diagnosed with a right intertrochanteric (hip) fracture which required surgical intervention to repair. Findings include: Review of the Facility's Policy, titled Comprehensive Person-Centered Care Plans, dated as revised November 2017, indicated 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 Interdisciplinary Team (IDT) develops and implements a comprehensive, person-centered plan for each resident; -the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -the comprehensive, person-centered care plan will incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths, enhance the optimal functioning of the resident, reflect currently recognized standards of practice for problem areas and conditions; -care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #1 was admitted to the Facility in October 2018, diagnoses included hemiplegia (one sided paralysis) and hemiparesis affecting left non-dominant side, type 2 diabetes mellitus, atrial fibrillation, malignant neoplasm of colon and muscle weakness. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, required extensive physical assistance of two staff members with transfers, bed mobility and toileting and was totally dependent on the physical assistance of two staff members with bathing. However, review of Resident #1's Care Plan related to Activities of Daily Living (ADL) and Functional Mobility, reviewed and renewed with his/her August 2023 MDS, indicated he/she was essentially helpless with left sided hemiparesis, required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (including incontinence care). Review of Resident #1's ADL Flowsheets, dated September 2023 and October 2023, (as documented by the CNA's) indicated that prior to his/her fall on 10/13/23, he/she consistently required and was provided extensive physical assistance of two staff members or was totally dependent on the physical assistance of two staff members for bed mobility, positioning, hygiene and toileting (including incontinence care) care needs on all three shifts. Review of Resident #1's Fall Risk Assessment, dated 10/06/23, indicated that he/she was at high risk for falls. Review of Resident #1's Resident Care Card, (used as a reference guide by CNA's), dated October 12, 2023, indicated he/she required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (including incontinence care). Although Resident #1's Care Plan and CNA Care Card related to ADL's both indicated the need for one to two staff members to assist with care, this was inconsistent with the actual level of assistance that was required and provided to Resident #1 during care, as evidence by documentation completed by nursing staff which clearly indicated he/she required two staff members physical assistance while meeting his/her care needs. There was no documentation to support that Resident #1's ADL Care Plan or resident Care Card were updated by nursing to reflect the need for two staff member to assist and participate during the provision of care. Review of the Facility's Internal Investigation Report, dated 10/19/23, indicated that on 10/13/23 at 7:20 P.M., CNA #1 provided personal care to Resident #1, rolled him/her towards her (CNA #1) when Resident #1 slid off the mattress and fell out of bed on the right side of bed onto his/her right side. The Report indicated that Resident #1 was bleeding from the back of his/her head and sustained a laceration to the back of his/her head. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department and was diagnosed with a right hip fracture that required surgery. Review of a Nurse Progress Note, dated 10/13/23, as a late entry, written by Nurse #1 indicated that she was called by CNA #1 to Resident #1's room where she (Nurse #1) found him/her on the floor. Review of a Fall Incident Report, dated 10/13/23, written by Nurse #1 indicated that CNA #1 called her to come to Resident #1's room where she found Resident #1 on the floor on the right side of the bed on his/her right side. The Report indicated that while providing care to Resident #1, CNA #1 rolled him/her toward her (CNA #1) and suddenly Resident #1's feet went to the floor, CNA #1 could no longer manage him/her and he/she hit the back of his/her head on the bedside table. The Report indicated that Resident #1 sustained an abrasion to the top of his/her scalp. Review of a Hospital Discharge summary, dated [DATE], indicated that Resident #1 sustained a fall at the Facility on 10/13/23 while being changed, rolled off the bed, hit the back of his/her head on a nightstand and sustained a laceration to the back of his/her head. The Discharge Summary indicated that Resident #1 required seven staples to close the laceration to the back of his/her head. The Discharge Summary indicated that a CT Scan of Resident #1's pelvis revealed a mildly comminuted (fragmented) minimally impacted right intertrochanteric (hip) fracture and he/she underwent an open reduction internal fixation (ORIF) surgery to repair his/her right hip. During an interview on 11/14/23 at 12:05 P.M., Nurse #1 said CNA #1 was providing personal care to Resident #1 without the assistance of another staff member and said that Resident #1 fell out of bed. Nurse #1 said that Resident #1 is very stiff, has hemiparesis and is unable to participate in any activities of daily living. Nurse #1 said that Resident #1 requires the physical assistance of two staff members with all his/her activities of daily living. Nurse #1 said that she believes it was CNA #1's first time taking care of Resident #1. Nurse #1 said that she did not review Resident #1's level of assistance with CNA #1. Review of CNA #1's Written Witness Statement, dated 10/13/23, indicated that at approximately 7:30 P.M., she was providing personal care to Resident #1 in bed, rolled him/her toward her (CNA #1) when his/her feet slid off the side of the bed with the bed sheet and he/she landed on the floor hitting his/her head on the bedside table (nightstand). The Statement indicated that she (CNA #1) was not aware that Resident #1 required the assistance of two staff members with care. During an interview on 11/14/23 at 3:30 P.M., Certified Nurse Aide (CNA) #1 said that on 10/13/23, she was providing personal care to Resident #1 in bed without the assistance of another staff member when his/her legs got caught in the bed sheet, he/she slid off the bed, and fell out of bed hitting the back of his/her head on the bedside table (nightstand) causing the back of his/her head to bleed. CNA #1 said that she has taken care of Resident #1 once before, said she thought that he/she required the physical assistance of one staff member with care and said that after the incident, she was made aware that he/she required the physical assistance of two staff members with bed mobility, bathing and personal care. CNA #1 said that the nurse did not inform her at the beginning of the shift the level of assistance Resident #1 required with care. CNA #1 said that she was not aware that each resident had a care card that informed the CNA of the level of assist required when providing care. During an interview on 11/14/23 at 1:30 P.M., CNA #2 said that even though Resident #1's Care Card indicates that he/she requires extensive physical assistance of one to two staff members with bed mobility, positioning, bathing, personal hygiene and dressing, said she always gets the assistance of another staff member. CNA #2 said that Resident #1 has hemiparesis and is very stiff and difficult to turn in bed. CNA #2 said she is unable to position, turn, bathe, dress, and provide personal hygiene safely to him/her without the physical assistance of another staff member. CNA #2 said the only thing you can do alone safely for Resident #1 is wash the front side of him/her, because he/she is laying flat in bed. During an interview on 11/14/23 at 1:45 P.M., CNA #3 said that Resident #1 requires extensive physical assistance of two staff members with bed mobility, positioning, bathing, personal hygiene and dressing. CNA #3 said that Resident #1 has hemiparesis, is very stiff and difficult to provide care without the assistance of another staff member. CNA #3 said that although Resident #1's Care Card indicates that she requires extensive physical assistance of one or two staff members, said the only thing you can do alone is wash his/her front side in bed. CNA #3 said that for everything else, Resident #1 requires extensive physical assistance of two staff members to care for him/her safely. During an interview on 11/14/23 at 3:05 P.M., the Unit Manager said that CNA's will ask another CNA or the nurse what level of assistance each resident requires. The Unit Manager said that every resident has a CNA Care Card that indicates the level of assistance they require with each activity of daily living task. The Unit Manager said that the care card should be specific as to the level of assistance the resident requires with each activity of daily living. During an interview on 11/14/23 at 4:15 P.M., the Director of Nurses (DON) said that Resident #1's resident CNA Care Card indicated that he/she required one to two person assist with his/her care needs and said that when a CNA gives care to Resident #1 and feels they need another staff member to assist them with care needs, they should ask another staff member for assistance with that resident. The DON said that is what one to two assistance with care needs means when indicated on the resident care card. The DON said that CNA #1 used poor judgment when she provided care to Resident #1 on 10/13/23 without the physical assistance of another staff member. The DON said that it is his expectation that the nurse lets the CNA's know what level of assistance each resident requires with each activity of daily living task at the beginning of the shift. Review of a CNA job description indicated that under the direction and supervision of a licensed/registered nurse, the CNA: -delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction; -the CNA will function within the standards of practice accorded by his/her certification; -the CNA performs various patient care activities and related non-professional services essential to caring for personal needs and comfort of patients; -provides patient care in a manner conducive to safety and comfort; -assists patient with or performs activities of daily living; -positions patients in correct body alignment in and out of bed; -reports changes in patient's condition to the charge nurse or supervisor; -promotes a culture of safety; -participates in the care planning process and implements care according to care plan. Review of the CNA job description indicated there is no documentation to support that in the CNA's job description, they can assess the level of assistance a resident requires with each activity of daily living task. Further review of the CNA job description, indicated that assessment of the level of assistance a resident requires is not within the scope of a CNA's practice.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was helpless, unable to participate in self care, had limited mobility due to left sided hemiparesis (paralysis on one side of the body), and who had been assessed by nursing as being at high risk for falls, the Facility failed to ensure he/she was provided with the necessary level of staff assistance during care to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 10/13/23, Certified Nurse Aide (CNA) #1 provided personal care to Resident #1 in bed without another staff member present to assist her, when she turned Resident #1 on his/her side in bed, he/she began to slide, CNA #1 could not manage him/her, and Resident #1 fell out of bed, landing on the floor on his/her right side. Resident #1 was noted to be bleeding from a laceration to the back of his/her head. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she received seven staples to close the laceration to the back of his/her head, and was also diagnosed with a right intertrochanteric (hip) fracture which required surgical intervention to repair. Findings include: Review of the Facility's Policy, titled Managing Falls and Fall Risk, dated as revised April 2018, indicated the following: -based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls; -if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling; -if interventions have been successfully in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved; -if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions; -the staff will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the Facility's Internal Investigation Report, dated 10/19/23, indicated that on 10/13/23 at 7:20 P.M., CNA #1 provided personal care to Resident #1, rolled him/her towards her (CNA #1) when Resident #1 slid off the mattress and fell out of bed on the right side of bed onto his/her right side. The Report indicated that Resident #1 was bleeding from the back of his/her head and sustained a laceration to the back of his/her head. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department and was diagnosed with a right hip fracture that required surgery. Review of a Nurse Progress Note, dated 10/13/23, as a late entry, written by Nurse #1 indicated that she was called by CNA #1 to Resident #1's room where she found him/her on the floor. Review of a Fall Incident Report, dated 10/13/23, written by Nurse #1 indicated that CNA #1 called her to Resident #1's room where she found Resident #1 on the floor on the right side of the bed on his/her right side. The Report indicated that while providing care to Resident #1, CNA #1 rolled him/her toward her (CNA #1) and suddenly Resident #1's feet went to the floor, CNA #1 could no longer manage him/her and he/she hit the back of his/her head on the bedside table. The Report indicated that Resident #1 sustained an abrasion to the top of his/her scalp. Review of a Hospital Discharge summary, dated [DATE], indicated that Resident #1 sustained a fall at the Facility on 10/13/23 while being changed, rolled off the bed, hit the back of his/her head on the nightstand and sustained a laceration to the back of his/her head. The Discharge Summary indicated that Resident #1 required seven staples to close the laceration to the back of his/her head. The Discharge Summary indicated that a CT Scan of Resident #1's pelvis revealed a mildly comminuted (fragmented) minimally impacted right intertrochanteric (hip) fracture and he/she underwent an open reduction internal fixation (ORIF) surgery to repair his/her right hip. Resident #1 was admitted to the Facility in October 2018, diagnoses included hemiplegia (one sided paralysis) and hemiparesis affecting left non-dominant side, type 2 diabetes mellitus, atrial fibrillation, malignant neoplasm of colon and muscle weakness. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, required extensive physical assistance of two staff members with transfers, bed mobility, hygiene care, toileting (which included incontinence care) and was totally dependent on the physical assistance of two staff members with bathing. Review of Resident #2's Care Plan related to Activities of Daily Living (ADL) and Functional Mobility, reviewed and renewed with his/her August 2023 MDS, indicated he/she was essentially helpless with left sided hemiparesis, required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (which included incontinence care). Review of Resident #1's ADL Flowsheets, dated September 2023 and October 2023, (as documented by the CNA's) indicated that prior to his/her fall on 10/13/23, he/she consistently required extensive physical assistance of two staff members or was totally dependent on the physical assistance of two staff members for bed mobility, positioning, hygiene care, and toileting (which included incontinence care) on all three shifts. However, review of Resident #1's Resident Care Card, (used as a reference guide by CNA's), dated October 12, 2023, indicated he/she required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (which included incontinence care). Review of Resident #1's Fall Risk Assessment, dated 10/06/23, indicated that he/she was at high risk for falls. During an interview on 11/14/23 at 12:05 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and when she entered the room, Resident #1 was on the floor bleeding from a laceration on the back of his/her head. Nurse #1 said that CNA #1 was providing personal care to Resident #1 without the assistance of another staff member and that Resident #1 fell out of bed, hit the back of his/her head on the bedside table (nightstand). Nurse #1 said that Resident #1 is very stiff, has hemiparesis and is unable to participate in any activities of daily living. Nurse #1 said that Resident #1 requires physical assistance from two staff members with all his/her activities of daily living and said CNA #1 should not have provided care to Resident #1 alone. Nurse #1 said that she believes it was CNA #1's first time taking care of Resident #1. Nurse #1 said that she did not review Resident #1's level of assistance with CNA #1 and said that the CNA's review the level of assistance that each resident's require with each other at the beginning of the shift. Nurse #1 said that nurses don't usually give report to the CNA's regarding the level of assistance the residents require with the CNA's. Review of CNA #1's Written Witness Statement, dated 10/13/23, indicated that at approximately 7:30 P.M., she was providing personal care to Resident #1 in bed, rolled him/her toward her (CNA #1) when his/her feet slid off the side of the bed with the bed sheet and he/she landed on the floor hitting his/her head on the bedside table (nightstand). The Statement indicated that she (CNA #1) was not aware that Resident #1 required the assistance of two staff members with care. During an interview on 11/14/23 at 3:30 P.M., Certified Nurse Aide (CNA) #1 said that on 10/13/23, she was providing personal care to Resident #1 in bed without the assistance of another staff member when his/her legs got caught in the bed sheet, he/she slid off the bed, and fell out of bed hitting the back of his/her head on the bedside table (nightstand). CNA #1 said that at the beginning of the shift, one of the CNA's told her that Resident #1 required the assistance of one staff member with care but said she could not recall which CNA told her. CNA #1 said that she had taken care of Resident #1 once before, and said she thought that he/she required the physical assistance of one staff member with care. CNA #1 said that after the incident, she was made aware that he/she required the physical assistance of two staff members with bed mobility, bathing and personal care. CNA #1 said that the nurse did not inform her at the beginning of the shift the level of assistance Resident #1 required with care. CNA #1 said that she was not aware that each resident had a care card that informed the CNA of the level of assist required when providing care. Review of the CNA job description indicated there is no documentation to support that in the CNA's job description, they can assess the level of assistance a resident requires with each activity of daily living task. Further review of the CNA job description, indicated that assessment of the level of assistance a resident requires is not within the scope of a CNA's practice. During an interview on 11/14/23 at 1:30 P.M., CNA #2 said that even though Resident #1's Care Card indicates that he/she requires extensive physical assistance of one to two staff members with bed mobility, positioning, bathing, personal care and dressing, she always gets the assistance of another staff member. CNA #2 said that Resident #1 has hemiparesis, is very stiff and is difficult to turn in bed. CNA #2 said she is unable to position, turn, bathe, dress, and provide personal hygiene safely without the physical assistance of another staff member. CNA #2 said the only thing you can do alone safely for Resident #1 is wash the front side of him/her, because he/she is laying flat in bed. During an interview on 11/14/23 at 1:45 P.M., CNA #3 said that Resident #1 requires extensive physical assistance of two staff members with bed mobility, positioning, bathing, personal care and dressing. CNA #3 said that Resident #1 has hemiparesis, is very stiff and is difficult to provide care without the assistance of another staff member. CNA #3 said that although Resident #1's Care Card does indicate that she requires extensive physical assistance of one or two staff members said the only thing you can do alone is wash his/her front side in bed. CNA #3 said that for everything else, Resident #1 requires extensive physical assistance of two staff members to care for him/her safely. During an interview on 11/14/23 at 3:05 P.M., the Unit Manager said that CNA's ask another CNA or the nurse what level of assistance each resident requires. The Unit Manager said that every resident has a care card that indicates the level of assistance they require with each activity of daily living task. The Unit Manager said that the care card should be specific as to the level of assistance the resident requires with each activity of daily living. During an interview on 11/14/23 at 4:15 P.M., the Director of Nurses (DON) said that Resident #1's resident care card indicated that he/she required one to two assists with his/her care needs. The DON said this means that when a CNA gives care to Resident #1 and feels they need another staff member to assist them with care needs, they need to ask another staff member for assistance with that resident. The DON said that CNA #1 used poor judgment when she provided care to Resident #1 on 10/13/23 without the physical assistance of another staff member. The DON said that it is his expectation that the nurse lets the CNA's know what level of assistance each resident requires with each activity of daily living task at the beginning of the shift.

Oct 2023 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0678 (Tag F0678)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders indicated he/she was a full code (if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive), the Facility failed to ensure nursing staff provided life saving measures to him/her, when on [DATE], at approximately 5:30 A.M., after Nurse #1 found Resident #1 unresponsive, without pulse and without respiration, she did not call a Code Blue, per facility policy, and Resident #1 was not administered cardiopulmonary resuscitation (CPR). Resident #1 was pronounced dead at the facility, approximately two hours after nursing initially found him/her unresponsive. Findings include: Review of the Facility Policy titled, Code Blue, dated as last revised 4/2023, indicated that if a resident is found to be unresponsive or becomes unresponsive under observation, staff will call a Code Blue and would be paged overhead three times, the page will include the unit, location, and room. The Policy also indicated that for a Full Code, upon arrival to the scene the nursing staff will assess victims who are unconscious, not breathing normally and showing no signs of circulation, such as normal breathing, coughing, and movement and if the victim is noted to have neither pulse nor respiration, the staff will initiate CPR. Review of the Massachusetts Board of Registration of Nursing Advisory Ruling on Nursing Practice, titled Nursing Practice and Cardio-Pulmonary Resuscitation (CPR), revised [DATE], indicated that to guide the decision making of the nurse, in context of practice in all settings where healthcare is delivered require initiating cardio-pulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L c. 469 except when a patient has a current valid Do Not Resuscitate (DNR) order/status. Review of the Report submitted by the facility, via the Health Care Facility Reporting Systems (HCFRS), dated [DATE], indicated on [DATE], in the morning, Resident #1 was found with his/her mouth open, chest not moving and nursing was unable to get vital signs. The Report indicated Nurse #1 checked his/her chart for a code status and was unable to do so (could not find code status or physicians' orders) and CPR was not immediately initiated. Resident #1 was admitted to the Facility in [DATE], diagnoses included adult failure to thrive, Alzheimer's type dementia, chronic obstructive pulmonary disease, malnutrition, and dysphagia (difficulty swallowing) with a gastrostomy (tube that brings nutrients directly into the stomach) in place. Review of Resident #1's Decree and Order for Appointment of Guardian for An Incapacitated Person, dated [DATE], indicated he/she had an active Guardianship in place, and Guardian was to make medical decisions. Review of Resident #1's Care Plan titled, Advanced Directives, reviewed and renewed with his/her Minimum Data Set (MDS) assessement completed in [DATE], indicated he/she was a Full Code. Review of Resident #1's History and Physical, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's Physician's Order, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's medical record indicated there was no pink Medical Orders for Life Sustaining Treatment (MOLST) form in place. Review of Nurse #1's written Witness Statement, dated [DATE], indicated she last saw Resident #1 alive at approximately 4:00 A.M. and then on her second set of rounds, (later determined to be at approximately 5:30 A.M.) she found Resident #1 with his/her mouth open, his/her chest was not rising, and she unable to obtain vital signs. The Statement indicated Nurse #1 checked his/her medical record for a code status and it was unspecified, so she called the Registered Nurse (RN, later identified as Nurse #2) who was in the building to pronounce Resident #1. During an interview on [DATE] at 9:20 A.M., Nurse #1 said during her morning rounds (5:30 A.M.) she found Resident #1 unresponsive and said he/she looked like she was completely dead. Nurse #1 said she went to his/her medical record, said she could not located his/her advanced directives and said she called, (later determined that the call was placed at 6:06 A.M.) the on-call Nurse Practitioner (NP). Nurse #1 said she did not call a Code Blue at the time she first noted Resident #1 to be unresponsive, and was unable to offer an explanation as to why. Nurse #1 said the NP asked her what she had found when assessing Resident #1 and Nurse #1 said she told the NP he/she had no blood pressure, no pulse, no respirations, and he/she was cold. During an interview on [DATE] at 8:34 A.M., the Nurse Practitioner (NP) said at 6:06 A.M. she received a phone call from Nurse #1. The NP said Nurse #1 was very difficult to understand, said she was all over the place with her thoughts and that English was not her (Nurse #1's) primary language. The NP said she thought to herself, does this nurse even know what she is talking about? The NP said Nurse #1 told her that Resident #1 was not breathing. The NP said she asked Nurse #1 if she checked him/her for a heartbeat and Nurse #1 said yes. The NP said Nurse #1 also informed her during the call that she (Nurse #1) had already left a message for his/her Guardian and called the funeral home. The NP said she gave Nurse #1 a verbal order for an RN to pronounce Resident #1. During an interview on [DATE] at 5:59 A.M., Certified Nurse Aide (CNA) #1 said Resident #1 was on her assignment on the 11:00 P.M.-7:00 A.M. (night shift) on [DATE] into [DATE]. CNA #1 said at approximately 3:00 A.M., Resident #1 was yelling out and said that was not unusual when he/she was wet and uncomfortable. CNA #1 said she provided incontinent care, and he/she stopped yelling out and was noted to be quiet at approximately 4:00 A.M. CNA #1 said Nurse #1 came to her at around 5:30 A.M., and said she (Nurse #1) could not find Resident #1's pulse and then Nurse #1 said, I think he/she is dead. CNA #1 said Nurse #1 did not call a Code Blue and asked her to go get Nurse #2 (only RN in the facility) to pronounce Resident #1. During an interview on [DATE] at 5:48 A.M., CNA #2 said on [DATE], she was the second CNA on the unit that night and said she did not hear a Code Blue called. CNA #2 said she was unaware that a resident had passed away during the shift until approximately 7:00 A.M., at the end of the shift. Review of Nurse #2's written Witness Statement and during an interview on [DATE] at 12:57 P.M., Nurse #2 (who was the only RN working on the overnight shift that night) said on [DATE] at approximately 6:15 A.M. she was passing her early morning medications when CNA #1 approached her and told her that Nurse #1 wanted her to come up to the second floor and help with an RN pronouncement. Nurse #2 said there was no Code Blue announced that night during the shift. Nurse #2 said she finished medicating the resident she was working on and then went to the second floor to assist Nurse #1. Nurse #2 said she asked Nurse #1 what Resident #1's code status was and said Nurse #1 told her he/she was a DNR. Nurse #2 said she did not check Resident #1's chart for his/her advanced directives and took Nurse #1's word for it. Nurse #2 said Nurse #1 told her she had already called the on-call Nurse Practitioner (NP) and that the NP had given her a verbal order for Resident #1's RN pronouncement. Nurse #2 said she went to Resident #1's room and performed an assessment. Nurse #2 said Resident #1 had no pulse, no respirations, vital signs were unable to be obtained, and he/she was white and cold. Nurse #2 said she was unable to locate the proper RN Pronouncement Form so she could not complete the pronouncement at that time. Nurse #2 said if she had the Form she would have pronounced Resident #1 dead at 6:35 A.M. During an interview on [DATE] at 8:19 A.M., Nurse #6 said she worked the 11:00 P.M.-7:00 A.M. (night) shift on [DATE] into [DATE], and said she did not hear a Code Blue called at all during the shift. During an interview on [DATE] at 11:27 A.M., the Nurse Manager said he knew Resident #1 was a full code, and that he/she had a Guardianship in place. The Nurse Manager said a Code Blue should have been called right away and said that staff should have followed the proper procedures. The Nurse Manager said if a nurse is unable to locate or confirm that a resident is a DNR, that the resident should be treated as a full code and CPR is to be initiated. During an interview on [DATE] at 11:06 A.M., the Assistant Director of Nurses (ADON) said when Resident #1 was found unresponsive a Code Blue should have been called immediately, allowing other staff to assist Nurse #1. The ADON said if a nurse is unable to locate or confirm a DNR status, CPR is to be initiated and 911 called. During an interview on [DATE] at 1:30 P.M., the Director of Nurses (DON) said as soon as Nurse #1 found Resident #1 unresponsive, without a pulse, and without respirations, Nurse #1 should have called a Code Blue and CPR should have been immediately initiated. The DON said on [DATE], after being made aware sometime after the start of the day shift (approximately 7:15 A.M. - 7:30 A.M.) that Resident #1 had been found unresponsive (during the overnight shift), he said he instructed nursing staff to call a Code Blue, call 911 and initiate CPR. Nurse #1 and Nurse #2 said they were made aware after the day shift nurses arrived that Resident #1 was a full code, and that although Resident #1 had been identified as being unresponsive, without a pulse and not breathing for more than an hour and a half before this, said they were directed to call a Code Blue, call 911, and initiate CPR. Nurse #1 said Resident #1 had obvious signs of rigor mortis (stiffening of the joints and muscles of a body a few hours after death), by then, that he/she was stiff. Nurse #1 said they did call 911, but had not started CPR and that EMS arrived right away. Review of the Emergency Medical Services (EMS) Final Report, dated [DATE], indicated EMS arrived at the Resident's room at 7:43 A.M. (more than two hours after Resident #1 was initially found unresponsive by nursing) and met the Fire Department at the door who stated they had findings of lividity (bluish-purple discoloration of skin after death) and resident was cold to the touch. EMS indicated they found Resident #1 in bed, pale, cold, and with lividity noted to the corners of his/her back. Resident #1 was noted to have stiffness in the jaw with minimal movement, he/she was rolled to the side and lividity was noted to the back and top of thighs, pupils were fixed and dilated, and resuscitation was considered futile, and Resident #1 was pronounced dead by EMS staff at 7:45 A.M.

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0726 (Tag F0726)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders indicated he/she was a full code (if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive), the Facility failed to ensure nursing staff were competent and had the necessary skill set to respond in an emergency situation which included adequately assessing a resident who was unresponsive with a significant change in condition, calling a Code Blue, and initiating 911 to activate Emergency Medical Services (EMS). On [DATE], at approximately 5:30 A.M., Nurse #1 found Resident #1 unresponsive, briefly assessed him/her, and although Nurse #1 (who was a Licensed Practical Nurse, LPN) was unable to identify Resident #1's code status in his/her medical record, determined him/her to be dead, and did not call a Code Blue or initiate cardiopulmonary resuscitation CPR) and did not call 911. Nurse #2, who was asked by Nurse #1 to complete the RN Pronouncement on Resident #1, did not review Resident #1's medical record for his/her code status, and took Nurse #1's word for it, when she said he/she was a DNR. On [DATE], Resident #1 was pronounced dead at the facility by EMS, approximately two hours after nursing initially found him/her unresponsive, which was when facility staff called a Code Blue and called 911. Findings include: Review of the Facility Policy titled, Code Blue, dated as last revised 4/2023, indicated that if a resident is found to be unresponsive or becomes unresponsive under observation, staff will perform the following: -Call a Code Blue and it would be paged overhead three times, the page will include the unit, location, and room; -For a full code victim, the nurse first responder will give directions to other staff who respond to retrieve the medical record and code cart, record the event, perform CPR, and call 911. Review of the Facility Policy titled, RN Pronouncement, dated as last revised 9/2018, indicated that the documentation in nurses' notes by the RN making the pronouncement should include the following: -Absence of respiration, apical pulse, and blood pressure; -Time of pronouncement; -Notification of the Funeral Home. Review of the Massachusetts Board of Registration of Nursing Advisory Ruling on Nursing Practice, titled Nursing Practice and Cardio-Pulmonary Resuscitation, revised [DATE], indicated that to guide the decision making of the nurse, in context of practice in all settings where healthcare is delivered require initiating cardio-pulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L c. 469 except when a patient has a current valid Do Not Resuscitate (DNR) order/status. Review of the Report submitted by the facility, via the Health Care Facility Reporting Systems (HCFRS), dated [DATE], indicated on [DATE], in the morning, Resident #1 was found with his/her mouth open, chest not moving and nursing was unable to get vital signs. The Report indicated Nurse #1 checked his/her chart for a code status and was unable to do so (could not find code status or physicians' orders), CPR was not immediately initiated and the Registered Nurse (RN) in the building was asked to pronounce Resident #1. The Report further indicated that once Resident #1's code status was verified (as a full code two hours later), nursing staff were directed to call a Code Blue, call 911, and initiate CPR. Resident #1 was admitted to the Facility in [DATE], diagnoses included adult failure to thrive, Alzheimer's type dementia, chronic obstructive pulmonary disease, malnutrition, and dysphagia (difficulty swallowing) with a gastrostomy (tube that brings nutrients directly into the stomach) in place. Review of Resident #1's Decree and Order for Appointment of Guardian for An Incapacitated Person, dated [DATE], indicated he/she had an active Guardianship in place, and his/her Guardian was to make medical decisions. Review of Resident #1's Care Plan titled, Advanced Directives, reviewed and renewed with his/her Minimum Data Set (MDS) assessement completed in [DATE], indicated he/she was a Full Code. Review of Resident #1's History and Physical, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's Physician's Order, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's medical record indicated there was no Medical Orders for Life Sustaining Treatment (MOLST) form in place. During an interview on [DATE] at 9:20 A.M., (which included a review of Nurse #1's written Witness Statement) Nurse #1 said she last saw Resident #1 alive at approximately 4:00 A.M. and then on her second set rounds, (later determined to be at approximately 5:30 A.M.) she found Resident #1 with his/her mouth open and his/her chest not rising. Nurse #1 said she was unable to obtain vital signs, so she checked Resident #1's medical record for a code status and said it was unspecified. Nurse #1 said she called the on-call provider (it was later determined that Nurse #1 placed the call at 6:06 A.M.) for a verbal order for an RN pronouncement. Nurse #1 said the on-call provider was a Nurse Practitioner (NP), and that the NP asked her what she had found when she assessed Resident #1. Nurse #1 said she told the NP he/she had no blood pressure, no pulse, no respirations, and he/she was cold. Nurse #1 said she did not tell the NP she had been unable to locate Resident #1's code status in his/her medical record. Nurse #1 said after she obtained the order, she sent a CNA to get Nurse #2 (the only RN in the building) to complete the pronouncement on Resident #1. Nurse #1 said when the day shift (7:00 A.M. to 3:00 P.M.) nursing staff came in to work, they told her Resident #1 was a full code. Nurse #1 said she was directed by the Director of Nurses (DON) at that time (sometime after 7:00 A.M.) to call a Code Blue and call 911. Review of Resident #1's Nursing Progress Noted, dated [DATE], written by Nurse #1, indicated that Resident #1 was found unresponsive, no pulse, chest not moving and called 911, when ambulance arrived EMS pronounced him/her dead. During an interview on [DATE] at 8:34 A.M., the Nurse Practitioner (NP) said at 6:06 A.M. she received a phone call from Nurse #1. The NP said Nurse #1 was very difficult to understand, she was all over the place with her thoughts and that English was not her (Nurse #1's) primary language. The NP said she thought to herself, does this nurse even know what she is talking about? The NP said Nurse #1 told her that Resident #1 was not breathing. The NP said she asked Nurse #1 if she checked him/her for a heartbeat and Nurse #1 said yes. The NP said Nurse #1 also informed her during the call that she (Nurse #1) had already left a message for his/her Guardian and called the funeral home. The NP said she gave Nurse #1 a verbal order for an RN to pronounce Resident #1. Review of Resident #1's Medical Record indicated there was no documentation to support that when Nurse #1 initially found Resident #1 unresponsive at 5:30 A.M., that she adequately assessed Resident #1 for signs of viable life. There was no documentation to support that Nurse #1 transcribed the order she obtained from the Nurse Practitioner for the RN pronouncement, into Resident #1's medical record. During an interview on [DATE] at 5:59 A.M., Certified Nurse Aide (CNA) #1 said Nurse #1 came to her at 5:30 A.M. and said she could not find Resident #1's pulse and that Nurse #1 said, I think he/she is dead. CNA #1 said Nurse #1 did not call a Code Blue. CNA #1 said Nurse #1 asked her to go get Nurse #2 (only RN in the facility) to do the pronouncement for Resident #1. During an interview on [DATE] at 12:57 P.M., (which included a review of Nurse #2's written Witness Statement) Nurse #2 said on [DATE] at approximately 6:15 A.M. she was passing her early morning medications when CNA #1 approached her and told her that Nurse #1 wanted her to come up to the second floor and help with an RN pronouncement. Nurse #2 said there was no Code Blue announced during their shift that night. Nurse #2 said, when she got to Resident #1's unit, Nurse #1 told her she had already called the on-call Nurse Practitioner (NP) and that the NP had given her a verbal order for Resident #1's RN pronouncement. Nurse #2 said she did not check Resident #1's medical record, before proceeding to do the RN Pronouncement, that Nurse #1 told her he/she was a DNR, and said she took her word for it. Nurse #2 said she went to Resident #1's room, performed an assessment and said Resident #1 had no pulse, no respirations, vital signs were unable to be obtained, and he/she was white and cold. Nurse #2 said she was unable to locate the proper RN Pronouncement Form so she could not complete the pronouncement at that time. Nurse #2 said if she had the Form she would have pronounced Resident #1 dead at 6:35 A.M. Review of Resident #1's Medical Record indicated there was no documentation to support Nurse #2 adequately assessed him/her for any signs of viable life prior to proceeding with pronouncement, there was no nurse progress note or assessment related to Nurse #2's findings in the medical record. During an interview on [DATE] at 11:27 A.M., the Nurse Manager said Resident #1 was a Full Code, a Code Blue should have been called right away, staff should have followed the process for a Code Blue, but said nursing staff did not follow appropriate procedures that night. The Nurse Manager said if a nurse is unable to locate or confirm that a resident is a Do Not Resuscitate (DNR) the resident is then treated as a full code and CPR is to be initiated. During an interview on [DATE] at 11:06 A.M., the Assistant Director of Nurses (ADON) said a Code Blue should have been called immediately, allowing other staff to assist Nurse #1. The ADON said if a nurse is unable to locate or confirm a DNR status, CPR is to be initiated and 911 needs to be called. During an interview on [DATE] at 1:30 P.M., the Director of Nurses (DON) said as soon as Nurse #1 found Resident #1 unresponsive, without a pulse, and without respirations Nurse #1 should have called a Code Blue and CPR should have been immediately initiated. The DON said on [DATE], after being made aware sometime after the start of the day shift (approximately 7:15 A.M. - 7:30 A.M.) that Resident #1 had been found unresponsive (during the overnight shift), that he instructed nursing staff to call a Code Blue, call 911 and initiate CPR. Nurse #1 and Nurse #2 said they were made aware after the day shift nurses arrived that Resident #1 was a full code, and that although Resident #1 had been identified as being unresponsive, without a pulse and not breathing more than an hour and a half before this, said they were directed to call a Code Blue, call 911, and initiate CPR. Nurse #1 said Resident #1 had obvious signs of rigor mortis (stiffening of the joints and muscles of a body a few hours after death), by then, that he/she was stiff. Nurse #1 said they did call 911, but had not started CPR and that EMS arrived right away. Review of the Emergency Medical Services (EMS) Final Report, dated [DATE], indicated EMS arrived at the Resident's room at 7:43 A.M. (more than two after Resident #1 was initially found unresponsive by nursing) and met the Fire Department at the door who stated they had findings of lividity (bluish-purple discoloration of skin after death) and that the resident was cold to the touch. EMS indicated they found Resident #1 in bed, pale, cold, and with lividity noted to the corners of his/her back. Resident #1 was noted to have stiffness in the jaw with minimal movement, he/she was rolled to the side and lividity was noted to the back and top of thighs, pupils were fixed and dilated, and resuscitation was considered futile, and Resident #1 was pronounced dead by EMS staff at 7:45 A.M.

Aug 2023 21 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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Based on policy review, observation, interview, and record review, the facility failed to ensure one Resident (#70), out of a total sample of 20 residents, received care and treatment to promote healing of a facility acquired deep tissue injury (DTI) (localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and to help prevent wound deterioration, resulting in worsening of the DTI to a Stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle). Specifically, the facility failed to: a. Ensure staff informed the Resident's primary care provider of the wound provider's treatment recommendations after three consecutive wound care visits dated 1/25/23, 1/31/23, and 2/17/23 to help prevent continued deterioration of a left medial ankle pressure wound and implement treatments as ordered; b. Identify and document the condition of the Resident's left medial ankle pressure wound on weekly skin checks; and c. Complete a pressure evaluation form to accurately reflect the date the pressure wound was acquired at the facility. Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated April 2018, indicated but was not limited to the following: -Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool. -Conduct a comprehensive skin assessment with every risk assessment. -Once inspection of skin is completed, document the findings on a facility-approved skin assessment tool. -If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. -Develop a resident centered care plan and interventions based on risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. The following information should be recorded in the resident's medical record utilizing facility forms: -Any change in the resident's condition. -The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. -Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. Review of the wound clinic Services Agreement, dated March of 2015, indicated but was not limited to the following: Facility Responsibilities: -Provide a dedicated nurse to round and communicate with the Provider. -Inform the resident's primary care provider of Provider's recommendation within 24 hours. -Discuss recommendations/wound care plan with the Provider on the day of rounds. Resident #70 was admitted to the facility in November 2022 with diagnoses including adult failure to thrive, diabetes mellitus type 2, difficulty in walking, and weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/21/23, indicated Resident #70 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and was an extensive assist for bed mobility, transfer, and personal hygiene. a. Review of the Norton Scale for Predicting Risk of Pressure Ulcers form, dated 11/9/22, indicated Resident #70 was a high risk for developing pressure ulcers. Review of the Pressure Ulcer Care Plan, initiated 11/10/22, indicated a goal to comply with the therapeutic regime. The care plan was resolved on 5/30/23. Review of the Venous Ulcer of the Left Ankle Care Plan, initiated 5/30/23, indicated the Resident's ulcer would be healed by the review date with the following interventions: -document the location of wound, amount of drainage, peri-wound area, edema, and circumference measurements with every dressing change -evaluate wound for size, depth, margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. -weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations Review of the Weekly Skin Evaluation, dated 1/12/23, indicated Resident #70 had an old wound present (left heel). No new wounds were identified. Review of the Wound Evaluation and Management Summary, dated 1/17/23, indicated Resident #70 developed a DTI of the left medial ankle greater than three days in duration. The skin was documented as being intact and measured 1.3 centimeters (cm) x 1.8 cm x not measurable. The quality of the wound was documented as a pressure wound with an arterial component. Wound recommendations included the following: -apply skin prep (creates an invisible layer on skin to protect it from friction and shear) to peri-wound once daily for 30 days -elevate legs and off-load the wound Review of the Physician's Orders indicated the following: -off-load heels as tolerated while in bed every shift, 12/15/22 -unstageable DTI of the left, medial ankle, skin prep every day shift, 1/18/23 Review of the January 2023 Treatment Administration Record (TAR) indicated the following: -17 of 93 shifts, heels not documented as being off-loaded -2 of 12 days (1/22/23, 1/23/23), skin prep treatment not documented as being completed Review of the Wound Evaluation and Management Summary, dated 1/25/23, indicated Resident #70's wound had deteriorated and was documented as being an unstageable full-thickness (amount of tissue loss, base of the ulcer is covered by slough/dead tissue, and/or eschar/non-viable tissue in the wound bed) pressure wound. Wound recommendations included the following: -normal saline wash, apply once daily for 30 days; Iodosorb gel (treats wet ulcers to kill bacteria, absorb exudate (pus), and clean out the wound so it heals faster), apply once daily for 30 days -gauze island with border (type of dressing), apply once daily for 30 days -skin prep to peri-wound, apply once daily for 30 days -elevate legs, float heels in bed; off-load wound Review of the medical record failed to indicate staff informed the Resident's primary care provider of the wound provider's recommendations and failed to indicate the recommendations were implemented. Review of the Wound Evaluation and Management Summary, dated 1/31/23, indicated Resident #70's wound had deteriorated and increased in size measuring 3.1 cm x 2.9 cm x 0.3 cm and required surgical debridement to remove necrotic (dead) tissue which revealed a stage 4 pressure wound. Wound recommendations included the following: -normal saline wash, apply once daily for 24 days; Iodosorb gel, apply once daily for 24 days -gauze island with border (type of dressing), apply once daily for 24 days -skin prep to peri-wound, apply once daily for 24 days -elevate legs, float heels in bed; off-load wound Review of the medical record failed to indicate staff informed the resident's primary care provider of the wound provider's recommendations and failed to indicate the recommendations were implemented. Review of the Wound Evaluation and Management Summary, dated 2/17/23, indicated Resident #70's stage 4 pressure wound had deteriorated measuring 3.2 cm x 3.8 cm x 0.3 cm and required surgical debridement to remove necrotic tissue. Wound recommendations included the following: -Iodosorb gel, apply once daily for 30 days, normal saline wash, apply once daily for 30 days, calcium alginate (wound dressing that keeps the wound moist enough for proper healing), apply once daily for 30 days -ABD pad, apply once daily for 30 days, gauze roll stretch 4 inch, apply once daily for 30 days -skin prep to peri wound, apply once daily for 30 days -reposition, elevate legs, float heels in bed, off-load wound Review of the medical record failed to indicate staff informed the resident's primary care provider of the wound provider's recommendations and failed to indicate the dressing treatment recommendations were ordered and implemented until 2/23/23. Review of the February 2023 Treatment Administration Record indicated the following: -19 of 84 shifts, heels not documented as being off-loaded Review of a Nurse Practitioner's Progress Note, dated 2/13/23, indicted Resident #70 had a CT Angio (type of test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues) on 2/2/23 for a large malleolar (medial ankle) non-healing ulcer which showed no signs of arterial disease. During an interview on 8/24/23 at 8:35 A.M., Unit Manager (UM) #1 said Resident #70 acquired a stage 4 pressure wound on his/her left medial ankle at the facility and was followed by the wound doctor. UM #1 said the facility did not have a dedicated wound care nurse and would just use whoever was available. During an observation with interview on 8/24/23 at 1:43 P.M., the surveyor observed Resident #70 sitting in a wheelchair next to his/her bed. A gauze wrap was observed wrapped around the Resident's left ankle and was dated 8/22/23. Resident #70 said he/she wasn't sure how the wound got there. Review of the current Physician's Orders indicated the following: -Elevate legs and float heels while in bed one time a day, 4/27/23 -Stage 4 pressure wound of the left, medial ankle, normal saline wash, pat dry, apply Iodosorb gel followed by calcium alginate, cover with ABD, skin prep peri area and wrap with gauze roll every day shift, 5/27/23 Review of the August 2023 Treatment Administration Record indicated the following: -3 of 28 days, no documentation the legs were elevated and heels floated -5 of 28 days (8/11/23, 8/18/23, 8/20/23, 8/23/23, 8/27/23), no documentation the stage 4 dressing change was completed On 8/28/23 at 1:25 P.M., the surveyor observed Nurse #5 perform a dressing change on the Resident's left medial ankle wound. Resident #70 said staff were not changing the dressing every day and only did it every now and then. Nurse #5 removed the old dressing which did not have an ABD pad applied per physician's orders and said the wound was a stage 4 pressure ulcer. Nurse #5 said the ABD pad was needed because, without it, the gauze could pull on the skin. The calcium alginate dressing was removed which contained a mild amount of yellow slough. The wound bed was observed covered with yellow slough and the surrounding skin was red and inflamed. The wound was approximately the size of a quarter in circumference with an irregular border. Nurse #5 said the surrounding skin was red and warm to touch. Nurse #5 did not measure the wound prior to completing the dressing change and did not off-load the Resident's heels upon completion of the dressing change. During an interview on 8/29/23 at 11:19 A.M., Nurse #6 said she was assigned to the Resident and was familiar with him/her. She said Resident #70 was admitted with a heel wound and developed a left ankle pressure wound while at the facility. Nurse #6 said the Resident's risk factors included circulation issues and diabetes and needed assistance from staff for bed mobility. She said interventions included putting boots on while in bed and said wound treatments were supposed to be done every day. Nurse #6 said if a new area is identified the wound doctor would come and make recommendations, a nurse would notify the attending physician who would then approve the recommendations, then the nurse would enter the order in the system. She said this should have been done right away but it wasn't. Nurse #6 further said nurses should document in a progress note the presentation of the wound and interventions placed. During an interview on 8/29/23 at 11:42 A.M., UM #1 said the 1/25/23, 1/31/23, and 2/17/23 wound recommendations were not communicated to the attending physician or implemented but should have been. He said there were two days in January when the skin prep was not applied as ordered. UM #1 said a nurse should have called the physician to communicate the wound recommendations to obtain orders but this was not done after the 1/25/23, 1/31/23, and 2/17/23 wound provider's visits. He further said the left medial ankle wound did deteriorate so the Resident was sent to vascular for a stent. UM #1 said the heels should have been consistently off-loaded and the wound started as a DTI on 1/18/23 then was a stage 4 pressure ulcer. He said nursing should write a progress note and complete the required pressure or non-pressure form as indicated. During an interview on 8/29/23 at 12:12 P.M., the Director of Nursing (DON) said the current order was for a left-medial ankle dressing change every day shift and there were five days in August that it was not documented as being done and was a concern. He said he believed one day, on the 18th, the Resident went to the hospital for an ultrasound, but there were no progress notes as to when he/she left and when he/she came back. The DON said the dressing should have been changed daily. b. Review of the Weekly Skin Evaluation forms failed to identify the left medial ankle pressure wound, identified by the wound physician on 1/17/23, as a new area on the 1/19/23, 1/27/23, 2/3/23, 2/21/23, and 2/28/23 forms including documentation of measurements of the skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations per facility policy. During an interview on 8/29/23 at 3:03 P.M., UM #1 said he completed the 1/19/23 skin evaluation and did not complete it correctly as he documented that there was an old wound, so it did not prompt him to document the new skin alteration of the left medial ankle. He said the 1/27/23, 2/3/23, 2/21/23, and 2/28/23 assessments did not reflect it either. c. Review of the Pressure Ulcer Evaluation, dated 1/18/23, indicated the date Resident #70's DTI of the left medial ankle was first observed on 11/4/22. During an interview on 8/29/23 at 3:03 P.M., UM #1 said he completed the 1/18/23 pressure form and documented the date first observed incorrectly. He said it was a facility acquired pressure wound that was first identified on 1/17/23 by the wound doctor and not upon admission to the facility. During an interview on 8/30/23 at 10:04 A.M., Physician #1 said he reviews all the decubitus wounds with staff but could not recall notification back in January of the Resident's new left medial ankle pressure wound. He said he did not recall communication made to him by staff regarding the wound and was not sure how the wound was doing currently as he had not been in to see the Resident. During an interview on 8/30/23 at 12:41 P.M., the Wound Physician said he was following Resident #70. He said he identified the Resident's wound on 1/17/23 and it was a mixed bag of a pressure wound with an arterial component to it. He said the Resident was revascularized on 2/24/23 but the left heel wound was the driving force for that. The Wound Physician said the left medial malleolus wound was facility acquired and in the process of the left heel turning over the medial malleolus went in the wrong direction and, if it continued, he was going to send the Resident back to the vascular surgeon. He said the medial malleolus had gotten worse, so he switched the dressings around. He said when he sees a resident and makes recommendations his preference is to have a dedicated wound care nurse at the facility, but the facility did not have one. He said back in January he had sporadic help from staff so whomever the nurse was would help or it would be an end of the week chore for the DON. The Wound Physician said the wound care recommendations should have been communicated to the attending physician and implemented. During an interview on 8/30/23 at 1:44 P.M, the surveyor reviewed the medical record with the DON and Regional Nurse #2 who said the left medial ankle pressure wound was facility acquired in January of this year. Regional Nurse #2 said treatments should have been completed as ordered. The DON said if there are wound recommendations, then staff should run the recommendations by the physician immediately and, if he agrees, then enter the orders. Regional Nurse #2 said the wound physician treatment recommendations from 1/25/23, 1/31/23, and 2/17/23 were not communicated to the physician or implemented that she could see until 2/23/23. She said the pressure ulcer evaluation form should have had the correct date of acquire and weekly skin checks should have indicated any new areas with a description of the wound.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interviews and records reviewed, the facility failed to treat one Resident (#28), of 20 sampled residents, with respect and dignity. Specifically, the facility failed to allow Resident #28 to exercise his/her right to smoke. Findings include: Resident #28 was admitted to the facility in May 2022 with the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), hypertension, and heart failure. Review of the Minimum Data Set (MDS) assessment, dated 5/16/23, indicated Resident #28 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 8/25/23 at 2:31 P.M., Resident #28 said he/she recently lost their right to smoke for a two-week timeframe after being observed smoking in the wrong location. Resident #28 said he/she was told they lost their smoking privileges for two weeks and if he/she was caught again they would be discharged . Resident #28 said he/she was informed that smoking is not a right but is a privilege. Review of Resident #28's Nurses Note, dated 7/5/23, indicated Resident #28 was observed smoking outside of facility implemented hours and he/she lost all smoking privileges for one week. During an interview on 8/29/23 at 1:18 P.M., the Assistant Director of Nurses (ADON) said on 7/5/23 Resident #28 was not abiding by the set smoking times and as a result his/her smoking privileges were revoked. The ADON said all residents sign a smoking contract and have been educated on the smoking policy. The ADON said the smoking contract includes the consequences that will be implemented if a resident does not abide by the contract. Review of the facility provided untitled document, signed by Resident #28 on 4/26/23, indicated but was not limited to: -Residents choosing to smoke are expected to follow the attached facility policy and procedure for the Smoking Policy - Residents and agree to the following Policy highlights. -Smoking is only permitted in designated resident smoking areas and at the designated times. -Failure to abide by the Smoking Policy - Residents will result in a potential loss of individual privileges to smoke. -Continued failure to abide by the Smoking Policy - Residents may result in a thirty-day discharge notice. -I have been provided with a copy of the Smoking Policy- Residents, it has been explained to me, and I agree to abide by policy during my stay. During an interview on 8/29/23 at 3:39 P.M., the Director of Nurses (DON) said the smoking contract was recently updated and is an extension of the smoking policy. The smoking contract explains the process, expectations, smoking times, and the facility's response to offenses. The DON said the smoking contract included notification to residents that they will lose their privileges if they do not follow the contract. The DON said the contract is reviewed with the residents and they sign it indicating agreement. Review of the facility provided Smoking Contract, dated 7/26/23, indicated but was not limited to: -I agree that I will follow facility smoking policy and I acknowledge and understand that I may be subject to lose my smoking privileges if I smoke outside the allotted smoking times and location (by gazebo) in place. I understand that the smoking times are as follows: 9:00 AM, 1:30 PM, 4:00 PM, and 7:00 PM -I also understand that I am not to have any smoking materials in my possession at any time. I understand that any resident smoking outside of the designated hours/location will be subject to lose their smoking privileges. -1st offense: 3 days loss of smoking privileges -2nd offense: 7 days loss of smoking privileges -3rd offense: 14 days loss of smoking privileges -4th offense: issued a discharge notice The facility was unable to provide the surveyor with a copy of the current smoking contract signed by Resident #28. During an interview on 8/29/23 at 3:39 P.M., the DON said Resident #28 did have a situation where his/her privileges were taken away, but he/she maintained his/her right to smoke, because the privileges were taken away because of a decision the Resident made. The DON said residents do have the right to smoke, but If the contract is not followed they will lose their privilege. During an interview on 8/30/23 at 8:45 A.M., Resident #28 said his/her smoking privileges had been revoked at least two times and he/she was told the next offense would require initiation of discharge from the facility. Resident #28 said he/she did not recall signing a smoking contract but was not sure. During an interview on 8/30/23 at 10:04 A.M., the DON said he will look to see if Resident #28 had signed the current smoking and provide the surveyor with a copy. At the time of the survey completion, no further information had been provided to the survey team.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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Based on record review, policy review, and staff interview, the facility failed to ensure the Resident Representative was fully informed in advance and given information necessary to make health care decisions to the extent required by the court for one Resident (#15), from a total sample of 20 residents. Findings include: Review of the facility's policy titled Psychotropic Medication, dated March 2018, indicated but was not limited to: -Obtain physician's order. -A physician's order and an appropriate diagnosis is required for all psychotropic medications. -An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medication. -The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review. The resident, and when indicated, the family or responsible person, will be included in this process prior to administration. Resident #15 was readmitted to the facility in July 2023 with diagnoses which included schizoaffective disorder, psychotic disorder with delusions, and hallucinations. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/5/23, indicated Resident #15 was unable to complete the interview for the Brief Interview for Mental Status. Resident #15's cognitive skills for daily decision making were coded as severely impaired. Review of the medical record indicated Resident #15 had been deemed incapacitated and a court appointed legal guardian was elected in January 2013. Review of Resident #15's current Physician's Orders indicated but was not limited to: -Clonazepam (benzodiazepine) 0.5 milligrams (mg) by mouth two times per day for anxiety, dated 2/4/22. Review of the Medication Administration Record for July and August 2023 indicated Resident #15 received Clonazepam per physician's orders. Review of the medical record failed to indicate informed consent had been obtained for the use of Clonazepam. During an interview on 8/28/23 at 8:06 A.M., Nurse #3 and the surveyor reviewed the medical record and failed to locate an informed consent for Clonazepam. Nurse #3 said the consent was not obtained from the guardian. During an interview on 8/28/23 at 8:45 A.M., the Director of Nurses (DON) and the surveyor reviewed the medical record and failed to locate an informed consent for Clonazepam. The DON said the expectation was for informed consent to be obtained for psychotropic medications and any medications used out of class, that were used for behaviors, prior to administration. On 8/28/23 at 10:30 A.M., the surveyor attempted to contact Resident #15's Legal Guardian for an interview with no return call back.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure for one Resident (#39), that medications were not self-administered without a physician's order and an assessment for self-administration, out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Safety and Supervision of Residents, revised April 2018, indicated but was not limited to the following: -As part of their overall evaluation, the staff and/or practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. -In addition to general evaluation of decision-making capacity, the staff and/or practitioner will perform a more specific skill assessment, including but not limited to the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. -The staff and/or practitioner will document their findings and the choices of residents who are able to self-administer medications. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. -Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration. Resident #39 was admitted to the facility in June 2023 with diagnoses including heart failure, pneumonia, diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD) (group of lung diseases that block airflow and make it difficult to breathe). Review of the Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #39 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and required extensive assistance with some activities of daily living. On 8/24/23 at 12:47 P.M. and 8/28/23 at 7:46 A.M., the surveyor observed Resident #39 lying in bed. There was a storage compartment located on top of his/her side table unlocked. The following medications were stored in the Resident's room, unlocked, and accessible to anyone entering the room: -one bottle of Azelastine HCL (antihistamine to treat allergies) nasal solution 0.1% -one bottle of Ipratropium bromide (used to treat runny nose) nasal solution 0.03%, 21 micrograms (mcg)/spray -one bottle of Vicks [NAME] (decongestant) saline nasal spray -one bottle of artificial tears (lubricates dry eyes) -one bottle of Afrin nasal spray (relieves nasal congestion) -one bottle of Fluticasone Propionate nasal spray (treats seasonal and year-round allergic and non-allergic nasal symptoms) -one Albuterol sulfate HFA inhaler (to prevent and treat wheezing and shortness of breath) During an interview on 8/24/23 at 12:47 A.M., Resident #39 said he/she took the medications for nasal congestion because he/she gets all clogged up. The Resident said he/she took the medications by him/herself and got a piece of paper that said he/she could do any of the stuff him/herself. Review of the medical record failed to indicate the Resident had been assessed to self-administer the Azelastine nasal spray and artificial tears. Further review failed to indicate a physician's order for the Afrin nasal spray. During an interview on 8/29/23 at 12:24 P.M., Unit Manager (UM) #1 said if residents want to self-administer, they need a physician's order, an assessment for each medication to ensure they're safe, and a lock box to put them in. UM #1 said the Resident was not assessed to self-administer the Azelastine or artificial tears and could not locate an order for Afrin. UM #1 said all the medications should have been secured in the lock box. During an interview on 8/30/23 at 8:56 A.M., the Director of Nursing (DON) said if medications were found at the bedside that weren't assessed, then staff would have to go through the process to ensure they were okay. He said there should be an assessment for each medication to see if a resident is capable, understands the side effects, the timing, and the dosage. If so, then staff would obtain an order from the physician that it was okay to self-administer each, which would include safety and storage of the medications so they would not be lying around and available to anyone. The DON said he was not aware the Resident had medications that were not approved stored at the bedside. He said the process was not followed per facility policy to include the proper assessments, orders, and storage. See F761

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure a reasonable accommodation was made for one Resident (#1), out of a total sample of 20 residents. Specifically, the facility failed to ensure the call system button was accessible to the Resident to summon assistance when needed. Findings include: Review of the facility's policy titled Answering Call Lights, revised April 2018, indicated but was not limited to the following: -Ask the resident to return the demonstration so that you will be sure that the resident can operate the system. -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. -Report all defective call lights to the nurse supervisor promptly. Resident #1 was admitted to the facility in February 2020 with diagnoses including dysphagia (difficulty swallowing), cerebral infarction with left hemiplegia (paralysis on one side of the body), muscle weakness, dementia, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and malignant neoplasm of the colon. Review of the Minimum Data Set (MDS) assessment, dated 8/17/23, indicated Resident #1 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and required extensive assistance for bed mobility, transfer, toileting, and personal hygiene. On 8/24/23 at 8:56 A.M., the surveyor observed Resident #1 lying in bed resting. The Resident's left hand was contracted and resting on top of his/her abdomen. The call system button was tied in a knot around the Resident's left side rail and was hanging down towards the floor. Resident #1 said he/she had had a stroke. Resident #1's roommate said the Resident's left arm was paralyzed. On 8/28/23 at 7:58 A.M., the surveyor observed Resident #1 lying in bed eating breakfast with his/her right hand. The Resident's left hand was contracted and resting on top of his/her lap. The call system button was tied in a knot around the Resident's left side rail and was hanging down towards the floor. Resident #1 said he/she could not use the call button because he/she could not move his/her left arm. Resident #1's roommate said the Resident has to yell to get staff when he/she needs them. On 8/29/23 at 10:10 A.M., Certified Nursing Assistant (CNA) #3 and Nurse #6 entered the room with the surveyor. The call system button was tied in a knot around the Resident's left side rail and was hanging down towards the floor. Nurse #6 said the call button was usually attached to the Resident's chest so he/she could use it. CNA #3 said the Resident was not able to use the call button and, when she tried pushing it, it did not work anyway. During an interview on 8/29/23 at 10:20 A.M., Unit Manager (UM) #1 said the Resident should have had a call bell that he/she was able to use and was within reach.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on interview, observation, and policy review, the facility failed to ensure the resident's right to personal privacy and confidentiality was promoted and protected when a staff member provided a printed copy of the facility's Resident Census to a visitor. Findings include: Review of the facility's policy titled Confidentiality of Personal Privacy, dated as last revised 11/2017, indicated but was not limited to: - The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. - Access to resident personal and medical records will be limited to authorized staff and business associates. - The facility will strive to protect the resident's privacy regarding his/her: a. accommodations e. visits - Release of resident information, including video, audio or computer stored information, will be handled in accordance with resident rights and privacy policies. On 10/19/23 at 11:59 A.M., a person knocked on the door of the conference room where the surveyors were seated for the duration of the survey. The person introduced himself as a visitor to the facility. The surveyor observed several computer printed sheets in the visitor's hand. The surveyor questioned the visitor about the document. During an interview at this time, the visitor said he had been provided with a Resident Census by the receptionist so he could walk through the facility and find residents who were his friends. The surveyor asked the visitor if he was employed by the facility, he said he was not, but had been a former administrator at the facility. During an interview on 10/19/23 at 12:50 P.M., Receptionist #1 said she was familiar with the visitor from previous employment at the facility and provided him with a Resident Census when the visitor asked which residents still resided in the facility. Receptionist #1 said she should not have provided private resident information to the visitor or anyone else. During an interview on 10/19/23 at 1:30 P.M., the Administrator said protected resident information including the Resident Census should not be provided to anyone who was not authorized to receive the information.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on policy review, record review, observation, and interview, the facility failed to develop and implement the Plan of Care for one Resident (#21), out of a total sample of 20 residents. Specifically, the facility failed to implement fall prevention and smoking interventions. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 11/2017, indicated but was not limited to the following: - A comprehensive, person-centered care plan is developed and implemented for each resident. - Each resident's person-centered care plan will be consistent with resident rights, including the right to receive the services and/or items included in the plan of care. - The comprehensive, person-centered care plan will: a. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and 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 the resident's functional status and/or functional levels. - Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area and their causes, and relevant clinical decision making. Resident #21 was admitted to the facility in June 2023 with diagnoses including history of falling, muscle weakness, hemiplegia following a cerebral infarction affecting left side (partial paralysis after a stroke), chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment, dated 6/18/23, indicated Resident #21 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, required assistance with activities of daily living (ADLs), transfers and wheelchair mobility. a. Review of the medical record indicated Resident #21 had five falls at the facility between June 2023 and August 2023. Review of the Falls Care Plan indicated but was not limited to the following: - Encourage resident to call for assistance with toileting and transfers. - Apply Dycem (non-slip mat to prevent sliding) to wheelchair. - Assist resident to pick out clothing. - Assist with toileting prior to smoking times. - Bedside table close to bed within reach. - PT (Physical Therapy) to see if a reacher (grabber tool used to pick up items not in reach) is appropriate. The surveyor made the following observations: - 8/28/23 at 9:36 A.M., Resident #21 was in bed after smoke break, no Dycem was on his/her wheelchair. - 8/29/23 at 11:35 A.M., Resident #21 was in bed resting before lunch, no Dycem was on his/her wheelchair. - 8/29/23 at 11:45 A.M., Resident #21 was in bed, no Dycem was on his/her wheelchair. - 8/29/23 at 1:28 P.M., Resident #21 was on the floor next to the bed, his/her wheelchair was next to the bed with no Dycem on it. - 8/30/23 at 9:00 A.M., Resident #21 was observed transferring from his/her wheelchair to the bed, no Dycem was on his/her wheelchair. During an interview on 8/29/23 at 11:35 A.M., Certified Nursing Assistant (CNA) #2 said Resident #21 did have a fall recently, but usually isn't a fall risk. Additionally, CNA #2 said there is no dycem or cushion on his/her wheelchair and was unsure if there should be any on the wheelchair. During an interview on 8/29/23 at 1:28 P.M., Unit Manager #1 said there is no dycem on his/her wheelchair, but it should be there. During an interview on 8/29/23 at 3:39 P.M., the Director of Nurses (DON) said every resident should have a cushion and Resident #21 should have a dycem on his/her chair. b. Review of the Smoking Care Plan indicated but was not limited to the following: - Apron use while smoking. - Monitor resident's safety while smoking. - Resident is assessed for supervision level. The surveyor made the following observations: - 8/28/23 at 8:58 A.M., Resident #21 was outside in the smoking gazebo smoking with no apron on and no staff member present. - 8/29/23 at 1:40 P.M., Resident #21 was outside in the smoking gazebo smoking with no apron on. During an interview on 8/29/23 at 1:44 P.M., CNA #1 said some residents can smoke independently and no residents wear smoking aprons. During an interview on 8/29/23 at 2:18 P.M., Activity Assistant #1 said no residents use any protective equipment or smoking aprons. Additionally, she said Resident #21 did not require supervision as far as she knew. During an interview on 8/29/23 at 3:39 P.M., the DON said none of the resident's wear smoking aprons and Resident #21 never wore one. Additionally, the DON said Resident #21 should be supervised while smoking.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#62) with a history of trauma, out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, revised October 2019, included but was not limited to: -Policy: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -Trauma informed care is culturally sensitive and person-centered. -Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. -Resident-Care Strategies -As part of the Comprehensive Assessment, identified history of trauma or interpersonal violence when such information is provided to the facility. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. -Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.) as able. Resident #62 was admitted to the facility in June 2022 with diagnoses including Post Traumatic Stress Disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being). Review of the quarterly Minimum Data Set (MDS) assessment, dated 2/17/23, indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the Resident was cognitively intact. Review of the most recent annual MDS, dated [DATE], indicated Resident #62 had a diagnosis of PTSD, and there was no BIMS score documented for this assessment. During an interview on 8/24/23 at 8:30 A.M., Resident #62 said he/she has been asking to speak with the facility social worker, with no results. The Resident said he/she is dealing with PTSD and was receiving counseling by a community provider prior to admission. He/she said that although he/she was being seen by the mental health service provider (psychotherapist) at the facility, he/she said the psychotherapist was not helpful and felt it was not enough to address his/her triggers. The Resident said he/she wanted to see a psychiatrist and no one at the facility was helping him/her with this issue. The Resident said everyone asks him/her if he/she is depressed, but the Resident said no, he/she is angry. Resident #62 said he/she tries not to put himself/herself in a trigger situation, but if it occurs, he/she goes to bed and shutdown (referring to shutting out everyone/everything). Resident #62 said that he/she had confided in Certified Nursing Assistant (CNA) #4 who has been helpful for one specific trigger. During an interview on 8/28/23 at 3:00 P.M., CNA #4 said the Resident shared with him that taking a shower is not a comfortable thing, so he provides assistance to the Resident during these times. CNA #4 said he did not share this with any other staff. Review of the Social Service admission Assessment, signed as completed on 6/28/22, indicated that the Resident had a diagnosis of PTSD, BIMS of 14 (indicating cognitively intact), and had experienced a serious accident at work or during recreational activity. The assessment did not include any other resident specific information about the nature of the trauma, or its effects on the Resident. Review of the quarterly Social Service Assessments, dated 9/18/22, 12/11/22, 3/5/23, and 6/6/23, all indicating Trauma Informed Care Issues (bullying) follow-up - hx (history) not forth coming with information. Review of the facility's Consultant Psychotherapist's Notes, dated 2/6/23, 2/13/23, 2/20/23, 2/27/23, 3/6/23, 3/13/23, 3/20/23, 3/27/23, and 4/3/23, documented the Resident's diagnosis as code 43.12, referring to the diagnosis of PTSD. The documented treatment plan for each visit was always the same; continue 1:1 therapy 1-4 times a month for 90 days. The psychotherapist failed to assess and document the traumas, and a plan to assess his/her triggers. During an interview on 8/28/23 at 3:30 P.M., the psychiatric Nurse Practitioner (NP) said she only sees Resident #62 for psychiatric medication management, and since the Resident is not on many medications, she does not see him every month. The NP suggested to speak with the psychotherapist, however he was unavailable for the next two weeks and could not be interviewed by the surveyor. Review of the medical record failed to indicate facility staff collaborated with the Resident's family, or any other health care professional that provided care to the Resident, to gather information related to the Resident's PTSD to develop a person-centered plan of care that identified potential triggers of trauma with interventions to prevent re-dramatization. During an interview on 8/29/23 at 10:26 A.M., Social Worker #2 said she has only been in the facility for 5 visits, and her usual schedule is two times a week, alternating with Social Worker #1. Social Worker #2 was not acquainted with Resident #62, and not aware that the Resident had a history of PTSD, nor had she heard that the Resident was asking to speak with a social worker. Social Worker #2 said the expectation is if a resident does not identify what the traumatic incidents were during the initial Social Worker Assessment, then the social worker should revisit the resident quarterly to address the concerns, then develop an appropriate care plan and provide services as needed. During an interview on 8/29/23 at 2:00 P.M., the Director of Nurses (DON) said he was aware of the Resident's medical status, but not aware that the Resident had a history of PTSD. The DON was not aware that CNA #4 was helping Resident #62 with an identified past trigger, and able to help Resident #62 out with personal care, including showers. During a follow-up interview on 8/29/23 at 3:00 P.M., Social Worker #2 said that although the Resident initially declined to provide specific triggers/traumatic event information, she said she could not find evidence that the Resident was ever reassessed for trauma.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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2. Resident #21 was admitted to the facility in June 2023 with diagnoses including diabetes mellitus, diabetic neuropathy, and diabetic foot ulcer. Review of the Minimum Data Set (MDS) assessment, dated 6/18/23, indicated Resident #21 had received insulin. Review of the Diabetes Care Plan indicated but was not limited to the following: - Diabetes: Potential for hyperglycemia/hypoglycemia - Administer insulin per physician orders - If resident exhibits signs and symptoms of hyperglycemia or hypoglycemia test blood sugar Review of the current Physician's Orders indicated but was not limited to the following: - Humalog Insulin Solution (Insulin Lispro) inject 7 units subcutaneously (under the skin) two times a day (fast acting insulin) - Insulin Glargine Solution 100 units/milliliter inject 42 units subcutaneously one time a day (long-acting insulin) - Jardiance 10 milligrams (mg) by mouth one time a day (prescription pill to help lower blood sugar) - Metformin HCL 1000 mg give one tablet by mouth two times a day (prescription pill to help lower blood sugar) Review of Resident #21's August 2023 Medication Administration Records (MAR) indicated he/she was administered insulin and prescription pills as ordered. Further review of the August MARs indicated the monitoring of adverse consequences to insulin medications were not being documented. During an interview on 8/29/23 at 11:03 A.M., Nurse #4 said hyperglycemia and hypoglycemia should be documented in the Resident's MAR. During an interview on 8/29/23 at 10:39 A.M., Unit Manager #1 said documentation should be in the medical record with an order in place for monitoring. During an interview on 8/29/23 at 11:29 A.M., the Director of Nurses (DON) said the facility should monitor for signs and symptoms of hyperglycemia and hypoglycemia every shift when a resident receives insulin. Based on observations, interviews, and records reviewed for two Residents (#13 and #21), of 20 sampled residents, the facility failed to monitor for signs and symptoms of adverse consequences (i.e., side effects) of medication. Specifically, for Residents #13 and #21 the facility failed to monitor for signs and symptoms of hyperglycemia and hypoglycemia (high and low blood sugars) with the administration of insulin (anti-diabetic injectable medication). Findings include: 1. Resident #13 was admitted to the facility in January 2023 with diagnoses which included diabetes mellitus and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 7/25/23, indicated Resident #13 had received insulin. Review of Resident #13's current Physician's Orders indicated but was not limited to: -Humalog Kwikpen (insulin) subcutaneous (under the skin) solution pen-injector 100 unit/milliliter (mL) inject as per sliding scale, dated 1/22/23 -Lantus Subcutaneous Solution (insulin) 100 unit/mL inject 52 units subcutaneously one time a day for diabetes, dated 6/14/23 Review of Resident #13's August 2023 Medication Administration Records (MAR) indicated he/she was administered insulin as ordered. Further review of the August MARs indicated the monitoring of adverse consequences to insulin medications were not being documented. During an interview on 8/29/23 11:03 A.M., Nurse #4 said hyperglycemia and hypoglycemia should be documented in the Resident's MAR. During an interview on 8/29/23 at 10:39 A.M., the Unit Manager said documentation should be in the medical record with an order in place for monitoring. During an interview on 8/29/23 at 11:29 A.M., the Director of Nurses (DON) said the facility should monitor for signs and symptoms of hyperglycemia and hypoglycemia every shift when a resident receives insulin.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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Based on policy review, record review, and interview, the facility failed to assess for eligibility, and offer Pneumococcal Vaccination per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#42), out of a sample of five residents. Findings include: Review of facility's policy titled Pneumococcal Vaccine, dated 11/2017 and last revised 7/2023, indicated but was not limited to the following: - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections - Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated. - If a resident refuses, appropriate entries will be documented in the medical record indicating the date of refusal. - For residents who receive the vaccines the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the medical record. - Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/15/23 indicated the following: - For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. Resident #42 was admitted to the facility in October 2021 with diagnoses including history of Parkinson's disease, glaucoma, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 7/4/23, indicated Resident #7 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, required assistance with ADLs, transfers, and wheelchair mobility. Further review of the MDS indicated the Resident was not up to date with the pneumococcal vaccine and the reason coded was not offered. Review of the medical record indicated Resident #42 had a signed consent for the Pneumococcal Vaccine, dated 2/11/22. Further review of the medical record failed to indicate Resident #42 received the vaccine or refused the vaccine. During an interview on 8/30/23 at 11:49 A.M., Unit Manger #1 said he had never given a pneumonia vaccine at the facility and was not sure why Resident #42 was never given the vaccine. During an interview on 8/30/23 at 1:49 P.M., the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said she did not know why the vaccine had not been given since 2022 when the consent was signed. During the interview the surveyor and ADON/IP reviewed the medical record together, and the ADON/IP was unable to provide any historical documentation to indicate why the vaccine was not offered and administered. ADON/IP said the vaccine should have been administered and it was not.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/28/23 at 9:23 A.M., 8/29/23 at 9:22 A.M., and 8/30/23 at 9:31 A.M., the surveyor observed the following in room [ROOM NUMBER]: -behind the television was a broken outlet faceplate with exposed wiring, -the resident complained that the television was not getting all the channels, -the wall behind the two headboards, had a electrical cover that was detached from the wall exposing wires and a hole. -a ripped window curtain, two out of three window screens with holes and/or ripped open, -the window had a green/brown colored moss-like substance visible on the windowsill. On 8/30/23, the surveyor observed the following: -room [ROOM NUMBER] at 9:33 A.M., a ripped and poorly secured window curtain. -room [ROOM NUMBER] at 9:35 A.M., a poorly secured window curtain. -room [ROOM NUMBER] at 9:36 A.M., a window with no screen and green/brown colored moss-like substance visible on the windowsill. -room [ROOM NUMBER] at 9:41 A.M., a ripped window screen and green/brown colored moss-like substance visible on the windowsill. During an interview on 8/30/23 at 10:43 A.M., the Director of Maintenance said he was aware of the electrical issues in room [ROOM NUMBER] and has an electrician coming to the facility, but did not identify when. The Director of Maintenance said he had not been made aware of the issues with the curtains, window screens and windowsills, or any other environmental concerns observed by the surveyors. He said that the previous Friday he had an in-service with anyone who would listen about TELS system (communication system to inform the Maintenance Director of broken equipment and other environmental issues at the facility), because staff were not informing him of any environmental issues or concerns. Based on observation and interview, the facility failed to maintain a clean environment and equipment and furniture in good repair, on one of two units. Findings include: On 8/30/23 at approximately 8:10 A.M. to 10:00 A.M., the surveyor observed the following on the first floor: -room [ROOM NUMBER]A, the drawer was broken and separated from the bedside table and sitting on the floor. -room [ROOM NUMBER]A, the resident said the call light was not working. Upon examination, the button was sticky to the touch, and could not be pushed in. The bed remote controls were not fully functioning, and the foot of the bed could not be elevated. -Main Dining Room, the large skylight had a buildup of mold along the edges, and the glass was dirty. The three sliders, located along one side of the dining room, were observed to have a buildup of moss/mold substance at the base of each door. -room [ROOM NUMBER]A, the floor fan had a buildup of dust, and there were two holes (approximately 2 X 4 inches) in the wall, located behind the headboard. The Resident said they have been there since his/her admission last year.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, grievance book review, and interview, the facility failed to implement their grievance policy and ensure that: 1. Grievances voiced by residents were addressed and prompt efforts were made to resolve the grievances relative to smoking and overnight staff sleeping during their shift; 2. Five out of nine Grievance/Compliant Forms reviewed were completed properly and/or resolved within 3-5 working days; and 3. Staff documented receipt of all grievances on the Grievance Log which is used for tracking and trending purposes. Findings include: Review of the facility's policy titled Grievances, revised [DATE], indicated but was not limited to the following: -The Administrator is identified as the Grievance Official responsible for oversight of the grievance process in the facility. This includes responsibility for reviewing and tracking grievances, leading any investigations, ensuring that grievances and/or complaints are confirmed or not confirmed, and that a written grievance decision has been provided to the person filing the grievance. -Grievances may be submitted orally or in writing. -Upon receipt of a written grievance and/or complaint, the Administrator will refer it to the appropriate department head for investigation. The department head will submit a written report of such findings to the administrator within 3 working days of receiving the grievance and/or complaint. The investigation and report should be completed using the Grievance/Complaint Report Form. -The Administrator will document receipt of all grievances on the Grievance Log. The report will be used for tracking and trending. -The resident, and/or health care representative, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. This report will be completed by the Administrator, within 3-5 working days of the receipt of the grievance or complaint within the facility. -The Resident Council is an additional forum within the facility for voicing complaints/grievances. 1. On [DATE] at 9:22 A.M., the surveyor held a Resident Council meeting with 15 residents in attendance, 13 of which actively participated in the group discussion representing 2 of 2 units. a. During the Resident Council meeting, 11 residents voiced concern that staff were sleeping during their shift with the 11:00 P.M.-7:00 A.M. shift being the worst, particularly between 1:00 A.M.-5:00 A.M. The Residents said staff would set their alarms to wake up and they had pictures of it happening which were brought to the attention of the Activities Director (AD) about six months ago who said to not do that. Three residents said they also told the Administrator about three weeks ago but, thus far, there had been no follow-up and said they felt as though he wouldn't do anything about it because then they wouldn't have enough staff. The residents said the problem persists. During an interview on [DATE] at 11:15 A.M., the Ombudsman said she was made aware by the residents that Certified Nursing Assistants (CNAs) were sleeping in cots in the hallway. She said she brought it to the attention of the Administrator about three weeks ago. During an interview on [DATE] at 9:10 A.M., the AD said she was aware residents complained of staff sleeping during the overnight shift. She said it was brought to her attention a couple months ago by residents during a coffee social. The AD said she wasn't sure but thinks she told the previous Administrator a couple months ago. Review of the Grievance book, dated [DATE] through [DATE], failed to indicate a grievance had been initiated and investigated by the AD or the Administrator. b. During the Resident Council meeting, seven (7) smokers were in attendance. 7 out of 7 voiced concern that they felt their smoking rights were being violated and when they went to the Administrator regarding their concerns, they were told it was a privilege and not a right to smoke. They said if they hide their cigarettes then their personal belongings will be searched, and the staff would take away their right to smoke. One resident said it was worse than prison. The residents also complained that the Administrator changed the smoking location to farther away from the facility entrance resulting in them having to go down a long walkway that's uneven. They said it was not safe for anyone with a wheelchair or a walker. The residents said they were also concerned about inclement weather approaching regarding ice and slush. They said they can no longer smoke directly in front of the building and the new location is a family area and people wouldn't want to bring their family there with the smoke and cigarette butts on the ground. The residents said they brought their concerns to the Administrator who told them no, they could not smoke closer. During an interview on [DATE] at 11:15 A.M., the Ombudsman said smoking at the facility was a disaster as the new location was difficult for residents to get to. She said residents used to be able to smoke on the side of the building. During an interview on [DATE] at 10:23 A.M., the Administrator said he was the designated Grievance Official and oversaw the grievance process, but the social workers assisted him. He said once staff receives a grievance, whether verbal or written, the grievance gets disseminated to the appropriate department and should be completed within five days though was unsure if it was business days or not. The Administrator said every grievance should be investigated and documented. He said he was made aware by residents of their smoking complaints and staff sleeping but did not file a grievance on their behalf or formally investigate per facility policy. He said the process was not followed. 2. Review of the Grievance Book, dated [DATE] through [DATE], indicated the following grievances: a. A grievance brought forward by residents during a Resident Council meeting to the Administrator, Director of Nursing, and Department Head, undated, indicated Certified Nursing Assistants were not passing out nourishments. The grievance failed to include the date filed and the date the grievance/complaint was resolved to ensure it was timely. During an interview on [DATE] at 10:54 A.M., the Administrator said the form should have been dated when it was initiated and when it was resolved but was not. He said he could not determine if it was completed timely if it wasn't dated. b. A [DATE] grievance was brought forward by a health care representative to the Administrator indicating a smoke detector was going off all weekend with no battery replacement, the elevator certificate was expired, and that there was a lack of soap in the bathroom. The form failed to indicate the date of resolution and that the health care representative who filed the grievance was informed of the findings of the investigation and the steps taken to resolve the grievance. During an interview on [DATE] at 10:54 A.M., the Administrator said the form should have been documented properly and dated to remain in compliance. c. A [DATE] grievance was brought forward to the Administrator by a health care representative indicating that a resident was wondering where his/her scooter was that the resident had brought in over five years ago. The form failed to indicate a date of resolution. During an interview on [DATE] at 10:57 A.M., the Administrator said it should have had a date of resolution. d. A [DATE] grievance brought forward by residents during a Resident Council meeting to the Administrator indicated showers and fresh sheets were not being done on shower day and the televisions were too loud at night for some residents. The form failed to indicate documentation of the investigative process and indicated the date of resolution as [DATE], 25 days after the grievance was initiated. During an interview on [DATE] at 10:58 A.M., the Administrator said the grievance was not completed timely and the investigative piece should have been completed. e. A [DATE] grievance brought forward to the Social Worker by a resident indicated that he/she was missing four pairs of colored underwear that were brand new and two shirts for three weeks. The resident stated he/she mentioned it to laundry staff more than once with no resolve. The form failed to indicate documentation of the investigative process and failed to indicate a date of resolution. During an interview on [DATE] at 10:59 A.M., the Administrator said the investigative piece was incomplete and there should have been a date of resolution. 3. Review of the Grievance Book, dated [DATE] through [DATE], failed to indicate Grievance Tracking Logs were completed for tracking and trending purposes per facility policy. During an interview on [DATE] at 11:01 A.M., the Administrator said logs had not been completed that he could find but was part of their policy and should be in place.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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Based on policy review, observation, record review, and interview, the facility failed to provide an environment free of accident hazards as possible for three Residents (#21, #37, and #63), out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #21, ensure supervision was provided, smoking articles were maintained safely, and protective equipment was utilized; 2. For Resident #37, ensure supervision was provided and smoking articles were maintained safely; and 3. For Resident #63, ensure that cigarettes were properly secured after use. Findings include: Review of the facility's policy titled Smoking Policy-Residents, dated 11/2017, indicated but was not limited to the following: - The facility shall maintain safe resident smoking practices. - Smoking is only permitted in designated smoking areas, which are located outside of the building. - Smoking is not allowed inside the facility under any circumstances. - The resident will be evaluated on admission and evaluation will include the ability to smoke safely with or without supervision. - Any smoking-related privileges, restrictions, and concerns shall be noted in the care plan, and all personnel caring for the resident shall be alerted to these issues. - Residents are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. All forms of lighters, including matches, are prohibited. - The facility maintains the right to remove smoking articles found in violation of the smoking policies. 1. Resident #21 was admitted to the facility in June 2023 with diagnoses including history of falling, muscle weakness, hemiplegia following a cerebral infarction affecting left side (partial paralysis after a stroke), Chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment, dated 6/18/23, indicated Resident #21 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, required assistance with activities of daily living (ADLs), transfers, and wheelchair mobility. Review of the Smoking Care Plan indicated but was not limited to the following: - Apron use while smoking. - Resident is assessed for supervision level The surveyor made the following observations: - 8/28/23 at 8:58 A.M., Resident #21 was outside in the smoking gazebo, smoking a cigarette with no apron on and no staff supervision. Certified Nursing Assistant (CNA) #1 entered the smoking area for the scheduled 9:00 A.M. smoke break and asked who was smoking. Resident #21 said he/she was and that he/she picked up an old cigarette from the ground and borrowed a lighter to light it. - 8/29/23 at 1:40 P.M., Resident #21 was outside in the smoking gazebo smoking with no apron on. Review of the Nurse's Note, dated 8/28/23 at 22:24, indicated Resident #21 was smoking in the bathroom of his/her room and had smoking articles in his/her possession. During an interview on 8/28/23 at 9:15 A.M., Resident #21 said no one wears a smoking apron, and he/she has never worn one. During an interview on 8/29/23 at 1:44 P.M., CNA #1 said some residents can smoke independently and no residents wear smoking aprons. During an interview on 8/29/23 at 2:18 P.M., Activity Assistant #1 said no residents use any protective equipment or smoking aprons. Additionally, she said Resident #21 did not require supervision as far as she knew. During an interview on 8/29/23 at 3:39 P.M., the Director of Nurses (DON) said none of the resident's wear smoking aprons and Resident #21 never wore one. Additionally, DON said Resident #21 should be supervised while smoking. 2. Resident #37 was admitted to the facility in January 2023 with diagnoses including COPD, adjustment disorder, and chronic respiratory failure. Review of the MDS assessment, dated 7/4/23, indicated Resident #37 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, required assistance with ADLs, transfers, and wheelchair mobility. Review of the Smoking Care Plan indicated but was not limited to the following: - Resident requires supervision while smoking The surveyor made the following observations: - 8/28/23 at 9:30 A.M., Resident #37 self-propelled his/her wheelchair from outside the smoking area into the smoking gazebo and lit a cigarette. No other residents or staff were present. - 8/29/23 at 1:40 P.M., Resident #37 self-propelled his/her wheelchair out to the smoking gazebo, then up to Activity Assistant #1 with a full-size cigarette in hand and asked for a light. Activity Assistant #1 proceeded to light the cigarette. During an interview on 8/29/23 at 1:44 P.M., CNA #1 said Resident #37 did not need supervision while smoking as far as she knew. Additionally, CNA #1 said there were no cigarettes in the box for Resident #37 and that she never gave him/her a cigarette or a lighter. During an interview on 8/29/23 at 2:18 P.M., Activity Assistant #1 said Resident #37 did not need supervision as far as she knew and that he/she had no cigarettes in the box. Additionally, she said Resident #37 is not supposed to have any cigarettes in his/her possession and she did light a cigarette for him/her during smoke break although she was not sure where he/she got it from. During an interview on 8/29/23 at 3:39 P.M., the DON said residents are not allowed to have any smoking paraphernalia on them or in their rooms. He said Resident #37 was reported to be smoking, however he/she denied having any cigarettes or lighter when I confronted him/her this morning. The surveyor informed the DON that Resident #37 had a full cigarette when he/she entered the gazebo for smoke break at 1:40 P.M. today. The DON said he/she must be hiding the cigarettes and lighter. The DON said he did not believe Resident #37 needed supervision while smoking. The DON reviewed the smoking evaluation, dated 5/11/23, with the surveyor which indicated Resident #37 needed supervision to smoke and should utilize an apron. The DON reviewed the smoking care plan which indicated Resident #37 required supervision while smoking. The DON said the process of who needs supervision is confusing and care plans are not always updated when they should be. Additionally, the DON said the evaluation and care plan should match indicating the level of care and supervision required. He also said all staff should know who requires supervision and there is a breakdown here that we need to fix. 3. Resident #63 was admitted to the facility in May 2022 with diagnoses that included solitary pulmonary nodule and chronic obstructive pulmonary disease. Review of Resident #63's Smoking Evaluation, dated 2/9/23, indicated the following: -The Resident was a smoker. -The Resident was deemed safe to smoke independently. -The Resident could communicate that they understood smoking materials are for use in designated smoking areas & must be stored in the facility's designated storage area (smoking box). On 8/24/23 at 12:30 P.M., the surveyor observed a loose cigarette on top of the Resident's nightstand. During an interview on 8/25/23 at 12:36 P.M., Resident #63 said he/she kept cigarettes and a lighter in his/her backpack. On 8/25/23 at 1:03 P.M., the surveyor and Unit Manager (UM) #1 observed a few cigarettes in an open pack on top of Resident #63's nightstand, with no one in the room. During an interview on 8/25/23 at 1:03 P.M., UM #1 said the cigarettes should not have been in the Resident's room and that all smoking materials are required to be kept in a locked box at the nurses' station.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, for one Resident (#69) of 20 sampled residents, the facility failed to ensure an indwelling urinary catheter was assessed for removal resulting in the extended use of an indwelling device. Findings include: Resident #69 was admitted to the facility in October 2021. He/she was re-admitted to the facility in March 2023 with an indwelling urinary catheter and diagnoses which included: diabetes mellitus, urinary tract infection, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/8/23, indicated Resident #69 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had an indwelling catheter. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #69 had an indwelling urinary catheter and a urinary tract infection. Further review of the Discharge Summary indicated Resident #69 should follow-up with urology as an outpatient. Review of the Care Plans for Resident #69 indicated the Resident had a urinary catheter, however the care plan failed to include a rationale related to the use of the indwelling catheter. Review of the Unit Appointment Book from February 2023 through the end of survey indicated Resident #69 did not have a urology appointment. During an interview on 8/29/23 at 10:07 A.M., Unit Manager (UM) #1 said he believed Resident #69 had an indwelling urinary catheter because he was retaining urine. UM #1 said at one time the Resident did not have the indwelling urinary catheter but went to the hospital and returned with a catheter. UM #1 said he did not think Resident #69 had been seen by urology. UM #1 said without a supporting diagnosis the indwelling catheter should be removed and a voiding trial should occur. UM #1 and the surveyor reviewed the electronic and paper medical records, which failed to indicate a diagnosis to support the extended use of the indwelling urinary catheter. During an interview on 8/29/23 at 11:29 A.M., the Director of Nurses (DON) said the Resident did not have a diagnosis to support the extended use of the indwelling urinary catheter. The DON said when a resident does not have an appropriate diagnosis the facility should conduct a voiding trial and attempt to remove the indwelling catheter. During an interview on 8/30/23 at 10:10 A.M., Physician #1 said he would have to review the medical record regarding the extended use of the indwelling urinary catheter but was unable to speak to the concern at that time. During an interview on 8/30/23 at 1:30 P.M., UM #1 said when a resident has an indwelling urinary catheter and no supporting diagnosis the facility should initiate a voiding trial. UM #1 and the surveyor reviewed Resident #69's physician orders from February 2023 until current which failed to indicate orders to remove the catheter, attempt a voiding trial, or set up a urology consult. During an interview on 8/30/23 at 3:00 P.M., the Administrator said he was unable to locate a facility policy that addressed the removal of an indwelling urinary catheter. Subsequent review of Resident #69's medical record, conducted after the surveyor/physician interview, indicated a new order to remove the indwelling urinary catheter and a urology consult.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected multiple residents

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3. Resident #69 was admitted to the facility in October 2021 with diagnoses including diabetes mellitus and peripheral vascular disease (a condition that affects circulation). Review of the medical record indicated Resident #69 was not seen by his/her attending physician between 1/28/23 and 7/8/23. 4. Resident #53 was admitted to the facility in October 2022 with diagnoses including dementia and heart disease. Review of the medical record indicated Resident #53 was not seen by his/her attending physician since 1/28/23. 5. Resident #28 was admitted to the facility in May 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and heart disease. Review of the medical record indicated Resident #28 was not seen by his/her attending physician between 1/16/23 and 6/14/23. Based on record review and interview, the facility failed to ensure that seven Residents (#39, #70, #69, #53, #28, #62, and #18), in a total sample of 20 residents, had physician visits every 60 days which would alternate between the physician and the nurse practitioner (NP) (indicating the physician would see the resident every 120 days). Findings include: 1. Resident #39 was admitted to the facility in June 2023 with diagnoses including heart failure, pneumonia, diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe). Review of the medical record indicated the following Physician/Nurse Practitioner documentation: 1/6/23 - Progress Note (NP) 1/16/23- Routine Progress Note (Physician) 4/11/23 - Progress Note (NP) 5/20/23 - Progress Note (NP) 6/14/23 - Progress Note (NP) (last entry) During an interview on 8/30/23 at 10:01 A.M., Resident #39 said he/she had not seen his/her physician in a long time and said it's ridiculous. During an interview on 8/30/23 at 10:04 A.M., Physician #1 said the Resident should be seen alternating with a NP every 60 days and could not recall when he last saw the Resident. 2. Resident #70 was admitted to the facility in November 2022 with diagnoses including adult failure to thrive, diabetes mellitus type 2, psychotic disturbance, anxiety disorder, depression, and mood disturbance. Review of the medical record indicated the following Physician/Nurse Practitioner documentation: 2/7/23 - readmission Progress Note (Physician) 2/13/23 - Progress Note (NP) 5/16/23 - Progress Note (NP) 8/11/23 - Routine Progress Note (Physician) During an interview on 8/30/23 at 12:20 P.M., the Director of Nursing (DON) said physician visits should occur every 60 days and are to be alternating between the NP and the MD. 6. Resident #62 was admitted to the facility in June 2022 with diagnoses including traumatic brain injury and PTSD. During an interview on 8/24/23 at 8:30 A.M., Resident #62 said he/she never sees the physician. Review of the medical record indicated Resident #62 was not seen by his/her attending physician between 2/2/23 and 6/23/23. 7. Resident #18 was admitted to the facility in January 2021 with diagnoses which included end stage renal disease requiring dialysis, cerebral palsy, hyperlipidemia (high cholesterol), and diabetes. Review of the medical record indicated Resident #18 was visited by the physician on 1/28/23. Resident #18 was visited by the Nurse Practitioner (NP) for all previous and subsequent visits. During an interview on 8/30/23 at 8:58 A.M., Unit Manager #1 said Physician #1 was in the facility a couple of times per week. Unit Manager #1 said the expectation was for residents to be seen by a physician within 48 hours of admission, then every 30 days for first three months then every 60 days. Unit Manager #1 said the physician should see the resident at least every 120 days. During an interview on 8/30/23 at 10:35 A.M., Physician #1 said if the Resident is not in the facility at the time of his facility visit (at dialysis, medical appointment, at the hospital etc.), he would not see the resident. Physician #1 said residents are required to be seen every 60 days, with alternating visits by the Nurse Practitioner. The physician said it was unacceptable that the visits have not occurred as required.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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2. Resident #15 was readmitted to the facility in July 2023 with diagnoses which included schizoaffective disorder and psychotic disorder with delusions and hallucinations. Review of the most recent MDS assessment, dated 8/5/23, indicated Resident #15 was unable to complete an interview for the Brief Interview for Mental Status. Resident #15's cognitive skills for daily decision making were coded as severely impaired. Review of Resident #15's current Physician's Orders indicated but was not limited to: -Clonazepam (benzodiazepine) 0.5 milligrams (mg) by mouth two times per day for anxiety, dated 2/4/22. Review of the MAR for July and August 2023 indicated Resident #15 received Clonazepam per physician's orders. Review of Resident #15's MAR for July and August 2023 failed to indicate he/she was monitored for side effects related to the use of antianxiety medication. During an interview on 8/28/23 at 8:06 A.M., Nurse #3 and the surveyor reviewed the medical record and failed to locate an order to monitor for side effects for Clonazepam. Nurse #3 said there is no order. During an interview on 8/28/23 at 8:15 A.M., the Assistant Director of Nurses (ADON) said the Clonazepam was being used as an antianxiety. The ADON said the nurses should have monitored for side effects of Clonazepam. Based on records reviewed, policies reviewed, and interviews, the facility failed to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two Residents (#13 and #15), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #13, to monitor for targeted behaviors with the use of psychotropic medication; and 2. For Resident #15, to monitor for signs and symptoms of side effects for a benzodiazepine being utilized for anxiety. Findings include: Review of the facility's policy titled Psychotropic Medication, dated March 2018, indicated but was not limited to: -Obtain physician's order. -A physician's order and an appropriate diagnosis is required for all psychotropic medications. -An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medication. -The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review. The resident, and when indicated, the family or responsible person, will be included in this process prior to administration. 1. Resident #13 was admitted to the facility in January 2023 with diagnoses which included bipolar disorder, anxiety, and psychosis. Review of the Minimum Data Set (MDS) assessment, dated 7/25/23, indicated Resident #13 had received psychotropic medications. Review of Resident #13's current Physician's Orders indicated but was not limited to: -Sertraline HCL (antidepressant)150 milligrams (mg) by mouth in the morning, dated 1/22/23 -Olanzapine (antipsychotic) 5 mg by mouth in the morning, dated 8/3/23 Review of Resident #13's August 2023 Medication Administration Records (MAR) indicated he/she was administered psychotropic medications as ordered. Further review of the August MARs indicated the monitoring of targeted behaviors related to the psychotropic medications was not documented. During an interview on 8/29/23 at 11:03 A.M., Nurse #4 said behaviors should be documented in the Resident's MAR. During an interview on 8/29/23 at 10:39 A.M., the Unit Manager said documentation should be in the medical record with an order in place for monitoring of behaviors and side effects. The surveyor and the Unit Manager reviewed Resident #13's medical record and could not find the order and/or supporting documentation. The Unit Manager said without this information monitoring the efficacy of the medication could not be determined. During an interview on 8/29/23 at 11:29 A.M., the Director of Nurses (DON) said the facility should monitor for behaviors and side effects every shift when a resident receives psychotropic medication.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on record review, policy review, and interview, the facility failed to ensure residents were free of significant medication errors for one Resident (#70), out of a total sample of 20 residents. Specifically, the facility failed to: a. ensure Novolog (Insulin Aspart) (fast acting insulin that controls blood sugar around meal times) injection solution was administered only if the capillary blood glucose (CBG) level was 120 or above in accordance with physician's orders, resulting in a potential for significant adverse consequences to the Resident; and b. monitor for potential signs and symptoms of adverse consequences (i.e., side effects) related to the use of an anti-diabetic injectable medication. Findings include: Review of the facility's policy titled Diabetes-Clinical Protocol, revised December 2020, indicated but was not limited to the following: -The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. -The staff will incorporate such parameters into the Medication Administration Record and care plan. -The staff will identify and report complications such as hypoglycemia. -The staff and physician will manage hypoglycemia appropriately. Resident #70 was admitted to the facility in November 2022 with diagnoses including diabetes mellitus type 2. Review of the Minimum Data Set (MDS) assessment, dated 8/21/23, indicated Resident #70 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. a. Review of current Physician's Orders indicated the following: -Novolog (Insulin Aspart) injection solution 100 units/milliliter (ml), inject 18 units subcutaneously (SC) one time a day related to type 2 diabetes mellitus, administer for CBG >120 or above, 6/13/23 -Novolog solution 100 units/ml, inject 14 units SC two times a day for diabetes, hold for CBG <120, 11/10/22 Review of the July 2023 Treatment Administration Record (TAR) indicated the following: Novolog solution, 18 units SC one time a day, administer for CBG >120 or above: 7/11/23 - CBG 98, Novolog documented as being given 7/14/23 - CBG 99, Novolog documented as being given 7/18/23 - CBG 94, Novolog documented as being given 7/24/23 - CBG 82, Novolog documented as being given Novolog solution, 14 units SC two times a day, hold for CBG <120 7/4/23 - CBG 85 (11:30 A.M.), Novolog documented as being given 7/8/23 - CBG 99 (11:30 A.M.), CBG 109 (4:30 P.M.), Novolog documented as being given 7/18/23 - CBG 102 (11:30 A.M.), Novolog documented as being given 7/21/23 - CBG 106 (4:30 P.M.), Novolog documented as being given Review of the August 2023 TAR indicated the following: Novolog solution, 18 units SC one time a day, administer for CBG >120 or above: 8/1/23 - CBG 72, Novolog documented as being given 8/3/23 - CBG 102, Novolog documented as being given 8/4/23 - CBG 93, Novolog documented as being given Novolog solution, 14 units SC two times a day, hold for CBG <120: 8/9/23 - CBG 87, Novolog documented as being given During an interview on 8/29/23 at 12:29 P.M., the surveyor reviewed the medical record with Unit Manager (UM) #1 who said the insulin doses should have been held for the reviewed CBGs <120 per physician's orders and considered them to be medication errors. During an interview on 8/29/23 at 4:02 P.M., Nurse #6 said she documented the insulin as being given on 7/4/23, 7/18/23, and 7/21/23 even though the CBG was <120. She said normally she would hold it, but her documentation did not reflect that. During an interview on 8/30/23 at 6:30 A.M., Nurse #7 said she documented the insulin as being given on 7/8/23 and 7/11/23 but should have documented it was held if the sugars were below range. She said the Resident's blood sugars are usually low in the morning, but he/she doesn't get symptomatic. b. Further review of Physician's Orders and the July and August 2023 TARs failed to indicate the physician ordered reporting information related to blood sugar management per facility policy and failed to indicate Resident #70 was being monitored for potential signs and symptoms of adverse consequences (i.e., side effects) related to the use of the anti-diabetic injectable medication. During an interview on 8/30/23 at 7:45 A.M., Resident #70 said he/she wasn't aware of what his/her blood sugars were in the morning, staff don't tell him/her. The Resident said he/she didn't know if staff were monitoring for side effects, they don't say anything. During an interview on 8/30/23 at 7:52 A.M., UM #1 said there was no order to monitor for signs and symptoms of hypo/hyperglycemia. During an interview on 8/30/23 at 9:23 A.M., the Director of Nursing (DON) said the insulin doses were to be given as written per physician's orders and should have only been given if the CBGs were >120. He said the insulin doses reviewed with the surveyor were documented as being given and there was no order to monitor for signs and symptoms of hypo/hyperglycemia. The DON said there should have been monitoring to ensure the Resident was not having any symptoms.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #39 was admitted to the facility in June 2023 with diagnoses including heart failure, pneumonia, diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe). Review of the Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #39 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. On 8/24/23 at 12:47 P.M. and 8/28/23 at 7:46 A.M., the surveyor observed Resident #39 lying in bed. There was a storage compartment located on top of his/her side table unlocked. The following medications were stored in the Resident's room, unlocked, and accessible to anyone entering the room: -one bottle of Azelastine HCL (antihistamine to treat allergies) nasal solution 0.1% -one bottle of ipratropium bromide (used to treat runny nose) nasal solution 0.03%, 21 micrograms (mcg)/spray -one bottle of Vicks [NAME] (decongestant) saline nasal spray -one bottle of artificial tears (lubricates dry eyes) -one bottle of Afrin nasal spray (relieves nasal congestion) -one bottle of Fluticasone Propionate nasal spray (treats seasonal and year-round allergic and non-allergic nasal symptoms) -one albuterol sulfate HFA inhaler (to prevent and treat wheezing and shortness of breath) During an interview on 8/24/23 at 12:47 A.M., Resident #39 said he/she takes the medications him/herself and did not store them in the locked storage compartment located on his/her side table. During an interview on 8/29/23 at 12:24 P.M., UM #1 said he was not aware the medications were not being stored in the lock box, but they should be. During an interview on 8/30/23 at 8:56 A.M., the Director of Nursing (DON) said the medications should not be lying around and available to anyone. Based on interview, observation, and policy review, the facility failed to maintain storage of all drugs and biologicals in locked compartments, under proper temperature controls. Specifically, the facility failed to ensure: 1. Compartments containing drugs and biologicals were locked when not in use, for one of two medication carts, on one of two floors; and 2. All drugs and biologicals were stored under proper temperature controls, for one of one medication refrigerator inspected; and 3. For Resident #63, ensure all drugs and biologicals were safely secured in a locked compartment, located in the Resident's room; and 4. For Resident #39, ensure all drugs were safely secured in a locked compartment, located in the Resident's room. Findings include: Review of the facility's policy titled, Storage of Medications, dated as revised August 2020, indicated, but was not limited to the following: - Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications such as medication aides are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. - Medications and biologicals are stored at their appropriate temperatures and humidity according to the USP guidelines for temperature ranges. - The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with the facility policy. 1. On 8/28/23 at 1:11 P.M., the surveyor observed that one of two medication carts stored in front of the nursing station on the second floor, had been left unlocked and unattended. There were no nurses behind the nursing station, or near the unlocked cart at the time. On 8/28/23 at 1:13 P.M., the surveyor observed the medication cart remained unlocked and unattended, while four residents passed by independently, without staff. On 8/28/23 at 1:15 P.M., the surveyor observed Unit Manager (UM) #1, walk by the unlocked medication cart twice, without stopping to lock the cart. During an interview on 8/28/23 at 1:16 P.M., UM #1 said the medication cart should always be locked when unattended, and immediately locked the cart. 2. On 8/28/23 at 1:23 P.M., the surveyor observed the first-floor medication room with the Director of Nursing (DON); no temperature log was found for the medication refrigerator. During an interview on 8/28/23 at 1:38 P.M., the DON said the medication refrigerator temperature log was not located in the medication room. He said the facility kept the temperature log in the 11-7 binder, on the nurses' station desk. Review of the Refrigerator Temperature Log indicated the record was incomplete with missing data for 8/25/23 P.M., 8/26/23 A.M. & P.M., 8/27/23 A.M. & P.M., and 8/28/23 A.M. entries. The DON said without the temperature log filled in, he was unable to determine if the refrigerator had been kept in range. He said the temperatures should have been recorded daily and the process wasn't followed, it had been missed. 3. Resident #63 was admitted to the facility in May 2022 with diagnoses that included solitary pulmonary nodule, chronic obstructive pulmonary disease, and psoriasis. Review of the facility's policy titled, Safety and Supervision of Residents, dated April 2018, indicated, but was not limited to the following: - Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the medication to the resident when the Resident requests them. On 8/24/23 at 12:29 P.M., the surveyor observed the following prescribed medications on top of the Resident's nightstand: - One tube of Clobetasol Propionate cream 0.5% (for treatment of psoriasis and eczema) - One bottle of Fluocinonide external solution 0.05% (for treatment of psoriasis and eczema) - One inhaler of Spiriva Respimat Aerosol solution 2.5 MCG/ACT (maintenance treatment of asthma) - One inhaler of Budesonide-Formoterol Fumarate Aerosol 160-4.5 MCG/ACT(bronchodilator) - One inhaler of Albuterol Sulfate HFA Aerosol solution 108 (90 base) MCG/ACT (rescue inhaler) During an interview on 8/24/23 at 12:30 P.M., Resident #63 said he/she always keeps the medications on top of his/her nightstand so he/she will remember to take them. During an interview on 8/25/23 at 12:36 P.M., Resident #63 said he/she does not have a lock box or key for medication storage in his/her room, but that it was a good idea, and he/she would ask the facility if they could get one. On 8/25/23 at 1:03 P.M., UM #1 and the surveyor observed Resident #63's door open, with no one in the room, and a tube of Clobetasol Propionate Cream, Fluocinonide, inhaler of Spiriva Respimat, inhaler of Budesonide-Formoterol Fumarate, and an inhaler of Albuterol Sulfate, unsecured and easily accessible, on the top of the Resident's nightstand. During an interview on 8/25/23 at 1:03 P.M., UM #1 said medications should not be left on top of the nightstand. He said medications need to be stored in a locked compartment, either in the medication cart/medication room/or if the Resident has been cleared to self-administer medications, a facility provided lockbox within the Resident's room. He said Resident #63 did not have a lockbox for medication storage in his/her room, and that he was unsure if he/she had been assessed and cleared for self-administration.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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3. Resident #7 was admitted to the facility in May 2023 with diagnoses including history of traumatic brain injury and symptoms involving cognitive functions following cerebral infarction (stroke) and subarachnoid hemorrhage (brain bleed). Review of the Minimum Data Set (MDS) assessment, dated 6/24/23, indicated Resident #7 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, required extensive assistance and was dependent with ADLs, transfers, and wheelchair mobility. Review of the facility's policy titled Advanced Directives, dated 10/2017, indicated but was not limited to the following: - Advanced directive shall be displayed prominently in the medical record - Health Care Proxy is a document delegating authority to a legal representative to make health care decisions Review of the medical record indicated Resident #7 was a Full Code with a Guardianship in place. Review of the electronic medical record indicated a document titled Guardianship was not the Guardianship document for Resident #7. The document scanned into Resident #7's medical record titled Guardianship was the Massachusetts Health Care Proxy for Resident #16. During an interview on 8/29/23 at 4:33 P.M., the Director of Nurse (DON) said medical records scans the documents into the charts and this Health Care Proxy was scanned into the wrong chart. Additionally, the DON said it is not safe to have other residents' legal documents in the medical record. 4. Resident #53 was admitted to the facility in October 2022 with diagnoses which included dementia and failure to thrive. Review of the most recent MDS assessment, dated 8/3/23, indicated Resident #53 was severely cognitively impaired as evidenced by a BIMS score of 4 out of 15 and had a guardian (a court ordered document electing a person to make decisions for one who has been deemed incapacitated). a. Review of Resident #53's Physician's Orders included but was not limited to: -Invoke Healthcare Proxy (HCP), dated 10/31/22 Review of Resident #53's care plan indicated his/her HCP was activated (indicating he/she was incapable of making medical decisions). Review of the Resident Profile for Resident #53 indicated his/her first emergency contact was the HCP. Review of a Social Service's Note, dated 4/30/23, indicated the HCP was activated and there was a hearing that month to pursue a change in Resident #53's responsible party. The note indicated the hearing had occurred, but the outcome was pending. Review of a Social Service6's Note, dated 5/2/23, indicated the guardianship court date had been set for 5/11/23 and notice of the hearing was provided to Resident #53 and the facility administrator. Review of the Care Plan Note, dated 8/23/23, indicated Resident #53 had a guardian. Review of the electronic and paper record failed to indicate evidence that a guardian had been named for Resident #53. During an interview on 8/29/23 at 10:04 A.M., the Unit Manager said he believed the Resident had a guardianship but review of the medical record indicated the HCP was activated and was the emergency contact. During an interview on 8/29/23 at 4:40 P.M., the DON said Resident #53 came to the facility with a HCP in place, however the HCP was unavailable and the facility social workers were working with a law firm to have a guardian invoked. The DON said he knew there was a court date in May but was not sure of the outcome. During an interview on 8/29/23 at 5:34 P.M. Social Worker #2 said she was unable to figure out who the responsible party for Resident #53 was. Social Worker #2 said she reviewed the record and saw that in February 2023 there was documentation showing there was an attempt to remove the HCP and change to a guardian but she was unable to find any further documentation. During an interview on 8/30/23 at 11:34 A.M., Social Worker #1 said Resident #53 initially had a HCP and a conservator, but the HCP was no longer available. Social Worker #1 said there was a court date set to remove the HCP and initiate a guardian. Social Worker #1 said there was a court date set but no documentation in the record to reflect that. Social Worker #1 said the responsible party for Resident #53 should be a guardian, but again there was no documentation to support that. Social Worker #1 said she had placed a call and had sent an e-mail to the facility law firm for clarification. Social Worker #1 said in case of emergency, Resident #53's HCP should not be contacted, and the medical record did not accurately reflect the resident's status. During an interview on 8/30/23 at 3:00 P.M., the Administrator said they had not heard back from the law firm and had no further information/documentation regarding Resident #53's responsible party. b). Review of Resident #53's electronic medical record indicated the following documents had been scanned into his/her record for Resident #1A: -siderail consent -consent to treat -consent for mobile health services During an interview on 8/29/23 at 4:40 P.M., the DON said the paper documentation was scanned into the electronic medical record by someone in the medical record department. The expectation was there would be no errors when scanning into the medical record. The DON and surveyor reviewed the electronic record for Resident #53 and the DON said the consents were scanned into the wrong chart. Based on policy and record review, observation, and interviews, the facility failed to maintain medical records that were complete, accurate, organized, and readily accessible, for 3 out of 20 sampled residents, and for 2 out of 5 Residents observed during a medication pass. Specifically, the facility failed: 1. For Resident #18, to ensure information received monthly from the dialysis center documenting new laboratory results and trends, was kept and included in the Resident's medical record; and 2. For Residents #26 and #16, to ensure Physician's orders for prescribed medication were complete, with instructions for mixing; and 3. For Resident #7, to ensure the medical record accurately reflects the parties responsible for each Resident; and 4. For Resident #53, a.) to ensure the medical record accurately reflected his/her responsible party, and b.) to ensure the medical record contained only his/her documentation. 1. Resident #18 was admitted to the facility in January 2021 with diagnoses that included end stage renal disease and receives dialysis three time a week, anemia, and type 2 diabetes mellitus. Review of Resident #18's medical record indicated he/she received dialysis every Tuesday, Thursday, and Saturday. Further review of the medical record included laboratory results and trending data on a monthly report card provided by the dialysis center, located within the dialysis communication binder, for the month of August 2023. No other laboratory results from the dialysis center were located within the electronic medical record (EMR), physical medical record, or dialysis communication binder. During an interview on 8/29/23 at 10:22 A.M., Unit Manager (UM) #1 said labs received from the dialysis center would be in the dialysis binder. Unit Manager #1 said he did not see any additional laboratory results from dialysis in the medical record. During an interview on 8/29/23 at 10:22 A.M., the facility's Dietitian said she received report cards with recent laboratory results, recommendations, and trends, from the dialysis center once or twice a month. She said she reviewed the findings regularly on receipt, and adjusted care as needed, but did not keep the documentation for her files, or include it in the medical record. During an interview on 8/29/23 at 2:16 P.M., the facility's Dietitian said she reviewed Resident #18's record and found only one dialysis report card with laboratory results from August 2023. She said she reached out to the dialysis center's dietitian and requested missing data from January 2023 to July 2023. 2A. Resident #26 was admitted to the facility in May 2021 with diagnoses that included difficulty walking, and acute pain due to trauma. Review of the Physician's Orders included but was not limited to the following: - MiraLAX Powder (Polyethylene Glycol 3350), Give 17 grams by mouth one time a day for constipation (Order start date: 5/09/21). On 8/28/23 at 10:03 A.M., the surveyor observed Nurse #2 as she prepared and administered the prescribed 17 grams of MiraLAX powder in a 5-ounce cup and mixed with water. B. Resident #16 was admitted to the facility in June 2023 with diagnoses that included muscle weakness with difficulty walking, and subsequent encounter for open fracture, nonunion (broken bone). Review of the Physician's Orders included but was not limited to the following: - MiraLAX Powder (Polyethylene Glycol 3350), Give 17 grams by mouth two times a day for constipation (Order start date: 6/2/2023). On 8/28/23 at 10:22 A.M., the surveyor observed Nurse #1 as she prepared and administered the prescribed 17 grams of MiraLAX powder in a 5-ounce cup and mixed with water. During an interview on 8/28/23 at 1:55 P.M., Nurse #2 reviewed Resident #26's medication administration record (MAR) and said the MiraLAX order was incomplete because instructions for mixing were not included. She said she should have clarified the order with the Nurse Practitioner prior to administration. During an interview on 8/28/23 at 1:59 P.M., the Director of Nursing (DON) said the MiraLAX order was incomplete and needed instructions for mixing added to it. On further review, the DON said a report was generated of all Residents with an active Physician order for MiraLAX and found those to be incomplete as well.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected multiple residents

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Based on policy review, record review, and interview, the facility failed to ensure 27 residents, out of a sample of 87 residents, were offered the COVID-19 vaccine in a timely manner. Findings include: Review of the facility's policy titled COVID Vaccine of Residents, dated 12/20 last revised 5/2023, indicated but was not limited to the following: - Residents will be offered COVID vaccine to aid in preventing/spreading of SARS infection. - Upon admission, residents will be assessed for eligibility to receive the recommended COVID vaccine/booster, and when indicated, will be offered the vaccine/booster unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated. - Administration of the COVID vaccine/booster will be made in accordance with current Centers for Disease Control and Prevention (CDC) / Department of Public Health (DPH) and Centers for Medicare and Medicaid Services (CMS). Review of the CDC website www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html, last updated July 17, 2023 recommends the following: -Everyone aged 6 years and older: You are up to date when you get 1 updated Pfizer-BioNTech or Moderna COVID-19 vaccine. -Updated (Bivalent) and Original (Monovalent) COVID-19 Vaccines: Updated vaccines, sometimes called bivalent vaccines. The updated vaccines are called updated because they protect against both the original virus that causes COVID-19 and the Omicron variant BA.4 and BA.5. Two COVID-19 vaccine manufacturers, Pfizer-BioNTech and Moderna, have developed updated COVID-19 vaccines. Review of the facility's COVID Vaccination Spreadsheet, dated 8/27/23, indicated 27 residents were not up to date of the 87 residents listed. During an interview on 8/30/23 at 12:15 P.M., the Assistant Director of Nurses (ADON)/Infection Preventionist (IP) said all the residents listed as not up to date and highlighted in yellow have consented to the booster but have not yet received it. Additionally, she said they have not received it because the facility does not have a fridge to properly store the vaccine in. The ADON/IP said she keeps a list of residents who want it. ADON/IP said she started in March 2023, no one has received the booster since at least that time, and the spreadsheet shows a cumulative list of who wants the vaccine, but we have not given it to any of them. The ADON/IP also said it has been a long time, they should have been given the vaccine sooner and this is not what would be considered timely. During an interview on 8/30/23 at 1:31 P.M., the Administrator said he was unaware the facility had not been offering and administering the COVID-19 vaccine. The Administrator said that the COVID-19 vaccine should have been given timely and this delay was not timely.

MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

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Based on interviews and records reviewed, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for three Residents (#53, #62, and #63), from a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #53, to accurately reflect the number of days he/she received an anticoagulant (a group of medications that decrease your blood's ability to clot); 2. For Resident #62, to accurately reflect the Resident's current use of tobacco, and complete the BIMS (Brief Interview for Mental Status) assessment; and 3. For Resident #63, to accurately reflect the Resident's current use of tobacco. Findings include: 1. Resident #53 was admitted to the facility in October 2022 with the following diagnoses: dementia, heart disease, and atrial fibrillation (an irregular heart rhythm). Review of the most recent Minimum Data Set (MDS) assessment, dated 8/3/23, section N, indicated Resident #53 had received an anticoagulant on seven of the seven days reviewed. Review of Resident #53's July and August 2023 Medication Administration Records (MAR) indicated he/she had not received an anticoagulant medication. During a telephonic interview on 8/29/23 at 9:05 A.M., the MDS Nurse said Resident #53 had an order for a medication that indicated the use was for anticoagulant therapy. During a telephonic interview on 8/30/23 at 11:22 A.M., the MDS Nurse said the medication was an antiplatelet medication, and should not have been coded as an anticoagulant. 2. Resident #62 was admitted to the facility in June 2022 with diagnoses including Post Traumatic Stress Disorder (PTSD), and a history of traumatic brain injury. a. Review of the annual MDS assessment, dated 6/1/23, section J1300 indicated that the Resident had no current tobacco use. Review of Resident #62's smoking assessment, dated 4/2/23, indicated the Resident had been assessed as an independent smoker. Review of Resident #62's care plan, initiated on 4/14/23, indicated that the Resident wishes to smoke and is independent. Review of the nursing quarterly assessment, dated 5/16/23, indicated that Resident #62 was a non-smoker. There was no documentation in the progress notes to indicate that the Resident had stopped smoking. During a telephonic interview on 8/29/23 at 8:50 A.M., the MDS Nurse said she works remotely and relies on the nursing assessments for information to complete the MDS. On 8/29/23 at 10:46 A.M., Resident #62 was observed smoking in the designated smoking area. During an interview on 8/29/23 at 11:50 A.M., Unit Manager (UM) #1 said the smoking assessment was completed when the Resident starting smoking on 4/2/23. UM #1 said the nursing assessment, dated 5/16/23, was not correct and if the Resident stopped smoking, there should be a nursing progress note to indicate that. UM #1 said to his knowledge, Resident #62 is a smoker, and said the MDS is incorrect (inaccurate). b. Review of the annual MDS assessment, dated 6/1/23, section C (C0200-C0500) indicated that the Brief Interview for Mental Status (BIMS) had not been assessed, therefore incomplete. During a telephonic interview on 8/29/23 at 8:50 A.M., the MDS Nurse said she works remotely and relies on the social worker's assessment to complete the BIMS on the MDS. During an interview on 8/29/23 at 10:26 A.M., Social Worker #2 said a social worker should have completed the BIMS prior to the annual MDS completion but could not explain why the BIMS assessment had not been completed. 3. Resident #63 was admitted to the facility in May 2022 with diagnoses that included solitary pulmonary nodule and chronic obstructive pulmonary disease. Review of Resident #63's nursing Smoking Evaluation, dated 2/9/23, indicated the Resident was a smoker. Review of the medical record indicated that the Resident signed a smoking agreement on 4/25/23. Review of Resident #63's Nursing Evaluation, dated 5/16/23, indicated within the respiratory assessment, that Resident #63 was not a smoker. Review of Resident #63's care plan, dated 5/23/23, indicated smoking was included as an active area of focus, and that it had been an ongoing area of focus since first initiated on 4/14/23. Review of the annual MDS assessment, dated 5/23/23, indicated Resident #63 had no current tobacco use in section J1300, of the assessment. During an interview on 8/24/23 at 12:30 P.M., Resident #63 said he/she was a long-time smoker. During an interview on 8/29/23 at 8:50 A.M., the MDS Nurse said she does not work on-site, and relied on another nurse's assessment from 5/16/23 to determine Resident #63's smoking status for the MDS assessment created on 5/23/23. During an interview on 8/29/23 at 10:17 A.M., UM #1 said Resident #63 has always been a smoker, and to the best of his knowledge, has not tried to quit. He said if the Resident had told a nurse that he/she wanted to quit smoking, it would have been documented in a nurse's note and nicotine patches would have been offered. UM #1 said he could not locate any documentation indicating the Resident said he/she wanted to quit smoking, or that the nicotine patch was offered or ordered.

Mar 2021 20 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interviews and record review, the facility failed to ensure the physician was notified of changes in weight, as ordered, for Resident #42 in a total sample of 18 residents. Findings include: Resident #42 was admitted to the facility in April 2019 with diagnoses including combined congestive systolic and diastolic heart failure (progressive heart disease that affects the pumping action of the heart muscles). A review of the physician's order, dated 1/31/21, indicated the Resident was to be weighed daily and the physician was to be notified of a weight gain greater than three pounds. A review of the weights for Resident #42 indicated on 2/1/21 the Resident weighed 228.0 pounds (lbs) and on 2/2/21 the Resident weighed 241.8 lbs; a gain of 13.8 lbs. There was no documentation to indicate the physician was notified of the weight gain, as ordered. A review of the medical record indicated on 2/25/21, Resident #42 weighed 236.5 lbs and on 2/26/21 weighed 251.0 lbs; a gain of 14.5 lbs. There was no documentation to indicate the physician was notified of the weight gain, as ordered. On 2/27/21, Resident #42 weighed 243.6 lbs; a gain of 7.1 lbs from 2/25/21. In February 2021 the Resident complained of chest pain and was sent to the emergency room and was hospitalized until March 2021 for coronary artery disease. A review of the cardiology progress note from 3/5/21, indicated during the hospitalization ,Resident #42 had a chest x-ray which indicated bilateral interstitial and groundglass density which could represent edema, pneumonia or interstitial disease. During an interview on 3/16/21 at 12:15 P.M., the Director of Nurses said when a physician was notified of changes, as ordered, the nurses would document it in the nursing progress notes. There was no documentation in the nursing progress notes regarding physician notification.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #9 was admitted to the facility in December 2019 with diagnoses of dementia and cerebrovascular disease affecting right dominant side. During the group meeting held with residents on 3/11/21 at 10:00 A.M., the roommate of Resident #9 said the Resident had fallen out of bed the previous evening and the roommate had put on the call light for staff to assist the Resident. The roommate said a staff member entered the room, saw the Resident on the floor, asked why he/she does this and left the room, leaving the Resident on the floor. The roommate said it was a half hour before anyone returned to assist the Resident off of the floor. During an interview on 3/11/21 at 1:00 P.M., Resident #9's roommate said, on 3/11/21 around 3:00 A.M., Resident #9 was moving around in bed and ended up on the floor next to the bed. The roommate said a staff member saw the Resident on the floor, said words to the effect of I should just leave you on the floor, left the room and did not return for 30 minutes. The roommate said the Resident had been moving around on the floor, as if trying to get up, and was banging in to items on the floor, such as the trash barrel. On 3/11/21 at 4:30 P.M., the survey team notified the Administrator and the Director of Clinical Operations of the allegation from the roommate regarding Resident #9 being on the floor, seen by staff who questioned why he/she does this and then was not assisted off of the floor for a half hour. During an interview on 3/17/21, the Director of Clinical Operations said she had received the information from the surveyor on 3/11/21, but had not recognized the allegation of being left on the floor for 30 minutes as an allegation of neglect and therefore had not started investigating the incident until 3/12/21. She said she had not reported the allegation of neglect within 2 hours, per the facility policy, to the State Agency. Based on interview, record review and policy review, the facility staff failed to implement written policies and procedures for two incidents of injury of unknown etiology for one Resident (#26) in a total sample of 18 residents. In addition, the facility failed to implement written policies and procedures for an allegation of neglect for one Resident (#9) who was identified during the Resident Council meeting held during survey. Findings include: Review of the facility's policy, titled Abuse Prohibition, dated as revised December 2017, included the following definitions: - Injury of Unknown Etiology: defined as any resident injury where: #1- the source of the injury was not observed OR #2- the source of the injury cannot be explained by the resident AND the injury is suspicious because of its extent, location, the number of injuries observed at one time or the number of incidences of injuries over time. - Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's policy, titled Abuse Investigation, dated as revised December 2017, included the following: - the facility will investigate all alleged/potential incidents of resident abuse, neglect and injuries of unknown etiology. - Upon receiving report of, witnessing or observing an event of abuse, neglect or injury of unknown etiology, the following actions will be taken: the staff member receiving an allegation verbally, witnessing a potentially inappropriate treatment, or observing an injury of unknown etiology will report the event immediately to the nursing supervisor. - In the case of abuse or neglect (suspected, witnessed or alleged), or injury of unknown etiology, the nursing supervisor will notify the Executive Director and the Director of Nursing Services immediately. Review of the facility's policy, titled Abuse Investigation and Reporting, dated as revised June 2018, included the following: - All reports of resident abuse, neglect, mistreatment and/or and injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. - An alleged violation of abuse, neglect or mistreatment (including injuries of unknown source) will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. 1. Resident #26 was admitted to the facility in April 2020 with diagnoses which included vascular dementia with behavioral disturbances, Parkinson's Disease and chronic atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #26 had a Brief Interview For Mental Status (BIMS) score of 3 out of 15, which indicated he/she was severely cognitively impaired. On 3/9/21 at 10:36 A.M., the surveyor observed Resident #26 ambulate independently throughout the nursing unit and was observed to have bruising around both eyes and in the area of his/her forehead above the right eye region. Resident #26 was unable to provide the surveyor with any information about his/her injury. Review of Resident #26's clinical record indicated a Progress Note, dated 2/4/21, indicated Resident #26 was observed to have a red/purple discoloration to his/her right forearm. The note indicated the Resident had full range of motion and no pain and the physician was notified. Review of the clinical record indicated a Situation-Background-Assessment-Recommendation (SBAR), dated 3/2/21, indicated Resident #26 was noted to be seated in his/her room with a bruise on his/her right forehead and right black eye. The SBAR indicated the nurse completed an assessment and noted Resident #26's forehead was purple in color and his/her eye was red. The SBAR indicated the Physician was notified and Resident #26 was transferred to the local emergency room for assessment. Further review of the clinical record indicated a Progress Note, dated 3/4/21. The note indicated Resident #26 had returned to the facility on 3/4/21 from the local hospital following an admission with a diagnosis of status post fall with right forehead hematoma. The note indicated Resident had a right and left hematoma noted to both eyes and right forehead. On 3/16/21 at 10:00 A.M., review of the Health Care Facility Reporting System (reporting system utilized by the Department of Public Health) dated 2/1/21 through 3/16/21, indicated the facility failed to report the incident of 2/4/21 or 3/2/21. During an interview on 3/16/21 at 11:00 A.M., the surveyor requested the Director of Nursing (DON) provide the surveyor with the investigations regarding the incidents from 2/4/21 and 3/2/21 for Resident #26. The Director of Nursing said he would need to locate the incident reports and was unable to provide any information regarding either incident at that time. During an interview on 3/16/21 at 2:30 P.M., the DON and the Director of Clinical Operations provided the surveyor with an Incident report, dated 3/2/21. Review of the section, Incident Description, indicated Resident was a poor historian and unable to explain how he/she obtained the injury. The incident report contained three witness statements. One statement, signed and dated 3/2/21, from a rehabilitation staff member. The statement indicated the staff member entered Resident #26's room and observed Resident #26 had a bruised eye and forehead. The statement indicated the staff member reported the injury to a nurse. The statement indicated the resident was assessed by nursing, a rehab staff member and the Assistant Director of Nursing. The second statement was signed and dated 3/3/21, by a Certified Nursing Assistant (CNA). The statement indicated on 3/1/21, at approximately 2:00 A.M., she found Resident #26 in another resident's room, seated on the floor near a chair that was tipped over. The statement indicated she reported the incident to the nurse and another aide on the shift. The third statement was undated and unsigned. During the interview on 3/16/21 at 2:30 P.M., the DON identified the unsigned statement as his interview with Resident #26. The DON said at first he believed the bruising on Resident #26's face was an injury of unknown origin, but as he interviewed Resident #26, Resident #26 pointed and tapped the side rails and the DON said he believed the Resident hit his/her head. The DON said he did not feel the need to report the incident. The DON said there were no witnesses to the injury. Further review of the incident report failed to include interviews and statements from other staff members who had provided care to Resident #26, a summary of findings or conclusion regarding the injury and failed to indicate the injury of unknown origin was reported to the Department of Public Health. During an interview on 3/16/21 at 3:30 P.M., the DON and Director of Clinical Operations said the facility was unable to provide the surveyor with an incident report/investigation/statements related to the incident on 2/4/21 for Resident #26. The Director of Clinical Operations said neither incident was reported to the Department of Public Health as required.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility staff failed to ensure two incidents of injury of unknown etiology were thoroughly investigated for one Resident (#26) in a total sample of 18 residents. Findings include: Review of the facility's policy titled Abuse Prohibition, dated as revised December 2017, indicated the following definitions: - Injury of Unknown Etiology: defined as any resident injury where: #1- the source of the injury was not observed OR #2- the source of the injury cannot be explained by the resident AND the injury is suspicious because of its extent ,location, the number of injuries observed at one time or the number of incidences of injuries over time. - Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's policy titled Abuse Investigation, dated as revised December 2017, included the following: - the facility will investigate all alleged/potential incidents of resident abuse, neglect and injuries of unknown etiology. - Upon receiving report of, witnessing or observing an event of abuse, neglect or injury of unknown etiology, the following actions will be taken: the staff member receiving an allegation verbally, witnessing a potentially inappropriate treatment, or observing an injury of unknown etiology will report the event immediately to the nursing supervisor. - In the case of abuse or neglect (suspected, witnessed or alleged), or injury of unknown etiology, the nursing supervisor will notify the Executive Director and the Director of Nursing Services immediately. Resident #26 was admitted to the facility in April 2020 with diagnoses which included vascular dementia with behavioral disturbances, Parkinson's Disease, and chronic atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS), dated [DATE],indicated Resident #26 has a Brief Interview For Mental Status (BIMS) score of 3 out of 15, which indicated he/she was severely cognitively impaired. Review of Resident #26's clinical record indicated a Progress Note, dated 2/4/21, indicated Resident #26 was observed to have a red/purple discoloration to his/her right forearm. The note indicated the Resident had full range of motion and no pain and the physician was notified. Review of the clinical record indicated a Situation-Background-Assessment-Recommendation (SBAR), dated 3/2/21 which indicated Resident #26 was noted to be seated in his/her room with a bruise on his/her right forehead and right black eye. The SBAR indicated the nurse completed an assessment and noted Resident #26's forehead was purple in color and his/her eye was red. The SBAR indicated the Physician was notified and Resident #26 was transferred to the local emergency room for assessment. Review of the clinical record indicated a Progress Note, dated 3/4/21. The note indicated Resident #26 had returned to the facility on 3/4/21 from the local hospital following admission with a diagnosis of status post fall with right forehead hematoma. The note indicated Resident had a right and left hematoma noted to both eyes and right forehead. During an interview on 3/16/21 at 11:00 A.M., the surveyor requested the Director of Nursing (DON) provide the surveyor with the completed investigations regarding the incidents from 2/4/21 and 3/2/21 for Resident #26. The Director of Nursing said he would need to locate the incident reports and was unable to provide any information regarding either incident. During an interview on 3/16/21 at 2:30 P.M., the DON and the Director of Clinical Operations provided the surveyor with an incident report, dated 3/2/21. Review of the incident report contained three statements. One statement, signed and dated 3/2/21, from a rehabilitation staff member. The statement indicated the staff member entered Resident #26's room and observed Resident #26 had a bruised eye and forehead. The statement indicated the staff member reported the injury to a nurse. The statement indicated the resident was assessed by nursing, a rehab staff member and the Assistant Director of Nursing. The second statement was signed and dated 3/3/21, by a Certified Nursing Assistant (CNA). The statement indicated on 3/1/21, at approximately 2:00 A.M., she found Resident #26 in another resident's room, seated on the floor near a chair that was tipped over. The statement indicated she reported the incident to the nurse and the other aid on the shift. The third statement was undated and unsigned. The DON identified the statement as his interview with Resident #26. The DON said at first he believed the bruising on Resident #26's face was an injury of unknown origin, but when he interviewed Resident #26, Resident #26 pointed and tapped the side rails and the DON said he believed the Resident hit his/her head. The DON said there were no witnesses to the incident which caused to the injury. Further review of the incident report failed to include interviews and statements from other staff members who had provided care to Resident #26, a summary of findings or conclusion regarding the injury and failed to indicate the injury of unknown origin was reported to the Department of Public Health as required. During an interview on 3/16/21 at 3:30 P.M., the DON and Director of Clinical Operations said the facility was unable to provide the surveyor with an incident report or investigation related to the incident of 2/4/21 for Resident #26.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7.) For Resident #49, the facility staff failed to ensure the MDS Significant Change Assessment accurately reflected the Resident's end of life status. Resident #49 was admitted to the facility in [DATE] with diagnoses which included dementia, renal insufficiency and cerebral vascular accident. Review of the clinical record indicated Resident #49 was admitted to hospice services on [DATE]. Further review of the clinical record indicated a form titled, Initial Physician Certification of Terminal Illness, 1st Certification Period from: [DATE] to 4/3021, with verbal certification date of [DATE]. Review of the MDS Significant Change Assessment, dated [DATE], section J1400; Prognosis: indicated Resident #49 did not have a life expectancy of less than six months. Further review of section O; indicated Resident #49 was not receiving hospice services. During an interview on [DATE] at 12:43 P.M., the MDS Coordinator said the Significant Change MDS Assessment was initially completed as Resident #49 was admitted to hospice services on [DATE]. The MDS Coordinator said there was an oversight as to sections not being accurate and she would complete a modification to accurately reflect the resident's status. 5.) For Resident #57, the MDS assessments did not accurately reflect the Resident's end of life status. Resident #57 was admitted [DATE] and received Hospice services for two years due to chronic illness. The Resident was diagnosed with End-Stage Multiple Sclerosis. Review of the medical record indicated, Resident #57 received Hospice services, initiated on [DATE] and continued with the last Hospice certification dated [DATE] through [DATE]. The certification was signed by a Physician indicating the Resident's chronic disease may result in a life expectancy of less than six months. Review of the annual MDS assessment, dated [DATE], and the last quarterly MDS assessment, dated [DATE], both were not checked for having a life expectancy of less than six months. During record review and interview on [DATE] at 9:45 A.M., the MDS nurse was shown the Hospice Recertification plan and the documentation that attested to the Resident's end of life status with six months or less. The MDS nurse was informed the two MDS assessments that did not reflect his/her end of life and she said she was not aware of that and did not look in the Hospice documentation for that information. 6.) For Resident #64, the MDS assessments did not accurately reflect the Resident's end of life status. Resident #64 was a closed record review, admitted [DATE] and received Hospice services from admission through [DATE] when the Resident expired. The Resident was diagnosed with COVID-19, urinary tract infection and sepsis. A review of the medical record indicated, Resident #64 received Hospice services, from admission in [DATE] and continued to receive Hospice services. A review of the admission MDS assessment, dated [DATE], and the last quarterly MDS assessment, dated [DATE], both were not checked for having a life expectancy of less than six months.Based on record review and staff interview, the facility failed to complete a comprehensive assessment for seven residents (#51, #48, #56, #62, #49, #57 and #64) to ensure the assessment accurately reflected the residents' preferences in activity and health status, out of a total sample of 18 residents. Findings include: 1.) For Resident #51, the facility failed to ensure that the Minimum Data Set (MDS) assessments for significant change in status and quarterly assessments accurately reflected the Resident's health and life expectancy status. Resident #51 was admitted to the facility in [DATE], with medical conditions including history of cancer and dementia. Record review indicated physician orders, dated [DATE], for hospice services. Review of the MDS assessment for significant change in status, with a reference date of [DATE], indicated the assessment Section J for health status did not indicate a life expectancy status of six months or less, and was not coded correctly to reflect that the Resident was on hospice services. Review of the MDS quarterly assessment, with a reference date of [DATE], indicated the assessment Section J for health status did not indicate a life expectancy status of six months or less, and was not coded correctly to reflect that the Resident was on hospice services. Review of Resident #51's MDS assessments ([DATE] and [DATE]) with the MDS Coordinator on [DATE], indicated that the MDS sections O for special services both indicated the Resident was receiving hospice and that sections J were not coded correctly to indicate life expectancy status and agreed the assessments were not accurate. During an interview on [DATE], the surveyor asked if Resident #51 was receiving hospice services and Nurse #5 said the Resident had been on hospice but was no longer on services. Review of Resident #51's medical record and physician orders with Nurse #5 indicated that hospice services had been discontinued on [DATE]. 2.) For Resident #48, the facility staff failed to complete a comprehensive MDS assessment that accurately reflected the Resident's preferences for activities. Resident #48 was admitted to the facility in [DATE]. Current medical conditions included diabetes and cancer. Review of the annual MDS assessment dated [DATE], indicated the Resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of this assessment for Section F: Preferences for Customary Routine and Activities, was incomplete as it was blank. Record review and review of Resident #48's care plan indicated that the activity plan had not been reviewed or revised since 5/2020. The care plan focus for activities indicated that the Resident had previous recreational interests and encouraged to participate. During an interview on [DATE] at 1:50 P.M., the MDS Coordinator reviewed the annual assessment for Preferences and Activities and said that it was not completed. The MDS Coordinator said she had started a list of residents for activity staff that needed assessments completed. 3.) For Resident #56, the facility staff failed to complete a comprehensive MDS assessment that accurately reflected the Resident's preferences for activities. Resident #56 was admitted to the facility in [DATE] with multiple medical conditions. Review of the Resident's admission (14-day) MDS assessment dated [DATE], indicated the Resident had a BIMS score of 15 out of 15. Review of this assessment for Section F: Preferences for Customary Routine and Activities, was incomplete as it was blank. During an interview on [DATE] at 1:50 P.M., the MDS Coordinator reviewed the annual assessment for Preferences and Activities and said that it was not completed. The MDS Coordinator said she had started a list of residents for activity staff that needed assessments completed. 4.) For Resident #62, the facility staff failed to complete a comprehensive Minimum Data Set (MDS) assessment that accurately reflected the Resident's preferences for activities. Resident #62 was admitted to the facility in [DATE] with multiple medical conditions. Review of the Resident's annual MDS assessment, dated [DATE], indicated the Resident had a BIMS score of 15 out of 15. Review of this assessment for Section F: Preferences for Customary Routine and Activities, was incomplete as it was blank. During an interview on [DATE] at 1:50 P.M., the MDS Coordinator reviewed the annual assessment for Preferences and Activities and said that it was not completed. The MDS Coordinator said she had started a list of residents for activity staff that needed assessments completed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to ensure that staff obtained daily weights of one Resident (#42), per the physician's order, out of a sample of 18 residents. Findings include: For Resident #42, the facility failed to ensure that staff obtained daily weights, per the physician's order Resident # 42 was admitted to the facility in April 2019 with diagnoses including combined congestive systolic and diastolic heart failure (progressive heart disease that affects the pumping action of the heart muscle) A review of the medical record indicated Resident #42 was hospitalized in January 2021. A physician order dated 1/31/21 indicated the Resident was to be weighed daily and the physician was to be notified of a weight gain greater than three pounds. A review of the medical record for Resident #42, indicated there were no weights recorded from 2/9/21 through 2/15/21, as ordered by the physician. The Treatment Administration Record for Resident #42, indicated the reason for not obtaining a weight was 8 for other. There was no indication in the nursing progress notes as to why the weights were not obtained as ordered or if the physician was notified that weights were not being obtained as ordered. A review of the medical record indicated weights may have been obtained on 3/3/21 and 3/4/21, but had been crossed out and indicated a re-weigh was needed. There was no record of the actual weights for either day. In addition, a review of the medical record indicated there was no weight obtained on 3/14/21, as ordered. During an interview on 3/17/21 at 12:18 P.M., the Director of Nurses said Resident #42 was normally weighed via the mechanical lift. The Director of Nurses said the Resident refused to be weighed between 2/9/21 and 2/15/21 and the staff had mistakenly chosen other instead of refused. The surveyor inquired if the Resident had stayed in bed from 2/9/21 through 2/15/21, as there was no nursing progress note to indicate the Resident had refused to get out of bed. The Director of Nurses said he was not sure if this occurred.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on record review, the facility failed to ensure that the Director of Nurses completed annual dementia training as required. Findings include: The Facility Assessment, dated as last revised 1/28/21, indicated that education and competency are completed annually for all staff. The assessment also indicated that Dementia training, under caring for people with Dementia, Alzheimer's and Cognitive impairments is to be done 8 hours on hire and 4 hours yearly for Recertification. The facility utilizes the electronic educational system that staff use to take required training and maintains the dates and the courses taken. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. A review of employee records indicated the Director of Nurses is also titled the Assistant Director of Nurses, the Staff Development Coordinator, and the Infection Preventionist. The Director of Nurses' employee file indicated a hire date of 12/6/18, and had no completed competencies for any of the assigned positions. The Director of Nurses' personnel record failed to indicate that he had received the mandated annual training for dementia in 2020. The Director presented a corporation 4 day training for Director of Nurses/Assistant Director of Nurses which he attended two years ago on 1/17/19 - 1/21/19. A review of the printed names and signatures indicated he attended on 3 of the 4 days. He could offer no other recent education in 2020.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and staff interviews, the facility failed to ensure that staff dated a Tuberculin vial after opening, and that staff failed to reorder an emergency Coumadin medication kit after opening. Findings include: On 3/10/21 at 11:30 A.M., the surveyor inspected the second floor medication room with Nurse #3. The surveyor observed: 1. The medication room refrigerator had one opened vial of Tuberculin. The vial was not sealed and the vial did not contain a date to indicate when the vial had been first opened. Failure to follow the Manufacturer's Directions for Use places the resident's safety at risk. 2. The medication room had an unsealed/ opened emergency Coumadin kit with a delivery date of January 2021. The Coumadin kit was missing one 5 milligram (mg) tablet and one 7.5 mg tablet. During an interview on 3/10/21 at 11:45 A.M., Nurse #3 said there were no residents taking Coumadin at this time (Unit 2) and could not explain why the emergency kit had not been reordered. During an interview on 3/10/21 at 12:00 P.M., Nurse #5 said, after looking in the pharmacy book, the emergency Coumadin kit should have been replaced 24 hours after the kit had been opened.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, and interviews with staff and residents, the facility failed to implement their policy to ensure the safety of foods stored in resident room refrigerators. Findings include: Review of the policy titled Resident Refrigerator, updated 4/4/19, indicated that personal refrigerators are to be maintained in a sanitary manner. The refrigerator be inspected by maintenance and monitored for function. All refrigerators will be cleaned by housekeeping and/or nursing. Nursing staff will check for out dated food items weekly and refrigerator temperatures daily. On 3/9/21, the surveyor observed a small refrigerator on a table in resident room [ROOM NUMBER]. With the resident's permission, the refrigerator was inspected for cleanliness and temperature to ensure safe storage. The interior of the refrigerator was observed with dried spillage and food particles on the bottom of the unit and on the table. Food items included yogurt, pudding, olives and individual vegetable-fruit blends pouches. The expiration date listed on the yogurt was 3/10/21. On 3/12/21 at 1:06 P.M., the surveyor observed that the refrigerator in resident room [ROOM NUMBER] remained unsanitary. The yogurt with expiration date of 3/10/21 had been consumed. The resident said he/she had eaten most of it today and was not sure where to put the container, so he/she put it back inside the refrigerator. During an interview on 3/16/21 at 9:00 A.M., the Food Service Director (FSD) was asked what the monitoring procedure was for refrigerators in resident rooms and he said that dietary does not manage resident refrigerators. The Director of Nurses was questioned about resident refrigerators and said he would look for information. During an interview on 3/18/21 at 1:38 P.M., Nurse #5 said she was uncertain what the facility practice was to monitor refrigerators in resident rooms. Review of a March 2021 temperature log sheet for the resident room refrigerator indicated that there was no record of cleaning or checking for outdated foods. During an interview on 3/18/21 at 1:30 P.M., Housekeeping Staff #3 said she was not aware of, and had not cleaned any, resident refrigerators. During an interview on 3/17/21 at 1:35 P.M., the Director of Housekeeping said that the department does not clean resident refrigerators and was not aware of resident rooms with refrigerators.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0572 (Tag F0572)

Could have caused harm · This affected multiple residents

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Based on interviews and record review, the facility failed to ensure residents were informed of their rights and all the rules and regulations governing resident conduct and responsibilities during their stay. Findings include: A review of the resident council documentation indicated a group meeting of resident council had not been held since March 2020 related to the pandemic. On 3/11/21 at 10:15 A.M., the survey team held a group meeting with eight residents. The residents said they had no idea what their rights were and felt as though they had lost all of their rights including going outside, communicating with family, leaving their rooms, and voicing grievances. The residents referred to themselves as inmates and said they felt like they were in prison. The residents said they may have been informed of their rights upon admission, but some had been there so long and there was so much paperwork upon admission that they could not recall. They said no staff had reviewed their rights with them. During an interview on 3/11/21 at 12:28 P.M., the Social Worker said she is not responsible for reviewing resident rights with the residents. She said resident rights were previously reviewed at the monthly resident council meeting, which had not been held since March 2020. She said it was the responsibility of the Activity Department to review resident rights with residents. During an interview on 3/11/21 at 3:21 P.M., Activity Assistant #1 said she had been working the screening desk at the front door for the past six to seven months and had not been assisting in the activity department, therefore, had not reviewed resident rights with any residents. During an interview on 3/17/21 at 2:28 P.M., Activity Assistant #2 said she had been doing one to one visits with residents and had not reviewed resident rights with residents.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews, document review, and observations, the facility failed to ensure that grievances brought forward by multiple residents (Resident #56, Resident #48, and Resident #62) were addressed in a timely manner. Specifically, the facility failed to 1.) Address concerns related to Wi-Fi reliability, 2.) Address concerns related to resident food preferences, 3.) Address concerns related to television reliability and 4.) Address concerns related to functioning toilets. Findings include: Review of the facility grievance policy, updated December 2018, indicated: the grievance official would collaboratively work with the team to resolve the issue and provide written grievance decisions to the resident. Upon receipt of a grievance, the Administrator would refer to the appropriate department head. The investigation and report would be completed using the grievance/complaint report form. The Administrator would document receipt of all grievances on the grievance log. The resident (or person filing the grievance) would be informed of the findings of the investigation and the actions that would be taken to correct any identified problems within 3-5 business days of receipt of the grievance. On 3/11/21 at 10:15 A.M., the surveyor held a group meeting with eight residents. The residents in the group said they had been unable to meet as a group since March 2020 due to COVID-19. They said they were aware of the grievance policy and had attempted to voice individual grievances, with no resolution. The residents voiced concerns regarding the wireless internet service (Wi-Fi) continuously going out, cable television channels had static and were fuzzy along with multiple, unresolved plumbing concerns. The residents said there had been no activities offered by the facility due to COVID-19 until the previous week and that the internet and cable had been their only entertainment, yet it continued to not work properly, despite multiple voiced concerns. The residents complained of too much chicken and fish on the menu and that the menu lacked variety. 1.) During an interview on 3/10/21 at 10:03 A.M., Resident #62 said he/she enjoyed using their iPad for entertainment but the Wi-Fi did not always work. He/she said at one point, the Wi-Fi had been out for two weeks and he/she had not heard anything about what the facility was doing to fix it. Resident #62 also said that there was too much chicken and fish on the menu. During an interview on 3/17/21 at 12:02 P.M., the Director of Maintenance said he had been alerted by residents back in February 2021 that the Wi-Fi was not working and he had reported this to the IT (Information Technology) department. He said there had been previous reports of the Wi-Fi going in and out or not having a strong signal, but he had not reported it to the IT department. He said he did report the issue to the IT department when surveyors asked about the issue on the first day of survey (3/9/21). Review of the communication with the IT department indicated that following the reported concern with Wi-Fi on 3/9/21, the offsite IT department attempted to fix the connection issue. On 3/10/21, the IT department requested the Director of Maintenance test the connection, with no response. On 3/11/21 and 3/15/21, the IT department reached out again, stating that the issue should be resolved, but again failed to get a response. During an interview on 3/17/21 at 12:02 P.M., the Director of Maintenance said he was not sure why he had not replied to the IT department and that he does not really handle the internet for the facility. He said, after further requests from the surveyors, an additional ticket was submitted to the IT department on 3/16/21. The IT department concluded there was a connection issue to the network and a technician was scheduled to be sent out the following day. 2.) During an interview on 3/10/21 at 10:05 A.M., Resident #62 said that there was too much chicken and fish on the menu. Review of the facility's resident grievance log indicated there was a food complaint on 12/7/20. The complaint indicated that too much fish and chicken was served at meals and too many eggs were served at breakfast. Although the dietary department had been made aware of food complaints, the residents did not feel the variety of menu choices had changed. Review of the week 2 fall/winter (4 week cycle) menu indicated chicken was served for 14 of 28 possible choices for the lunch and dinner meals including the alternate choice. Chicken was served for five of seven noon meals, including the main meal (3/10/21 and 3/13/21) or as an alternate (3/9/21, 3/11/21 and 3/14). For the supper meal, chicken was the alternate on 3/8/21 and 3/12/21. A fish option was served twice for the noon meal (3/9/21 and 3/12/21) and served as an alternate for supper (3/11/21). During an interview on 3/10/21 at 10:00 A.M., the Food Service Director (FSD) was asked how resident food preferences are obtained and the FSD said he and the dietician visit with new residents or upon request. The FSD was not aware of resident food concerns or menu dissatisfaction. 3.) During an interview on 3/11/21 at 11:00 A.M., Resident #56 said the cable television channels were fuzzy and he/she had told the Activity Director before the Superbowl (2/7/21). The Resident identified that he/she enjoyed watching sports and found it frustrating to watch a fuzzy television. On 3/17/21 at 9:45 A.M., the surveyors observed the televisions on both units. For the second floor there were 14 television sets on. Seven out of 14 television sets were found to have static or have a fuzzy picture (rooms: #200A, #201A, #201B, #208B, #216B, #220B, and #218B). For the first floor there were 11 television sets on. Three out of 11 television sets were found to have static or have a fuzzy picture (rooms: #113A, #111A and #107B). A review of the work orders submitted to the maintenance department between 1/1/21 and 3/11/21 indicated there was poor picture quality in room [ROOM NUMBER]B and a fuzzy picture for room [ROOM NUMBER]B. At the time of the survey, neither of the issues had been resolved. During an interview on 3/11/21 at 12:00 P.M., the Director of Maintenance said he was not aware of the concerns with the picture quality on the televisions. 4.) During an interview on 3/10/21 at 9:15 A.M., the Ombudsman said there had been concerns regarding the plumbing which had not been resolved. She said this had been ongoing for months. During observations on 3/12/21 between 8:50 A.M. and 9:10 A.M., a toilet in a resident bathroom was observed, in response to concerns voiced by residents. A toilet shared between resident rooms #108-#110 did not properly flush and appeared to be clogged. Residents said that the toilet has been in and out of service (clogged and/or has water overflowing onto flooring) for months. During an interview on 3/12/21 at 3:26 P.M., the Maintenance Director said the facility uses a TELS communication system to report needed maintenance work. Review of the maintenance TELS log on 3/12/21, indicated that toilet problems had been reported 20 times on Unit 1 over the past three months. Of the 20 times, at least nine were reported about room [ROOM NUMBER]-#110. During an interview on 3/12/21, at the same time, the Maintenance Director provided a copy of plumbing work, dated October 2020, which indicated maintenance was unable to determine a source of clogging. The Maintenance Director said he feels that it is often due to operator error. During an interview on 03/17/21 at 12:30 P.M., the Ombudsman said she had been hearing about the issues with the resident Wi-Fi and cable for months. She said she had brought these concerns to the Social Worker and had not had full resolution. She said she specifically heard from Resident #48 on 9/16/20 regarding concerns with the Wi-Fi and cable and had called the Administrator for follow-up and had not heard back. She said Resident #48 had complained multiple times in the six months since then and no resolution had been offered. She said she had received two additional complaints from residents on 01/20/21 and was told by the Social Worker it was being worked on. She said within the past month she had received two calls from residents about the Wi-Fi and the lack of activities, with no resolution at this time.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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Based on observations, record review, interviews, and facility policy review, the facility failed to ensure, for one of three sampled smoking residents, that staff followed Resident #50's smoking plan of care for the use of an apron to ensure the safety of the Resident while smoking. Findings include: For Resident #50, the facility staff failed to follow the smoking policy and the Resident's plan of care by not having the Resident use an apron while smoking to ensure the Resident's safety. Review of the facility's policy for smoking residents, dated 11/2017, indicated that residents who choose to smoke are evaluated on admission to determine the residents' ability to smoke safely and will be re-evaluated quarterly, upon a significant change and as determined by staff. Under guideline #9 of the facility policy, the policy indicated any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Resident # 50 was admitted to the facility in February 2021, with a diagnoses of malignant neoplasm (cancerous tumor) of the colon and adult failure to thrive. Review of the initial Minimum Data Set Assessment, with an Assessment Reference Date of 02/10/21, indicated a Brief Interview for Mental Status score of 15 out of 15 (no cognitive deficits) and assessed the Resident to be a current smoker. A review of the smoking evaluation completed on 02/03/21, indicated Resident #50 was an independent smoker. The Smoking care plan, dated 02/03/21, indicated that the Resident required an apron while smoking. There was no documentation to substantiate the difference between the evaluation indicating independent smoking status and the smoking care plan identifying the Resident to require an apron while smoking. During an interview on 03/09/2021 at 9:10 A.M., Resident #50 said he/she is a smoker and explained the smoking times to the surveyor as 10:00 A.M., 1:00 P.M., 4:00 P.M., and 7:00 P.M. with supervision and the cigarettes are stored with the nurses and kept his/her own lighter. The surveyor observed the following: -On 03/10/2021 at 9:54 A.M., the Resident was sitting at the Nurse's station on Unit 1 and was seen to remove a black lighter from his/her coat pocket while awaiting staff to escort him/her to the smoking area. Certified Nursing Assistant (CNA) # 2 intervened and informed Resident they would secure the lighter. - On 03/12/2021 at 10:04 A.M., the Resident was in the designated outdoor smoking area with staff supervision. The Resident was sitting outside throughout the 15 minute smoking break and not wearing the designated apron as outlined in the Resident's smoking plan of care . - On 03/16/2021 at 4:11 P.M., the Resident was smoking with supervision in the outdoor designated smoking area, and not wearing the designated apron as outlined in the Resident's smoking plan of care for safety. - On 03/18/2021 at 10:04 A.M., the Resident was in the designated smoking area with CNA supervision, but without an apron in place as per his/her plan of care. During an interview on 03/18/2021 at 10:04 A.M., CNA #9 said there were no residents in the facility that required a safety device (such as an apron) when he brought them out to smoke. CNA #9 could not identify where those items would be kept. CNA #9 said the Resident has not worn an apron while he has supervised the Resident smoking at the facility. During an interview on 03/18/2021 at 10:17 A.M., Nurse #5 said she could not remember a time when any resident has ever needed an apron for smoking and she is unsure where they would be stored. During an interview and review of the observations on 03/18/2021 at 11:55 A.M., the Director of Nurses was informed of the surveyors' observations for the Resident not wearing an apron as outlined in the Smoking Care plan for safety. The Director of Nurses was unsure where the facility would store an apron for smoking or what the process would be if a resident did require the use of an apron for smoking. He said he was unaware of the Resident having the Smoking care plan list a safety intervention for an apron while smoking.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected multiple residents

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Based on interviews and record review, the facility failed to develop, implement and permanently maintain an effective training program for all staff, to include training on prevention of abuse, neglect, exploitation, and misappropriation of resident property. Specifically, a review of employee education records indicated 4 out of 7 employees had not received education related to prohibition of abuse. Findings include: A review of the education files for the Director of Nurses, Certified Nursing Assistant #7, Nurse #2 and Nurse #3 did not include education on prohibition of abuse. During an interview on 3/17/21 at 1:50 P.M., the Director of Nurses said he was not sure why the abuse prohibition training was not included in the education files for these employees.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0563 (Tag F0563)

Could have caused harm · This affected most or all residents

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Based on interviews, the facility failed to ensure that residents had virtual or window visits with family/loved ones, while in-person visits were suspended due to the COVID-19 pandemic. In addition, Resident #48 was restricted from a family window visit. Findings include: A review of the Centers for Medicare and Medicaid Services (CMS) memorandum QSO-20-39-NH, dated 9/17/20, indicated that physical separation from family and other loved ones has taken a physical and emotional toll on residents. The memorandum indicated that in-person visitation could be restricted due to COVID-19, but virtual visits could not be restricted. During a group meeting on 3/11/21 at 10:15 A.M., the surveyor met with eight residents. The residents voiced that they had not had virtual visits with their family members and were told their families could no longer come up to the windows for visits and staff tell the families to go away. All of the residents resided on the first floor. One resident stated he/she was happy to have their own cellular phone, otherwise they would not have been able to communicate with their family. One resident said he/she had an iPad, but the Wi-Fi for the residents to use was always going in and out, making virtual visits impossible. During the group meeting, Resident #48 said, when he/she was previously on quarantine, their spouse pulled in to the parking lot, sat in their car, and called Resident #48 on the telephone. Resident #48 said their spouse stayed in the car, but he/she could see their spouse through the closed window. The Resident said staff told him/her that their spouse had to leave and they could not be doing this. During an interview on 3/16/21 at 9:27 A.M., the spouse of Resident #48 said the facility staff had given the Resident a hard time about having window visits and told the Resident that they shouldn't be doing it. The spouse said the Resident gets upset because he/she does not want to break the rules. The spouse confirmed that he/she pulled in to the parking lot one day to see the Resident from the car, through the Resident's closed window. The spouse said he/she heard a staff member come into the room and ask Resident #48 what he/she was doing, and when the Resident said their spouse was in the car outside, the Resident was told they were not supposed to be doing that. The spouse said Resident #48 kept saying, I just want to see your face. The spouse said Resident #48 had been told restriction of window visits was not a policy, but the facility did not want families visiting at the windows because other people had not been following the rules. The spouse said, when in-person visitation was first restricted in March 2020, they had heard about virtual visits, but had never heard about it again. The spouse said last summer, during the in-person visits, the spouse would utilize the time they had together on their personal iPad to contact other family members for virtual visits. During an interview on 3/11/21 at 3:05 P.M., the Social Worker said in-person visitation had been restricted since mid-December 2020 until 3/11/21 due to an outbreak of Covid-19. She said prior to this day (3/11/21), the facility was doing virtual visits and phone calls so that residents could stay connected with family. She said virtual visits were available when a family called and asked for it and this was set up by Activity Assistant #1. She said some families had been told not to go to the windows of residents due to passing items through the windows, but was unaware that all residents and families were being told not to have window visits. During an interview on 3/11/21 at 3:20 P.M., Activity Assistant #1 said she had been working the screening desk at the front door, five days per week for seven to eight hours per day. She said she had been doing this for the past six to seven months. She said she had assisted with a few virtual visits when in-person visitation was restricted in the beginning of 2020. She said she had not done any during the most recent in-person visitor restriction from mid-December 2020 to 3/11/21. She said Activity Assistant #2 had been doing virtual visits over that time period. During an interview on 3/16/21 at 10:38 A.M., the Activity Director said she had started her position on 2/1/21 and had not assisted in any virtual visits since. The surveyor observed two electronic devices on stands in the activity room. The Activity Director said she was not familiar with them and when she first arrived the devices were still wrapped in bubble wrap. During an interview on 3/17/21 at 2:30 P.M., Activity Assistant #2 said she worked approximately 16 hours per week. She said she had been doing one to one activities with residents. She said she had not personally done any virtual visits for residents. She said Activity Assistant #1 had been doing virtual visits with residents and their families. She said she could not recall any family members coming to the windows for visits either, except for one family at Christmas time (almost three months prior). During an interview on 03/16/21 at 11:08 A.M., Certified Nursing Assistant #3 said she normally works on the first floor unit and was familiar with the unit and residents. She said she was told by the Administrator that residents were not allowed to have window visits and she had never seen any resident have a window visit in the previous three months. During an interview on 3/17/21 at 2:45 P.M., the Administrator said he did not know why the staff and residents thought they could not have window visits. The Administrator said the Admissions Director had helped residents facilitate virtual visits. During an interview on 3/17/21 at 2:50 P.M., the Admissions Director said she was helping residents from a technical aspect of setting up a device for virtual visits and this had happened more in the beginning of the in-person visitor restriction in 2020. She said she could not necessarily say if any virtual visits were conducted since the restriction of in-person visits in December 2020. She said the only assistance she could recall was for two residents who needed assistance for virtual legal visits and could not recall any family or socialization visits during this time.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment for two of two resident units, which included unclean resident rooms, dust laden heating vents, walls in disrepair, dirty resident furniture and lack of bedspreads. In addition, the facility failed to maintain functional toilet facilities in residents' rooms. Findings include: On 3/11/21 at 10:15 A.M., in room [ROOM NUMBER], the surveyor observed that the oxygen concentrator equipment in use was dirty with a thick, white/gray, dust-like matter on the filter. There was a label dated 4/10/2015, which indicated last checked. During an observation and interview on 3/11/21 at 10:30 A.M., Nurse #4 with the surveyor, observed the condition of the equipment. Nurse #4 indicated that the 11:00 P.M. to 7:00 A.M. shift usually checks or cleans equipment. On 3/11/21 at 11:50 A.M., in room [ROOM NUMBER], the surveyor observed the flooring, behind B bed, was coated with thick dust and unclean. The electrical wiring cover had been pulled away from the wall. The wall heating vent was full of dust. On 3/12/21 from 8:50 A.M. to 9:10 A.M., the surveyor observed a toilet in a resident bathroom in response to environmental concerns voiced by residents in the corridor. A toilet shared between resident rooms #108-#110 did not properly flush. The toilet appeared to be clogged. Residents said that the toilet has been in and out of service (clogged and/or has water overflowing onto flooring) for months. Other areas in the bathroom were also observed to be in disrepair, including the flooring tiles near the toilet which were spongy with a liquid substance seeping up when stepped on. The walls behind and on the side of the toilet buckled, and a dark substance was observed along the floor and wall joints. On 3/16/21 at 3:20 P.M., the surveyors made the following observations on Unit 1 and Unit 2: Unit 1: -None of the resident beds had a bedspread and overbed tables were observed to be dirty on the legs and table base with dried like substances. -room [ROOM NUMBER]: was an empty resident room and was made up for new admissions. The room was observed to have crumbs in the bedside table and the bed frames were observed with dust and stained areas and a paper wrapper on the floor. -room [ROOM NUMBER]: had a heater vent that was dust laden. Unit 2: -room [ROOM NUMBER]: the heater vent was covered in a thick dust; the bathroom sprinkler was covered with thick dust, and the legs of the overbed tables were dirty. -room [ROOM NUMBER]: there were no doors on the closets; the heater vent was dust laden; there was chipped paint on the lower walls and numerous patched, unpainted holes; the toilet and sink were observed with an orange discolored pipe with a tucked towel around the pipes. -room [ROOM NUMBER]: there was missing paint behind A bed; the heater vent was dust laden, and the bathroom vent fan was not functioning. -room [ROOM NUMBER]: there were nine dime sized holes in the wall by the room door entrance; discolored paint behind B bed. -room [ROOM NUMBER]: there were eight strips of missing paint behind A bed with exposed sheet rock. -room [ROOM NUMBER]: there were seven strips of missing paint with exposed sheet rock behind A bed, and six holes behind the television of B bed. -room [ROOM NUMBER]: the corner of the wall near the bathroom was observed with chipped paint; the overbed table legs were observed to be dirty with dried like substance. -room [ROOM NUMBER]: the transfer bars on A bed were observed with a brown, dried like substance on the rails; missing paint with exposed sheet rock was observed behind B bed. -room [ROOM NUMBER]: the bathroom vent was observed with an orange substance and thick dust; missing paint behind B bed, and the cord cover was pulled away from the wall. -room [ROOM NUMBER]: there were 12 strips of missing paint with sheet rock exposed behind the bed; there were cracked, browned ceiling tiles in the bathroom; the fan in the room was dusty with black build up on cage and blades, and the overbed table legs were dirty. -room [ROOM NUMBER]: there was an unpainted area behind bedside B table and brown stained ceiling tiles were observed in the bathroom. -Shower room: there were three missing floor tiles at the entrance of the tub area; the wheelchair scale was observed with missing paint and missing a large area of non-skid flooring on the scale with exposed metal; there were unlabeled, unassigned personal care items stored in the shower room. -Second floor Dayroom: the baseboard underneath the heating vent was pulled away from the wall; there was missing paint around the window frame; the heater vents were dust laden; the large white heater/cooling vent device in the back of the dayroom was observed with black dried substance by the vents. During an interview on 3/18/21 at 10:00 A.M., the Administrator said he was aware of the residents' rooms and the need for repairs. The Administrator said a QA project was started in December 2020 for maintenance to do at least two rooms a week. The Administrator said he was not aware of the lack of cleanliness within the rooms and the lack of bedspreads in the rooms. During an interview and observation on 3/18/21 at 11:40 A.M., with the Administrator and the Director of Housekeeping, the surveyor observed the laundry area and counted 15 bedspreads for the 100 bed facility. The Administrator said he was not aware of the lack of bed coverings for the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0680 (Tag F0680)

Could have caused harm · This affected most or all residents

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Based on interviews and review of the Activity Director's personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include: On 3/16/21, review of the Activity Director's personnel file failed to indicate that the Activity Director was certified as a qualified activities professional and had not completed a training course approved by the Commonwealth of Massachusetts. During an interview on 3/16/21 at 10:38 A.M., the Activity Director said she was hired for the position on 2/1/21. The Activity Director said she was currently enrolled in an on-line activity director certification program, but had not yet completed the program. The Activity Director said she told the facility Administrator upon hire, she would require approximately two more months to complete the certification program. During an interview on 3/16/21 at 3:00 P.M., the Administrator said he was aware the Activity Director had not yet completed the required activity director certification program, and was in the process of finishing the program within the next several months. The Administrator said the Activity Director was being supervised by the the Rehabilitation Director, who was an Occupational Therapist. During an interview on 3/16/21 at 3:08 P.M., the Activity Director said she did not receive supervision from anyone, including the Rehabilitation Director. The Activity Director said she was unsure who the Rehabilitation Director was. The Activity Director said she developed the calendar of events and activities for the residents by herself. During an interview on 3:12 P.M., the Rehabilitation Director said she has not offered or provided any formalized supervision to the Activity Director as the Activity Director does her own thing or words to that effect. The Rehabilitation Director said she met with the Activity Director upon hire and gave her some examples of leisure activities the residents on the second floor secured unit might enjoy.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

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Based on record review and staff interview, the facility failed to accurately assess the facility's equipment resources, services, and staff education during the annual Facility Assessment. Findings include: Review of the Facility Assessment Tool, last updated 1/28/21, indicated the following: 1. The facility had a dialysis chair and station and ventilators. 2. The facility had available resources for art therapy. 3. The Activities Director coordinated and monitored the delivery of any religious, spiritual and therapeutic activities. 4. The facility resources needed to provide activity staff (two full time personnel and one half time personnel). 5. The annual Abuse, Neglect, and Exploitation training is conducted upon hire, annually and as needed. During an interview on 3/18/21 at 11:30 A.M., the Administrator and surveyor reviewed the Facility Assessment Tool and the Administrator said the information needed to be changed as the facility did not have a dialysis chair and station and ventilators; the facility did not offer art therapy; and the Activities Director position had been vacated since 6/2020, which was not reflected in the assessment. The facility hired an Activities Director on 2/1/21. During an interview on 3/10/21 at 12:45 P.M., Activity Assistant #1 said she for the last six to seven months, she is just working at the reception desk, five days a week, doing Covid-19 screening. Activity Assistant #1 said she is not doing any activities. A review of training education records indicated that four staff had not completed annual Abuse, Neglect, and Exploitation training.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

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Based on staff interviews and staff COVID-19 testing results, the facility's Quality Assurance committee failed to analyze the root cause data collected to improve COVID-19 staff testing. The facility's weekly staff testing for unvaccinated COVID-19 health care personnel was found to be incomplete and staff not tested were allowed to work. Findings include: Review of the facility's root cause analysis indicated the facility did not follow infection control policy for COVID-19 testing. The form did not indicate what the root cause of the deficient practice was to assist the facility in determining an appropriate plan of action to make improvements. During an interview on 6/17/21 at 9:15 A.M., the Infection Preventionist (IP) said the facility was doing surveillance testing on all unvaccinated staff once per week. He said the testing schedule the facility was following started on Thursday and ended at midnight on Wednesday. He said the most recent weekly testing was conducted from 6/10/21 through 6/16/21. The IP provided the surveyor with a list of unvaccinated staff and said this was the list he was basing his weekly surveillance testing from. The surveyors reviewed the testing documentation and the facility schedules and found six staff members to have not been tested between 6/10/21 through 6/16/21. During an interview on 6/17/21 at 12:20 P.M., the IP said he had initiated a QAPI plan regarding staff testing prior to the survey. He said he was aware that unvaccinated staff were not all being tested weekly and had not made any changes to the plan. The IP nurse said he thought he was not testing all unvaccinated staff due to the staff not being available, but could offer no specific information of a plan that the management team had developed or considered. Review of the working schedules indicated the unvaccinated staff had worked and were available for testing. During an interview on 6/17/21 at 1:40 P.M., the Administrator and the IP said the Quality Assurance committee met on 6/10/21. The IP said during the meeting the facility discussed how the plan for improvement regarding testing had not been effective and testing was not being completed on all unvaccinated staff. The IP and the Administrator said there were no changes made to the ineffective plan at that time or in the week between the meeting and the survey on 6/17/21.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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Based on observations, interviews, and record review, the facility failed to ensure that staff implemented infection prevention and control practices and policies. Specifically, (1) staff failed to utilize the appropriate Personal Protective Equipment (PPE) and perform hand hygiene when entering and exiting the rooms of quarantine residents and when providing high contact care to quarantine residents; (2) the staff failed to ensure a resident maintained quarantine status, thereby increasing the potential for transmission of COVID-19 within the facility. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus 2019 Pandemic, updated February 10, 2021, indicated healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection, and also patients who have met criteria for 14 day quarantine and should be isolated, that HCP follow recommendations for proper use of personal protective equipment (PPE) including gowns, face masks, eye protection and gloves. For residents requiring transmission based precautions and placed in quarantine for suspected COVID-19, the CDC recommendation for gown use is to put on a clean isolation gown upon entry into patient room or care area. Change the gown if soiled. Remove and discard the gown into a dedicated waste or linen container before leaving the patient room. A review of the quarantine precaution sign indicated everyone must clean hands when entering and exiting, wear a gown, mask, eye protection and gloves. A. Resident #113, who was identified by staff on 3/9/21 as requiring droplet/contact precautions for suspected Covid-19 infection, was observed residing in a room designated for residents placed on 14-day quarantine. On 3/9/21 at 11:05 A.M., the surveyor observed Nurse #1 donning (putting on) personal protective equipment (PPE) before entering Resident #113's room. The notice on the wall next to the door indicated to STOP Quarantine Droplet/Contact Precautions in addition to Standard Precautions. Only essential personnel should enter. Everyone Must: including visitors, doctors and staff. Clean hands when entering and exiting. A precaution cart containing PPE was located directly outside of this Resident's room as well as a contact precaution sign indicating required PPE: gown, gloves, N95 facemask, and eye protection, along with instructions for hand hygiene, how to put on (don) PPE before entering and take off (doff) PPE when leaving the room. The surveyor observed Nurse #1 entering Resident #113's room to administer medication. At 11:08 A.M., Nurse #1 exited the Resident's room still wearing a gown. The surveyor observed Nurse #1 return to the medication cart in the unit hallway outside the Resident room and proceed to push the medication cart around the corner and towards the nurse's station. During an interview on 3/9/21 at 11:10 A.M., Nurse #1 said, Oh, I forgot to take the gown off. Nurse #1 then proceeded to re-enter the Resident's room to doff the gown, as the trash receptacle was in the middle of the room and not near the doorway. Nurse #1 said the Resident was on quarantine for 14 days. Nurse #1 failed to follow proper infection prevention and control practices for PPE use (gown) and disposal. During an interview on 3/17/21 at 10:41 A.M., the Infection Preventionist (IP) said the expectation of staff caring for residents on quarantine was for staff to follow the signs posted at the room entrance. The IP provided a copy of Quarantine Droplet/Contact Precautions sign which included instructions for what type of PPE was required and how to don (put on) and doff (remove) PPE. The IP agreed Nurse #1 should have discarded the gown before exiting the resident room and said that Nurse #1 had attended prior Personal Protective Equipment (PPE) training (12/23/20) on PPE use. B. Resident #26 was re-admitted to the facility and placed on quarantine status for 14 days. On 3/9/21 at 10:30 A.M., the surveyor observed Resident #26 sit on the floor in the hallway across from the nurse's station. Nurse #4 approached Resident #26 and physically assisted him/her off the floor by holding his/her arm and hand. Nurse #4 was observed to be wearing a mask and eye protection, no gown or gloves. Nurse #4 walked with the Resident to his/her room where a sign was posted indicating the Resident was on quarantine with droplet precautions and all staff were to don a gown and gloves upon entering the room. Nurse #4 was only then observed to put on a gown (no gloves) to enter the room of Resident #26. Nurse #4 assisted the Resident to sit in a chair by the window. Nurse #4 doffed the gown and used her hands to slide open the Resident's closet to hang the gown up, without performing hand hygiene after removing the gown. On 3/9/21 at 1:48 P.M., the surveyor observed Rehabilitation Staff #2 assist Resident #26 from the floor by holding him/her by the hand and elbow. Rehabilitation Staff #2 did not don a gown or gloves prior to contact with the Resident. C. Resident #42 was re-admitted to the facility and placed on quarantine status for 14 days. A sign outside the Resident's room indicated quarantine precautions. On 3/11/21 at 8:05 A.M., the surveyor observed Certified Nursing Assistant (CNA) #4 enter the room of Resident #42 without a gown and gloves to deliver the breakfast tray, then exited the room and did not perform hand hygiene prior to moving on to deliver additional meals to residents. On 03/11/21 at 9:40 A.M., the surveyor observed Nurse #3 approach the room of Resident #42 with medications. Nurse #3 was observed to doff her surgical mask by grabbing the mask from the front and holding it in her hand, open the precaution cart and get a gown, while keeping the surgical mask in her hand and then donned the gown and did not tie the gown. She then reached into the precaution cart and grabbed a KN95 mask and donned the mask and then donned gloves. There was no hand hygiene performed during any of these steps. With her gloved hand, she then tied the top of the gown (not the 2nd tie, leaving it open in the back) and entered the room of Resident #42. Upon exiting the room, Nurse #3 was observed to doff gloves, perform hand hygiene, doff the gown and then hold the gown in her hand to walk down the hall to the dirty utility room. While doffing the gown, the surgical mask was observed to fall out of the gown and on to the floor. During an interview on 3/11/21 at 9:46 A.M., Nurse #3 said the process was to change the surgical mask out for KN95 prior to entering the room of a resident on quarantine. She confirmed there was no trash barrel at the door of the quarantine room to change her mask. She said when she doffed the surgical mask, she tucked it in to her gown because there was nowhere else to put it. On 3/11/21 at 1:09 P.M., the surveyor observed a physician enter the room of Resident #42 without donning a gown or gloves. At 1:11 P.M., the surveyor observed the physician exit the room of Resident #42 while wearing a gown and gloves, walk down the hall, pick up a straight back chair and bring it in to the room of Resident #42. The physician failed to doff the PPE prior to exiting the resident room. 2. Review of the facility's policy titled Isolation-Categories for Droplet Precautions (revised 5/2020) (CLO137.1) indicated that staff were to ensure residents on droplet precautions (including COVID-19) wore a mask and had limited movement from (quarantine) room for essential purposes only, to prevent potential spread of infection to other residents and staff. On 3/9/21 at 10:00 A.M., the surveyor observed Resident #113, a resident identified as being on quarantine, walk through the resident unit and stand near the elevator on the first floor, which was across from the nurse's desk. Staff and other residents were also sitting/walking nearby and getting on and off the elevator. The surveyor did not observe any staff direct Resident #113 to wait in quarantine. On 3/16/21 at 1:00 P.M. and on 3/17/21 at 10:00 A.M., the surveyor observed Resident #113 standing near the elevator waiting to go outside. The Resident was not in quarantine. Staff did not redirect the Resident to remain in the quarantine room until accompanied outside to smoke.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0886 (Tag F0886)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to conduct COVID-19 testing based on parameters set forth by the Secretary including testing frequency during an outbreak, for one Nurse (#3) out of four staff reviewed and the response time for test results for four (Nurse #2, Nurse #3, Maintenance Director, Certified Nursing Assistant #2) out of four staff reviewed. Findings include: A review of the Center for Medicare and Medicaid Services memorandum dated 8/26/20 and titled: Interim Final Rule, CMS -3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care Facility Testing Requirements and Revised COVID-19 Focused Survey Tool indicated the following: -An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. -For outbreak testing, all staff and residents should be tested and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. During an interview with the Administrator and the Director of Nurses upon entrance to the facility on 5/11/21 at 8:30 A.M. the survey staff was informed the facility had a staff member test positive for COVID-19 on 4/22/21 and had completed outbreak testing with no additional positive cases. 1. A review of the COVID-19 testing documentation for Nurse #3 indicated the nurse was tested on [DATE] and then not again until 5/4/21; 11 days between retesting. A review of the schedule for Nurse #3 indicated the nurse worked the following shifts during this testing period: 4/24/21 7:00 A.M. until 11:00 P.M. 4/25/21 7:00 A.M. until 11:00 P.M. 4/28/21 7:00 A.M. to 3:30 P.M. 4/30/21 7:00 A.M. until 11:00 P.M. 5/1/21 7:00 A.M. until 7:30 A.M. on 5/2/21 During an interview on 5/12/21 at 11:45 A.M. the Director of Nurses said Nurse #3 must not have been working on the days testing was conducted. He said the procedure was to test staff who were working and if a staff member was not working, they would be tested on the next testing day. He said he did not keep track of each individual employee to ensure they had been tested every three to seven days. 2. A review of the COVID-19 testing documentation for the outbreak testing conducted from 4/23/21 through 5/7/21 indicated test results were not received timely for four out of four sampled staff members: Nurse #2, Nurse #3, Certified Nursing Assistant (CNA) #2 and the maintenance director. A review of the outbreak testing for the four sampled staff members indicated a COVID-19 test was collected on 4/23/21 and results were returned to the facility on 4/30/21 (7 days later). A review of the outbreak testing for the four sampled staff members indicated a COVID-19 test was collected on 5/7/21 and results had not been received as of 5/11/21 at 3:30 P.M. (4 days later). During an interview on 5/12/21 at 11:45 A.M. the Director of Nurses said he had not notified the epidemiologist assigned to the facility of the delayed COVID-19 test results and testing results ranged anywhere from a day to seven days. He said he had not contacted the laboratory to determine the delay in testing results. In addition, the Director of Nurses said the facility had completed the outbreak testing and returned to routine surveillance on 5/10/21 as there had been no additional COVID-19 cases in the facility in 14 days. He said the determination was made to switch out of outbreak testing and stop utilizing PPE (personal protective equipment) for high contact care without the results from the COVID-19 outbreak testing conducted on 5/7/21. During an interview on 5/12/21 at 4:20 P.M. the Administrator said he was not sure why the facility had ended outbreak testing or made changes to PPE utilization without all of the test results from their outbreak testing.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 6 harm violation(s), $42,254 in fines. Review inspection reports carefully.
• 64 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $42,254 in fines. Higher than 94% of Massachusetts facilities, suggesting repeated compliance issues.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Plymouth Harborside Healthcare's CMS Rating?

CMS assigns PLYMOUTH HARBORSIDE HEALTHCARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Massachusetts, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Plymouth Harborside Healthcare Staffed?

CMS rates PLYMOUTH HARBORSIDE HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 48%, compared to the Massachusetts average of 46%. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Plymouth Harborside Healthcare?

State health inspectors documented 64 deficiencies at PLYMOUTH HARBORSIDE HEALTHCARE during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 6 that caused actual resident harm, 54 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Plymouth Harborside Healthcare?

PLYMOUTH HARBORSIDE HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NEXT STEP HEALTHCARE, a chain that manages multiple nursing homes. With 101 certified beds and approximately 82 residents (about 81% occupancy), it is a mid-sized facility located in PLYMOUTH, Massachusetts.

How Does Plymouth Harborside Healthcare Compare to Other Massachusetts Nursing Homes?

Compared to the 100 nursing homes in Massachusetts, PLYMOUTH HARBORSIDE HEALTHCARE's overall rating (1 stars) is below the state average of 2.9, staff turnover (48%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Plymouth Harborside Healthcare?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.

Is Plymouth Harborside Healthcare Safe?

Based on CMS inspection data, PLYMOUTH HARBORSIDE HEALTHCARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Massachusetts. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Plymouth Harborside Healthcare Stick Around?

PLYMOUTH HARBORSIDE HEALTHCARE has a staff turnover rate of 48%, which is about average for Massachusetts nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Plymouth Harborside Healthcare Ever Fined?

PLYMOUTH HARBORSIDE HEALTHCARE has been fined $42,254 across 3 penalty actions. The Massachusetts average is $33,501. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Plymouth Harborside Healthcare on Any Federal Watch List?

PLYMOUTH HARBORSIDE HEALTHCARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 101
Avg. Residents: 82
Occupancy: 82.0%
Ownership: For profit - Corporation
Chain: NEXT STEP HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
2 Immediate Jeopardy citations: -24
6 Actual Harm citations: -30
64 Deficiencies: -10
Fines ($42,254): -5
Abuse Finding: -15
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 225284