Based on observations, interviews, and record review, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for two Residents (#63 and #34), out of a total sample of 18 residents. Specifically: 1.) For Resident #63, the facility failed to ensure nursing implemented a care plan intervention for bilateral floor mats for fall prevention. 2.) For Resident #34, the facility failed to ensure nursing developed and implemented a care plan intervention for bilateral floor mats for fall prevention. Findings include: Review of the facility policy titled 'Falls', undated, indicated, but was not limited to the following: - The licensed nurse, in conjunction with the interdisciplinary team will identify interventions to try to prevent subsequent falls. - Interventions that will be considered include but are not limited to: equipment-related interventions, surrounding environment modifications. - Care plans will be updated to reflect final interventions as necessary. 1.) Resident #63 was admitted to the facility in September 2023 with diagnoses including a history of a stroke and right sided hemiparesis (weakness on one side of the body). Review of the most recent Minimum Data Set (MDS) assessment, dated 6/23/24, indicated Resident #63 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. Review of Resident #63's active physician's order, initiated 7/21/24, indicated: - Bed in low position with fall mats on both sides of the bed while Resident is in bed. Check fall mats placement every shift. Review of Resident #63's active care plan related to falls, dated as reviewed 8/3/24, indicated: - Bed in low position with fall mats on both sides of the bed while Resident is in bed. Check fall mats placement every shift. Further review of Resident #63's care plan failed to indicate any history of refusal of fall mats. On 9/3/24 at 1:50 P.M., 9/4/24 at 6:48 A.M., 9/4/24 at 7:55 A.M., 9/4/24 at 8:30 A.M., 9/4/24 at 9:28 A.M., and 9/4/24 at 10:10 A.M., the surveyor observed Resident #63 in bed. There was a fall mat in place only on the left side of his/her bed, and there was no fall mat in place on the right side of his/her bed. There was another fall mat stored leaning upright against the wall near the bathroom in the Resident's room. During an interview on 9/4/24 at 10:17 A.M., Certified Nurse Assistant (CNA) #1 said she consistently cares for Resident #63. CNA #1 said Resident #63 should have fall mats on both sides of his/her bed. CNA #1 and the surveyor visualized a fall mat in place on the left side of Resident #63's bed and another fall mat leaning upright against the wall near the bathroom in the Resident's room. CNA #1 said they must have forgotten to put the right fall mat into place, but it should have been in place in addition to the left fall mat. Review of Resident #63's Certified Nurse Assistant (CNA) Documentation Survey Report, dated August 2024, indicated CNA #1 provided care to Resident #63 during nine shifts in August 2024. During an interview on 9/4/24 at 10:25 A.M., Nurse #1 said Resident #63 should have fall mats in place on both sides of the bed, not just on the left side, because he/she has a physician's order and care plan intervention for fall mats on both sides of the bed while the Resident is in bed. During an interview on 9/4/24 at 10:40 A.M., Unit Manager #1 said Resident #63 should have fall mats in place on both sides of the bed, not just on the left side, because he/she has a physician's order and care plan intervention for fall mats on both sides of the bed while the Resident is in bed. Unit Manager #1 said it should have been documented in either the TAR or progress notes if there was any refusal or rationale for only one fall mat being in place instead of two. Unit Manager #1 said Resident #63 should have both fall mats in place whenever he/she is in bed, not just at night. Review of the medical record, including the TAR and progress notes, failed to indicate any refusal or rationale for the right fall mat not being in place on 9/3/24 or 9/4/24. During an interview on 9/4/24 at 11:19 A.M., the Director of Nursing (DON) said Resident #63 should have fall mats in place on both sides of the bed, not just on the left side, because he/she has a physician's order and care plan intervention for fall mats on both sides of the bed while the Resident is in bed. The DON said Resident #63 should have both fall mats in place whenever he/she is in bed, not just at night. 2.) Resident #34 was admitted to the facility in May 2024 with diagnoses including altered mental status and recent history of fall. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/9/24, indicated Resident #34 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. This MDS also indicated Resident #34 had two falls since he/she was admitted to the facility in May 2024, one fall with injury (except major) and one fall with major injury. Review of Resident #34's active physician's order, initiated 5/9/24, indicated: - Bed in low position with fall mats on both sides of the bed while resident in bed, every shift. Review of Resident #34's fall investigation report, dated 8/3/24, indicated Resident #34 was found on the floor after being last seen in bed. This investigation indicated fall interventions utilized for Resident #34 included floor mats. Review of Resident #34's active care plan failed to indicate an intervention for fall mats on both sides of the bed while the Resident is in bed. On 9/3/24 at 8:45 A.M., 9/3/24 at 11:19 A.M., 9/3/24 at 1:55 P.M., and 9/4/24 at 6:53 A.M., the surveyor observed Resident #34 in bed. There was a fall mat in place only on the right side of his/her bed, and there was no fall mat in place on the left side of his/her bed. During an interview on 9/3/24 at 8:45 A.M., the surveyor observed Resident #34 in bed with a large purple bruise-like area on his/her forehead. Resident #34 said he/she sustained the bruise during a fall in his/her room. During an interview on 9/4/24 at 10:17 A.M., Certified Nurse Assistant (CNA) #1 said she consistently cares for Resident #34. CNA #1 said Resident #34 only has one fall mat that should be in place whenever he/she is in bed. CNA #1 and the surveyor visualized only one fall mat in Resident #34's room. Review of Resident #34's Certified Nurse Assistant (CNA) Documentation Survey Report, dated August 2024, indicated CNA #1 provided care to Resident #34 during nine shifts in August 2024. During an interview on 9/4/24 at 10:25 A.M., Nurse #1 said Resident #34 should have fall mats in place on both sides of the bed, not just on the right side, because he/she has a physician's order for fall mats on both sides of the bed while the Resident is in bed. During an interview on 9/4/24 at 10:40 A.M., Unit Manager #1 said Resident #34 should have fall mats in place on both sides of the bed, not just on the right side, because he/she has a physician's order for fall mats on both sides of the bed while the Resident is in bed. Unit Manager said if only one fall mat was available, the nurses should have clarified the order for fall mats to both sides of the bed or obtained another fall mat instead of signing it off as complete. During an interview on 9/4/24 at 11:19 A.M., the Director of Nursing (DON) said she wrote the interventions for floor mats in Resident #34's fall investigation report, dated 8/3/24, and that the plural meant that two fall mats should be in place. The DON said the intervention for Resident #34 to have fall mats on both sides of the bed, not just the right side, while in bed should have been part of the Resident's plan of care and should have been implemented, but was not. The DON further said that since the physician's order stated fall mats on both sides of the bed, the nurses should have clarified the order or obtained another fall mat if only one fall mat was available instead of signing it off as complete since the physician's order was not implemented as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide respiratory care services in accordance with professional standards of care and the plan of care for one Resident (#31) out of a total sample of 18 residents. Specifically, the facility failed to ensure nursing implemented a physician's order to change Resident #31's oxygen tubing. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #31 was admitted to the facility in October 2018 with a diagnosis including respiratory failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/5/24, indicated Resident #31 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Review of Resident #31's physician's order, initiated 12/26/21, indicated: - Change oxygen tubing every week on Sunday 11-7 (date and initial). Review of Resident #31's Treatment Administration Record (TAR) indicated the following order was documented as implemented on 9/1/24: - Change oxygen tubing every week on Sunday 11-7 (date and initial). On 9/3/24 at 8:39 A.M., 9/3/24 at 1:51 P.M., 9/4/24 at 6:52 A.M., and 9/4/24 at 10:26 A.M., the surveyor observed Resident #31 in bed receiving oxygen through a nasal cannula with tubing dated 8/26. During an interview on 9/3/24 at 8:3:9 A.M., Resident #31 said he/she always wears oxygen. During an interview on 9/4/24 at 10:28 A.M., Nurse #1 said oxygen tubing should be changed every seven days. Nurse #1 visualized the label on Resident #31's oxygen tubing dated 8/26 and said that the oxygen tubing change was overdue, and it should have been changed three days ago. Nurse #1 said the order to change oxygen tubing should not have been documented as implemented in the TAR because it was not done. During an interview on 9/4/24 at 10:35 A.M., Unit Manager #1 said oxygen tubing should be changed every seven days. Unit Manager #1 said nurses are supposed to check the oxygen tubing every shift, and if it was overdue, it should be changed immediately. Unit Manager #1 said the order to change oxygen tubing should not have been documented as implemented in the TAR because it was not done. Unit Manager #1 said if there was reason the oxygen tubing was not changed it should have been documented in the TAR or progress notes. Review of Resident #31's medical record, including the TAR and progress notes, failed to indicate any rationale for oxygen tubing not being changed as ordered by the physician on 9/1/24. During an interview on 9/4/24 at 11:17 A.M., the Director of Nursing (DON) said oxygen tubing should be changed every seven days and/or as ordered by the physician if it is being used. The DON said nurses are supposed to check the oxygen tubing every shift, and if it was overdue, it should be changed immediately. The DON said the order to change oxygen tubing should not have been documented as implemented in the TAR because it was not done.

Based on record review and interview, the facility failed to revise the physician's orders for one Resident (#43) out of a sample of 23 residents. Specifically, the facility failed to update the physician's orders after Resident #43 was determined to not be at risk for elopement. Findings include: A review of the facility policy titled 'Care Plans-Comprehensive' with no revision date indicated the following: *10. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Resident #43 was admitted to the facility in June 2022 with diagnoses including Parkinson's disease. Review of the most recent Minimum Data Set (MDS) completed 5/25/23, indicated a Brief Interview Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Review of Resident #43's August 2023 physician's orders indicated the following: *Resident has a wander guard alarm attached to his/her wheelchair, check for proper functioning of device Q shift, (every shift)for risk of elopement. A review of an elopement assessment completed on 8/22/23, indicated the following: *History of elopement episodes in the last 6 months-no history, not a risk for elopement. Further review of an elopement assessment completed on 8/31/23, indicated the following: *Resident is no longer a risk for elopement. During an interview on 8/31/23, at 8:43 A.M., Unit Manager #1 said the Resident is not an elopement risk anymore based on the last two recent elopement assessments, she said the Resident's physician's orders should have been revised to reflect that. During an interview on 8/31/23, at 11:02 A.M., the Director of Nurses said the Resident's physician's orders should have been revised to indicate that the Resident is not an elopement risk.

Based on observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. medications were refrigerated per manufacturer's directions, 3. once opened were dated as required and 4. topical and treatment items were not stored with oral medications. Findings include: On 8/30/23, at 9:54 A.M., the surveyor observed the following in the 2A medication cart: 1. a Breztri inhaler (used to treat Chronic Obstructive Pulmonary Disease (COPD)) open and without a date. Review of the manufacturer's directions indicated that the inhaler expires three months after removal from foil pouch. 2. 2 Fluticasone propionate inhalers (used to treat COPD) open and without a date. The inhalers were not in the manufacturer's packaging. Review of the manufacturer's directions indicated that the inhaler expires according to the manufacturer's expiration date on the packaging. 3. a Levabuterol inhaler (used to treat asthma and COPD) open and without a date. The inhaler was not in the manufacturer's packaging. Review of the manufacturer's directions indicated that the inhaler expires according to the manufacturer's expiration date on the packaging. During an interview on 8/30/23, at 9:54 A.M., Nurse #3 said that she did not know when the inhalers were opened, but they are supposed to be dated. 1. On 8/30/23, at 11:02 A.M., the surveyor observed the following in the 1 D/E medication cart: A. a medicine cup containing 7 pills and labeled E6. During an interview on 8/30/23, at 11:02 A.M., Nurse #1 said that the resident had gone to mass so she saved them in the medication cart for later. 2. On 8/30/23, at 11:08 A.M., the surveyor observed the following in the 1 A/BC medication cart: 1 bottle of Latanoprost (used to treat glaucoma) open without a date. 1 bottle of Latanoprost unopened and not refrigerated. Review of the manufacturer's directions indicated to refrigerate until opened. 1 tub of Aquaphor cream. 1 Foley catheter insertion tray During an interview on 8/30/23 11:13 AM Nurse #4 said that the Aquaphor cream and the Foley catheter insertion tray belong in the treatment cart.

Based on observations, record review and interviews, the facility failed to maintain accurate medical records for one Resident (#43) out of a sample of 23 residents. Specifically, the facility documented that Resident #43's wander guard alarm was administered, when it wasn't. Findings include: Resident #43 was admitted to the facility in June 2022 with diagnoses including Parkinson's disease. A review of the most recent Minimum Data Set (MDS) completed 5/25/23 indicated a Brief Interview Mental Status (BIMS) score of 4 out of a possible 15 indicating severe impairment. A review of Resident #43's August 2023 physician's orders indicated the following: *Resident has a wander guard alarm attached to his/her wheelchair, check for proper functioning of device Q shift, every shift for risk of elopement. On 8/29/23, at 9:14 A.M., the surveyor observed Resident #43 sitting at the dining table, his/her wheelchair did not have a wander guard alarm on. On 8/30/23, at 8:43 A.M., and 12:24 P.M., the surveyor observed Resident #43 sitting at the dining table, his/her wheelchair did not have a wander guard alarm on. A review of Resident #43's August 2023 Treatment Administration Record (TAR) indicated that on 8/29/23 and 8/30/23 day shift, staff had documented that the wander guard alarm was administered. During an interview with the Unit Manager #1 on 8/31/23, at 8:43 A.M. she said nurses are expected to maintain accurate documentation. During an interview with the Director of Nurses on 8/31/23, at 11:02 A.M., she said medical records should be documented to reflect what is going on with a Resident, she said the nurses are expected to document accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement a comprehensive care plan for 4 Residents (#1, #17, #18, and #21) from a total sample of 23 residents. Finding Included: Review of the facility policy titled, Care Plans-Comprehensive, undated, indicated the following: Policy Interpretation and Implementation *2. Residents will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. *10. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. 1. For Resident #21 the facility failed to implement the medical plan of care for Resident #21's daily use of hearing aids for communication in accordance with the physician's orders. Resident #21 was admitted to the facility in August 2020 with diagnoses that include cerebral infarction unspecified, chronic systolic heart failure and unspecified hearing loss, bilateral. Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating he/she is cognitively intact. Further review of the MDS indicated Resident #21 requires extensive assistance of one person for daily activities and has moderate difficulty hearing when using his/her hearing aids. During an interview on 8/29/23, at 9:25 A.M., Resident #21 had difficulty answering questions due to being hard of hearing. Resident #21 said he/she wears hearing aids and was currently not wearing them. Resident #21 said the hearing aids are kept in the medication cart and the nursing staff normally assist him/her putting them on in the morning. During an interview on 8/29/23, at 10:30 A.M., Resident #21 was asked if he/she received his/her hearing aids. Resident #21 said no. Review of Resident #21's physician orders dated 10/22/21, indicated the following: Give resident both hearing aids in the a.m. and remove at bedtime (place them in resident's box in med cart), two times a day. Further review of Resident #21's medical record indicated the following audiology recommendations on 7/28/22: Daily use of hearing aids is recommended; Staff should assist with insertion and care of hearing aid(s). On 8/30/23, at 8:33 A.M.,10:28 A.M., and 11:05 A.M., Resident #21 was observed sitting up in bed. Resident #21 did not have his/her hearing aids on. During an interview on 8/31/23, at 8:15 A.M., Nurse #1 was asked if Resident #21 uses a hearing device. Nurse #1 said yes, he/she wears hearing aids. Nurse #1 was asked if she had given them to Resident #21 this morning, she said no but I can give them to him/her now. During an interview on 8/31/23, at 10:33 A.M., the Director of Nursing said the expectation would be that the physician's orders should be followed as written for the on and off schedule for Resident #21's hearing aids, and the nursing staff is responsible for putting on and removing the Resident's hearing aids. 2. Resident #1 was admitted to the facility in August 2017 with diagnoses including dysphagia (difficulty swallowing), dementia and gastro-esophogeal reflux disease. Review of the care plan indicated a focus for risk for aspiration with the intervention for: supervise resident for all meals. On 8/29/23, at 12:45 P.M. the surveyor observed Resident #1 in her/his room eating without staff present. The surveyor observed a nurse set up Resident #1's meal and then leave the room. On 8/30/23, at 12:53 P.M., the surveyor observed Resident #1 in her/his room eating without staff present. The surveyor observed a nurse set up Resident #1's meal and then leave the room. 3. Resident #17 was admitted to the facility in April 2019 with diagnoses including dysphagia, stroke and hemiplegia. Review of the care plan indicated a focus for ADL (activities of daily living) with an intervention for eating with continual supervision after set up during the day. Further review indicated that Resident #17 is dependent on staff for eating on the 3-11 shift ( 3:00 P.M.-11:00 P.M.) Further review indicated a focus for nutrition related to dysphagia with an intervention to supervise with feeding. On 8/29/23, at 12:47 P.M., the surveyor observed Resident #17 eating alone in her/his room. On 8/30/23, at 12:46 P.M., the surveyor observed Resident #17 eating alone in her/his room. 4. Resident #18 was admitted to the facility in December 2020 with diagnoses including gastroesophogeal reflux disease, anxiety and depression. Review of the care plan with a focus for ADL (activities of daily living) assist dated 10/22/21, and an intervention for assist/supervise resident during meals. On 8/29/23,, at 12:47 P.M., the surveyor observed Resident #18 in her/his room eating without supervision. On 8/30/23, at 8:41 A.M., and 12:41 P.M., the surveyor observed Resident #18 in her/his room eating without supervision. On 8/31/23, at 8:32 A.M., the surveyor observed Resident #18 in her/his room eating without supervision. During an interview on 8/31/23, at 8:38 A.M., Nurse #2 said that continual supervision and supervision, with eating, means that somebody has to watch the resident while they are eating and can not leave them alone. During an interview on 8/31/23, at 8:49 A.M., Certified Nurse's Aide (CNA) # 1 said that the nurse's tell the CNAs what level of dependence a resident has for eating, if they require supervision with eating.