Every finding on record at Bay Path at Duxbury Nursing & Rehabilitation CTR

Based on observation, interview, and record review, the facility failed to adhere to infection control procedures during a wound dressing change for one Resident (#26) of a sample size of 22 residents. Findings include: The surveyor was provided as the facility policy the form titled Competency Assessment Dressing, Dry/Clean, dated 2018, which indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. -Verify that there is a physician's order for this procedure. -Assemble the equipment and supplies needed. Date and initial all bottles and jars upon opening (unless product is single use). Wipe nozzles of wound cleanser with alcohol wipe or facility disinfected wipe. -Explain procedure to resident and provide privacy. -Clean bedside stand. Establish a clean field. -Place the clean equipment on the clean field. -Wash and dry your hands thoroughly. -Put on a clean gloves. Loosen tape and remove soil dressing. -Pull glove over dressing and discard into plastic or biohazard bag. -Wash and dry your hands thoroughly. -Open dry, clean dressing by pulling corners of exterior wrapping outward, touching only the exterior surface. -Using clean technique, open other products (i.e., prescribe dressing; dry, clean gauze.) -Wash and dry your hands thoroughly. -Put on clean gloves. -Cleanse the wound with the ordered cleanser. If using gauze use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward). -Use dry gauze to pat the wound dry. -Apply the ordered dressing and secure with tape or boarded dressing per order. -Discard disposable items into designated container. Resident #26 was admitted to the facility April 2024 with diagnoses which included: Left heel pressure wound and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 4/8/24, indicated Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated he/she had moderate cognitive impairment. Further review of Section M: Skin Conditions of the MDS assessment indicated the Resident had a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers/injuries on admission and was receiving care and treatment for the areas. Review of current physician orders indicated but was not limited to the following: -Left heel: cleanse with wound wash, pat dry followed by (f/b) calcium alginate, f/b abdominal gauze (ABD) pad, and stretch wrap daily for wound care, effective 5/2/24. On 7/3/24 at 1:20 P.M., the surveyor observed Nurse #3 perform a dressing change on Resident #26's left heel and made the following observations: -Nurse #3 transferred Resident #26 into bed. -Nurse #3 washed hands and donned a pair of gloves. -Nurse #3 set up the following supplies on the over bed tray table, which she did not clean the table or and/or establish a clean barrier: a. Opened the ABD pad and placed it on the outside of the package, with a portion of it in contact with overbed tray table. b. Removed a small stack of gauze pads from the package and placed directly on the over bed tray table. c. Calcium alginate which remained on the inside of the package, uncut. d. Placed a pair of scissors on the over bed tray table. e. Placed a bottle of wound cleanser, not labeled, or dated. -Nurse #3 pulled the bedside curtain partially closed leaving the Resident's feet and affected heel visible from the hallway and the door to the room was open. -Nurse #3 was then observed using the scissors to cut off the old dressing that was on the Resident's left heel and then placed the scissors on the bed side table. -Nurse #3 sprayed the gauze with wound cleaner and cleaned the wound. -Nurse #3 changed her gloves but did perform hand hygiene. -Nurse #3 used the same scissors which were used to cut off the dirty dressing to cut a small piece of the calcium alginate to size without cleaning them. Nurse #3 then placed the trimmed piece of calcium alginate on the wound, applied the ABD pad, wrapped the ankle, and applied a dated piece of tape. During an interview on 7/3/24 at 2:20 P.M., the Director of Nurses (DON) said her expectations are the nurse would wear the appropriate personnel protective equipment (PPE), prepare the supplies, and have a clean barrier or sanitize the surface, and provide full privacy to the resident during the dressing change. She said the nurse is expected to wash her hands and change gloves before starting the dressing change, and after removing dirty dressing, and before cleaning the wound and applying the new dressing. The DON said she would also expect the nurse to clean the scissors after being used to remove the old dressing, before cutting the calcium alginate to size. The DON said the nurse did not follow protocol.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the Resident's status for two Residents (#44 and #70), out of a sample of 22 residents. Specifically, the facility failed: 1. For Resident #44, to accurately reflect hospice services; and 2. For Resident #70, to accurately reflect Post Traumatic Stress Disorder (PTSD) Findings include: 1. Resident #44 was admitted to the facility in September 2022 with diagnoses including left sided hemiplegia, hypertension and dementia. Review of Resident #44's current physician's orders indicated he/she had an order for Cranberry Hospice, order date 2/14/24. Review of the hospice binder included a Recertification of Terminal Illness form with certification period from 5/28/24 to 7/26/24. Review of the MDS assessment, dated 6/6/24, Section O, failed to indicate he/she had received hospice services. During an interview on 7/9/24 at 8:42 A.M., the surveyor and MDS Nurse #1 reviewed Resident #44's physician's orders and the Recertification of Terminal Illness form. MDS Nurse #1 reviewed the MDS assessment completed 6/6/24, including Section O. MDS Nurse #1 said Resident #44's MDS assessment should have indicated that he/she was receiving hospice services. MDS Nurse #1 said the assessment would need to be modified to correctly reflect Resident #44's hospice status. 2. Resident #70 was admitted to the facility in May 2023 with diagnoses including diabetes, peripheral vascular disease and depression. Review of Resident #70's medical record included a psychiatric assessment dated [DATE]. Diagnoses included depression, unspecified, F32.A (ICD-10) (Active) and Post-traumatic stress disorder (PTSD), chronic, F43.12 (ICD-10) (Active). Recommendations included: -He/she may benefit from 1:1 therapy if he/she would agree to it for PTSD -Start Lexapro 10 milligrams daily for depression/PTSD -Contact Pinnacle with worsening or persistent symptoms Review of nursing progress note, dated 4/16/24, indicated psychiatric recommendations reviewed with Nurse Practitioner #1 who was in agreement. Review of Resident #70's Trauma assessment, dated 6/5/24, indicated he/she had indicators of PTSD. Review of Resident #70's care plan, included but was not limited to: -Resident has a potential for re-traumatization due to history abuse from mother at a younger age, initiated 6/5/24. Review of the MDS assessment, dated 6/6/24, Section I, failed to indicate he/she had an active diagnosis of PTSD. During an interview on 7/9/24 at 9:08 A.M., the surveyor and MDS Nurse #1 reviewed Resident #70's medical record. MDS Nurse #1 reviewed the MDS assessment completed 6/6/24, including Section I. MDS Nurse #1 said she was not sure PTSD should have been checked off as she did not see documentation from the physician. MDS Nurse #1 said she would contact her [NAME] President (VP) of clinical reimbursement for clarification. The MDS Nurse #1 and surveyor placed a call to the VP of clinical reimbursement. The VP of clinical reimbursement said she would get back to MDS Nurse #1 after she had an opportunity to review the resident's medical record. During an interview on 7/9/24 at 10:11 A.M., MDS Nurse #1 said she heard back from the VP of clinical reimbursement. MDS Nurse #1 gave the surveyor an e-mail correspondence indicating: Based on the documentation in the resident record and the RAI (Resident Assessment Instrument) manual instructions I do agree this was and should be added to the MDS. MDS Nurse #1 said Resident #70's MDS assessment should have indicated that he/she had an active diagnosis of PTSD. MDS Nurse #1 said the assessment would need to be modified to correctly reflect Resident #70's active diagnosis.

Based on record review, interviews, and policy review, the facility failed to ensure the Physician signed and dated all orders for 12 Residents (#11, #51, #80, #105, #71, #50, #108, #21, #52, #5, #56, and #67), out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Medication Orders, dated April 2014, included but was not limited to: -Supervision by a Physician: -Physician orders/Progress notes must be signed and dated every thirty (30) days. (Note: this may be changed to every sixty (60) days after the first ninety (90) days of the resident's admission) 1. Resident #11 was admitted to the facility in November 2019 with diagnoses which included schizophrenia, multiple sclerosis, major depressive disorder, and failure to thrive. Review of the clinical record, Electronic Medical Record (EMR), and the Order Review History report, indicated the Registered Nurse Practitioner (RNP) last signed the Resident's orders on 5/12/2019. There were no additional orders signed by the Physician. 2. Resident #51 was admitted to the facility in August 2021 with diagnoses which included kidney failure, dementia, and anxiety. Review of the clinical record, EMR, and the Order Review History report, indicated there were no signed physician orders since admission. Additional review indicated the Order Review History was blank (signifying orders were not signed). The next due date for Order Review indicated not specified. 3. Resident #80 was admitted to the facility in August 2022 with diagnoses which included Parkinson's disease, major depressive disorder, and anxiety. Review of the clinical record, EMR, and the Order Review History report, indicated there were no signed physician orders since admission. Additional review indicated the Order Review History was blank (signifying orders were not signed). The next due date for Order Review indicated not specified. 31830 4. Resident #105 was admitted to the facility in July 2022 with diagnoses which included dementia, major depressive disorder, fibromyalgia, and anxiety disorder. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #105's medical orders on 5/16/2023. 5. Resident #71 was admitted to the facility in January 2019 with diagnoses which included morbid obesity and diabetes mellitus with other diabetic kidney complications. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #71's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #71 until 5/16/2023. 6. Resident #50 was admitted to the facility in August 2020 with diagnoses which included major depressive disorder and insomnia. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #50's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #50 until 5/16/2023. 7. Resident #108 was admitted to the facility in December 2022 with diagnoses which included Parkinson's disease, anxiety, and dementia. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #108's medical orders on 5/16/2023. 8. Resident #21 was admitted to the facility in November 2019 with diagnoses which included post-traumatic stress disorder, dementia, and schizoaffective disorder. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #21's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #21 until 5/16/2023. 9. Resident #52 was admitted to the facility in October 2022 with diagnoses which included end stage renal disease, muscle weakness, and history of falls. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #21's medical orders on 5/16/2023. 10. Resident #5 was admitted to the facility in November 2022 with diagnoses which included essential hypertension, chronic obstructive pulmonary disease, and cerebrovascular disease. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #5's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #5 until 5/16/2023. 11. Resident #56 was admitted to the facility in July 2020 with diagnoses which included aphasia following cerebral infarction, non-pressure chronic ulcer of the skin, and dementia. Review of the clinical record, EMR, and the Order Review History report, indicated the RNP electronically signed Resident #56's medical orders on 5/12/2021. There were no additional medical orders signed by the Physician for Resident #56 until 5/16/2023. 12. Resident #67 was admitted to the facility in September 2022 with diagnoses which included heart failure, dementia, major depressive disorder, and anxiety. Review of the clinical record, EMR, and the Order Review History report, indicated the Physician only electronically signed Resident #67's medical orders on 5/16/2023. During an interview on 5/16/23 at 9:15 A.M., the surveyor and Nurse #1 reviewed the EMR to verify the physician signed off on the orders. Nurse #1 said she was unaware when physicians signed orders. During an interview on 5/16/23 at 9:20 A.M., Nurse Manager (NM) #1 said she did not have a list which indicated when the physician should review and sign their orders. NM #1 said she was not sure why the physician's orders were not signed. During an interview on 5/16/23 at 9:23 A.M., the surveyor and Assistant Director of Nurses (ADON) reviewed the Order Review History for Resident #11. The Order Review History indicated that the Physician's orders were overdue by 674 days. The ADON said the physician's orders appear to not be signed. During an interview on 5/16/23 at 10:05 A.M., the Director of Nurses (DON) said she recognized that the Physician did not sign the orders of his Residents.

Based on record review, interview, and policy review, the facility failed to ensure residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic medications prior to their use for one Resident (#50), out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use Consent, effective date 11/17, indicated but was not limited to: - Prior to administering psychotropic medication the prescriber will discuss with the resident or resident representative the reason for prescribing the medication, dosage, anticipated effects of the drug therapy and the most commonly noted side effects. The discussion may take place by phone. - At the time of the discussion, or thereafter, but prior to the administration of the prescribed medication a facility representative must complete (for each medication) the Informed Consent for Psychotropic Administration form. This included obtaining all required signatures. - Written consent must be obtained each time a new prescription is ordered and renewed once a year. Resident #50 was admitted to the facility in August 2020 with diagnoses which included unspecified dementia without behavioral disturbance and major depressive disorder. Resident #50's Health Care Proxy was invoked on 9/23/2020. Review of Resident #50's discontinued Physician orders, dated 10/13/2021 through 2/28/2023, indicated an order for: - Trazodone (anti-depressant) 25 milligrams (mg) by mouth two times a day started on 10/13/2021 and discontinued on 2/28/2023. - Trazodone 25 mg by mouth one time per day as needed started on 10/13/2021 and discontinued on 10/27/2021. Review of Resident #50's clinical record indicated his/her Health Care Proxy signed an Informed Consent For Psychotropic Administration dated 10/13/2021 for the previously discontinued orders. Review of Resident #50's current Physician's Orders, dated 2/28/2023 through review on 5/16/2023, indicated an order for Trazodone 25 mg by mouth two times a day started on 2/28/2023. Review of the Medication Administration Record (MAR) indicated Resident #50 received the medication as ordered from 2/28/2023 through review on 5/16/2023. Further review of the clinical record failed to include an Informed Consent For Psychotropic Administration Form was obtained from the Health Care Proxy for administration of the current physician's orders for the anti-depressant medication dated 2/28/2023. During an interview on 5/16/2023 at 1:46 P.M., the Assistant Director of Nursing (ADON) reviewed the clinical record and was unable to locate the signed Informed Consent For Psychotropic Administration Form for the administration of the Trazodone medication. The ADON said the expectation would be for the signed consent to be completed prior to initiation of the medication on 2/28/2023 due to the new order.

Based on observation, record review and staff interview, the facility failed to ensure that for 1 resident (#24), that bed dimensions were appropriate for the Resident's size and weight as required, in a total sample of 12 Residents. Findings include: Resident #24 was readmitted to the facility in 9/2019 and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with a reference date of 9/20/19, indicated that Resident #24 had mild cognitive impairment, and required extensive assistance from staff for bed mobility. Review of 11/2019 physician's orders [REDACTED].#24 had two half side rails to his/her bed (initiated 9/2019). A consent for the use of side rails was signed by Resident #24's Health Care Proxy on 9/14/19. Resident #24 was observed lying in bed with bilateral half side rails up on the following occasions: -11/12/19 at 2:59 P.M. -11/13/19 at 8:09 [NAME]M. -11/13/19 at 2:45 P.M. -11/14/19 at 1:45 P.M. Review of the side rail assessment dated [DATE], indicated that the resident's most recent weight was 204.4 lbs (pounds), measured on 11/5/18. Review of Resident #24's weight record indicated that his/her weight at the time of the side rail assessment was 177.0 lbs, measured on 9/14/19. Resident #24's side rail assessment was reviewed with Unit Manager #1 during interview on 11/14/19 at 10:35 [NAME]M The unit manager said that the electronic side rail assessment automatically populated the resident's weight, and he did not notice that it was inaccurate to ensure the bed was appropriate for the resident's size and weight.

Based on observation, record review and interview, the facility failed to ensure services to maintain personal grooming and hygiene needs were provided for 1 resident with (#30) from a total of 12 sampled residents. Findings include: For Resident #30, the facility failed to address nasal hair removal needs to address prominent hair growth from both of his/her nostrils that a reasonable person would want groomed to maintain proper hygiene and dignity. During observation on 11/12/19 at 10:09 [NAME]M., Resident # 30 was observed lying in bed resting. The resident was observed to have a significant amount of nasal hair protruding from both of his/her nostrils. Resident #30 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), with a reference date of 10/22/19, indicated that Resident #30 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and was dependent on staff for personal hygiene. Review of interdisciplinary care plans, indicated that Resident #30 required assistance of 1 staff for bathing, showering, and personal hygiene. During interview with Unit Manager #2 on 11/13/19 at 12:30 P.M., Resident #30 was observed lying in bed resting. The Unit Manager and surveyor greeted the resident. Unit Manager observed, and confirmed that the Resident had significant nasal hair, and that a reasonable person would want to be groomed appropriately without nasal hair protruding from ones nose. During interview on 11/13/19 at 2:26 P.M., CNA #1 said that she works the 7:00 [NAME]M. to 3:00 P.M. shift and provides Resident #30 with personal care on a daily basis. She said that everyday she wakes the resident up, washes and dresses the resident. She also said that Resident #30 is cooperative with care, and has not refused to be groomed. The CNA said that she does not trim his/her nasal hair.

Based on observation, record review and interview, the facility staff failed to ensure that the medication error rate was not 5 percent or greater. There were 25 medication observation opportunities and 2 errors resulting in a 8.00 percent error rate. Observation included 2 shifts( 7:00 [NAME]M.-3:00 P.M., 3:00-11:00 P.M.) and 2 different units with 3 nurses observed as well as multiple routes of administration. This affected 1 Resident (#10) . Findings include: On 11/13/19, during the morning medication administration pass, at 9:37 [NAME]M., Nurse #1 was observed administering [MEDICATION NAME] 10 milligrams (mg) orally to Resident # 8. The medication was ordered by the physician to be given three times daily with meals. This Resident had been served and had eaten their breakfast at 8:00 [NAME]M. This medicine was 1 1/2 hours late. In addition, on 11/13/19, at 9:37 [NAME]M., Nurse #1 attempted to administer to Resident #8 a dose of Calcium [MEDICATION NAME]/ Vitamin D 600 mg/200 I.U. ( international unit ), surveyor intervened as the physician had ordered Calcium [MEDICATION NAME]/Vitamin D 600 mg/200 I. U. This medication was not available and Nurse #1 was attempting to administer an incorrect compound of Calcium/Vitamin D. Nurse #1 said that she was unaware of the different compounded Calcium/ Vitamin D that was ordered versus what he/she was attempting to administer.

Based on record review, observation and staff interview, the facility failed to ensure that the comprehensive assessment and Minimum Data Set (MDS) Assessment accurately reflected the status of one Resident (#30), out of a total sample of 12 residents. Findings include: Resident #30 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. Review of the admission MDS with a reference date of 4/25/19, indicated that Resident #30 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, was dependent on staff for personal hygiene, and had no broken or missing teeth. During observation on 11/12/19 at 10:09 [NAME]M., Resident # 30 was observed lying in bed resting. The resident responded to the surveyor's greeting and smiled, exposing multiple brownish-yellow discolored and broken front teeth. Review of the 4/19/19 admission oral assessment indicated that Resident #30's had natural teeth that were free from decay and unbroken. During interview with Unit Manager #2 on 11/13/19 at 12:30 P.M., he said that there had been no changes in the resident's dental status since admission in 4/2019. Resident #30 was observed lying in bed resting. The Unit Manager and surveyor greeted the resident. As the resident spoke, brownish yellow discolored and broken front teeth were exposed. Unit Manager #2 confirmed that the resident had discolored and broken front teeth. The Unit Manager also confirmed that the admission oral assessment and MDS were not accurate to reflect the condition of the resident's teeth.

Based on observations, interviews and record review the Facility staff failed to perform nail care for 2 Residents (#46 and #16) in a total sample of 12 Residents. Findings include: 1. Resident #46 was admitted to the Facility in 03/2016 with a [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set ((MDS) dated [DATE] indicated the Resident was cognitively intact with a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated the Resident needed extensive assist of one staff person with personal hygiene. A review of the care plan for Resident #46 indicated that during bathing/showering to check nail length and trim and clean nails on bath day as necessary. On 11/15/18 at 11:20 A.M. Resident #46 was observed to be sitting in a straight back chair in his/her room. The Resident was observed to have very long yellow fingernails on both hands. The fingernail lengths ranged from 0.1 cm to approximately 1 cm (the width of a standard pen). Resident #46 said that he/she had asked to have his/her fingernails cut multiple times, but they have not been cut. The Resident was observed again on 11/16/18 at 8:50 A.M. to continue to have long nails on both hands. On 11/20/18 at 10:25 A.M. Certified Nursing Assistant (CNA) #1 was interviewed. The CNA said that she was a regular caregiver for Resident #46. She said that the Resident accepts care with Activities of Daily Living (ADLs) without issue. The CNA said that she files the nails of Residents when it is needed based on length. The CNA and the Surveyor went to see the Resident. The CNA acknowledged that the Resident had long nails. The Resident said that he/she would like some one to cut the fingernails. The CNA responded that she can only file the nails of Residents and is unable to cut/trim them. Unit Manager #1 was interviewed on 11/20/18 at 10:30 A.M. The Unit Manager said that the CNAs can cut/trim the nails of Residents and would address this with CNA #1. 2. Resident #16 was admitted to the Facility in 05/2016 with a [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set ((MDS) dated [DATE] indicated the Resident was cognitively intact with a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated the Resident was dependent of one staff person with personal hygiene. A review of the care plan for Resident #16 indicated that during bathing/showering to check nail length and trim and clean on bath day as necessary. Review of the shower schedule indicated Resident #16 had a shower on 11/14/18. The Resident was observed in bed on 11/15/18 at 8:54 A.M. The Resident was was observed to have dirt under his/her fingernails, some were long and untrimmed. Resident #16 said he/she had a shower the previous day. On 11/16/18 at 10:00 A.M. Resident #16 showed the surveyor his/her fingernails. The Resident said his/her nails were longer than he/she likes and that his/her significant other was having a friend come on this day to cut the fingernails. CNA #1 was interviewed on 11/20/18 at 10:24 A.M. The CNA said she was familiar with the care for Resident #16 and that she would provide nail care of filing the nails when necessary. The CNA said that she was not to cut/trim the nails of Residents. The significant other of Resident #16 was interviewed by phone on 11/21/18 at 8:35 A.M. The significant other said that Resident #16 was particular about nail length and preferred to have short nails. The significant other said that the Facility would provide toenail care, but was uncertain of fingernail care, therefore a friend would come to cut and trim the nails of Resident #16 as needed.

Based on observations, staff interviews and record review, the facility failed to provide adequate supervision and assistive devices to prevent a fall, which resulted in a major injury for one Resident (Resident #4), from a total sample of 23 residents. Findings include: Resident #4 was admitted to the facility in 11/2013 with the following pertinent Diagnoses: [REDACTED]. Review of the Minimum Data Set (MDS) for a significant change (after fall with major injury 8/5/2016) with an assessment reference date of 8/9/16, indicated the following: Resident #4 had adequate vision/hearing, clear speech and was able to understand others with a Brief Interview for Mental Status (BIMS) of 10 out of 15 (indicates moderate cognitive impairment). Resident #4 requires extensive assist with one person assist for transfer, does not ambulate in room or corridor (ambulated prior to fall with rolling walker), is incontinent of bladder/bowel and is totally dependent with 2+ physical assist for toilet use, experiences pain almost constantly with a rating of 8 /10. Resident #4 had a fall with major injury since original admission. Review of the Fall Care Plan for Resident #4 indicates the following fall risk interventions were in place at the time of fall on 8/5/16: slipper socks, bed alarm, ½ side rails during the night, safety education (dated 11/12/13). Review of the CNA Kardex for Fall Precautions (no dates) indicates: bed alarm, low bed, floor mat, non-skid slipper socks in bed, assist of 2 with rolling walker and toileting every 2 hours. Review of the facility's Incident Analysis Report for an un-witnessed fall on 8/5/16 indicated that staff responded to Resident and roommate screaming in his/her room. The Resident was found on the floor at 2:15 A.M. complaining of severe pelvic and right buttock pain and with blunt head trauma. Possible Contributing Factors indicated bed alarm did not activate. The Resident was sent out to the hospital and the Emergency Department Physician Report indicates: 1.) frontal subarachnoid hemorrhage (small), 2.) right pelvic fractures. Interventions following fall #1 include physical therapy, pain management and continue bed alarm. Review of the Initial Fall Investigation Form (dated 8/5/16) indicates that the Resident's bed alarm did not work correctly, the Resident was found at the foot of his/her roommate's bed supine on floor with feet facing bathroom. Question #17 indicates What do you think could have prevented this fall? The staff response indicates improved pad alarms. On 7/27/17 at 12:30 P.M., the Surveyor interviewed Nurse #1 and Nurse #2. Both nurses said that there has been a problem with bed/chair alarms not functioning because the clips (which attach to the battery and make the device operable) break so easily. Both staff said that this had been going on for a long time and that the facility was now changing alarm companies. On 7/27/17 at 1:30 P.M. the Surveyor reviewed the Maintenance Logs for all units with the Facility Plant Director for June 17th through August 17th 2016 (prior to Resident's fall). The Surveyor observed all 3 units to have a total of 7 non-functioning chair/bed alarms. Resident #4's alarm was not indicated on the list of alarms not functioning or repaired during this time frame. On 7/27/17 at 9:00 A.M. the Surveyor interviewed the Director of Nursing (DON) with the Clinical Nurse Consultant (CNC). The DON said that the facility was having some previous trouble with clips breaking (with the old alarm pads). On 7/27/17 at 2:30 P.M. the Surveyor observed the Resident sitting up at edge of bed holding the bedside table. The Resident was squirming around in the bed. The Surveyor asked if everything was okay. The Resident said I have to go to the bathroom. The Surveyor went to find assistance and observed 5 staff members in the rear nursing station preparing for change of shift. The Surveyor did not observe available staff on the unit to assist the Resident. The Surveyor went to the other side of the unit and asked a restorative aide (RA) for assistance. The Surveyor and RA walked toward the Resident's room and heard the bed alarm start to sound. The staff members in the rear nursing station did not respond to the bed alarm. The Resident's family member, who was at the front nursing station ran to the Resident's room with the RA and assisted the Resident who was attempting to ambulate to the bathroom. The Surveyor went into the rear nursing station (where 5 staff members remained) and could not hear Resident #4's bed alarm sounding. The above observation was shared with the DON on 7/27/17 at 3:40 P.M.

Based on observation, record review and staff interview, the Facility failed to provide services which meet professional standards of quality for medication administration and documentation for 3 sampled Residents (#17, #9 and #11) out of a total sample of 23 Residents. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Findings include: 1) Resident #17 was admitted to the Facility in March 2017, with [DIAGNOSES REDACTED]. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/30/17, indicated that the Resident scored 05 out of 15 on a Brief Interview of Mental Status (BIMS), indicating that he/she had severe cognitive impairment. Review of Resident #17's clinical record indicated that the Resident had been on a [MEDICATION NAME] taper in June 2017. Review of Resident #17's physician order [REDACTED]. Review of Resident #17's July 2017 Medication Administration Record [REDACTED].M. Nine doses of [MEDICATION NAME] 25 mg were administered to the Resident without a physician's orders [REDACTED].>The Surveyor interviewed the Unit Manager (UM) #1 at 11:55 A.M. on 7/28/17. UM #1 said she would have to check into the medication error and get back to the Surveyor. At 12:30 P.M. UM #1 said the nine does of [MEDICATION NAME] administered to the Resident in July 2107 was a medication error. The Surveyor interviewed the DON at 1:00 P.M. on 7/28/17. The DON said UM #1 told her about the medication error after it was identified by the Surveyor. The DON said the [MEDICATION NAME] 25 mg that was administered to the Resident 7/1/17 through 7/9/17 was a medication error and that the discontinued medication had been missed during the edit process. 2) Resident #9 was admitted to the Facility in May 2017, with [DIAGNOSES REDACTED]. Review of the admission MDS assessment with an ARD of 6/9/17, indicated that Resident #9 scored 12 out of 15 on a BIMS, indicating that he/she had moderate cognitive impairment. Review of Resident #9's physician's orders [REDACTED]. Review of the Resident #9''s July 2017 MAR indicated [REDACTED] * On 7/23/17 at 10:00 A.M., Vitamin D3 was circled indicating that the medication was not administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/23/17 at 6:00 P.M., [MEDICATION NAME] and Magnesium Oxide were circled indicating that the medications were not administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/25/17 at 6:00 P.M., [MEDICATION NAME] was circled indicating that the medication was not administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M. on 7/26/27. The DON had no explanation why medications were not administered. 3) Resident #11 was admitted to the Facility in June 2017, with [DIAGNOSES REDACTED]. Review of the admission MDS assessment with an ARD of 6/27/17, indicated that the Resident scored 15 out of 15 on a BIMS, indicating that he/she was cognitively intact. Review of physician's orders [REDACTED].#11 was to receive the following medications: [REDACTED] Review of the Resident's June 2017 and July 2017 MAR indicated [REDACTED] * On 6/21/17 at 8:00 P.M., [MEDICATION NAME] was circled indicating that the medication was not administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 6/23/17, 6/24/17, 6/28/17, and 6/29/17 at 8:00 A.M., [MEDICATION NAME] was circled indicating that the medication was not administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 6/25/17 and 6/28/17 at 2:00 P.M., [MEDICATION NAME] was circled indicating that the medication was not administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/6/17, 7/7/17, 7/17/17, 7/24/17, 7/26/17 and 7/27/17 at 10:00 A.M., Slow Release Iron was circled indicating that the medication was not administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. The Surveyor interviewed the DON at 11:00 A.M. on 7/27/27. The DON had no explanation why medications were not administered as ordered.

Based on record review and staff interviews, the Facility failed to accurately maintain medical records for 5 sampled residents (#9, #11, #14, #15, and #17) out of a total sample of 23 Residents. Findings include: 1) Resident #9 was admitted to the Facility in May 2017, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/9/17, indicated that Resident #9 scored 12 out of 15 on a Brief Interview of Mental Status (BIMS), indicating that he/she had moderate cognitive impairment. Review of Resident #9's physician's orders [REDACTED]. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 0.005% eye drops instill one drop in each eye once a day in the evening, [MEDICATION NAME] (stool softener) 100 mg twice a day. Review of the Resident #9''s July 2017 MAR indicated [REDACTED] * On 7/22/17 at 4:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/22/17 at 10:00 P.M., [MEDICATION NAME] eye drops were not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/22/17 at 10:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M. on 7/26/27. The DON had no explanation why medications were not administered as ordered by the physician. 2) Resident #11 was admitted to the Facility in June 2017, with [DIAGNOSES REDACTED]. Review of the admission MDS assessment with an ARD of 6/27/17, indicated that Resident #11 scored 15 out of 15 on a BIMS, indicating that he/she was cognitively intact. Review of physician's orders [REDACTED].#11 was to receive the following medications: [REDACTED] [MEDICATION NAME] (used to treat nerve pain) 100 mg twice a day for three days (start 6/21/17), [MEDICATION NAME] (used to treat irritable bowel syndrome) 20 mg every 8 hours (start 6/21/17), [MEDICATION NAME] 100 mg once a day for three days (start 6/25/17), [MEDICATION NAME] (antihypertensive) 25 mg twice a day, [MEDICATION NAME] ([MEDICATION NAME]) 250 mg twice a day, Slow release Iron 142 mg (45 mg iron) extended release ([MEDICATION NAME]) once a day, [MEDICATION NAME] ([MEDICATION NAME]) 10 mg once a day, [MEDICATION NAME] ([MEDICATION NAME] use to treat urinary tract infections) 100 mg twice a day, [MEDICATION NAME] (antifungal) 150 mg once a day for two days (start 7/19/17), [MEDICATION NAME] (antacid) 20 mg twice a day. Review of the Resident #11's June 2017 and July 2017 MAR indicated [REDACTED] * On 6/21/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 6/21/17 at 10:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 6/27/17 at 8:00 A.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 6/27/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/3/17 at 8:00 A.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/14/17 at 10:00 A.M., Slow Release Iron was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. On 7/17/17 at 8:00 A.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. On 7/17/17 at 8:00 A.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/17/17 at 8:00 A.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the the back of the MAR indicated [REDACTED]. * On 7/20/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/26/27 at 4:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the the back of the MAR indicated [REDACTED]. The Surveyor interviewed the DON at 11:00 A.M. on 7/27/27. The DON had no explanation why medications were not administered as ordered by the physician. 3) Resident #14 was admitted to the Facility in June 2017, with [DIAGNOSES REDACTED]. Review of the admission MDS assessment with an ARD of 6/23/17, indicated that Resident #14 scored 13 out of 15 on a BIMS, indicating that he/she was cognitively intact. Review of Resident #14's physician's orders [REDACTED].M., Vitamin D3 (used to treat [MEDICAL CONDITION]) 2,000 mg once a day. Review of Resident #14's July 2017 MAR indicated [REDACTED] * On 7/8/17 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/9/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/14/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/16/17 at 8:00 A.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/18/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/20/17 at 6:00 A.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/22/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/23/17 at 8:00 P.M., Vitamin D3 was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. The Surveyor interviewed the DON at 8:00 A.M. on 7/26/27. The DON had no explanation why medications were not administered as ordered by the physician. 4) Resident #15 was admitted to the Facility in March 2014, with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment with an ARD of 6/27/17, indicated that Resident #15 scored 05 out of 15 on a BIMS, indicating that he/she had severe cognitive impairment. Review of Resident #15's physician's orders [REDACTED]. Review of Resident #15's July 2017 Medication Administration Record [REDACTED] * On 7/22/17 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/22/17 at 8:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/22/17 at 8:00 P.M., Senna was not documented as administered to the Resident as ordered as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. The Surveyor interviewed the DON at 10:30 A.M. on 7/28/27. The DON had no explanation why medications were not administered as ordered by the physician. 5) Resident #17 was admitted to the Facility in March 2017, with [DIAGNOSES REDACTED]. Review of Resident #17's quarterly MDS assessment with an ARD of 6/30/17, indicated that Resident scored 05 out of 15 on a BIMS, indicating that he/she had severe cognitive impairment. Review of Resident #17's physician's orders [REDACTED]. Review of Resident #17's July 2017 Medication Administration Record [REDACTED] * On 7/15/17 at 10:00 A.M., Calcium [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/20/17 at 10:00 A.M., [MEDICATION NAME] was not documented as administrated to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/26/17 at 10:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. * On 7/26/17 at 10:00 P.M., [MEDICATION NAME] was not documented as administered to the Resident as ordered by the physician. There was no documentation on the back of the MAR indicated [REDACTED]. The Surveyor interviewed the DON at 1:00 P.M. on 7/28/17. The DON had no explanation why medications were not administered as ordered by the physician.

Based on observation, staff interviews, dietary ticket and medical record review, the facility failed to ensure that one Resident (Resident #2), received 2 meals with appropriate diet texture, and according to the Speech Language Pathologist's recommendations, from a total sample of 23 residents. Findings include: Resident #2 was admitted to the facility in 8/2013 with [MEDICAL CONDITION], dysphagia (difficulty swallowing), [MEDICAL CONDITION] stricture and obstruction with a recent significant weight loss. Review of the most recent Quarterly Minimum Data Set (MDS) with an assessment reference date of 2/14/17 indicates a Brief Interview for Mental Status (BIMS) score of 00 or severely cognitively impaired, requires supervision with cueing and setup assistance and had an un-intentional weight loss of 10 % or more in the last 6 months. Review of the Resident's Weight Loss Care Plan (6/20/17) indicates the following: Diet as ordered/ House, Puree texture, thin liquids, may thin pureed texture with milk or broth for easier consumption with straw/mug spoon. Eats meals in dining room and lunch club group. Review of a Speech Language Pathology Treatment Encounter Note on 7/4/17 indicated that the Resident had received the wrong tray due to an error on the dining ticket. The Resident incorrectly received a few bites of chicken and rice. The Resident began to reflux (regurgitate) shortly into the meal and brought up thick, stringy secretions and the bites presented. The note also indicates that the SLP will report ticket error to dining management. Review of the 5/23/17 dietary note indicates that the Resident has a recent and significant weight loss (12 % in 6 months) and has not been accepting of solid foods, but has been accepting liquids and soft pureed foods with a straw. Review of the SLP Discharge Summary of 7/12/17 indicates following cues in 1:1 setting, increased ease of access with blended pureed, increased [MEDICAL CONDITION] challenges this period with audible gurgles with rapid sips, rate needs to be controlled by caregiver to prevent reflux and subsequent aspiration (breathing in liquid or solid food particles into the lungs). Staff education ongoing and discharge with puree diet/ thin liquids and consistent cues/assist for use of strategies. On 7/28/17 at 9:45 A.M. Surveyor #1 observed Resident #2's tray following breakfast with CNA#1 outside of the Resident's room. The CNA said that she had assisted the Resident with breakfast and said that he/she only ate about 30%. The Surveyor observed a whole corn muffin in a small bowl and an empty banana peel with no straws on the tray. The CNA said that the muffin was in a slurry (slurry refers to a thickener dissolved in liquid and helps dry, crumbly foods (bread) become softer and more liquid, which makes them easier to swallow) and that she had cut the banana into pieces. The entire banana had been eaten. The Surveyor observed the muffin whole with a bite missing and the slurry sitting in the bottom of the bowl. Following the tray observation at 10:00 A.M., the Surveyor interviewed the SLP (covering for vacation). The Surveyor showed the meal ticket to the SLP. The SLP looked at the meal ticket and said that's not the right meal. P is for pureed muffin and pureed means pureed. The SLP also said that the Resident should never have been given a banana. The Surveyor asked about the slurry and the SLP said that the ticket indicates No slurried/pureed sandwiches and thin puree with milk to milkshake consistency. Pureed does not mean slurried is acceptable. The Surveyor interviewed the Food Service Director (FSD) at 10:15 A.M. The FSD looked at the meal ticket and said I don't know why the Resident got a banana. On 7/28/17 the Surveyor requested the incident report for 7/4/17 from the DON. An incident report was not created following the tray error and therefore, no action plan was put in place on 7/4/17 to prevent it from happening again.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), who was assessed at risk for falls, the Facility failed to ensure there was a system in place for communicating safety interventions in the plan of care to direct care staff, and failed to document changes on the Certified Nurses' Aide Care (CNA) Kardex. On 9/18/16, Resident #1 was left unattended in the bathroom, had a unwitnessed fall, and sustained a laceration to his/her right hand third finger, which required 8 sutures to close, and abrasions to both knees. Findings include: The Nursing Admission Assessment, dated 8/31/1/6, indicated Resident #1 was at high risk for falls and fall risks factors that may require further interventions or follow-up included: required assist with bed mobility, transfers, ambulation and used an assistive device. The Assessment indicated Resident #1 experienced a change in mobility, gait or balance, had new medications or dosage changes in the last 7 days, experiencing an acute illness or infection, has pain or requires interventions for pain, and Resident #1 has had a change in environment in the last 7 days (new admission, room, or bed). The Care Plan for Alteration in Self Care Ability, updated 9/03//16, indicated Resident #1 required use of a sit to stand lift for transfer out of bed and toileting. The Certified Nurse Aide (CNA) Care Kardex, undated, was not updated to indicate Resident #1 required a sit to stand lift for getting out of bed or toileting. The physician's orders [REDACTED].#1 required bed and chair alarms at all times, and alarms were to be check every shift. The CNA Care Kardex, undated, indicated Resident #1's intervention for bed and chair alarms were not included as part of Resident #1's safety plan. The Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required an extensive assist of two staff for toilet use (how the resident uses the toilet room, commode, bedpan, urinal, and transfers on and off the toilet. The Resident/Visitor Incident Report, dated 9/18/16, indicated Resident #1 had an unwitnessed fall in the bathroom, Resident #1 was found sitting on his/her buttocks, legs stretched out in front of him/her, and Resident #1's rolling walker was on top of him/her. The Report indicated Resident #1 sustained a skin tear to his/her right knee, skin tear to his/her right hand third digit, and facial bruising. The Nurse's Note, dated 9/18/16, indicated Resident #1 was transferred to the emergency department for evaluation of injuries sustained during the fall. The Hospital Emergency Department Report, dated 9/18/16 indicated, Resident #1 had a 2 centimeter irregular shaped laceration to his/her right hand third finger which required 8 sutures to close; [MEDICATION NAME] (topical antibiotic) was to be applied to right third finger daily, keep splinted to avoid sutures from popping out, and sutures to be removed in 7 to 10 days. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:57 A.M. on 10/28/16. CNA #1 said before she provided care for Resident #1 she checked the CNA Care Kardex and waited for Nurse #2 to give her report. CNA #1 said the CNA Care Kardex indicated Resident #1 required two staff to assist with transfers and ambulation, and said Resident #1's Plan of Care had not provided any information that Resident #1 required alarms. CNA #1 said she did not recall if Resident #1 had bed or chair alarms, however, it was the Facility's practice that if a resident required bed or chair alarms staff were not to leave the resident alone in the bathroom,or words to that effect. The Surveyor interviewed Nurse #5 at 2:36 P.M. on 10/28/16. Nurse #5 said she obtained a physician's orders [REDACTED]. Nurse #5 said she did not update Resident #1's plan of care or the CNA Care Kardex because she did not believe it was her responsibility to do so. Nurse #5 said there was no set procedure for updating the CNA Care Kardex. The Surveyor interviewed Nurse #2 at 3:15 P.M. on 10/31/1/6. Nurse #2 said she does not believe there is a protocol in place to identify who was responsible for updating resident care plans and CNA Care Kardex when a new order was obtained. The Surveyor interviewed the Director of Nurses (DON) 12:45 P.M., and throughout the day, on 10/28/16. The DON said when a nurse obtained new orders from the physician, that same nurse was responsible for transcribing the order, updating the medication and/or treatment sheet as needed, as well as updating the residents' plan of care and CNA Care Kardex.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), who was assessed at risk for falls due to poor safety awareness and mobility problems, the Facility failed to ensure nursing staff maintained Resident #1's safety, to prevent a fall with injury. On 9/18/16 Resident #1 was left unattended in the bathroom, fell and sustained a laceration to his/her right hand third finger which required 8 sutures to close, and abrasions to both knees. The Director of Nurses (DON) and Certified Nurse Aide #1 (CNA), said normally residents whose plan of care included use of alarms at all times, were not to be left alone in the bathroom. CNA #1 said she left Resident #1 alone in the bathroom prior to the fall on 9/18/16, because she was not aware Resident #1 used alarms. Findings include: The Facility's Fall Prevention Guidelines, not dated, indicated upon admission, a nurse performs a Fall Risk Assessment within 8 hours and a Falls Care Assessment Area (CAA) was completed within 14 days of admission. The Guidelines indicated, all residents have the potential to be at risk for falls and should have a fall prevention care plan initiated. The Guidelines indicated daily meetings should be held to discuss residents who have fallen and members of the Fall Committee were responsible for communicating updated information to others in their department. The Hospital Discharge Summary, dated 8/31/16, indicated Resident #1 was transferred to the Facility following treatment for [REDACTED]. The Nursing Admission Assessment, dated 8/31/1/6, indicated Resident #1 was at high risk for falls and fall risks factors that may require further interventions or follow-up included; requires assist with bed mobility, transfers, ambulation and used an assistive device. The Assessment indicated Resident #1 experienced a change in mobility, gait or balance, had new medications or dosage changes in the last 7 days, experienced an acute illness, required interventions for pain, and Resident #1 has had a change in environment in the last 7 days (new admission, room, or bed). The Interim Plan of Care related to Fall Safety Risk, dated 8/31/16, indicated staff were to assess Resident #1 for contributing factors related to falls, and included; encourage to use call light, physical therapy referral, and instruct on safety. The Occupational Therapy Initial Evaluation, dated 8/31/16, indicated Resident #1 had impaired range of motion and strength in his/her right upper arm and right shoulder due to an old injury. The Evaluation indicated Resident #1 had impaired range of motion and strength in his/her right lower and left extremities due to pain. The Evaluation indicated Resident #1 required moderate assistance and upper extremity support while standing for activities of daily living. The Physical Therapy Initial Evaluation, dated 9/01/16, indicated Resident #1's fall risk impairments included: balance and posture control, neuromuscular (nerves controlling voluntary muscles), pain, and decreased strength. The Activities of Daily Living Flow Sheet, dated September 2016, indicated Resident #1 was non-ambulatory, required assistance from two staff for transfers, and required assistance from two staff for toilet use. A Nurse's Note, dated 9/05/16, indicated Resident #1 required bed and chair alarms at all times due to a history of falls. The CNA Care Kardex, undated, indicated Resident #1's safety plan included a low bed, however, the Kardex had not included the information to indicate Resident #1 required alarms. The Occupational Therapy Treatment Encounter Note, dated 9/10/16, indicated Resident #1 was only able to stand for 30 seconds and required bilateral upper extremity support for stability. The Falls Care Area Assessment (CAA) Documentation Notes, dated 9/12/16, indicated Resident #1 had impaired balance during transitions, difficulty with transfers, several falls at home in the last month with most recent fall resulting in pelvic fracture, bed and chair alarms are in place for fall prevention, encouraged to use call light, and Resident #1 has occasional episodes of confusion and impulsive behaviors. The Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had moderate cognitive impairment, with short and long term memory deficits; required an extensive assistance of two staff for toilet use; Resident #1's balance was unsteady, and he/she was unable to move on or off the toilet, or complete a surface to surface transfer, without physical assistance for stability. The Resident/Visitor Incident Report, dated 9/18/16, indicated Resident #1 had an unwitnessed fall in the bathroom, at the time was found sitting on his/her buttocks, legs stretched out in front of him/her, and Resident #1's rolling walker was on top of him/her. The Incident Report indicated, Resident #1 sustained a skin tear to his/her right hand third digit, a skin tear to his/her right knee, and facial bruising. The Nurse's Note, dated 9/18/16, indicated Resident #1 was transferred to the emergency department for evaluation of injuries sustained during the fall. The Hospital Emergency Department Report, dated 9/18/16, indicated Resident #1 had a 2 centimeter irregular shaped laceration to his/her right hand third finger which required 8 sutures to close, bacitracin (topical antibiotic) to be applied to right third finger daily, keep splinted to avoid sutures from popping out, and sutures to be removed in 7 to 10 days. The Surveyor interviewed the Occupational Therapist #1 at 10:37 A.M. on 10/27/16. Occupational Therapist #1 said despite Resident #1 having several weeks of rehabilitation, Resident #1 continued to demonstrate poor safety awareness, and was unable to stand independently to complete his/her own personal hygiene. Occupational Therapist #1 said Resident #1 should not have been left alone in the bathroom. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:57 A.M. on 10/28/16. CNA #1 said before she provided care for Resident #1 she checked the CNA Care Kardex and waited for Nurse #2 to give her report. CNA #1 said the CNA Care Kardex indicated Resident #1 required assistance of two staff with transfers and ambulation. CNA #1 said she transferred Resident #1 to the bathroom with the assistance of different CNAs throughout the day, and left Resident #1 in the bathroom each time with instructions to ring call light when when he/she was done, and Resident #1 had done so without difficulty. CNA #1 said she toileted Resident #1 again around 2:45 P.M., at Resident #1's request, and she had not noticed any changes from earlier. CNA #1 said normally residents whose plan of care included use of alarms at all times, were not to be left alone in the bathroom. The Director of Nurses (DON) was interviewed at 12:45 P.M. and through out the day, on 10/28/16. The DON said that although the Facility provided documented guidelines for the prevention of falls, or words to that effect, the Facility did not have a Formal Fall Management Program in place for the prevention of falls. The DON said residents who require alarms at all times should not be left alone in the bathroom.

Based on record review and interview the facility failed to follow the medical plan of care for 1 Resident (#15) in a sample of 24 Residents. Findings include: For Resident #15, the facility failed to follow the physician's orders [REDACTED]. Resident #15 was admitted in 12/2015 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 3/15/16, Resident #15 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS), indicating that he/she was alert with cognitive impairment, was in need of staff assistance with all activities of daily living except to eat, weighed 145 pounds and required a urinary catheter to collect urine According to physician orders, Resident #15's medication regime with an order date of 4/2/16, included [MEDICATION NAME] 20 milligram (mg) to be administered every other day. Further record review indicated the resident was followed by the physician/nurse practitioner due to medical condition changes which included weight gain and discomfort from Foley catheter. Daily weight monitoring was reduced to weekly monitoring on 4/1/16. Weekly weight documentation indicated the resident continued with weight fluctuations. During the third week of April, Resident #15 weighed 147.2 pounds on 4/16/15; and 150.4 pounds on 4/23/16 with an additional weight recorded during the fourth week of April, noting a total of 5.4 weight increase to 152.6 pounds. Physician orders [REDACTED]. An additional physician's orders [REDACTED]. every other day on 5/1/16. Review of the Medication Administration Record [REDACTED]. was administered daily from 5/1/16 to 5/12/16, and the resident received six incorrect doses. The physician's orders [REDACTED]. every other day (starting 5/1/16) was not followed. During an interview on 5/19/16 at 11:30 A.M., Unit Manager #2, agreed that an editing error had occurred and that Resident #15 did not receive the [MEDICATION NAME] medication correctly as prescribed by the physician.

Based on record review and staff interview, the facility failed to assure that a Rogers Treatment Plan was in place for one Resident (#20) out of 1 sampled Resident with a Guardianship, who was receiving an antipsychotic medication, out of 24 sampled Residents. Findings include: Resident #20 had [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident #20 had an Appointment of Guardian for an Incapacitated Person dated 6/7/12. Review of the nurse's notes dated 2/9/16, indicated that Resident #20 had an unwitnessed fall out of his/her wheelchair at 5:00 P.M. on 2/9/16. Resident #20 sustained a hematoma to the left temporal area and complained of a very bad headache. The Nurse Practitioner was notified and an order was obtained to transfer Resident #20 to the hospital for evaluation. The hospital discharge summary indicated that Resident #20 was intermittently agitated and psychiatry was consulted. The psychiatrist recommended using [MEDICATION NAME] as needed for agitation. Resident #20 was readmitted to the facility in 2/2016 with the addition of the antipsychotic medication [MEDICATION NAME] 5 milligrams (mg) every day for agitation and [MEDICATION NAME] 5 mg every four hours as needed (PRN) for agitation. During clinical record review on 5/18/16, Resident #20 had a physician's orders [REDACTED]. There was no documented evidence that a Roger's Treatment Plan was obtained when the Resident #20 started on the antipsychotic medication on. Resident #20 continued to receive [MEDICATION NAME] 5 mg every day beginning 2/13/16 through 5/18/16, when it was identified by the Surveyor that a Roger's Treatment Plan had not been obtained from the court. The Director of Social Service (DSS) was interviewed at 1:28 P.M. on 5/18/16, and said that a Roger's Treatment Plan was never obtained for Resident #20. The DSS said she just heard about this and that, it must have fallen thru the cracks. The Director of Nursing Services (DNS) was interviewed at 2:00 P.M. on 5/18/16. The DNS said she just heard there was not a Roger's Treatment Plan in place for Resident #0 who was receiving the antipsychotic medication [MEDICATION NAME].

Based on record review, family and staff interviews, the facility failed to address an identified need for speech-language services for one resident (#11), who had shown a decline in his/her speech. The total sample was 24 residents. Findings include: Resident #11 was admitted to the facility in 3/2012 and had [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 3/10/15, indicated the resident speech was impaired, but that he/she could be understood with a degree of difficulty. The MDS indicated the resident was alert and oriented to person, place and time and required extensive assistance from staff for his/her activities of daily living. Further review of the clinical record on 4/7/15 and 4/13/15 indicated the Resident's disease ([MEDICAL CONDITION]'s)affected his/her speech and swallowing. Record review indicated the facility had last provided speech-language services and treatment from 10/3/14 - 10/24/14. The speech-language discharge note dated 10/24/14 indicated that skilled services was to develop communication books that would assist the resident in functional tasks and communication. The therapist indicated, at the time of discharge from speech services, the Resident was 90 % successful in his/her ability to communicate wants and needs with both familiar and unfamiliar conversational partners, with the tools provided and taught. The care plan for a decline in communication skills related to the disease process was initiated on 8/24/12. The goals were for the Resident to make needs known to the best of his/her ability and not to be stressed while communicating. Interventions included quiet setting use yes/no questions, allow sufficient time for resident to respond, wait for resident to form reply, encourage resident to speak slowly, don't pretend to understand if you do not and use communication book. Further review of the care plan failed to indicate when the last revision had been made, although the target dates indicated the plan was active through 5/2015. Review of the interdisciplinary care plan meeting notes dated 12/9/14 indicated the team had identified a decline in the Resident's speech. There was no documentation for review to indicate any change or if speech-language services had been considered. On 1/7/15, the Resident was evaluated by his/her neurologist. The consult report indicated a need for speech-language services. The neurologist indicated he recommended speech language services to help with the Resident's declining articulation and that he would contact the hospital's speech therapist. The 1/7/15 nurse's note indicated that the resident had been seen by his/her neurologist and had recommended follow-up speech services to help the resident with his/her speech. Further review of the clinical record failed to indicate a follow-up to the neurologist visit on 1/7/15. The record failed to indicate if the neurologist had spoken to the hospital's speech therapist and failed to indicate that the facility investigated or was informed of the outcome. On 3/19/15, the interdisciplinary team meeting note indicated an ongoing decline in the Resident's speech. There was no indication that staff had investigated speech-language services to help with the decline. During the tour with Unit Manager (UM) #2 on 4/7/15 at 8:00 A.M., UM #2 said Resident #11 had shown a decline in his/her speech function. During interview on 4/10/15 at 9:50 A.M., the Surveyor reviewed the neurologist's 1/7/15 consult with UM #2. UM #2 said that she would talk with the facility's speech therapist and investigate the outcome to the consult for speech-language services. UM #2 said that the Resident's family visited daily and that they were involved in all aspects of resident care and needs. The UM said the family would know what had occurred following the neurology visit. During observations on 4/10/15 at 10:30 A.M., Resident #11 was in room watching the television. The Surveyor approached Resident #11 and the resident responded with single words, such has hi, yes and no. A white board with letters and a notebook (communication tools) were visible in room, but the resident chose not to use them. The resident required time to formulate his/her words. On 4/10/15 at 2:15 P.M., Unit Manager #2 said that she reviewed the neurology consult with the facility's speech therapist. She said the consult indicated that the neurologist was going to contact "his" speech therapist at the hospital to discuss treatment for [REDACTED]. She said that because the neurologist indicated he was going to contact speech therapist, the facility had not followed up with the neurologist. She said she did not know if the neurologist had followed through with his plan. UM #2 referred the Surveyor to the family for information. The Surveyor asked if the facility had considered speech language services since UM #2 had informed the surveyors that the Resident's speech had been declining. She said she was not aware of any facility decision to provide speech-language services. During interview on 4/13/15 at 12:45 P.M., with the Resident's family member (who had been identified by the facility as the active person involved with services and care for the resident), the Family Member said he/she had gone to the appointment on 1/7/15 with the Resident. The Family Member said he/she was unaware of the neurologists plan to contact the hospital's speech language therapist for services. He/she said there has been a decline in the Resident's ability to talk and he/she and the Resident agreed that they were willing to receive services (if determined appropriate) to help. The Family Member said that it was unlikely the neurologist had followed-up with his plan to contact the hospital's speech therapist. The Family Member said the doctor was very busy and difficult to get in touch with. The Family Member said if he/she had known about the recommendations, that he/she would have pursued the services. The Resident and Family said they would prefer the Resident receive the speech-language services at the facility and have the facility coordinate the treatment with the hospital speech therapist, rather than going outpatient. During interview on 4/13/15 at 1:45 P.M., the Speech therapist said she did not know about the 1/7/15 consult and treatment recommendations, until the Surveyor had brought it to the attention of the Unit Manager. She said she knew the Resident's speech was declining and was surprised that the Resident's Family Member had not pursued speech services following the appointment. She said the Family was very active in the Resident's care. The therapist said she was surprised when the Surveyor shared that neither the Resident and Family knew that the neurologist had recommended speech services to determine treatment to help with language skills. The Speech therapist said she did not understand what the Surveyor was asking, but then said she would contact the hospital's speech therapist.

Based on closed record review and staff interviews, the facility failed to maintain professional standards of practice, for documentation of an R.N. (Registered Nurse) pronouncement of death, for the 1 closed record of a deceased resident (#24) in a total sample of 24 residents. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." Resident #24 was admitted from the acute care hospital with a [DIAGNOSES REDACTED]. Documentation from the hospital reported that the physician advised the resident's family member/Health Care Agent that there was no intention to treat and the resident would "most assuredly die." The Health Care Agent made the decision for the resident to be transferred to the facility for comfort care. On [DATE] during review of the closed clinical record, it was noted that the resident died at 9:05 P.M. on [DATE]. Per review of the nurse's note, dated [DATE] and noted as the 3:00 to 11:00 P.M. shift, the staff R.N. wrote the resident could be aroused with verbal stimuli, received mouth care, was using oxygen at 2 liters per minute and repositioning and comfort care continued. The Nurse also noted the resident's breathing was unlabored with 16 to 20 breaths per minute. In the same note, the RN then wrote, "At 9:05 P.M. patient passed away." The Commonwealth of Massachusetts R.N. Pronouncement of Death form was completed by the R.N. who wrote the nurse's note. There was no documentation by the pronouncing R.N. related to the final assessment of the resident's physical condition and absence of vital signs. During interview on [DATE] at 2:00 PM, the Director of Nursing (DON) was advised of the lack of clinical assessment documentation by the nurse making the R.N. pronouncement of death. The DON inquired if the R.N. Pronouncement of Death form constituted such an assessment. However, no clinical documentation related to the resident's condition and absence of vital signs was included on the form. No other information or documentation related to the R.N.'s clinical assessment of the resident's death was provided.

Based on record review and staff interview, the facility failed to assure that all sections of the residents' Minimum Data Set (MDS) assessments accurately reflected the resident's status for 3 of 24 sampled residents (#2, 11 and 19). Findings include: 1. Resident #2 was found to have a urinary tract infection [MEDICAL CONDITION] per lab results of a urine culture and sensitivity on 2/20/15. The laboratory culture results identified the bacteria Lactobacillus in a concentration over 100,000 cfu/ml (colony-forming units per milliliter) and Escherichia coli in a concentration of 1,000 cfu/ml. The physician was notified and an order was given to treat the infection with the drug [MEDICATION NAME]. Review of the quarterly Minimum Data Set (MDS) assessment, with a reference date of 2/24/15, identified that the entry for UTI in the [DIAGNOSES REDACTED]. During interview on 4/14/15 at 2:00 P.M., the Director of Nursing was advised of the MDS error related to the resident's UTI. At 3:00 P.M. the Director of Nursing said a correction to the MDS had been made. 2. Resident #11 had a primary [DIAGNOSES REDACTED]. Review of the record of Resident #11 indicated that on 12/23/14 the resident was found on the floor after a fall. The resident had a quarterly MDS assessment on 12/9/14, and an annual MDS assessment on 3/10/15. The section indicating any falls since the previous assessment, on the 3/10/15 annual MDS, was coded "0" to indicate the resident had no falls since the previous assessment of 12/9/14. 3. Resident #19 was admitted to the facility in 6/2014. At the time of the annual MDS assessment reference date of 6/28/14 and the quarterly MDS assessment reference date of 3/24/15 the Resident had current [DIAGNOSES REDACTED]. The MDS Section for Active [DIAGNOSES REDACTED].