Every finding on record at Life Care Center of Acton

Based on record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure that water testing for Legionella was completed at least annually placing facility residents at risk for exposure to Legionella Bacterium (bacteria which lives in fresh water and can cause pneumonia-like or flu-like illnesses). Findings include: Review of the facility's Water Management Program, reviewed 5/20/25, included but was not limited to the following: -Environmental Risk Management Program procedures = Legionella Testing -Control Measure = Test quarterly or annually -Procedure = Make sure water samples are tested and are within guidelines. During an interview on 7/17/25 at 7:55 A.M., the Maintenance Director said he was responsible for the Water Management Program in the facility. The Maintenance Director said that Legionella testing had not been conducted quarterly or annually by the facility as outlined in the Water Management Program. The Maintenance Director said he was unaware if the town tested for Legionella. The Maintenance Director also said that if the facility's Water Management Program indicated that Legionella testing was to be conducted that testing should have been done. During an interview on 7/17/25 at 11:12 A.M., the Administrator said that he was unaware if Legionella testing had been completed in accordance with the Water Management Program and was unaware of any Legionella testing results at the time of the survey team entrance.

Based on observations, interviews, and record reviews, the facility failed to ensure proper treatment relative to the Resident's vision was obtained in a timely manner for one Resident (#6) out of a total sample of 24 residents. Specifically, the facility failed to assist Resident #6 in scheduling a follow-up ophthalmology appointment for greater than seven months, after the Resident was evaluated and recommendation made by the Ophthalmologist for cataract surgery to his/her left eye, increasing the Resident's risk for further visual decline.Findings include: Review of the facility's policy titled Vision and Hearing Assistive Devices, dated 6/8/20 and reviewed 9/19/24, indicated the following:-The facility's policy was to ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities. -The facility will assist as needed with making appointments and arranging transportation to obtain needed services. Resident #6 was admitted to the facility in July 2023 with diagnoses including Category Three Right Eye Blindness with Normal Vision Left Eye, and Combined Forms of Age-Related Cataract Bilateral. Review of Resident #6's Physician's orders, dated 7/18/23, indicated: May have . Optometry care as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #6:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points.-vision was adequate. Review of Resident #6's Nurse Practitioner (NP) Progress Note, dated 9/12/24, indicated:-The Resident went to an appointment on 9/12/24, for his/her Glaucoma due to worsening eyesight.-Will appreciate recommendations. Review of Resident #6's Nursing Progress Note, dated 9/12/24, indicated:-Resident went out for Ophthalmologist appointment.-Returned with new order. Review of Resident #6's Ophthalmologist Consult dated 9/12/24, indicated:-Advance Stage Neovascular Glaucoma Absolute Stage Right Eye.-Mature Cataract Left Eye.-Patient to schedule exam under anesthesia and cataract surgery for [his/her] left eye. Review of a Nursing Progress Note, dated 11/15/24, indicated:-Call to the [Ophthalmologist] office and said surgery was declined by the Resident's Guardian.-Informed [Ophthalmologist] office Resident was his/her own person and makes their own decisions.-Awaiting return call [sic] so we can move forward. Review of the MDS assessment dated [DATE], indicated Resident #6:-was moderately cognitively impaired as evidenced by a BIMS score of 11 out of 15 total possible points.-vision was moderately impaired. On 7/16/25 at 7:52 A.M., the surveyor observed the following in Resident #6's room:-Resident #6 was sitting upright in bed with his/her tray table in front of him/her.-Certified Nurse Aide (CNA) #1 delivered Resident #6's breakfast tray to the Resident on the tray table.-CNA #1 uncovered the Resident's food and drink items and told the Resident where each item was located on the breakfast tray.-Resident #6 asked CNA #1 for the Unit Manager (UM), CNA #1 said the UM was on vacation that week and then left the room.-Resident #6 then used his/her left hand to reach and touch different items on the tray and asked the surveyor where the cereal was placed on the tray.During an interview at the time, Resident #6 said he/she was blind in his/her right eye and had difficulty seeing any detail out of his/her left eye. Resident #6 said he/she wanted to speak with the UM because he/she had been waiting for an appointment to be scheduled with the eye doctor, and no one had gotten back to him/her relative to whether an appointment had been scheduled. On 7/18/25 at 7:50 A.M., the surveyor observed the following in Resident #6's room:-Resident #6 was sitting upright in bed with his/her breakfast meal on the tray table in front of him/her.-Resident #6 drank orange juice from a plastic cup, then placed the cup down in his/her bowl of oatmeal.-Resident #6 used his/her left hand to reach and was touching different food items on the tray, then grasped and picked up the cup of orange juice again, drank from it, and placed it on the tray after attempting to place the cup where the bowl of oatmeal was.-CNA #2 entered the room at 7:58 A.M., asked the Resident how he/she was doing and if he/she needed any help.-Resident #6 said he/she was fine and requested CNA #2 just keep checking on him/her.-CNA #2 exited the room at 8:00 A.M. During an interview on 7/18/25 at 8:00 A.M., CNA #2 said Resident #6 had difficulty seeing so she would check in on the Resident to ensure he/she was not having trouble feeding him/herself. CNA #2 said she knew the Resident had one eye that was worse than the other, but she could not recall which eye that was. CNA #2 said she knew the Resident could see, but that the Resident could not see any detail. During an interview on 7/18/25 at 9:43 A.M., Resident #6 said he/she had not been back to see the Ophthalmologist since he/she was last there in September 2024. Resident #6 said he/she needed and wanted surgery on his/her left eye, but no one ever got back to him/her on whether an appointment had been made for the surgery. Resident #6 said he/she wanted to ask the UM about the appointment, but the UM was on vacation. Resident #6 said he/she did not think his/her vision had gotten any worse since last seeing the Ophthalmologist. Resident #6 said he/she could not see anything out of his/her right eye and that he/she could see shadows and no detail out of his/her left eye. Resident #6 said his/her only concern was his/her impaired vision and that he/she wanted left eye surgery. During an interview on 7/18/25 at 11:00 A.M., the NP said Resident #6 made his/her own medical decisions and the Resident's Healthcare Proxy (HCP) was not invoked. The NP said that Resident #6 had some illnesses between September 2024 and July 2025 and said that with these illnesses, follow-up with the Ophthalmology office to schedule surgery may have gotten lost. The NP further said despite Resident #6's periods of illnesses since September 2024, facility staff should have followed up with the Ophthalmology office relative to the Resident's cataract surgery. During an interview on 7/18/25 at 1:58 P.M., the Director of Nursing (DON) said the UM alerted the Ophthalmologist's office that Resident #6 made his/her own medical decisions when the UM spoke with the office in November 2024 and that the facility was awaiting a return call from the Ophthalmologist's office to schedule the surgery. The DON said the UM was on vacation and that when the surveyor inquired about whether the Resident had been scheduled for cataract surgery, the DON called the UM and the Ophthalmologist's office for more information on 7/18/25. The DON said she found out that the Resident's HCP, who was not invoked, originally declined the surgery for the Resident due to an insurance coverage issue, and that this was not communicated with the facility. The DON also said no one at the facility had followed up with the Ophthalmology office after the initial call was placed in November 2024 in an attempt to schedule the Resident's surgery. The DON said that if staff at the facility had followed up with the Ophthalmology office and identified there was an insurance coverage issue for that specific office, facility staff would have spoken with the Resident about whether he/she would like to have the surgery performed through another Ophthalmologist who did accept the Resident's insurance, but this did not occur. The DON further said the Resident's cataract surgery was scheduled on 7/18/25 following the surveyor's inquiry, for 11/5/25.

Based on interview, record review, and policies reviewed, the facility failed to offer the Pneumococcal Vaccination as recommended to two Residents (#2 and #50) out of five applicable residents, in a total sample of 25 residents, putting the Residents at risk for developing facility acquired Pneumonia. Specifically, the facility failed to ensure that: 1. Resident #2 was offered an updated Pneumococcal vaccination within the appropriate timeframe as indicated by the CDC (Centers for Disease Control). 2. Resident #50 was offered any Pneumococcal vaccination after admission to the facility. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/15/23 indicated but was not limited to the following: - For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20). Review of the facility policy titled Influenza Vaccine and Pneumococcal Vaccine Policy for Residents, revised 9/13/23, indicated the following procedure: -Each resident should be offered pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized. -There should be documentation in the medical record if there is reason to believe that the pneumococcal vaccine was given previously. -Refusals should be documented in the medical record. -The facility should re-address the refusal with the resident an/or resident representative each year to ensure they have not changed their decision. -These conversations should be captured in the medical record. 1. Resident #2 was admitted to the facility in May 2016 and was over the age of 65. Review of the Medical Record indicated Resident #2 had received the Prevnar-13 (PCV13) Pneumococcal Vaccine on 6/23/2016. Further review of the Medical Record failed to indicate that Resident #2 had a medical contraindication to or had been offered, received, or declined a Pneumococcal Vaccination since 6/23/2016. 2. Resident #50 was admitted to the facility in May 2019 and was over the age of 65. Review of the Immunization Report dated 5/28/24 for Resident #50 did not indicate any history of pneumococcal vaccinations being administered, offered, or refused. Review of the Massachusetts Immunization Information System (MIIS) Vaccine Administration Record, provided by the facility indicated Resident #50 had no history of receiving the Pneumococcal Vaccine. Further review of Resident #50's medical record failed to indicate that the Resident had a medical contraindication to or had been offered, received, or declined a Pneumococcal Vaccination. During an interview on 5/24/24 at approximately 10:30 A.M., the Infection Preventionist (IP) said the process is to obtain consent for Pneumococcal vaccinations on admission to the facility and she will do chart reviews and speak to the Resident's or their Responsible Parties regarding vaccination options. The IP said that documentation of vaccinations are noted in the electronic medical record under Immunizations and documentation of refusal of vaccinations will also be noted under Immunizations. During a follow-up interview on 5/24/24 at 12:41 P.M., the IP said that she was unable to provide evidence that Residents #2 and #50 had been offered, received, or declined updated pneumococcal vaccinations.

Based on record review, policy review, and interview, the facility failed to provide mental health services for two Residents (#60 and #2) out of a total sample of 25 residents, with a documented history of mental health concerns. Specifically, the facility failed to ensure its staff: 1. followed the facility Suicidal Precaution policy when Resident #60 had expressed suicidal ideation to staff members. 2. provided timely Behavioral Health Services for Resident #2 who was expressing multiple depressive symptoms during the comprehensive assessment. Findings include: 1. Review of the facility policy for Suicide Precautions, last reviewed 8/22/23, indicated that when a Resident has an expression of an intent to commit suicide: - Complete the P4 Suicidality Screener (suicide risk assessment). - Report findings to the Director of Nursing, Executive Director, Social Services and attending Physician. - Make resident responsible party aware of risk and verbalizations. - Based on risk category, implement the following: MINIMAL RISK: - Refer to mental health provider. - Develop an individualized care plan to address behavior. Resident #60 was admitted to the facility in January 2023 with diagnoses including Depression and Metabolic Encephalopathy (a brain dysfunction caused by problems with your metabolism) Review of Resident #60's Nursing progress notes indicated that on 1/30/24 the Social Worker notified the nurse that Resident #60 wanted to kill themselves. Further review of the progress notes indicated a late entry Social Services note, dated 2/1/24, documenting that the Resident was at minimal risk for self-harm. There was no further documented evidence in Resident #60's medical record that the facility policy had been followed related to: - completion of the P4 Suicidality Screener. - that the findings were reported to the Director of Nurses, Executive Director, and attending Physician. - Resident #60's responsible party had been made aware of risk and verbalizations. - referral was made to a mental health provider regarding the suicidal expression. - care plan was updated to address Resident #60's behavior. During an interview on 5/23/24 at 10:02 A.M., Social Worker (SW) #1 and SW #2 said that the Physician had not been notified of Resident #60's suicidal statement and they should have been. During a follow up interview on 5/23/24 at 11:58 A.M., SW #1 said that they did not provide the appropriate treatment and services according to their facility policy on Suicide Precautions for Resident #60 and they should have. 48206 2. Review of the facility policy titled Behavioral Health Services, reviewed 8/22/23, indicated the procedure was to complete the nursing assessment and social services assessment upon admission/readmission, quarterly, and as needed a change in condition. The procedure indicated: -The facility should identify residents who [demonstrate] decreased social interaction and/or increased [withdrawal], angry or depressive behaviors, and may have made verbalizations indicating these. -Identify if a resident would benefit based on above assessment in conjunction with: mental health history and current medication regimen additional mental health consultation (psychiatry, psychology, clinical social work). -If a determined need is present, the facility should consult with attending physician to make referral to mental health professional for assessment and potential for ongoing follow-up. Resident #2 was admitted to the facility in May 2016 and had diagnoses including Parkinson's (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), Schizoaffective Disorder Bipolar type (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present], incoherence and physical agitation and also includes symptoms of mood disorder) and Delusional Disorder (false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary). During an interview on 5/22/24 at 9:21 A.M., Resident #2 said to the Surveyor he/she felt depressed and said I am sad and I cry every morning, noon, and night. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of a possible 15. The MDS further indicated the Resident reported depressive symptoms of little interest or pleasure in doing things, feeling depressed or hopeless, had trouble sleeping, felt fatigued, had a poor appetite, and always felt isolated or lonely from those around him/her. Review of Resident #2's Psychotropic (medications used to treat mental health disorders) Medication Care Plan, last revised 1/3/24, indicated the Resident was being treated with psychotropic medications for behavior management, Schizophrenia, and Bipolar disease. The care plan included the intervention to refer to Psychiatric Nurse Practitioner for psychotropic medication management and Licensed Social Worker from Behavioral Health as needed. Review of the Resident's Care Plan for loneliness and isolation, initiated 3/28/24, included the intervention to consult with appropriate services. Review of the Psychosocial Note dated 3/28/24 indicated Resident #2 reported to Social Worker (SW) #2 that he/she was feeling lonely all the time and that he/she was seen regularly by Behavioral Health Services Nurse Practitioner. Review of the note failed to indicate that a referral for additional behavioral health support was made after the Resident expressed symptoms of psychosocial distress. During an interview on 5/28/24 at 1:11 P.M., SW #2 said he recalled the assessment with Resident #2 in March 2024 and said the Resident had expressed loneliness and depressive symptoms. He said Resident #2 was seen regularly by Behavioral Health and was scheduled to be seen every 2 months. He said that the Resident was seen by Behavioral Health on 3/14/24 but he did not refer the Resident for additional Behavioral Health services after his assessment on 3/28/24. Further review of the medical record indicated the Resident #2 was not evaluated until 5/14/24 by Behavioral Health services after the 3/28/24 MDS indicated increased symptoms of depression and feelings of isolation.

Based on interview and record review, the facility failed to ensure a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASRR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) was submitted for one Resident (#48) out of a total sample of 25 residents. Specifically, for Resident #48, the facility staff failed to request a Level II PASRR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings Include: Review of the facility policy for Pre-Admission Screening and Resident Review; last reviewed 9/25/23, indicated the following: -as part of the PASRR process, the facility is required to notify the appropriate State Mental Health (SMH) authority when a resident with a mental disorder has significant change in their physical or mental condition. -Examples of individuals who may not have previously been identified by PASSR to a mental disorder .or related condition include but is not limited to: -A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder. -A resident transferred, admitted , or readmitted to a nursing facility following an inpatient psychiatric stay or equally intensive treatment. Resident #48 was admitted to the facility in February 2023 with diagnoses including: Unspecified Psychosis (a mental illness that causes abnormal thinking and perceptions. Psychotic illnesses alter a person's ability to think clearly, make good judgments, respond emotionally, communicate effectively, understand reality, and behave appropriately) not due to a substance or known physiological condition. Review of Resident #48's Level I PASRR screen dated 2/14/23, indicated that he/she had a history of a Mood Disorder and Substance Disorder and did not meet criteria for Serious Mental Illness, therefore a Level II PASRR evaluation was not needed. Review of Resident #48's Social Services Progress Notes indicated the following: -On 3/1/23, Resident #48 was exit seeking at night, often packing clothes, confused behavior, refusing anti-psychotic medication (used to treat symptoms of psychosis such as delusions, hallucinations, paranoia, or confused thoughts) -On 5/9/23, the Resident was out of control verbally and physically, pacing the floor, banging their cane, having verbal outbursts, wanting to leave. Interventions attempted by staff, family and the behavioral health counselor were ineffective, and Resident #48 was transferred to the hospital for an evaluation. -On 5/16/23, Resident #48 was threatening their roommate and was given a Section 12 (transportation order to the hospital which allows for an individual to be brought against their will to the hospital for an evaluation by a physician or psychiatrist). Review of the hospital discharge paperwork, dated 5/13/23 to 5/15/23, indicated that Resident #48 was hospitalized for a psychiatric consultation after threatening to harm their roommate. Further review of the clinical record did not indicate that the PASRR Level I evaluation had been updated and submitted for Resident #48 review as required, after it had been identified that the Resident had a diagnosis of mental illness and had limitations in major life activities related to interpersonal functioning. During an interview on 5/23/24 at 10:02 A.M., Social Worker (SW) #1 said that a PASRR Level II screen request should have been submitted to the Department of Mental Health PASRR office and had not been, as required.

Based on observation, policy review, record review, and interview, the facility failed to ensure its staff provided necessary treatment and services, according to professional standard of practice, to promote healing of a facility acquired (FA) deep tissue pressure injury (DTPI- persistent non-blanchable deep red, maroon or purple discoloration resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface) for one Resident (#15) out of two applicable sampled residents, out of 22 total sampled residents. Specifically, the facility failed to ensure its staff: 1) implemented a Physician-directed treatment order for a FA DTPI within a timely manner when the DTPI was identified on the Resident's right heel and communicated to the Physician, 2) assessed the FA DTPI within a timely manner once it was identified, 3) consulted the Physician for a recommended treatment change for the Resident's DTPI, 4) consulted the Physician for a treatment change prior to implementing the change, and 5) consulted the Physician regarding the Resident's response to the current treatment intervention when the dressing provided consistently adhered to the Resident's wound, which increased the Resident's risk for repeated trauma to the DTPI, and preventing wound healing. Findings include: 1) Review of the facility's policy, titled Documentation and Assessment of Wounds, dated 4/19/22, included that residents with pressure injuries would receive necessary treatment and service, consistent with professional standards of practice, to promote healing . Resident #15 was admitted to the facility in January 2008 with diagnoses including Diabetes Mellitus and Peripheral Vascular Disease (PVD- a condition in which narrowed arteries restrict blood flow to the extremities/ legs). Review of a Physician Progress Note, dated 10/24/22, included that the Unit Manager (UM) reported some changes on the Resident's right heel described as black in color, soft, but with some drainage, which was clear. Further review of the Note indicated the plan was for the wound team to assess the Resident's right heel that week and to initiate antibiotic to the Resident's heel with a foam border dressing. Review of the clinical record included no evidence that the Resident's right heel was thoroughly assessed when it was identified on 10/24/22. Review of a Norton Plus Pressure Ulcer Scale, dated 10/25/22, indicated Resident #15 had been identified as high risk for pressure ulcers. 2) Review of a Wound Observation Tool, dated 10/27/22 (three days after the change of skin to the right heel was noted), included the following: - The Resident had an unstageable (full thickness skin and tissue loss in which the extent of the damage cannot be confirmed because the wound bed is obscured by slough; non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed, or eschar; dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) DTPI on his/her right heel that measured 1.0 centimeter (cm) long x 1.0 cm wide x 0.1 cm deep. - The wound bed consisted of 90% necrosis (eschar) and the wound was draining a scant amount of serosanguineous (discharge that contains both blood and a clear yellow liquid known as blood serum) drainage. - The current treatment plan was to wash with normal saline (NS), pat dry, apply Calcium Alginate (used to absorb wound fluid and provides a dry environment to promote wound healing), and cover with dry protective dressing (DPD) one time a day. Review of the October 2022 Physician Orders indicated that treatment for the Resident's right heel was not initiated until it was assessed on 10/27/22, (three days after the DTPI was identified). 3) Review of a Nurse Progress Note dated 11/13/22, indicated: right heel with moderate amount of yellowish drainage to old dressing. Review of a Physician Progress Note Addendum, dated 11/16/22 (three days after an increase in drainage was noted), indicated the following: - There was a change in condition of the Resident's right heel wound. - The treatment plan was changed to include MediHoney (used to aid and support autolytic debridment and a moist wound healing environment in acute and chronic wounds) with a flexible rolled gauze wrap twice a day. Review of a Wound Observation Tool, dated 11/18/22, included the following: - The Resident had an unstageable DTPI that had worsened in condition and measured 5.0 cm long x 5.0 cm wide x 0.1 cm deep. - The wound bed consisted of 100% slough and the wound was draining a scant amount of serosanguineous drainage. - The treatment plan was to wash the right heel with NS, pat dry, apply MediHoney Alginate, and cover with a DPD one time a day. 4) Review of a Wound Observation Tool, dated 11/25/22, included the following: - The Resident's unstageable DTPI still measured 5.0 cm long x 5.0 cm wide x 0.1 cm deep. - The wound bed consisted of 90% slough and 10% eschar, and the wound was draining a scant amount of serosanguineous drainage. - The treatment plan was to wash with NS, pat dry, apply nickel size amount of Santyl (prescription medicine used to remove dead tissue from wounds so they can start to heal), and cover with DPD one time a day. Review of a Physician Progress Note, dated 11/25/22, included the following: - The wound team reported the condition of the Resident's right heel had worsened. - The treatment would include to continue MediHoney with Alginate. Review of the November 2022 Physician Orders included no order for the use of Santyl to treat Resident #15's right heel, as indicated on the Wound Observation Tool. 5) Review of a Physician Order, dated 12/2/22 and initiated 12/3/22, indicated: Wound care to right heel cleanse with NS, pat dry, apply Telfa (gauze wound dressing pad that is non-adherent, to help absorb light wound drainage) and ABD (dry protective gauze dressing used to absorb large or heavily draining wounds) followed by Kerlix (bandage rolls that provide fast-wicking action, aeration, and absorbency with cushion and protection to wounds) wrap every day shift. Review of a Wound Observation Tool, dated 12/4/22, included the following: - The Resident's unstageable DTPI continued to measure 5.0 cm long x 5.0 cm wide x 0.1 cm deep. - The wound bed consisted of 100% eschar in the center and there was no indication of slough being present in the wound bed. - The treatment plan was to wash with NS, pat dry, apply Santyl (nickel size), apply non-adherent gauze dressing, cover with DPD one time a day. Review of a Wound Observation Tool, dated 12/10/22, included the following: - The Resident's unstageable DTPI continued to measure 5.0 cm long x 5.0 cm wide x 0.1 cm deep, but had improved. - The wound bed consisted of 50% eschar and that granulation tissue (new tissue that forms on the surface of a wound during the healing process) was present. - The treatment plan was to cleanse the right heel with NS, pat dry, apply non-adherent gauze dressing and DPD followed by flexible rolled gauze wrap every day shift. During an observation on 12/15/22 at 9:05 A.M., the surveyor observed Nurse #3 complete the treatment to Resident #15's right heel with the Wound Nurse present. Nurse #3 put NS in a bowl and placed several gauze pads in the bowl. She said that she did this because the dressing usually stuck to the Resident's heel and had to be soaked off. Nurse #3 proceeded to remove the gauze dressing from around the right foot, the outer protective dressing was observed to have a quarter size amount of serosanguineous drainage on it and the primary non-adherent gauze dressing was dried to the wound bed. Nurse #3, under instruction from the Wound Nurse, attempted to remove the non-adherent gauze dressing without soaking it off, but was unable to remove it. Nurse #3 then said, In my experience it's always stuck and needs to be soaked off. Nurse #3 then applied the saline soaked gauze to Resident #15's heel and removed the non-adherent gauze dressing which was observed to have a moderate (not scant) amount of serosanguineous drainage on it. The wound bed consisted of 50% eschar and 50% yellow slough with a very small amount of granulation near one edge of the wound. Maceration (soft, white deteriorating skin around the site of an original injury that occurs when too much moisture is trapped between the wound and its bandage) was observed on the edge of 50% of the wound. During an interview on 12/15/22 at 11:34 A.M., with the Wound Nurse and the Assistant Director of Nursing (ADON), the Wound Nurse said Resident #15 had developed an unstageable DTPI while at the facility in October 2022 and that once a change in skin condition like this was communicated to her, she would assess it. The ADON said that other nurses could identify a change in skin condition and notify the Physician of the change, but the facility process did not allow for them to assess the wound for size or staging. The ADON said that once a change in skin condition or wound was identified, the Wound Nurse was required to assess the wound. The Wound Nurse said that she was first alerted to the Resident's DTPI on 10/27/22. She said she assessed it that day and a treatment order was put in place. The Wound Nurse and ADON reviewed the 10/24/22 Physician Progress Note, the Resident's Physician Orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) and said no treatment had been implemented for the Resident's right heel on 10/24/22, as indicated by the Physician, and that a treatment order had not been initiated until 10/27/22. The Wound Nurse then said she had spoken with the Physician, and he ordered Calcium Alginate to treat the wound at that time. The Wound Nurse said that Resident #15's wound had deteriorated in November 2022 and, at that time, she had assessed the wound and thought Santyl should have been implemented, but she did not communicate with the Physician about this and an order for Santyl had never been obtained. The Wound Nurse said that the bottom of the wound was open and draining at that time, and everything was sticking to the wound, so a non-adherent gauze dressing was initiated. When the surveyor asked whether the concern with treatment supplies, including the non-adherent gauze dressing sticking to the Resident's wound was communicated with the Physician in order to assess for the most effective treatment, no response was provided. During an interview on 12/15/22 at 1:06 P.M., the Physician said he had been notified by the Unit Manager (UM) that Resident #15 presented with a change in skin condition to his/her right heel on 10/24/22. The Physician then reviewed the 10/24/22 Physician Progress Note and said the word antibiotic was a transcription error, but he spoke to the UM at that time and believed his instruction was to initiate a treatment to the Resident's right heel using Alginate and a dressing. The Physician said this is what should have been implemented for Resident #15 until the wound team assessed him/her on 10/27/22. The Physician also said his expectation was for staff to implement the orders he gave. He said that he signs a lot of orders and relies on people to put the orders in that he gives, and due to the volume of orders he signs, he cannot go back and verify the orders were implemented as directed. The Physician said when addressing wounds, he went by the Wound Nurse recommendations because Wound Nurses were highly trained. The Physician said the Wound Nurse informed him the Resident's wound was worsening on 11/16/22, the recommendation was to add Medi-honey Alginate to the treatment, but he did not recall the Wound Nurse recommending the use of Santyl to treat the Resident's right heel wound. The Physician said he spoke with the Wound Nurse regarding the condition of the Resident's wound on 11/25/22 and that the wound had slightly worsened, and he did not change the treatment being provided, which was MediHoney with Alginate. The Physician further said he did not recall speaking with the Wound Nurse to change the order from MediHoney with Alginate to cleanse with NS, pat dry, apply Telfa and ABD followed by Kerlix wrap every day shift on 12/2/22. The Physician said that nurses could change treatment orders if they called him and spoke to him about it, but he did not expect orders to be changed if he was not consulted. The Physician further said that he was available to assess the Resident's wound if the facility needed him to, but he did not think he needed to because he trusted the facility's wound team recommendations, so he had not assessed the wound.

Based on observation, policy review, and interview, the facility failed to ensure its staff maintained a clean and sanitary environment in the kitchen where food items were stored and prepared for resident consumption. The facility also failed to ensure its staff adhered to food storage requirements in one of two nourishment kitchens and for one medication room refrigerator. Specifically, the facility failed to ensure its staff: 1) maintained equipment used for meal preparation that was clean and sanitary, 2) discarded outdated food items stored for resident consumption in the central nourishment kitchen freezers, and 3) monitored the temperature in one medication room refrigerator where resident food items were stored. Findings include: 1. The facility failed to ensure its staff maintained kitchen equipment used for meal preparation in a manner that was free of dried food and debris. Review of the facility's policy, titled Cleaning and Caring for Equipment, undated, included the following: - It was important for equipment used in Food and Nutrition Services to be clean. - Equipment was required to be cleaned and sanitized before each use if this was not done after its last use. Accumulated food, grease, and dirt encourage bacteria and mold growth. - A regular, routine cleaning schedule would be provided. During an observation on 12/12/22 at 7:18 A.M., the surveyor observed the following during the initial brief kitchen tour: - One box of white cake mix open, and the zip lock bag inside containing the cake mix was open to air. - Dripped and dried white substance on the front and right side of the double-door stand up refrigerator. - Dark brown colored dried substance on the blade of the can opener. On 12/13/22 at 11:46 A.M., the surveyor observed the following during the return kitchen visit: - The box of cake mix was still open, with the zip lock bag inside containing the cake mix was open to air. - Adjacent to a countertop next to the food preparation area, a covered trash can with dried food and debris on top of and along the edges of the trash can cover. - Dripped and dried white substance on the front and right side of the double-door stand up refrigerator - A covered white trash can between the food preparation area and the three-compartment sink that had dried red and brown debris on it. - A cart that contained sugar packets had dried, crusted debris along the bottom edge of the cart and the side of the cart had white and brown and white dried substances on the side of it. - The blade of the can opener had a dark colored dried debris on it. - The Steam Chef Sure Cook had dried dried debris on the front of it, on the handle, on the dial, and around the button used for timed or manual setting. - Dried crumbs and debris on the oven handle, where the handle and the oven met. During an interview on 12/13/22 at 12:10 P.M., the Food Service Director (FSD) said that the open box of white cake mix had last been used on 12/11/22 and it should have been sealed and closed after its last use, but it was not. During a follow-up interview on 12/13/22 at 1:15 P.M., the FSD said that there was a cleaning schedule for equipment in the kitchen to be maintained, but they were having difficulty keeping up with the cleaning schedule because there were not enough staff to fill each position to maintain the schedule. He said that he probably should condense the schedule so the equipment could be maintained in a clean manner with the staff that he had working, but this had not been done. 2. The facility failed to ensure its staff discarded outdated food items stored in the central nourishment freezers that were stored for resident consumption. Review of the facility's policy, titled Food from Outside Sources, dated 9/8/22, included the following: - All residents, family members, and other visitors should be informed of the policy on food from outside sources. - Adhere to expiration date on pre-packaged food items; items should be discarded if past expiration date. During an observation on 12/13/22 at 2:00 P.M., the surveyor observed two refrigerators, positioned side by side, with top freezers. Observations inside the freezers were as follows: - One container of vanilla ice cream with a best by date of 7/6/23, undated when opened, and the lid was partially off. The ice cream was partially gone and there was ice build-up on the top of the remaining ice-cream. - Three zip lock bags of hot dogs in a larger plastic bag. The larger plastic bag was labeled with a name and dated 6/16/22. Each zip lock bag of hot dogs were undated for when they were packaged and there was ice build-up on the hot dogs in each of the bags. - One open box of frozen sausages containing 5 sausage links that were covered with ice, and the box was open to air. During an interview on 12/13/22 at 2:30 P.M., the FSD said food items stored in these freezers were residents' personal food items. He said all food items should be properly sealed after being opened and any food items that had ice build up on them should be discarded. The FSD said it was hard to throw food items away that belonged to residents, but the the ice cream, three packages of hot dogs, and the box of sausage links should have been discarded. 37086 3. The facility staff failed to monitor the temperature of a refrigerator that was used to store residents food on the Thoreau Unit. During an observation on 12/13/22 at 1:03 P.M., the surveyor observed a refrigerator in a medication storage room located behind the nurses station on the Thoreau Unit. The refrigerator temperature was 48 degrees Fahrenheit and had a plate with a covered sandwich, a yogurt, and a container of Glucerna (nutritional supplement) in it. Unit Manager (UM) #1 was with the surveyor and said the refrigerator was used to store resident food items only. The surveyor asked to see the temperature logs for the refrigerator and UM #1 said they only kept a temperature log for the refrigerator they used to store medications and not the one they used to store resident food items.

Based on record review and interview, the facility failed to ensure that its staff completed a quarterly Minimum Data Set (MDS) assessment in a timely manner, for two Residents (#4 and #57), out of 22 sampled residents. Findings include: 1. Resident #4 was admitted to the facility in March 2022. Review of a quarterly MDS assessment indicated the assessment reference date (ARD) was 11/8/22 and the assessment was completed on 12/7/22 (past the 14 day required timeline for completion). 2. Resident #57 was admitted to the facility in July 2021. Review of a quarterly MDS assessment indicated the ARD was 11/8/22 and the assessment was completed on 12/10/22 (past the 14 day required timeline for completion). During an interview on 12/13/22 at 2:19 P.M., the Assistant Director of Nurses (ADON) reviewed the transmittal record for both assessments and said they were completed later than the required timeline.

Based on record review and interview, the facility failed to ensure that its staff honored the rights of one Resident (#2) to formulate advanced directives (an individual's wishes regarding medical treatment), out of a total sample of 22 residents. Specifically, the facility staff executed a Medical Order for Life-Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders) form with the Resident's Representative, when the Resident continued to be capable of making their own health care decisions. Findings include: Review of the Facility policy titled Advanced Directives and Advanced Care Planning, revised 3/28/2022, indicated: -Residents have the right to self determination regarding their medical care. - .a resident should not be presumed incompetent unless a Physician renders an opinion of such . Resident #2 was admitted to the facility in June 2019. Review of the Resident's Health Care Proxy (HCP- a person that you trust as your proxy, or agent to express your wishes and make health care decisions for you) dated 5/14/2015, did not show any evidence that the HCP was ever invoked (made active). Review of the Resident's progress note dated 4/3/2020 indicated: -alert and oriented with some forgetfulness -Resident is a Full Code (attempt resuscitation if the heart stops beating or breathing ceases) per (his/her) request (no MOLST in place/Resident refuses to facilitate/sign the document). Review of the Resident's MOLST form indicated that the Resident's status was: Do Not Resuscitate (DNR - do not perform cardiopulmonary resuscitation if a patient's breathing stops or if the patient's heart stops beating), and was signed by the Resident's HCP on 4/16/2020 and the Physician on 4/20/2020. Review of the document titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, dated 4/21/21, indicated the Resident was unable to make health care decisions due to impaired cognition, and invokes the HCP. During an interview on 12/14/22 at 8:43 A.M., the Social Worker said that if the HCP was not invoked the MOLST form should be signed by the Resident. During an interview on 12/14/22 at 9:04 A.M., the Director of Nurses (DON) said that the Resident's HCP was not invoked at the time of the signing of the MOLST form on 4/16/20 so the MOLST form should have been signed by the Resident.

Based on record review, policy review, and interview, the facility failed to ensure its staff notified one Resident's (#15) responsible party of deterioration in the Resident's physical condition, out of 22 sampled residents. Specifically, the facility failed to ensure its staff notified the Resident's appointed guardian of: a) deterioration of the Resident's right heel wound and change in treatment ordered by the Physician when the wound was identified to have deteriorated, and b) a change in skin condition to the Resident's sacrum (bony structure at the base of the spine/ backbone) that required a new treatment intervention to commence. Findings include: Review of the facility's policy, titled Changes in Resident's Condition or Status, dated 8/18/22, included the following: - The facility would notify a resident's representative of changes in the resident's condition or status. - The facility was required to notify a resident's representative of deterioration in a resident's health .or to commence a new form of treatment. Resident #15 was admitted to the facility in January 2008 with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease (PVD- a condition in which narrowed arteries restrict blood flow), abnormal posture, and Dementia. Review of an active Physician Order, initiated 6/10/19, indicated that the Resident had Guardianship (legal process to make decisions for an adult who is unable to make their own medical decisions) in place. Review of a Physician Progress Note, dated 10/24/22, indicated Resident #15 had a change in skin condition to his/her right heel and was described as black in color, soft, but with some drainage. Review of a Physician Progress Note, dated 11/16/22, indicated that the Resident's right heel wound was felt to be improving and that the plan was to continue to apply Calcium Alginate after washing with normal saline (NS) and applying a dressing once a day, and to update the Resident's Responsible Party. Further review of the Progress Note included an addendum which indicated the following: - There was a change in condition of the Resident's right heel wound. - The treatment plan was changed to include MediHoney with a flexible rolled gauze dressing twice a day. Review of a Wound Observation Tool, dated 11/18/22, included the following: - The Resident had an unstageable deep tissue injury (DTI) to the right heel, related to pressure, that had worsened in condition. - The Physician was notified 11/18/22. - The section of the document that indicated the date and name of the Responsible Party notified was blank. Review of a Physician Progress Note, dated 11/25/22, included the following: - The wound team reported the condition of the Resident's right heel had worsened. - New excoriations (skin wearing off) on the resident's buttocks had been identified with treatment in place. - The plan included to update the Resident's Responsible Party relative to new coccyx and buttocks skin changes. Review of a Wound Observation Tool, dated 12/10/22, indicated the Resident had a change in skin condition on the sacrum that was excoriated and measured 0.5 centimeters (cm) long x 0.5 cm wide x 0.1 cm deep. Further review of the document indicated that the Physician was notified of the condition of the Resident's sacrum and the treatment plan was to cleanse the sacral area with NS, pat dry, and apply house barrier cream twice a day, followed by a dry protective dressing, two times a day. Review of Resident #15's clinical record included no evidence that his/her Responsible Party was notified when: - The condition of the wound to the Resident's right heel had deteriorated. - The treatment provided for care of the Resident's right heel had changed due to deterioration of the wound. - Facility staff identified that the Resident had a change in skin condition to his/her sacrum, as directed by the Physician. On 12/15/22 at 9:45 A.M., the surveyor requested from the Director of Nursing (DON) any evidence that Resident #15's Responsible Party was notified of the Resident's change in right heel and sacral skin condition, and the Physician ordered treatment changes. During an interview on 12/15/22 at 11:00 A.M., the Administrator provided an undated facility-created typed document which indicated the Wound Nurse notified Resident #15's Responsible Party on 10/26/22, that he/she had developed a wound. No further evidence was provided to indicate that the Resident's Responsible Party was notified of any other changes in skin condition or related Physician-ordered treatments after 10/26/22. During an interview on 12/15/22 at 11:04 A.M., Resident #15's Responsible Party said she had been made aware of a wound on the Resident's right heel at the end of October 2022. She said she had attended care plan meetings by phone and that she came in to see the Resident at times, but she had never seen the wound. The Responsible Party said staff informed her the wound was improving and that the Resident was seen regularly by a Wound Physician. She said staff informed her the wound may act up again, but she had not been notified of any deterioration in the Resident's right heel wound or of any other changes in skin condition. Please refer to F641.

Based on record review and interview, the facility failed to ensure that its staff accurately coded Minimum Data Set (MDS) assessments for two Residents (#15 and #2). Specifically, the facility failed to ensure its staff coded: 1) Resident #15's deep tissue pressure injury (DTPI - persistent non-blanchable deep red, maroon or purple discoloration resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface) when the Resident had developed a DTPI during the observation period for the MDS assessment, and 2) Resident #2's fall that was sustained since the prior MDS assessment. Findings include: 1. For Resident #15, the facility failed to ensure its staff accurately coded one MDS assessment to reflect he/she had a DTPI when the Resident had developed a DTPI during the observation period for the MDS assessment. Resident #15 was admitted to the facility in January 2008. Review of a Physician Progress Note, dated 10/24/22, included that the Unit Manager (UM) reported some changes on the Resident's right heel described as black in color, soft, but with some drainage, which was clear. Review of a Wound Observation Tool, dated 10/27/22, included the Resident had an unstageable (full thickness skin and tissue loss in which the extent of the damage cannot be confirmed because the wound bed is obscured by slough: non-viable tissue) DTPI related to pressure on his/her right heel. Review of an MDS assessment, dated 10/27/22, indicated the following: - The assessment reference date (ARD) for the MDS assessment was 10/27/22. - Section M, Skin Conditions, indicated that the Resident did not have any unhealed pressure ulcers or unstageable DTPIs. During an interview on 12/14/22 at 4:10 P.M., the MDS Coordinator said that the Resident's change in skin condition should have been coded on the MDS dated [DATE], but it was not. Please refer to F686. 44222 2) For Resident #2 the facility failed to ensure that its staff accurately documented falls on the Minimum Data Set (MDS) assessment. Resident #2 was admitted to the facility in June of 2019 with diagnoses including weakness, difficulty in walking, and a history of falls. Review of the Resident's clinical record indicated that the Resident sustained a fall on 7/2/2022. Review of the Resident's MDS assessment dated [DATE] indicated that the Resident had not sustained any falls since the last MDS assessment dated [DATE]. During an interview on 12/14/22 at 4:30 P.M., the MDS Nurse said the Resident's fall that occurred on 7/2/2022 should have been coded on the MDS assessment dated [DATE], but it was not.

Based on observation, interview, and record review, the facility failed to ensure its staff developed and implemented a comprehensive care plan for one Resident (#304) with a gastrostomy tube (G-tube - a tube that is placed directly into the stomach through an abdominal wall incision for the enteral administration of food, fluids and medication), out of a total sample of 22 residents. Specifically, the facility staff failed to: 1) develop a comprehensive care plan relative to weight monitoring, and 2) implement Physician orders relative to documentation of gastric residual volume (GRV- the volume of stomach contents that can be aspirated through the G-tube using a syringe). Findings include: Resident #304 was admitted to the facility in November 2022 with diagnoses including gastrostomy tube, Dysphagia (difficulty swallowing) and Malnutrition. 1) Review of the Resident's current care plan, revised by the Registered Dietician (RD) 12/13/22 included a care plan focus indicating: - that the Resident required G-tube feeding related to Dysphagia, and Malnutrition And a care plan goal that: -the Resident will maintain adequate nutritional and hydration status as evidenced by stable weight (weight stable), -no signs or symptoms of malnutrition . -Resident will maintain current weight of 168 pounds plus or minus five pounds through review date. Review of the Resident record indicated an admission weight of 168.4 pounds recorded on 11/22/22 in the electronic health record (EHR). Further review indicated no Physician order to weigh the Resident and no subsequent weight measurements were recorded in the EHR. During an interview on 12/14/22 at 10:54 A.M., Unit Manager (UM) #3 said that all weight measurements were documented in the EHR. She said the Resident has had only one weight measurement since being admitted to the facility, but he/she should have been weighed weekly since he/she had a G-tube. During an interview on 12/14/22 at 11:02 A.M., the RD said that the Resident should have been weighed periodically in order for staff to monitor his/her nutritional status. She said all Residents with G-tubes should be weighed weekly but Resident #304 had not been weighed since admission. 2) Review of the December 2022 Medication Administration Record (MAR) for Resident #304 indicated the following Physician order initiated on 11/22/22: - Check residual (GRV) at the beginning of each shift and record amount. -Notify Physician if the GRV is greater than 60 milliliters (ml) or if the Resident has nausea, abdominal distension, or bleeding. Further review of the MAR indicated check marks documented in all of the spaces corresponding to the Physician order on the December 2022 MAR, but no fluid measurements were recorded as ordered. During an interview and record review on 12/14/22 at 8:38 A.M., UM#3 said there were check marks documented in the corresponding spaces next to the order on the MAR, but no GRV amounts. She said that the GRV amount should have been documented in milliliters in the corresponding spaces next to the Physician order on the MAR as ordered.

Based on observation, record review, and interview, the facility failed to ensure its staff provided audiology services for one Resident (#77) out of 22 sampled residents. Findings include: Resident #77 was admitted to the facility in March 2021. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had minimal hearing difficulty and did not use a hearing aid. During an interview on 12/12/22 at 9:57 A.M., Resident #77 said that he/she needed hearing aids. On 12/13/22 at 10:20 A.M., the surveyor observed staff members going in and out of the Resident's room, asking the Resident if he/she would be going on the lunch trip that day. The staff members had to repeat themselves at least once, so the Resident could hear what was being said. Review of the consent form for ancillary services, indicated the Resident's Representative requested audiology services on 3/24/22. Further review of the clinical record indicated no evidence that the Resident had been provided audiology services as requested. During an interview on 12/13/22 at 12:55 P.M., Unit Manager (UM) #2 reviewed the consent form and said the Resident's family signed a new form in March 2022, which included to add audiology services to the previously requested services. UM #2 reviewed the clinical record and said she could not find any evidence that the Resident had been provided audiology services.

Based on observation, interview, and record review, the facility failed to ensure its staff provided appropriate care and services to one Resident (#304) with a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for the enteral administration of food, fluids and medication), out of one applicable sampled resident, out of a total sample of 22 residents. Specifically, the facility staff failed to: 1) verify proper placement of a G-tube prior to administering medications, and 2) administer medications via a G-tube according to facility policy and professional standards. Findings include: Review of the facility policy titled Medication Administration via Enteral Tube reviewed 8/26/22 indicated the following: -The facility will provide medication administration in accordance with professional standards of practice as outlined by [NAME] (a professional resource used in Nursing practice). -Verify proper enteral tube placement by observing a change in the external tube length if you observe a change in the external tube length use other bedside methods to help determine whether the tube has dislodged . aspirate (withdraw stomach contents using a syringe connected to the G-tube) the stomach contents and inspect the visual characteristics of the aspirate. Fasting gastric secretions appear grassy green, brown, or clear. Aspirate from a tube that has perforated the pleural space typically has a pale-yellow serous appearance. -Don't mix different medications intended for administration together through the enteral tube because of the risks of physical and chemical incompatibilities, tube obstruction and altered therapeutic response. Resident #304 was admitted to the facility in November 2022 with a diagnosis of gastrostomy tube. During an observation and interview on 12/13/22 at 9:44 A.M., the surveyor observed Nurse #1 enter the Resident's room with a cup containing approximately 120 milliliters (ml) of pink, opaque liquid, and a cup of water. The Nurse then accessed the Resident's G-tube and instilled approximately 120 ml of water followed by the contents of the cup containing the pink, opaque liquid. Nurse #1 said that she dissolved all the Resident's medications in one cup of water. She said that all the Resident's 9:00 A.M. morning medications were crushed and dissolved in the cup containing the pink opaque liquid. She also said that she forgot to verify the Resident's G-tube placement prior to administering the medications but that she should have verified placement. Review of the Resident's Medication Administration Record (MAR) indicated Nurse #1 signed off that she had administered ten medications during the surveyor's observation. During a follow up interview on 12/13/22 at 9:50 A.M., Nurse #1 said she forgot to check the placement of the Resident's G-tube prior to administering the medications. She said she should have checked the G-tube placement by aspirating stomach contents from the G-tube using a syringe and then re-instill the stomach contents while listening with her stethoscope to the Resident's abdomen. She said if she heard a grumbling sound then the G-tube was in the right place. She also said that she did not know if the facility had a policy specific to administering medications through a G-tube.

Based on observation, record review, policy review, and interview, the facility and its staff failed to ensure the care and treatment of a tracheostomy (a surgical opening that is made through the front of the neck into the windpipe) was provided in accordance with facility policy/protocols and professional standards of practice for one Resident (#13), out of one applicable sampled resident, out of a total sample of 22 residents. Specifically, the facility failed to provide emergency bedside tracheostomy equipment needed in the event of accidental decannulation (the unexpected removal of a tracheostomy tube) or mucus plugging (buildup of thick mucus). Findings include: Review of the facility's policy for Tracheostomy Emergency Supplies/Kits last revised 10/7/22, indicated the facility will ensure that each resident who presents with a tracheostomy that is actively being used to maintain an airway, will have emergency supplies/kit available at bedside. Resident #13 was admitted to the facility in November 2017 with diagnoses including generalized Idiopathic Epilepsy and Epileptic syndromes, tracheostomy status and unspecified intracranial injury without loss of consciousness. Review of Resident #13's care plan for tracheostomy care last revised 6/17/22, indicated an intervention for tube removal procedures to keep an extra tracheostomy tube at bedside. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had impaired short and long term memory and severely impaired decision making abilities. Further review of the MDS revealed that he/she was totally dependent on staff for Activities of Daily Living (ADLS), required Oxygen therapy, suctioning, and tracheostomy care. Review of the December 2022 Physician's orders indicated to keep an emergency replacement tracheostomy kit attached to the Resident's chair at all times. During an observation on 12/12/22 at 1:05 P.M., the surveyor observed Resident #13 sitting up in a tilt-in-space chair (a type of wheelchair that allows its user to remain in a seated position while being tilted at various angles) in his/her bedroom. There was no replacement tracheostomy kit attached to his/her wheelchair. During an observation on 12/12/22 at 2:38 P.M., the surveyor observed Resident #13 sleeping in his/her wheelchair in the dayroom. There was no replacement tracheostomy kit attached to his/her wheelchair. The surveyor was able to locate the replacement tracheostomy kit in the Resident's bedroom hanging from a portable Oxygen tank handle located in the back corner of the room. Upon opening the kit, the surveyor observed that the kit was missing a spare tracheostomy tube. During an observation on 12/13/22 at 2:30 P.M., the surveyor entered Resident #13's room with Nurse #2. The surveyor observed that the emergency tracheostomy kit remained hanging on the portable Oxygen tank. There was no emergency tracheostomy tube inside the kit. During an interview on 12/13/22 at 2:32 P.M., Nurse #2 said that the emergency tracheostomy tube should be in the kit, which it was not, and that the kit should be attached to Resident #13's wheelchair. She clarified that the kit should be attached to the wheelchair so that it is with Resident #13 whether he/she is in bed or not. Nurse #2 also said that she had ordered the emergency tracheostomy tube last Friday and had forgotten to place it in the kit.

Based on observation, policy review, record review, and interview, the facility failed to ensure its staff accurately assessed one Resident (#57) for the risk of entrapment from bed rails, out of 22 sampled residents. Findings include: Resident #57 was admitted to the facility in July 2021. Review of the facility's policy, titled Bed Rails-Safe and Effective Use, dated 6/22/21, indicated the following: -Policy: To prevent entrapment and other safety hazards associated with bed rail use. -Procedure: The resident will be assessed upon admission, readmission, or upon initiation, utilizing the Evaluation for Use of Bed Rails Assessment. If bed rails are determined to be appropriate for use, a reassessment will be done quarterly or with a change of condition. Review of the Evaluation for Use of Bed Rails, dated 7/21/21, indicated the Resident and Resident Representative requested the use of bed rails as a positioning enabler. Review of the Minimum Data Set (MDS) assessment, dated 11/8/22, indicated the bed rails were used daily. Review of the December 2022 Physician's Orders indicated the following order: Two quarter (1/4) bed rails up when in bed as enabler (initiated 7/21/21). Review of the Evaluations For Use of Bed Rails, dated 1/19/22, 7/23/22, 8/9/22, and 10/20/22, all indicated the Resident did not use bed rails (therefore, the assessment for risk of entrapment was not done). During an observation on 12/13/22 at 9:07 A.M., the surveyor observed Resident #57 seated on the side of the bed with bilateral 1/4 bed rails up. During an interview on 12/13/22 at 1:12 P.M., Unit Manager (UM) #1 said the Resident had always used bed rails and that he/she should have been assessed quarterly for the risk of entrapment. UM #1 said the bed rail assessments were wrong because the Resident had always used, and needed, the bed rails.

Based on records reviewed and interviews, for one of three sampled residents, Resident #1, who had been assessed by nursing to be lethargic, was not eating or drinking fluids, the Facility failed to ensure nursing provided adequate care and services consistent with professional standards of practice, when on [DATE], Resident #1 had an elevated temperature of 100.2 degrees Fahrenheit (F, normal range 97.0 F-99.0 F) and Nurse #1, believing that Resident #1 was on Care and Comfort Measures only, did not implement any nursing interventions in an attempt to lower his/her temperature. 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, 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. The Facility's Policy titled Changes in Resident's Condition or Status, dated [DATE], indicated the Facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications, a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the Facility. The Facility's Policy titled Advance Directives and Advance Care Planning, dated [DATE], indicated the resident's physician is notified of any change in condition regardless of the Do Not Resuscitate (DNR) order (medical order not to administer cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The Policy indicated, the Facility does not condition the provision of care or otherwise discriminate against residents based on the existence of an advance directive. The Policy further indicated that an advance directive will not be construed to diminish the quality of care provided, deny any treatment necessary for a resident's comfort, or to alleviate pain. Review of Resident #1's medical record indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated [DATE], indicated per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Plan of Care for Advanced Directives, dated [DATE], indicated he/she was a DNR, DNI, DNV, No [CONDITION(S)], No Artificial Nutrition, use of Artificial Hydration Short Term, and wanted to be transferred to Hospital, per the MOLST. Review of Resident #1's Nurse Practitioner Progress Note, dated on [DATE], indicated the Nurse Practitioner spoke with Resident #1's Health Care Proxy (HCP), to discuss, that based on his/her decline in status, whether the HCP wanted to consider having Resident #1 be treated with Comfort and Care Measures in the Facility or be transferred to a Hospice House. The Note indicated Resident #1 remained a DNR, DNI, and that the HCP still wanted Resident #1 to be transferred to hospital, if needed. Review of Nurse #1's Progress Note, dated on [DATE] at 8:33 P.M. indicated Resident #1 continued on antibiotics secondary to an Urinary Tract Infection. The Note indicated Resident #1 was basically unresponsive during the 3:00 P.M. to 11:00 P.M. shift, had a body temperature of 100.2 degrees F, and no food or fluids were consumed during the shift. During an interview on [DATE] at 11:09 A.M., Nurse #1 (who was assigned to care for Resident #1 on [DATE]) said during the 3:00 P.M. to 11:00 P.M. Resident #1 was not eating, drinking, or responding to any stimuli, that Resident #1 would not open his/her eyes when she (Nurse #1) spoke to him/her. Nurse #1 said when she checked on Resident #1, he/she had temperature of 100.2 F, and said she was unable to give Resident #1 Acetaminophen (Tylenol, [MEDICATION(S)]) because he/she was not alert enough to swallow a pill. Nurse #1 said she did not want to give Resident #1 pills because she did not want Resident #1 to aspirate (breathing food or fluid into the lungs) the medication. Review of Resident #1's medical record indicated there was no documentation to support Nurse #1 notified the Physician of Resident #1's elevated temperature or requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's temperature. There was also no documentation to support that Nurse #1 tried any other methods such as cool compresses or a bed bath, to try to lower Resident #1's temperature. Nurse #1 said she did not notify Resident #1's Physician of his/her change of condition because she believed the Physician was already aware of Resident #1's decline and she thought Resident #1 was on Care and Comfort Measures. Nurse #1 said when a resident is on Care and Comfort Measures, there is an order in his/her chart. Review of Resident #1's Medical Record indicated that on [DATE], Resident #1 did not have a Physicians order that he/she was Care and Comfort Measures. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 had an active order for Acetaminophen tablet 325 mg order to give two tablets by mouth every six hours as needed for pain or fever. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 11:00 P.M., Resident #1 was not administered Acetaminophen (Tylenol) by Nurse #1 for his/her fever. During an interview on [DATE] at 7:40 A.M., Nurse #3 said on [DATE] into [DATE], she was Resident #1's nurse during the 11:00 P.M.-7:00 A.M. shift, and said when she assessed Resident #1, he/she a temperature of 101.0 degrees F, with increased respirations in the 30's (normal adult range 12 to 16 breaths per minute), decreased heart rate 50 (normal adult heart range 60 to 100 beats per minute), and his/her oxygen saturation level on room air was in the 80's (normal adult oxygen range 95%-100%). Nurse #3 said she administered 2 liters of oxygen via nasal cannula to Resident #1 and applied cold packs to Resident #1's body as immediate nursing interventions. Nurse #3 said she immediately notified the Physician regarding Resident #1's change of condition. Nurse #3 said when she spoke to the Physician she had received an order to administer an Acetaminophen Suppository to treat Resident #1's fever, and was instructed to call Resident #1's HCP to inform him/her of Resident #1's change of condition and to inquire if the HCP wanted Resident #1 transferred to the hospital. During an interview on [DATE] at 9:32 A.M., the Nurse Practitioner said on [DATE] she was not contacted by nursing on the 3:00 P.M. to 11:00 P.M. shift of Resident #1's change in condition, that he/she had a temperature of 100.2 F, or that Resident #1 was unable to swallow medications. The Nurse Practitioner said nursing interventions for Resident #1 would have been to inform the Physician of Resident #1's change in condition and administer Acetaminophen 650 mg to treat his/her fever. The Nurse Practitioner said if she had been made aware that Resident #1 was unable to swallow medications in pill form, she would given nursing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse Practitioner said Resident #1 was recently started on an antibiotic for a possible Urinary Tract Infection and said if Resident #1 developed a fever, it would also need to be treated. The Nurse Practitioner said Resident #1 would need be monitored closely if he/she had a fever of 99.0 degrees F or greater, and said the HCP still wished Resident #1 be transferred to the hospital, if needed. The Nurse Practitioner said if a resident was on Care and Comfort Measures, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews and facility policy review, the facility failed to implement infection control procedures to properly prevent the spread of COVID-19 by failing to perform hand hygiene when indicated on 2 of 4 resident units. Findings include: Review of the Centers for Disease Control and Prevention guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated July 15, 2020 indicated the following: * HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. *Put on clean, non-sterile gloves upon entry into the patient room or care area. *Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. The facility policy titled Hand Hygiene, revised 11/10/20, indicated the following: * Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. * Staff should perform hand hygiene before and after all resident contact, before applying gloves and after removal of gloves. On 12/8/20, at 10:10 A.M., on the Alcott unit, a unit with a mix of COVID-19 negative and COVID-19 recovered residents, the surveyor observed Housekeeper #1 remove a trash bag from a resident room with gloves on . The surveyor then observed Housekeeper #1 place the bag of trash into a large trash barrel in the hallway. Housekeeper #1 then removed his gloves and threw them into the large barrel, and without performing hand hygiene, he walked down the hallway and touched the double doors to exit the unit. The surveyor was unable to interview Housekeeper #1. On 12/8/20, at 10:15 A.M., on the Hawthorne unit, a unit with a mix of COVID-19 negative and COVID-19 recovered residents, the surveyor observed Certified Nurse's Aide (CNA) #1 put on a gown and gloves and then enter a resident room to assist a resident. A few minutes later, the surveyor observed CNA #1 remove her gown and gloves and dispose of them in the trash inside the resident room. CNA#1 then exited the resident's room, without performing hand hygiene, walked down the hall, touched the utility room door to open it, entered the utility room and washed her hands. During an interview on 12/8/20, at 10:17 A.M., CNA#1 said that she did not perform hand hygiene prior to exiting the room. During an interview on 12/8/20, at 11:38 A.M., the Infection Control Nurse said that staff should perform hand hygiene immediately after removing their gloves, and that there is an alcohol based sanitizer dispenser in every resident room.

Based on observations, interviews and facility policy review, the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases including COVID-19 by failing (1.) to wear Personal Protective Equipment (PPE) and (2.) perform hand hygiene when indicated on 3 of 4 resident units. Findings include: Review of the Centers for Disease Control and Prevention guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated July 15, 2020 indicated: - HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. - Put on clean, non-sterile gloves upon entry into the patient room or care area. - Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. CDC guidance titled Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, published by the Centers for Disease Control, dated 7/15/20, indicated when health care personnel (HCP) working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. The facility policy titled Hand Hygiene, revised 11/10/20 indicated the following: * Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. * Staff should perform hand hygiene before and after all resident contact, before applying gloves, after removal of gloves. On 12/2/20 at 8:14 A.M., during an initial tour of the facility the surveyor observed a staff member, with a glove on each hand, pushing a large cart through the facility's main level hallway. The staff person, pushed open a door, with a gloved hand, contaminating the door's surface, and entered the unit that housed the residents in the facility who were on quarantine for COVID-19 exposure. On 12/2/20 at 8:20 A.M., the surveyor toured the Allcott Unit which housed a mix of COVID-19 negative and COVID-1 recovered residents. The following observations were made: * At 8:24 A.M., a Certified Nursing Assistant (CNA) #1 was observed seated in a resident room feeding a resident. CNA #1 was not wearing a gown or gloves. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a gown and glove at the door upon entry. * At 8:27 A.M., CNA #2 was observed to enter a room, wearing neither a gown nor gloves. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a gown and glove at the door upon entry. Moments later CNA#2 exited the room and without performing hand hygiene, entered another room, still not wearing a gown or gloves. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a gown and glove at the door upon entry. * At 8:28 A.M., CNA #2 exited that room, carrying trash and a used cup. Without performing hand hygiene, the CNA placed items inside a food truck, and then without performing hand hygiene, knocked on the door of another resident room, contaminating the doors surface, and entered. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a gown and glove at the door upon entry. A short while later CNA #2 exited the room without performing hand hygiene, and retrieved two cups of water that she had left on top of the food truck, next to trays of dirty breakfast items. Without performing hand hygiene she re-entered the room and gave the cups to the residents in the room. CNA #2 then exited the room, and without performing hand hygiene, closed the door, contaminating the door handle and walked down the hallway. * At 8:41 A.M., CNA #3 was observed in a room feeding a resident wearing neither gloves nor a gown. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a gown and glove at the door upon entry. * At 8:42 A.M., CNA #1 was observed to enter a room, wearing neither a gown nor gloves, and without performing hand hygiene. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a gown and glove at the door upon entry. From the doorway, the surveyor observed CNA #1 enter the bathroom with a resident and shut the door, contaminating the resident, the door and bathroom. On 12/2/20 at 8:45 A.M., the surveyor re-entered the facility's main level hallway and observed a Diet Aide (DA) walk off of the elevator, wearing a glove on each hand and carrying a cup. The DA approached the entryway to the quarantine unit, and without removing the gloves or performing hand hygiene, knocked on the door to the unit, contaminating the door. A Nurse opened the door and the DA handed her the cup, contaminating the nurse's hands. During an initial interview with the Director of Nursing (DON) and Nursing Home Administrator on 12/2/20 at 9:40 A.M., the DON said that it was her expectation that gowns and gloves be worn whenever feeding a resident, due to the risk of being exposed to secretions and high contact with the resident On 12/2/20 at 10:03 A.M., during a tour of the Hawthorne Unit (housed a mix of COVID-19 negative and COVID-19 recovered residents) the following observations were made: * At 10:03 A.M., a Housekeeper (HK) #1 was observed in a room mopping the floor. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a face shield, a gown and glove at the door upon entry. HK #1 was wearing a mask, however was not wearing eye protection or a gown. * At 10:05 A.M., HK#1 exited the room, and without performing hand hygiene, pushed his cart across the corridor, contaminating the cart. HK#1 began to enter a resident room, when he saw the surveyor. He stopped, turned around and retrieved Personal Protective Equipment (PPE) from his cart. Without performing hand hygiene, HK #1 put on a pair of gloves, a face shield and a gown, contaminating all of the PPE. HK#1 then entered the room contaminating the resident and the environment. On 12/2/20 at 10:08 A.M., the surveyor re-entered the Allcott Unit. HK #2 was observed in a room mopping the floor. A sign at the entryway to the room indicated that a resident in the room was on Special Droplet Precautions with instructions to put on a face shield, a gown and glove at the door upon entry. HK#2 wore a face shield and a gown, which was untied and draped forward only covering the front part of her body. * At 10:11 A.M., HK#2 exited the room, removed the gown, and without performing hand hygiene, walked across the hall to her housekeeping cart and placed the gown in the trash. HK#2, then without performing hand hygiene, put on a pair of gloves, removed wipes from her cart and began wiping down the banister along the length of one side of the hallway. She then returned to her cart, obtained more wipes and wiped down the banister on the other side of the hall. At no time was HK#2 observed to perform hand hygiene, potentially contaminating the banisters and environment. * At 10:14 A.M., HK#2, removed the gloves, and without performing hand hygiene, knocked on a resident room, contaminating the door and entered the room. On 12/2/20 at 10:16 A.M., the surveyor toured the designated COVID-19 unit. The unit consisted of 25 residents positive for COVID-19. The following observations were made: * At 10:19 A.M., HK#3 exited a room with a glove on each hand, removed the gloves and placed them in the trash. Then, without performing hand hygiene, HK#3 walked across the hall, placed both hands on a chair and moved it, contaminating the chair. * At 10:21 A.M., CNA#4 exited a room with a glove on each hand, walked to the clean linen cart and removed several items, contaminating the linen she was carrying and on the cart. CNA#4 then returned to the room, used the gloved hand to open the door and re-entered. * At 10:23 A.M., CNA#5 stepped into the doorway of a room with a glove on each hand. Using the gloved hands he emptied the contents of a bag of soiled linen, by pulling out the soiled items, and placed them in a cart in the doorway. He then removed the gloves, reentered the room and without performing hand hygiene put on a new pair of gloves. * At 10:25 A.M., CNA#5 exited the room, with a glove on each hand and without performing hand hygiene, and pushed his dirty linen cart down the length of the hallway to the exit door. At the exit door, without removing the gloves and without performing hand hygiene, he entered the passcode into the key pad, contaminating the keypad and exited the unit carrying the bag of soiled linen. Moments later, he re-reentered the unit still wearing gloves. During an interview with the surveyor CNA#5 said that he was not supposed to wear gloves in the hallway and that he was supposed to perform hand hygiene before and after the glove use, but that he had not. * At 10:26 A.M., the surveyor observed CNA#5 remove the gloves, place them in the trash, and without performing hand hygiene, put on a new pair of gloves and enter another resident room. On 12/2/20 at 12:15 P.M., the surveyor met with the facility's Infection Prevention Nurse (IPN) and reviewed all of the observations. She said that hand hygiene was required before and after wearing gloves or contact with the environment. As well, due to the current COVID-19 outbreak in the facility the staff were expected to: * Wear a gown and gloves whenever they are feeding a resident as it is considered high impact care. * Wear a gown and gloves whenever mopping or cleaning resident rooms as this too is considered high impact. * It was not okay to wear a gown that was not tied, due to the risk of coming in contact and spreading pathogens. On 12/2/20 at 12:30 P.M., the IPN provided the surveyor with a form titled Appendix A: Personal Protective Equipment Used When Providing Care to Residents in Long Term Care, dated 11/18/20. She said that presently the facility was following the guidance on the form for COVID Negative resident and COVID recovered and as indicated on Appendix A, all staff were expected to wear full PPE to include a facemask, face shield/goggles, gown and gloves. During a follow-up interview with the DON, Administrator and IPN, on 12/2/20 at 12:45 P.M., the surveyor reviewed all of the observations. The DON said that hand hygiene and the use of PPE as stated by the IPN, was her expectation at all times.

Based on observation, record review and interview the facility failed to assess 1 Resident (#82) for the self-administration of medications out of a total sample of 28 residents. Findings include: Resident #82 was admitted in January 2020 with [DIAGNOSES REDACTED]. The most recent Minimum (MDS) data set [DATE], indicated that Resident #82 scored a 3 out of 15 on the Brief Interview for Mental Status, indicating a severe cognitive deficit. The Minimum Data Set also indicated that Resident #82 did not ambulate, was independent with eating and required extensive assistance with all other activities of daily living. On 2/26/20, at 1:42 P.M., the surveyor observed that Resident #82 had [MEDICATION NAME] gummies (a dietary supplement that promotes digestive and immune health) on his/her shelf in his/her room. On 2/27/20, at 8:15 A.M., the surveyor observed that Resident #82 had a bottle of [MEDICATION NAME] gummies on a shelf in his/her room. On 2/28/20, at 9:05 A.M., the surveyor observed that Resident #82 had a bottle of [MEDICATION NAME] gummies on a shelf in his/her room. *[MEDICATION NAME] side effects are listed as gas, bloating, constipation, diarrhea and allergy symptoms. Review of #82's clinical record failed to indicate an order for [REDACTED].>Review of the clinical record failed to indicate a self-administration of medications form. During an interview on 2/28/20, at 9:10 A.M., Unit Manager #3 said that there are no residents on the unit that self-administer medication. He also said that no one should have medication in their room, unless it was in a lock box. He said that if a resident wants to self-administer medications, a self-administration assessment would be required, and if the resident is able to self-administer then the medications would be a lock box. Review of the facility policy titled Self-Administration of Medications last revised on 11/28/16, indicated the following: *Facility, in conjunction with the interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition *To ensure safe and appropriate Self-Administration, facility should educate residents to ensure that a resident is able to state the name, dose, strength, frequency and purpose for use of his/her medications, understand the possible side effects of his/her medication and that he/she should notify facility staff if he/she experiences side effects, correctly administer, inject or apply his/her medications, correctly store his/her medications in a locked compartment. *Facility should ensure that orders for Self-Administration list the specific medication the resident may self-administer.