Every finding on record at Life Care Center Of Stoneham

Based on observation and interview, the facility failed to maintain a homelike setting in resident rooms on the first and second floor nursing units. Findings include:On 9/18/25 at 11:50 A.M., the following was observed on the 1st floor unit. 102: Chipped paint on walls, and a nightstand with peeling laminate. 103: Peeling laminate on the nightstand by A bed. 104: Peeling paint/laminate on nightstand A bed 106: Laminate on B bed bureau was bubbled and peeling laminate on the nightstand. The walls in the bathroom were scuffed and there was a stained ceiling tile. 111: Scuffed/gauged walls by bathroom 112: Missing handle on 2nd drawer of A bed's nightstand and peeling laminate. Large gauges/scrapes behind bed. 115: Rubber baseboard under air conditioner pulling away from the wall. The nightstand by B bed had peeling laminate and A bed's nightstand had a broken handle. There was peeling paint in the bathroom. 116: Scuff marks by window, and baseboard pulling away from the window, with stained ceiling tile. The top drawer of A bed's nightstand was missing. 117: Deep gouges on the wall behind A bed. 118: Scrapes and gouges on wall behind A bed. There was a stained ceiling tile and chipped paint in the bathroom. 120: Deep gouges along wall by the bathroom. 124: Peeling and bubbling paint on the wall by the windowsill. On 9/17/25 at 11:57 A.M. the surveyor observed following on the second floor. 200: a red vinyl chair seat was cracked and peeling. 204: the wall behind bed a was gouged. 205: the bathroom wall was patched without paint. 208: a red vinyl chair seat was cracked and peeling. 210: the walls behind beds A and B were gouged. 211: the top of bed A's dresser was cracked and peeling. 215: a red vinyl chair seat was cracked and peeling. The baseboard under the sink in the bathroom was pushed in. 216: bed A's nightstand had pieces of laminate missing. 221: the walls were scraped and gouged behind bed B. 222: the walls were scraped and gouged. 223: two red vinyl chairs were cracked and peeling. 224: the wall in front of bed B was gouged. 225: the wall behind the bed was gouged. During an interview on 9/17/2025 at 12:55 P.M., the Maintenance Director said that he started employment at the facility in June and does daily rounds of the facility. The Maintenance Director said that was aware of some plans for updating the exterior and service hallways but was not aware of any room updates or reports of furniture needing replacement. The Maintenance Director said that not all staff have access to the TELS communication system so he relies on being told verbally or being called to fix issues as they arise. During an interview on 9/17/25 at approximately 1:10 P.M. the Administrator said that he did not have any plans in place or purchase orders to fix the condition of the furniture or the resident rooms.

Based on observation and interview the facility failed to ensure that drugs and biologicals used in the facility were 1. labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, including the expiration date in two of two medication carts and in one vital sign cart observed. 2. were stored in a locked area not accessible to residents and or visitors. Findings include:Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated revised 6/30/25, indicated that the facility should ensure all medications and biologicals .are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Further review indicated that the facility should ensure medications and biologicals have an expiration date on the label. On 9/17/25 at 8:59 A.M. the surveyor observed a mobile vital sign cart in the WN unit hallway, to contain one Arnuity Ellipta inhaler and one Anoro Ellipta inhaler (both used to treat asthma) in the basket of the vital sign cart. No nurse was present.The surveyor then observed the following in the medication cart on the WN unit:A Wixela inhaler (used to treat asthma) with a label or date of when opened. According to the manufacturer's instructions the inhaler expires one month after opening.A Wixela inhaler without a date of when it was opened.A bottle of Lantanoprost eye drops (used to treat glaucoma) without a patient label or date when opened and left on top of the medication cart in the hallway, when Nurse #2 entered a resident's room.During an interview on 9/17/25, at 9:15 A.M. Nurse #2 said that she forgot the inhalers in the basket and should not have left the eye drops on top of the medication cart. Nurse #2 then said that the eye drops should have been labeled correctly. On 9/17/25, at 9:25 A.M. the surveyor observed the following in the WS unit medication cart: One bottle of Prosource (liquid protein) without a date opened. Review of the manufacturer's instructions indicated that the Prosource expires three months after opening.2 bottles of Pataday eye drops open without a date of when opened. Review of the manufacturer's directions indicated that the eye drops expire 28 to 30 days after opening.One bottle of artificial tears without a label or date of when opened.On bottle of Prednisolone eye drops without a date of when opened.One bottle of Ofloxacin antibiotic eye drops open without a date.During an interview on 9/17/25 at 9:30 A.M., Nurse #3 said that the eye drops should have been labeled with the date opened so that nurses could determine what the expiration date should be. Nurse #3 then said that he was not aware that the Prosource had an expiration date after opening.

Based on observation an interview, the facility failed to implement appropriate monitoring for a pacemaker for one Resident (#25), out of a total of 19 sampled residents. Findings include:Review of the American Heart Association's article, dated 10/29/24 titled Living with your Pacemaker, indicated: Make sure you understand your pacemaker's programmed lower and upper heart rate. Talk to your health care professional about the maximum acceptable heart rate above your pacemaker rate. Your pacemaker should be checked periodically to assess the battery and find out how the wires are working. Be sure to keep your pacemaker checkup appointments. It's usually every six months or one yearOn 9/17/25 the surveyor was provided with a copy of the facility's Pacemaker Policy, dated as revised 9/17/25. The surveyor requested a copy of the policy previous to 9/17/25 and the facility was unable to provide one.Resident #25 was admitted to the facility in July 2024 with diagnoses including cognitive communication deficit and Parkinsons. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #25 was severely cognitively impaired as evidenced by a score of 4 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). On 9/16/25 at 1:48 P.M., the surveyor observed a pacemaker monitor on his/her bedside table. Resident #25 was unable to participate in the interview process due to his/her cognitive status. Review Resident #25's care plans indicated: The resident has a pacemaker defibrillator implant r/t (related to) atrial fibrillation, 9/16/24. Interventions: Vital signs as ordered, ICD CRT QUADRA ASSURA MP CRT-D 40 Q DF4 Serial # 9887550 Device identifier: 05414734508377 Implant date: 5/19/2020 Model #: CD3369-40Q Manufacturer L: St. [NAME] Medical INC Device Identifier type: GS1. Observe and report PRN (as needed) any s/sx (signs/symptoms) of altered cardiac output or pacemaker malfunction, dizziness, syncope difficulty breathing, pulse rate lower than programmed rate, lower than baseline b/p (blood pressure). Teach resident/family/caregivers to avoid activities and equipment which interfere with pacemaker activity: large magnets, MRI scanner, TENS machine, radio frequency ablation. Review of the clinical record failed to indicate any physician orders related to monitoring, programmed heart rate or involvement with cardiology. During an interview on 9/17/25 at 9:32 A.M. Nurse #1 said that Resident #25 has a defibrillator and she was unsure how it was being monitored. Nurse #1 said that there should be physician orders related to monitoring and taking vital signs. During an interview on 9/17/25 at 9:41 A.M., Unit Manager #1 said that Resident #25 has a monitor at his/her bedside and the office would contact the facility if anything was wrong. Unit Manager #1 and the Director of Nursing said that there should be physician orders related to monitoring Resident #25's pacemaker. Unit Manager #1 said she understood that the care plan indicated monitoring a programmed heart rate, but there was no documentation in the clinical record indicating Resident #25's programmed heart rate.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall and was found on the floor by staff, the facility failed to ensure he/she was free from neglect, when although Resident #1 told staff he/she was hurt and was screaming I'm in pain, without assessing him/her for the potential for injuries, Nurse #1 picked Resident #1 up off the floor put him/her in a wheelchair, picked him/her up again, transferred him/her back into bed and left the room. Despite Certified Nurse Aide (CNA) #1 reporting to Nurse #1 that Resident #1 was still complaining of and was in obvious pain, Nurse #1 did not go check on Resident #1 and still did not assess him/her for injuries. Nurse #1 finished his shift, left the facility and never reported the incident to anyone. Day shift nursing staff, who were totally unaware that Resident #1 had an unwitnessed fall on the previous shift, were unable to provide care, as Resident #1 screamed whenever staff tried to touch him/her. Resident #1 was emergently transferred to the Hospital Emergency Department, where he/she was diagnosed with a left hip fracture. Findings include: The Facility's Policy titled, Abuse, dated as reviewed 06/17/24, indicated neglect is defined as the failure of the Facility its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Policy indicated the Facility is to prevent and prohibit all types of abuse and neglect. The Policy indicated the Facility assures that residents are free from neglect by having the structures and process to provide needed care and services to all residents, which includes but is not limited to the provision of a facility assessment to determine what resources are necessary to care for its residents competently. The Facility's Policy titled, Resident Rights, dated as reviewed 09/10/24, indicated the following: a resident has the right to be treated with respect and dignity; a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of the Facility's Incident Report, dated 02/06/25, indicated on 01/31/25 sometime around 8:30 A.M. Resident #1 was observed by Certified Nurse Aide (CNA) #2 screaming as if in pain and would not allow CNA #2 to provide care to him/her. The Report indicated Resident #1 reported 10/10 pain (a pain scale where 0 is no pain and 10 is the worst pain imaginable, severe or unbearable pain) his/her leg. The Report indicated Resident #1 informed Nurse #2 and the Staff Development Coordinator (SDC) that he/she had fallen out of bed in the early morning and two men assisted him/her back to bed. The Report indicated Resident #1's left leg was rotated outward and noted to be larger than the right leg. The Report indicated Emergency Medical Services (911) had been called and in the Emergency Department Resident #1 was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hip). Resident #1 was admitted to the Facility in December 2024, diagnoses included Rhabdomyolysis (breakdown of muscle tissue), Hypertension (high blood pressure), Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down), Bradycardia (slower than expected heart rate, generally beating fewer than 60 minute), Wedge Compression fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing (occurs when the front (anterior) portion of the vertebra collapses, resulting in a wedge-shaped deformity), difficulty with walking, muscle weakness and history of falling. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #1's Brief Interview for Mental Status (BIMS), score was 14/15 (score of 13-15 indicates intact cognition, 12-8 indicates moderate cognitive impairment, 0-7 indicates severe cognitive impairment). Review of the Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 02/03/25, indicated on 01/31/25 at 2:30 A.M., she was helping Resident #3, heard a fall [loud bang] and left Resident #3's room to see what was going on. The Statement indicated Resident #1 was on the floor screaming, help me. The Statement indicated CNA #1 told Nurse #1, to call the ambulance because Resident #1 was screaming, but Nurse #1 said they should put Resident #1 back into bed. The Statement indicated Nurse #1 picked Resident #1 up off the floor put him/her into his/her wheelchair, then picked Resident #1 up from his/her wheelchair and put him/her into the bed. The Statement indicated CNA #1 did not move or touch Resident #1, but did hold the wheelchair. The Statement indicated she (CNA #1) was uncomfortable, that Resident #1 was screaming, I'm in pain, and that Nurse #1 told her not to say anything about this. During an interview on 03/18/25 at 2:00 P.M., (and during a follow-up interview on 03/19/25 at 1:07 P.M.) CNA #1 said on 01/31/25, sometime around 2:30 A.M., she heard a loud bang while providing care to Resident #3 and went to find out what the noise was. CNA #1 said the noise came from the room diagonally across from the room she was providing care in. CNA #1 said she found Resident #1 in his/her room lying face up on the floor and called Nurse #1 for help. CNA #1 said when Nurse #1 came to the room, Resident #1 was screaming, I'm in pain, I'm in pain. CNA #1 said that Nurse #1 said to get Resident #1 up off the floor. CNA #1 said she told Nurse #1 No, that in school she learned that when a patient falls and screams, they may have something broken and that they should call an ambulance. CNA #1 said Nurse #1 said No, we do not need to call the ambulance, and told her to bring Resident #1's wheelchair over to him. CNA #1 said she brought the wheelchair over to Nurse #1 and Nurse #1 picked up Resident #1 up off the floor, by himself, that Resident #1 was screaming, I'm in pain, I'm in pain. and placed him/her in the wheelchair. CNA #1 said then Nurse #1 transferred Resident #1 out of the wheelchair by himself to the bed. CNA #1 said Resident #1 was still screaming, I'm in pain. CNA #1 said Nurse #1 did not perform an assessment on Resident #1 prior to moving Resident #1 up off the floor and did not even check his/her vital signs. CNA #1 said shortly thereafter, she and Nurse #1 left the room at the same time and Resident #1 was still saying he/she was in pain. CNA #1 said she asked Nurse #1 if he was going to call 911 and complete the paperwork and Nurse #1 said, to her Forget about it, Forget about it. CNA #1 said around 4:00 A.M., she assisted Resident #1's roommate with care and Resident #1 was moaning like he/she was in pain. CNA #1 said she told Nurse #1 again about Resident #1's pain and asked him to take Resident #1's vital signs and to see if he/she was ok. CNA #1 said Nurse #1 waved his hand in a backward motion at her, as if he was dismissing her concerns and telling her to go away. CNA #1 said she never saw Nurse #1 go check on or assess Resident #1, after she asked him to. During an interview on 03/18/25 at 1:15 P.M., Nurse #2 said on 01/31/25 she started her shift around at 8:00 A.M. and had not receive an oncoming Nurse Change Shift Report from Nurse #1, because he had left the Facility prior to her arrival. Nurse #2 said the other nurse who was working with her on the day shift did not report to her that there was any change of condition or a fall regarding Resident #1. Review of the Nurse #1 Written Witness Statement, dated 01/31/25, indicated he was called into Resident #1's room by CNA #1, because Resident #1 was seated halfway in his/her wheelchair and CNA #1 could not sit him/her up by herself. The Statement indicated he assisted Resident #1 in the wheelchair and back to bed with CNA #1's help and left for the day. The Statement indicated Nurse #1 did not witness any fall. During an interview on 04/01/25 at 9:40 A.M., Nurse #1 said on the night shift (1/30/25 into 1/31/25), he did not hear Resident #1 fall, and when he transferred Resident #1 into bed, he/she was not in pain. Nurse #1 denied he received any reports from CNA #1 that Resident #1 was in pain and that he had no idea how Resident #1 fractured his/her hip. During an interview on 03/19/25 at 9:40 A.M., the Director of Nurses (DON) said she received a phone call on 01/31/25, at around 9:00 A.M. from the Staff Development Coordinator (SDC) that Resident #1 reported he/she had fallen during the overnight shift, and two men picked him/her up and put him/her back into bed. The DON said the SDC reported that Resident #1's left hip was larger than his/her right and Resident #1 was sent to the Hospital. The DON said she had not received any phone calls from the night shift Nurse (Nurse #1) regarding Resident #1's fall on 01/31/25. The DON said she had asked the SDC to start an investigation. The DON said it was not until she and the Administrator spoke with CNA #1 on 02/03/25 and obtained her statement that they were informed Resident #1 had fallen on 01/31/25, and had been found on the floor. The DON said CNA #1 told them she called Nurse #1 for help, told him that they should call 911 and that Nurse #1 told her (CNA #1), No, we were going to put him/her back to bed. The DON said CNA #1 said Resident #1 told them (CNA #1 and Nurse #1) he/she was in pain and that his/her leg hurt. The DON said she reviewed Resident #1's Medical Record and there was no documentation related to Resident #1's fall on 01/31/25, that there were no Nursing assessment including no pain assessment, no documentation to support the Physician was notified of Resident #1's acute pain to obtain orders, and that Resident #1 was not given any medication to treat or manage his/her pain. The DON said her expectations were that the Nursing staff follow the Facility's Policy and Procedures which included that Resident #1 should not have been moved off the floor after the fall occurred until Nursing completed a Nursing Assessment which includes a physical and pain assessment and taking care of the resident's needs immediately. The DON said Nursing staff should have called Emergency Medical Services if Resident #1 was in pain and/or an injury was suspected. The DON said her expectations were that Nursing notify the Physician, Health Care Proxy, Facility Management, complete the Fall Packet/Risk Management Progress Note, and inform the oncoming shift. Review of Resident #1's Hospital Discharge Summary, dated 02/07/25, indicated Resident #1 had an unwitnessed fall at the Facility, was diagnosed with a Closed Displaced Subtrochanteric Fracture of the Left Femur, with the broken pieces out of alignment, treated surgically using a metal rod (intramedullary nail) inserted into the bone's hollow channel) on 02/01/25. On 03/18/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 01/31/25, Resident #1 was transferred to the Hospital and was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hips). B) 02/03/25, Nurse #1 was suspended pending an Investigation, and on 02/06/25, Nurse #1 was terminated from the Facility. C) 02/07/25, Resident #1 returned to the Facility status post Left Femur Open Reduction and Internal Fixation (ORIF) with intramedullary nail on 02/01/25, and his/her Care Plans were reviewed and updated as needed. D) 02/07/25, the Director of Nursing and Cooperate Nurse reviewed and performed an audit of the Facility's previous three months of resident falls, including conducting an audit related to Nurse #1's involvement with any Facility incidents. There were no concerns identified during the audits and it was determined Nurse #1 was not involved in any of the fall incidents. E) 02/10/25 through 02/26/25, the Staff Development Coordinator provided in-person education to all Licensed staff on the following topics: - Fall Management - Review Policy & Procedure - Assessments - Fall Reporting Tools - Falls - Immediate action - Reporting - Resident Rights, Abuse and Neglect F) 02/20/25 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team. The Director of Nursing and the Cooperate Nurse developed a plan of correction related to the deficient practice, the plan and corrective measures were reviewed. G) 02/26/25 and ongoing, the Unit Manager and Director of Nursing review each fall (Incident/Accident Reports) to ensure Licensed Staff are following Facility's Policy and Procedure, they will collect the data and present findings to QAPI Committee. H) Effectiveness of corrective action plan will be reviewed during Monthly QAPI meetings until further notice. I) Director of Nursing and Executive Director are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff complaining of pain, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Resident #1 was crying out in pain, without completing any type of assessment, Nurse #1 picked Resident #1 up off the floor, initially put him/her in a wheelchair, then transferred him/her again by picking him/her up out of the wheelchair, put him/her in bed, and left the room. Nurse #1 did not complete any type of assessments, did not document the fall in a progress note that night, did not complete an incident report, and did not inform oncoming nursing staff during change of shift report that Resident #1 had been found on the floor after an unwitnessed fall and had been complaining of pain since the fall. Resident #1 was transferred to the Hospital Emergency Department, at the start of the day shift, where he/she was diagnosed with a left hip fracture. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated 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 Incident and Reportable Event Management, dated as reviewed 09/25/24, indicated an accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The Policy indicated an unwitnessed or witnessed fall is an event management, a fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force; An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall; a fall without injury is a fall, unless there is evidence suggesting otherwise and when a Resident is found on the floor, a fall is considered to have occurred. The Policy indicated if an event Incident/Injury occurs the Licensed Nurse should do the following: - Evaluate the residents and render first aid if needed. The Nurse evaluation be completed prior to moving a resident who has fallen, to determine presence of injury. - Create an event note and include the following details: Assessment details of the resident-including location details of the resident; Presence or absence of injury, and any treatments rendered; If resident can report what occurred, this should be included in the notes; Notification of Family or responsible party; and Notification of Physician and any orders received. - Create a risk report in the electronic system and identify the most appropriate type of event from the available options in the system. - Notify the following in accordance with state and federal requirements including the Supervisor on duty and/or Director of Nursing. Review of the Facility's Incident Report, dated 02/06/25, indicated on 01/31/25 sometime around 8:30 A.M. Resident #1 was observed by Certified Nurse Aide (CNA) #2 screaming as if in pain and would not allow CNA #2 to provide care to him/her. The Report indicated Resident #1 reported 10/10 pain (a pain scale where 0 is no pain and 10 is the worst pain imaginable, severe or unbearable pain) in his/her leg. The Report indicated Resident #1 informed Nurse #2 and the Staff Development Coordinator (SDC) that he/she had fallen out his/her bed in the early morning and two men assisted him/her back to bed. The Report indicated Resident #1's left leg was rotated outward and noted to be larger than the right leg. The Report indicated Emergency Medical Services (911) had been called and in the Emergency Department Resident #1 was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hip). Review of Resident #1's Hospital Discharge Summary, dated 02/07/25, indicated Resident #1 had an unwitnessed fall at the Facility, was diagnosed with a Closed Displaced Subtrochanteric Fracture of the Left Femur, with the broken pieces out of alignment, treated surgically using a metal rod (intramedullary nail) inserted into the bone's hollow channel) on 02/01/25. Resident #1 was admitted to the Facility in December 2024, diagnoses included Rhabdomyolysis (breakdown of muscle tissue), Hypertension (high blood pressure), Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down), Bradycardia (slower than expected heart rate, generally beating fewer than 60 minute), Wedge Compression fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing (occurs when the front (anterior) portion of the vertebra collapses, resulting in a wedge-shaped deformity), difficulty with walking, muscle weakness and history of falling. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #1's Brief Interview for Mental Status (BIMS), score was 14/15 (score of 13-15 indicates intact cognitive, 12-8 indicates moderate cognitive impairment, 0-7 indicates severe cognition impairment). Review of Resident #1's Care Plan, titled Pain, dated 01/07/25, indicated Resident #1's Pain interventions included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain, pain meds as ordered, observe and report to Nurse any signs or symptoms of non-verbal pain and observe and report to Nurse resident complaints of pain or requests for pain treatment. During an interview on 03/18/25 at 2:00 P.M., (and during a follow-up interview on 03/19/25 at 1:07 P.M.) Certified Nurse Aide (CNA) #1 said on 01/31/25, sometime around 2:30 A.M., she heard a loud bang while providing care to Resident #3 and went to find out what the noise was. CNA #1 said the noise came from the room diagonally across from the room she was providing care in. CNA #1 said she found Resident #1 in his/her room lying face up on the floor and she called Nurse #1 for help. CNA #1 said when she called for help, Nurse #1 was at the Nurses Station sitting in a chair, his feet were up on another chair, he had a blanket covering him and his eyes were closed. CNA #1 said she called Nurse #1's name, he did not answer, then she called his name again and he jumped. CNA #1 said when Nurse #1 came to Resident #1's room, he/she was screaming, I'm in pain, I'm in pain. CNA #1 said Nurse #1 said to get Resident #1 up off the floor. CNA #1 said she told Nurse #1 No, they should not move him/her. CNA #1 said she told Nurse #1 that in school she learned that when a patient falls and screams, they may have something broken and they needed to call for an ambulance. CNA #1 said Nurse #1 said to her, No, we do not need to call the ambulance, and told her to bring Resident #1's wheelchair over to him. CNA #1 said she brought the wheelchair over to Nurse #1 and Nurse #1 picked up Resident #1 up off of the floor, by himself, and put him/her in the wheelchair, and that Resident #1 was screaming, I'm in pain, I'm in pain. CNA #1 said Nurse #1 then transferred Resident #1 out of the wheelchair by himself to the bed. CNA #1 said Resident #1 was still screaming, I'm in pain. CNA #1 said Nurse #1 did not perform an assessment on Resident #1 prior to him moving Resident #1 up off the floor and did not even check his/her vital signs. CNA #1 said shortly thereafter, she and Nurse #1 left the room at the same time and Resident #1 was still crying out in pain. CNA #1 said she had asked Nurse #1 if he was going to call 911 and complete the paperwork and Nurse #1 said to her, Forget about it, Forget about it. CNA #1 said around 4:00 A.M., she assisted Resident #1's roommate with care and Resident #1 was moaning like he/she was in pain. CNA #1 said she had informed Nurse #1 again about Resident #1's pain and asked him to take Resident #1's vital signs and to check to see if he/she was ok. CNA #1 said Nurse #1 waved his hand in a backward motion at her, as if he was dismissing her concerns and telling for her to go away. CNA #1 said she did not see Nurse #1 go check on or assess Resident #1 when she asked him to. Review of the Facility's Witness Statement, dated 01/31/25, written by Nurse #1, indicated he was called into Resident #1's room by CNA #1, because Resident #1 was halfway seated in his/her wheelchair and CNA #1 could not sit him/her up by herself. The Statement indicated he assisted Resident #1 in the wheelchair and back to bed with CNA #1's help and left for the day. The Statement indicated Nurse #1 did not witness any fall. During an interview on 04/01/25 at 9:40 A.M., Nurse #1 said on 01/30/25 he started his shift around at 3:00 P.M. and ended his shift on 01/31/25 around 7:00 A.M. Nurse #1 said Resident #1 was alert to self but confused. Nurse #1 said Resident #1 was able to express if he/she was in pain or in discomfort. Nurse #1 said at the start of the 11:00 P.M. to 7:00 A.M. shift, Resident #1 was in bed sleeping and he did not see Resident #1 again until around 4:30 A.M. or 5:00 A.M. Nurse #1 said he was at the Nursing station, preparing to start his morning medication pass when CNA #1 called him to help her, because Resident #1 was position half way out (sliding) of his/her wheelchair and CNA #1 was unable to sit up Resident #1 in his/her wheelchair. Nurse #1 said he had asked Resident #1 what he could do to help him/her and if he/she needed to go to the bathroom. Nurse #1 said Resident #1 said, No. Nurse #1 said he pulled on Resident #1's pants to get him/her back in a sitting position in his/her wheelchair and then transferred him/her back into bed. Nurse #1 said that although Resident #1 was in bed at the start of the shift, that he did not know how Resident #1 had gotten into the wheelchair that night. Nurse #1 said he did not see Resident #1 fall and said he does not know how Resident #1 fractured his/her hip. Nurse #1 said he did not need to assess Resident #1 since he had no concerns and Resident #1 did not say anything to him about being in pain. Nurse #1 said he did not hear any banging noises during the 11:00 P.M. to 7:00 A.M. shift. Nurse #1 said he did not observe Resident #1 to be in pain and was not informed by anyone that Resident #1 was in pain. Nurse #1 said around 5:30 A.M. or 6:00 A.M., was the last time he saw Resident #1, because he had gone to the room to help his/her roommate. Nurse #1 said Resident #1 was not in pain then. Nurse #1 said he did not speak to any oncoming shift staff regarding Resident #1. Nurse #1 said he had no clue what happened to Resident #1. Review of Resident #1's Medical Record indicated there was no documentation of Resident #1's fall, no incident report, no type of assessment including Pain and Neurological as having been completed on 01/31/25, by Nurse #1. During an interview on 03/18/25 at 1:15 P.M., Nurse #2 said on 01/31/25 she started her shift around at 8:00 A.M. and did not receive an oncoming Nurse Change of Shift Report from Nurse #1 because he had left the Facility prior to her arrival. Nurse #2 said there was no progress note or incident report in Resident #1's Medical Record about him/her being found on the floor during the overnight shift or that he/she had complained of being in pain all night. During an interview on 03/18/25 at 4:31 P.M., the Unit Manager said her expectations was that Nurses would immediately assess a resident after a fall for the potential for injury and pain prior to moving them and notify the oncoming shift Nursing Staff of any incidents, accidents or changes in a resident. The Unit Manager said she reviewed Resident #1's Medical Record and there was no documentation of Resident #1's fall, no notification to Physician or Facility Administrative Staff, no incident report, and no assessments, having been completed on 01/31/25, by Nurse #1. During an interview on 03/19/25 at 9:40 A.M., the Director of Nurses (DON) said she and the Administrator interviewed Nurse #1 and he said around 4:30 A.M., CNA #1 called him to help her since Resident #1 was hanging out off his/her wheelchair and he assisted Resident #1 back to bed. The DON said she had asked Nurse #1 if he completed an assessment since Resident #1 was positioned that way in his/her wheelchair and that Nurse #1 said, No. that there was no need to assess Resident #1 and there was nothing wrong with him/her. The DON said she asked Nurse #1 if Resident #1 fell and he said, No. The DON said Nurse #1 did not respond when she asked how he thought Resident #1 obtained a hip fracture. The DON said she reviewed Resident #1's Medical Record and there was no documentation related to Resident #1's fall on 01/31/25, that there were no nursing assessments including a pain assessment, and no documentation to support the Physician was notified of Resident #1's new onset of acute pain. The DON said her expectations were that the Nursing staff to follow the Facility's Policy and Procedures which include residents should not have been moved off the floor after a fall occurred until first completing a thorough Nursing Assessment. The DON said Nursing staff should call Emergency Medical Services if Resident #1 was in pain and or an injury was suspected. On 03/18/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 01/31/25, Resident #1 was transferred to the Hospital and was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hips). B) 02/03/25, Nurse #1 was suspended pending an Investigation, and on 02/06/25, Nurse #1 was terminated from the Facility. C) 02/07/25, Resident #1 returned to the Facility status post Left Femur Open Reduction and Internal Fixation (ORIF) with intramedullary nail on 02/01/25, and his/her Care Plans were reviewed and updated as needed. D) 02/07/25, the Director of Nursing and Cooperate Nurse reviewed and performed an audit of the Facility's previous three months of resident falls, including conducting an audit related to Nurse #1's involvement with any Facility incidents. There were no concerns identified during the audits and it was determined Nurse #1 was not involved in any of the fall incidents. E) 02/10/25 through 02/26/25, the Staff Development Coordinator provided in-person education to all Licensed staff on the following topics: - Fall Management - Review Policy & Procedure - Assessments - Fall Reporting Tools - Falls - Immediate action - Reporting - Resident Rights, Abuse and Neglect F) 02/20/25 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team. The Director of Nursing and the Cooperate Nurse developed a plan of correction related to the deficient practice, the plan and corrective measures were reviewed. G) 02/26/25 and ongoing, the Unit Manager and Director of Nursing review each fall (Incident/Accident Reports) to ensure Licensed Staff are following Facility's Policy and Procedure, they will collect the data and present findings to QAPI Committee. H) Effectiveness of corrective action plan will be reviewed during Monthly QAPI meetings until further notice. I) Director of Nursing and Executive Director are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff and was crying out in pain, the facility failed to ensure he/she was provided with care and treatment consistent with professional standards of practice related to pain management. Certified Nurse Aide (CNA) #1 said she found Resident #1 on the floor in his/her room, he/she was crying out in pain and immediately called Nurse #1 for help. CNA #1 said she asked Nurse #1 more than once to check on Resident #1 that night, because he/she kept crying out in pain. Nurse #1 did not complete a pain assessment on Resident #1, there was no documentation to support Nurse #1 medicated or did anything to treat or manage Resident #1's pain including not notifying the Physician. Day Shift nursing staff were unable to provide care, as Resident #1 screamed whenever staff tried to touch him/her, he/she was transferred to the Hospital Emergency Department, and was diagnosed with a left hip fracture. Findings include: The Facility's Policy titled Pain Assessment and Management, dated reviewed 09/05/24, indicated that the Facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The Policy indicated based on the comprehensive assessment of a resident, the Facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The Policy indicated all residents will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition. The Facility's Policy titled Changes in Resident's Condition or Status, dated reviewed 09/05/24, indicated the Facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. Review of the Facility's Incident Report, dated 02/06/25 at 1:48 P.M., indicated on 01/31/25 sometime around 8:30 A.M. Resident #1 was observed by Certified Nurse Aide (CNA) #2 screaming as if in pain and would not allow CNA #2 provide care to him/her. The Report indicated Resident #1 reported 10/10 pain (a pain scale where 0 is no pain and 10 is the worst pain imaginable, severe or unbearable pain) in his/her leg. The Report indicated Resident #1 informed Nurse #2 and the Staff Development Coordinator (SDC) that he/she had fallen out his/her bed in the early morning and two men assisted him/her back to bed. The Report indicated Resident #1's left leg was rotated outward and noted to be larger than the right leg. The Report indicated Emergency Medical Services (911) had been called and in the Emergency Department Resident #1 was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hip). Review of Resident #1's Hospital Discharge Summary, dated 02/07/25, indicated Resident #1 had an unwitnessed fall at the Facility, was diagnosed with a Closed Displaced Subtrochanteric Fracture of the Left Femur with the broken pieces out of alignment, treated surgically using a metal rod (intramedullary nail) inserted into the bone's hollow channel) on 02/01/25. Resident #1 was admitted to the Facility in December 2024, diagnoses included Rhabdomyolysis (breakdown of muscle tissue), Hypertension (high blood pressure), Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down), Bradycardia (slower than expected heart rate, generally beating fewer than 60 minute), Wedge Compression fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing (occurs when the front (anterior) portion of the vertebra collapses, resulting in a wedge-shaped deformity), difficulty with walking, muscle weakness and history of falling. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #1's Brief Interview for Mental Status (BIMS), score was 14/15 (score of 13-15 indicates intact cognition, 12-8 indicates moderate cognitive impairment, 0-7 indicates severe cognitive impairment). Review of Resident #1's Care Plan, titled Pain, dated 01/07/25, indicated Resident #1's Pain interventions included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain, pain meds as ordered, observe and report to Nurse any signs or symptoms of non-verbal pain and observe and report to Nurse resident complaints of pain or requests for pain treatment. Review of Resident #1's Medication Administration Record, for January 2025, indicated Resident #1 had the Physician's Orders for medications for pain management as follows: - Lidocaine External Patch 4% apply at 9:00 A.M. to Left & Right lower back for Pain and Remove patch at 9::00 P.M. - Tylenol (Acetaminophen) Oral Tablet 325 mg (milligram), give two tablets every 6 hours as needed for pain. Further Review of the MAR indicated up until 01/31/25 Resident #1 had only requested Tylenol once. Documentation on the MAR for 01/31/25, indicated that, despite CNA #1 reporting to and making Nurse #1 aware, more than once that Resident #1 was moaning and saying he/she was in pain, he/she was not administered anything to treat or manage his/her pain. There was no documentation to support the Physician was notified or that new orders were obtained to treat his/her acute pain. During an interview on 03/18/25 at 2:00 P.M., (and during a follow-up interview on 03/19/25 at 1:07 P.M.) CNA #1 said on 01/31/25, sometime around 2:30 A.M., she heard a loud bang while providing care to Resident #3 and went to find out what the noise was. CNA #1 said she found Resident #1 in his/her room lying face up on the floor and she called Nurse #1 for help. CNA #1 said Nurse #1 came to Resident #1's room, that Resident #1 was screaming, I'm in pain, I'm in pain, but that Nurse #1 told her to get Resident #1 up off the floor. CNA #1 said she told Nurse #1 No, they should not move him/her. CNA #1 said she told Nurse #1 that in school she learned that when a patient falls and screams, they may have something broken and they needed to call for an ambulance. CNA #1 said Nurse #1 said No, we do not need to call for an ambulance, and said to bring Resident #1's wheelchair over to him. CNA #1 said Nurse #1 picked up Resident #1 off the floor, by himself and that Resident #1 was screaming, I'm in pain, I'm in pain and placed him/her in the wheelchair. CNA #1 said then Nurse #1 transferred Resident #1 out of the wheelchair by himself to the bed, and that Resident #1 was still crying out, I'm in pain. CNA #1 said when she and Nurse #1 left the room, she asked Nurse #1 if he was going to call 911 and complete the paperwork and that Nurse #1 said, Forget about it, Forget about it! CNA #1 said around 4:00 A.M., she assisted Resident #1's roommate with care and Resident #1 was still moaning like he/she was in pain. CNA #1 said Resident #1 had to urinate, but she was unable to assist him/her to use a urinal/bedpan, because when she touched Resident #1 to move him/her, he/she was in pain. CNA #1 said she was unable to pull down Resident #1's pants and that just touching Resident #1, he/she was groaning in pain. CNA #1 said she informed Nurse #1 again about Resident #1's pain, asked him to take Resident #1's vital signs and to check to see if he/she was ok. CNA #1 said Nurse #1 had motioned his hand in a backward motion at her as if he was dismissing her concerns and telling her to go away. During an interview on 03/19/25 at 2:29 P.M., CNA #2 said she worked with Resident #1 in the past, had worked with Resident #1 the day prior and he/she had not been in or complained of pain. CNA #2 said she was usually able to get Resident #1 out of bed without any difficulty or concerns. CNA #2 said on 01/31/25, she worked the 7:00 A.M. to 3:00 P.M. shift, and around at 7:45 A.M., she observed Resident #1 in bed, that he/she was screaming and when she tried to assist him/her with care to get him/her out of bed, Resident #1 said to her, I'm in a lot of pain, do not touch me, I'm in a lot of pain. CNA #2 said she could tell by Resident #1's facial expression that he/she was very uncomfortable. CNA #2 said she informed Nurse #2 right away, and she (Nurse #2) immediately assessed Resident #1. During an interview on 03/18/25 at 1:15 P.M., Nurse #2 said on 01/31/25 she started her shift around at 8:00 A.M. and shortly thereafter CNA #2 came to her reporting that Resident #1 was complaining of left leg pain. Nurse #2 said she went to assess Resident #1 and asked Resident #1 to move his/her left leg, and he/she said, No, it hurts. Nurse #2 said when she touched Resident #1's left hip area, he/she said Ouch, Ouch. Nurse #2 said she asked Resident #1 what happened, and Resident #1 said he/she had fallen this morning, and a man got him/her up. Nurse #2 said she asked the Staff Development Coordinator (SDC) and the Unit Manager to come help with assessing Resident #1 with her. During an interview on 03/18/25 at 3:10 P.M., the Staff Development Coordinator (SDC) said on 01/31/25 he helped Nurse #2 assess Resident #1. The SDC said he observed Resident #1's left upper thigh area was larger than his/her right and with any slight movement, Resident #1 said it was very painful for him/her. The SDC said when he assessed Resident #1's pedal pulses (rhythmic throbbing or pulsations that can be felt when palpating the arteries in the feet) his slight touch, per Resident #1, hurt. The SDC said Resident #1 said he/she had fallen out of bed and a male placed him/her back into bed. The SDC said Resident #1 had sweat pants on and they had to cut them off him/her to provide Resident #1 some comfort and relief from the pain. The SDC said Resident #1's left leg was rotated in an outward position and Resident #1's left thigh was twice as large than his/her right. The SDC said Resident #1 was groaning, had facial grimacing and he/she clearly was in pain. The SDC said staff called Emergency Medical Services to transfer Resident #1 to the Hospital. During an interview on 03/18/25 at 4:31 P.M., the Unit Manager said on 01/31/25 she helped assess Resident #1. The Unit Manger said Resident #1 was verbalizing he/she was in pain, she observed that his/her left leg was swollen and was in an externally (outward) rotated position. The Unit Manager said Resident #1 said he/she fell out of bed and a man picked him up and placed him/her back to bed. The Unit Manager said Resident #1's was wearing sweat pants that were tight, staff were unable to take them off him/her because Resident #1 was in so much pain, so they had to cut them off him/her. The Unit Manager said her expectations was that Nurses would immediately assess a resident after a fall for the potential for injury and pain prior to moving them. The Unit Manager said she reviewed Resident #1's Medical Record and there was no documentation of Resident #1's fall, no notification to Physician or Facility Administrative Staff, no incident report and no Pain Assessment completed on 01/31/25, by Nurse #1. During an interview on 04/01/25 at 9:40 A.M., Nurse #1 said on 01/30/25 he started his shift around at 3:00 P.M. and ended his shift on 01/31/25 around 7:00 A.M. Nurse #1 said Resident #1 was alert to self but confused. Nurse #1 said Resident #1 was able to express if he/she was in pain or in discomfort. Nurse #1 said at the start of the 11:00 P.M. to 7:00 A.M. shift, Resident #1 was in bed sleeping and he did not see Resident #1 again until around 4:30 A.M. or 5:00 A.M. Nurse #1 said he was at the Nursing station, preparing to start his morning medication pass when CNA #1 called him to help her, because Resident #1 was position half way out (sliding) of his/her wheelchair. Nurse #1 said he pulled on Resident #1's pants to get him/her back in a sitting position in his/her wheelchair and then transferred him/her back into bed. Nurse #1 said that although Resident #1 was in bed at the start of the shift, that he did not know how Resident #1 had gotten into the wheelchair that night. Nurse #1 said he did not need to assess Resident #1 since he had no concerns and Resident #1 did not say anything to him about being in pain. Nurse #1 said he did not observe Resident #1 to be in pain and was not informed by anyone that Resident #1 was in pain. Nurse #1 said around 5:30 A.M. or 6:00 A.M., was the last time he saw Resident #1, because he gone to the room to help his/her roommate. Nurse #1 said Resident #1 was not in pain then. During an interview on 03/19/25 at 9:40 A.M., the Director of Nurses (DON) said she reviewed Resident #1's Medical Record and there was no documentation related to Resident #1's fall on 01/31/25, that there were no Nursing assessments including a pain assessment, no documentation to support the Physician was notified of Resident #1's acute pain to obtain new orders, and that Resident #1 was not given any medications to treat or manage his/her pain. On 03/18/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 01/31/25, Resident #1 was transferred to the Hospital and was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hips). B) 02/03/25, Nurse #1 was suspended pending an Investigation, and on 02/06/25, Nurse #1 was terminated from the Facility. C) 02/07/25, Resident #1 returned to the Facility status post Left Femur Open Reduction and Internal Fixation (ORIF) with intramedullary nail on 02/01/25, and his/her Care Plans were reviewed and updated as needed. D) 02/07/25, the Director of Nursing and Cooperate Nurse reviewed and performed an audit of the Facility's previous three months of resident falls, including conducting an audit related to Nurse #1's involvement with any Facility incidents. There were no concerns identified during the audits and it was determined Nurse #1 was not involved in any of the fall incidents. E) 02/10/25 through 02/26/25, the Staff Development Coordinator provided in-person education to all Licensed staff on the following topics: - Fall Management - Review Policy & Procedure - Assessments - Fall Reporting Tools - Falls - Immediate action - Reporting - Resident Rights, Abuse and Neglect F) 02/20/25 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team. The Director of Nursing and the Cooperate Nurse developed a plan of correction related to the deficient practice, the plan and corrective measures were reviewed. G) 02/26/25 and ongoing, the Unit Manager and Director of Nursing review each fall (Incident/Accident Reports) to ensure Licensed Staff are following Facility's Policy and Procedure, they will collect the data and present findings to QAPI Committee. H) Effectiveness of corrective action plan will be reviewed during Monthly QAPI meetings until further notice. I) Director of Nursing and Executive Director are responsible for overall compliance.

Based on record review and interview, the facility failed to ensure professional staff are licensed, certified, or registered in accordance with applicable State laws. Specifically, when the facility indicated they had one nurse employed under a nursing waiver, they failed to ensure that the nurse had graduated from a board approved nursing program. Findings Include: Review of The Department of Public Health (DPH) Circular Letter, issued on June 3, 2024, regarding Guidance for Nursing Practice by Graduates and Students in Their Last Semester of Nursing Education Programs, indicated, but was not limited to: -An individual who graduated from a registered nursing or practical nursing program approved by the board or who is a senior nursing student attending the last semester of a registered nursing or practical nursing program approved by the board may practice nursing; provided that: -(iii) the employing licensed health care facility or licensed health care provider has verified that the individual is a graduate of a registered nurse or practical nursing program approved by the board or that the individual is a senior nursing student attending the last semester of a registered nursing or practical nursing program approved by the board. -In order to practice under the authorization of Chapter 88 of the Acts of 2023, a graduate or student in their last semester: 1. Must have graduated from a board approved nursing education program within one year of the hire date or be a student currently enrolled in their last semester of a board approved nursing education program. -Responsibilities of Licensed Healthcare Facilities and Licensed Healthcare Providers -In order to allow a graduate or student in their last semester to practice under the authorization of Chapter 88 of the Acts of 2023, a licensed healthcare facility or licensed healthcare provider shall: -1. Verify the individual is a graduate from a board approved registered nursing program or practical nursing program or is a student in their last semester of a board approved registered nursing or practical program. The licensed healthcare facility or licensed healthcare provider must obtain independent verification and/or official documentation from the nursing education program. It is not sufficient for a licensed healthcare facility or licensed healthcare provider to rely on an individual's representation of their education status. Review of the board approved nursing education programs included programs that were located only in Massachusetts. During the entrance conference on 9/17/24 at 8:54 A.M., the Director of Nurses (DON) and Administrator they said they have one nurse (Nurse #2) working in the facility under a state waiver who has graduated from nursing school and is waiting to take her boards exam in November. Review of Nurse #2's personnel file included a resume indicating a graduation from Nova Southwestern University in [NAME], Florida in May 2020 and an application for employment indicating she had completed a nursing program. Nurse #2's personnel file failed to include independent verification and/or official documentation from the nursing education program to confirm completion. Review of the License verification site for the Office of Health and Human Services for Massachusetts, failed to indicate an active nursing license for Nurse #2. Review of Nurse #2 worked hours and punch log indicated that Nurse #2 worked 670.02 hours as a nurse from 5/22/24 through 9/18/24. During an interview on 9/18/24 at 1:51 P.M., the DON said she was aware that Nurse #2 went to school in Florida, graduated from the program and moved to this area not too long ago. The Surveyor and the DON reviewed the personnel file together and the DON said that with the information in the file there was no evidence that the employee completed the nursing program and that the statement on the resume is not enough to confirm. The surveyor and DON also reviewed the State Circular Letter with respect to board approved nursing programs, and the DON said she had not reviewed the list of schools. During a follow up interview on 9/18/24 at 3:03 P.M., the DON said that the nurse should not be working in the facility. During an interview on 9/18/24 at 1:59 P.M., the Corporate Recruiter said the facility should have confirmation that the employee completed and graduated from an accredited nursing program, and they do not. He was not able to confirm if Nurse #2 completed a nursing program. He said the nurse should not be employed at the facility at this time.

Based on observations and interviews the facility failed to ensure a dignified existence was maintained for residents who require assistance with meals. Findings Include: Review of facility policy titled Dignity, dated as reviewed 9/25/23, indicated the following: -Each resident has the right to be treated with dignity and respect. -Examples of treating residents with dignity and respect include, but are not limited to: -e. Addressing residents by the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders or walkers. On 9/19/24 at 8:03 A.M., the surveyor overheard a staff member in a resident's room yell out into the hallway to another staff member to go downstairs and help with breakfast because they have more feeders on that unit. The Staff member yelling into the hallway was sitting in a resident room, assisting a resident with his/her meal. During an interview on 9/19/24 at 10:32 A.M., the Director of Nurses (DON) said staff should not refer to residents as feeders as it is not dignified to refer to someone that way.

Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive person centered care plan for three Residents (#43, #31 and #16) out of a total sample of 20 residents. Specifically, 1. For Resident #43, the facility failed to develop a care plan regarding a new skin tear and treatment applied. 2. For Resident #31, the facility failed to develop a care plan for Resident #31's resident specific Activities of Daily Living needs. 3. For Resident #16, the facility failed to implement the plan of care for completing weekly skin checks. Findings include: 1. Resident #43 was admitted to the facility in September 2019 and has diagnoses that include dementia, anxiety disorder and history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/20/24, indicated that on the Brief Interview for Mental Status exam Resident #43 scored a 2 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #43 was dependent on staff for activities of daily living. On 9/17/24 at 8:34 A.M., Resident #43 was observed in bed. There was a bandage on his/her left hand, not labeled or dated with approximately a nickel size red area on the bandage. Resident #43 said some woman came in two days ago and said what happened here, its bleeding and put on the bandage. On 9/17/24 at 12:37 P.M., Resident #43 was observed in bed with the same unlabeled and undated bandage on the left hand. On 9/18/24 at 7:35 A.M., Resident #43 was observed in bed with the same unlabeled and undated bandage on the left hand, as evidenced by the curling of all sides of the bandage. Review of Resident #43's current care plan failed to indicate a plan of care for a left-hand skin tear or for a left-hand skin treatment. During an interview on 9/18/24 at 7:31 A.M., the Director of Nursing said that when the skin tear was discovered staff should have developed a care plan specific to the skin tear and the treatment applied. 2. Resident #31 was admitted to the facility in July 2024 and has diagnoses that include an unstageable pressure ulcer of the right heel and Type II Diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/22/24, indicated that on the Brief Interview for Mental Status exam Resident #31 scored a 6 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #31 requires substantial/maximal assistance with lower body care, including putting on/taking off footwear. Review of Resident #43's care plan failed to indicate a plan of care had been developed regarding Resident #31's Activities of Daily Living needs. During an interview on 9/19/24 at 8:05 A.M., the Director of Nursing said that it was the expectation that a care plan be developed by nursing for every resident's Activities of Daily Living needs. 49880 3. Review of facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated as reviewed 7/9/24, indicated the following: -A skin assessment/ inspection should be performed weekly by a licensed nurse. Resident #16 was admitted to the facility in August 2024 with diagnoses that included acute on chronic diastolic congestive heart failure and lymphedema. Review of Resident #16's most recent Minimum Data Set (MDS) assessment, dated 8/19/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating that Resident #16 is cognitively intact. The MDS further indicated that the Resident has no pressure areas but is at risk for developing pressure ulcers/ injuries. Review of Resident #16's active plan of care for skin integrity, dated 8/14/24, indicated interventions for weekly skin checks. Review of Resident #16's medical record indicated the only skin check was completed on 8/23/24, and no further skin checks were completed after this date. Review of nursing progress notes since the Residents' admission failed to indicate that Resident #16 refused any weekly skin checks. During an interview on 9/19/24 at 9:18 A.M., Nurse #4 said that every resident has a skin check weekly that triggers automatically in the electronic health record (EHR). During an interview on 9/19/24 at 10:25 A.M., the Director of Nurses (DON) said the plan of care should be followed for weekly skin checks, and that they are assigned automatically on the computer in the EHR (Electronic Health Record). The Director of Nursing said If a skin check is refused by a resident, it should be documented in a nurses note.

Based on observations, record review and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and hygiene. Specifically, the facility failed to provide nail care for one Resident (#54) out of a total sample of 20 residents. Findings Include: Review of facility policy titled Nail Care. dated as reviewed 9/10/24, indicated but was not limited to the following: - For general fingernail care for most residents, the following procedure will be followed: - 1. Ensure fingernails are clean and trimmed to avoid injury and infection. Resident #54 was admitted to the facility in August 2024 with diagnoses that included fracture of the right femur and muscle weakness. Review of Resident #54's most recent Minimum Data Set (MDS) assessment, dated 9/2/24, indicated a Brief Interview for Mental Status score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident is dependent on staff for activities of daily living (ADLs). Further review of the MDS indicated that rejection of care is not a behavior exhibited by Resident #54. On 9/17/24 at 8:32 A.M., the surveyor observed Resident #54 sitting up dressed in his/her wheelchair eating breakfast. His/her right arm was in a sling and his/her left hand had a dark black substance under all of his/her fingernails. On 9/18/24 at 7:26 A.M., the surveyor observed Resident #54 laying in bed. The Resident's fingernails on his/her left hand were observed to have had a dark black substance under them. On 9/19/24 at 8:14 A.M., the surveyor observed Resident #54 in bed eating breakfast. His/her fingernails on the left hand were observed to have had a dark black substance under them. Resident #54 said that the staff assist him/her with activities of daily living and hygiene tasks because of his/her current condition. When asked if anyone has offered to help clean under his/her nails, Resident #54 said no. Resident #54 said he/she would like help cleaning their nails because this isn't typically how they keep them. Review of Resident #54's nursing progress notes since the Residents' admission failed to indicate any refusal of care. Review of Certified Nurses Aid (CNA) documentation failed to indicate any behaviors for refusal of care for Resident #54. Review of Resident #54's Activities of Daily Living (ADLs) care plan, dated 9/3/24, indicated that for personal hygiene and oral care, Resident #54 requires extensive assistance. During an interview on 9/19/24 at 10:12 A.M., Certified Nurses Aid (CNA) #2 said that Resident #54 requires extensive assistance with ADLs. CNA #2 said nail care should be part of the ADL process each day and CNAs should be checking resident's nails ensure they are not too long and are not dirty. The surveyor and CNA #2 observed Resident #54's nails and CNA #2 said they are dirty and need to be cleaned. CNA #2 said Resident #54 does not refuse care. During an interview on 9/19/24 at 10:20 A.M., Nurse #5 said that CNAs should be performing nail care as part of daily ADL care. Nurse #5 said that if a resident refuses, the CNA would tell the nurse and the nurse would document it in a nurses note. During an interview on 9/19/24 at 10:23 A.M., the Director of Nurses (DON) said that if nails are long or dirty, nail care should be performed as part of ADLs and hygiene care.

Based on observation, record review and interview the facility failed to ensure standards of quality care were implemented for one Resident (#43) out of a total sample of 20 residents. Specifically, the facility failed to a.) notify the physician or responsible party of a new skin tear, b.) failed to obtain an order for a treatment applied to a new skin tear and c.) failed to document an assessment of the new skin tear. Findings include: The facility policy titled area of Focus: Basic Skin Management, dated 11/29/23, indicated the following: -All residents have a head-to-toe inspection upon admission/readmission, then completed weekly, and as needed by nursing. It is documented in PCC: NRSG: Weekly Skin. -If any new skin alteration/wound is identified, it is the responsibility of the nurse to perform and document an assessment/observation, obtain treatment orders, and notify the MD and responsible party. -Orders are required for skin and wound care. There are wound care protocol orders in PCC under Orders-TX (treatment) Template. Resident #43 was admitted to the facility in September 2019 and has diagnoses that include dementia, anxiety disorder and history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/20/24, indicated that on the Brief Interview for Mental Status exam Resident #43 scored a 2 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #43 was dependent on staff for activities of daily living. On 9/17/24 at 8:34 A.M., Resident #43 was observed in bed. There was a bandage on his/her left hand, not labeled or dated with approximately a nickel size red area on the bandage. Resident #43 said some woman came in two days ago and said what happened here, its bleeding and put on the bandage. On 9/17/24 at 12:37 P.M., Resident #43 was observed in bed with the same unlabeled and undated bandage on the left hand. On 9/18/24 at 7:35 A.M., Resident #43 was observed in bed with the same unlabeled and undated bandage on the left hand, as evidenced by the curling of all sides of the bandage. During an observation and interview on 9/18/24 at 7:23 A.M., with Resident #43's Nurse (#1) the surveyor and Nurse #1 observed Resident #43's hand with an unlabeled and undated bandage on the left hand. Nurse #1 said the bandage should be labeled and dated and that she would expect there is an order for the treatment. Nurse #1 reviewed the record and said that there was not a Physician's order for the treatment. Following review of the record Nurse #1, the Director of Nursing and the surveyor observed Resident #43's hand and Nurse #1 removed the bandage, exposing an approximately 1-inch-long skin tear. Review of the most recent Skin Integrity update assessment, dated 9/9/24, indicated Resident #43 had no skin tears. The option to indicate Resident #43 had any skin tears was blank. Review of the Physician/PA/NP visit note, dated 9/16/24, indicates Resident #43 was assessed by the NP and there was no documented skin tear or treatment to the left hand indicated. Review of the current Physician orders for Resident #43 failed to indicate an order for a treatment to the left hand. Review of the record failed to indicate that the Physician or Activated Health Care Proxy for Resident #43 were notified of a skin tear to the left hand. Review of the record failed to indicate that when the new skin alteration/wound was identified that the nurse documented an assessment/observation of the area. Review of Resident #43's current care plan failed to indicate a care plan for a left-hand skin tear or for a left-hand skin treatment. During an interview on 9/18/24 at 7:31 A.M., the Director of Nursing said that when the skin tear was discovered staff should have done the following: -Created a risk report, which would include getting statements from staff and attempting to determine the cause of the skin tear; -notify the Physician and obtain an order for a treatment to the skin tear; -notify Resident #43's responsible party of the incident; -develop a care plan specific to the skin tear; and, -document all the above in the electronic medical record. In this case the Director of Nursing said that none of those things occurred.

Based on observation, record review and interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#31) out of a total sample of 20 residents. Specifically, the facility failed to ensure Resident #31 wore Prevalon boots while in bed, as ordered by the Physician. Findings include: The facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated as revised 7/9/24, indicated the following: 5. Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction and shear are implemented in the plan of care: d. heel protection/suspension if indicated. Resident #31 was admitted to the facility in July 2024 and has diagnoses that include an unstageable pressure ulcer of the right heel and Type II Diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/22/24, indicated that on the Brief Interview for Mental Status exam Resident #31 scored a 6 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #31 substantial/maximal assistance with lower body care, including putting on/taking off footwear. Review of the current Physician orders indicated Resident #31 had the following order: -Wear Prevalon Boot when in bed or not walking, Do not walk or transfer while wearing the Prevalon boot, start date 7/16/24. (sic) Review of Resident #31's care plans indicated the following: -A care plan that indicated Resident #31 has an unstageable pressure ulcer right heel. Interventions on the care plan include: Treatment as ordered. -A care plan that indicated Resident #31 has a Skin Tear of the left hand (back) and DTI to right heel. Interventions on the care plan include: Prevalon boots to bilateral lower extremities as tolerated -A behavior care plan, indicating Resident #31 was resistive to care, however the care plan failed to indicate Resident #31 refused to wear the Prevalon boots. Review of the clinical progress note dated 9/17/24 that Resident #31 has area to right heel which requires treatment and Prevalon boot daily. On 9/17/24 at 7:58 A.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots and none were observed in the room. On 9/17/24 at 8:40 A.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots and none were observed in the room. On 9/17/24 at 12:40 P.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots, and none were observed in the room. On 9/18/24 at 2:35 P.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots. On 9/19/24 at 7:29 A.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots. During an interview on 9/19/24 at 7:49 A.M., Resident #31's Certified Nursing Assistant (CNA) #1 said that Resident #31 fluctuates and requires one person assist to total care by 2 staff. He said that the nurses are responsible to put the Prevalon boots on Resident #31. During an interview and observation on 9/19/24 at 7:55 A.M., Resident #31's Nurse (#3) said that Resident #31 has an area on his/her heel and that nurses are responsible to put the Prevalon boots on when Resident #31 is in bed. The surveyor and Nurse #3 observed Resident #31 in bed without the Prevalon boots on. Nurse #3 searched the room but could not locate the boots. During an interview on 9/19/24 at 8:05 A.M., the Director of Nursing said that she would expect that staff follow MD orders and ensure Resident #31 had his/her Prevalon boots applied when in bed. The DON said that if Resident #31 refused the boots it should be documented in the Treatment Administration Record.

Based on observation, record review and interview the facility failed to ensure professional standards of practice for food service safety by failing to perform proper hand hygiene. Findings include: Review of the facility's policy, titled Chapter 1: Food Safety and Infection Control, Washing Hands Properly, not dated, indicated the following: -Training objective: Participants will know when they should wash their hands and will demonstrate the proper way to do so. Discussion, as food service workers, our hands come into contact with many unsanitary things during the day. Some of these contacts are part of our job tasks and some are not. Harmful bacteria can pass from an infected person to a well person from objects such as food, dishes, eating, utensils, glasses etc. These bacteria, in turn can make a person very ill. We can reduce the risk of becoming contaminated by washing out hands properly. When you should wash your hands: included but not limited to: -When they become soiled, -After completing a task and before beginning a new one. -Before handling food, clean dishes, or flatware. 1. During observation of the breakfast tray line in the kitchen on 9/19/24 at 7:35 A.M., the surveyor made the following observations. -Diet Aid #1, wearing gloves on both hands, was rolling flatware into napkins. Diet Aide #1 then removed his gloves, and without hand washing, touched the food truck, the door handle and left the kitchen with the food truck. Diet Aide #1 then returned to the kitchen, went to the hand washing sink, washed his hands and used his clean hands to turn off the water, thus contaminating his hands. Diet Aide #1 then proceeded to place on gloves and returned to rolling flatware into napkins. -Diet Aide #1 left the kitchen with the food truck two additional times after removing gloves and failing to perform hand hygiene after glove removal. Both additional times, Diet Aide #1 returned to the hand washing sink, washed his hands, turned off the water using his clean hands and in doing so contaminated his hands. After each of the two times he proceeded to put on gloves and returned to task including putting away clean items from the dish room. During an interview on 9/19/24 at 9:40 A.M., the Food Service Director (FSD) said staff are to wash hands when removing gloves and use proper hand washing techniques which would include using a paper towel to turn off the water to prevent contamination of clean hands.

Based on observation, record review and interview the facility failed to maintain an accurate medical record for two Residents (#31 and #43) out of a total sample of 20 residents. Specifically, 1. Nurses documented in the Treatment Administration Record (TAR) that Resident #31 wore Prevalon boots while in bed, contrary to direct observation of the boots not being worn. 2. A nurse inaccurately documented on a Skin Assessment that Resident #43 did not have a skin tear, when he/she had a skin tear to the left hand. Findings include: The facility policy titled Nursing Documentation, dated as reviewed 9/5/24, indicated the following: -The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and /or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. 1. Resident #31 was admitted to the facility in July 2024 and has diagnoses that include an unstageable pressure ulcer of the right heel and type II diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/22/24, indicated that on the Brief Interview for Mental Status exam Resident #31 scored a 6 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #31 substantial/maximal assistance with lower body care, including putting on/taking off footwear. Review of the current Physician orders indicated Resident #31 had the following order: -Wear Prevalon Boot when in bed or not walking, Do not walk or transfer while wearing the Prevalon boot, start date 7/16/24. (sic) On 9/17/24 at 7:58 A.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots, and none were observed in the room. On 9/17/24 at 8:40 A.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots, and none were observed in the room. On 9/17/24 at 12:40 P.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots, and none were observed in the room. On 09/18/24 at 2:35 P.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots. On 9/19/24 at 7:29 A.M., Resident #31 was observed in bed with his/her feet flat on the mattress. Resident #31 was not wearing Prevalon boots. Review of the September 2024 TAR indicated the following: -On 9/17/24, day shift, Nursing documented Resident #31 wore Prevalon boots while in bed, contrary to observations at 7:58 A.M., 8:40 A.M., and 12:40 P.M., of the Resident #31 in bed with his/her feet flat on the mattress. -On 9/18/24, day shift, Nursing documented Resident #31 wore Prevalon boots while in bed, contrary to the observation at 2:35 P.M., of Resident #31 in bed with his/her feet flat on the mattress. During an interview on 9/19/24 at 7:55 A. M., with Resident #31's Nurse (#3) she said that Resident #31 has an area on his/her heel and has an order for Prevalon boots to be worn when in bed. The surveyor and Nurse #3 observed Resident #31 in bed without the Prevalon boots on and upon searching the room Nurse #3 could not locate the boots. Nurse #3 said that she had not yet been in to see Resident #3 that morning, but because the night nurse had documented that the boots were on overnight, she would have expected the boots to be on when she went into the patient that morning. During an interview on 9/19/24 at 8:05 A.M., with the Director of Nursing (DON) she said that she would expect that the documentation in the TAR to be accurate. The DON said that if the boot were not applied as ordered this should be documented and a note written explaining the reason. 2. Resident #43 was admitted to the facility in September 2019 and has diagnoses that include dementia, anxiety disorder and history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/20/24, indicated that on the Brief Interview for Mental Status exam Resident #43 scored a 2 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #43 was dependent on staff for activities of daily living. On 9/17/24 at 8:34 A.M., Resident #43 was observed in bed. There was a bandage on his/her left hand, not labeled or dated with approximately a nickel size red area under the bandage. Resident #43 said some woman came in two days ago and said what happened here, its bleeding and put on the bandage. On 9/17/24 at 12:37 P.M., Resident #43 was observed in bed with the same unlabeled and undated bandage on the left hand. Review of the most recent Skin Assessment, dated 9/17/24 at 23:01 P.M., indicated Resident #43 had Scattered bruises all over the body especially the arms and hands. Skin is very fragile, however the assessment failed to indicate Resident #43 had a skin tear to the left hand. The option to indicate Resident #43 had any skin tears was blank. During an observation and interview on 9/18/24 at 7:23 A.M., the surveyor and Resident #43's Nurse (#1) observed Resident #43's hand with an unlabeled and undated bandage on the left hand. Nurse #1 removed the bandage, exposing an approximately 1-inch-long skin tear. During an interview on 9/18/24 at 7:31 A.M., the Director of Nursing said that the Skin Assessment completed 9/17/24 at 23:01 P.M., should have been completed accurately and noted the skin tear on the left hand.

Based on records and interviews, for one of three sampled residents (Resident #1) whose Physicians Orders included the administration of multiple bowel medications for the management of constipation and frequently complained of abdominal pain, the Facility failed to ensure they developed and implemented a Comprehensive Plan of Care that identified goals, outcomes and interventions related to constipation and abdominal pain, so identified care needs would be met by Nursing. Findings include: Review of the Facility's Policy, titled Person-Centered Care Planning, dated as reviewed 08/22/23, indicated each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Review of the Facility's Policy, titled Comprehensive Care Plans and Revisions, dated as reviewed 08/22/23, indicated the Facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs. Resident #1 was admitted to the Facility in November 2022, diagnoses included sepsis, acute renal failure, hypertension, seizures, and advanced Alzheimer's. Review of Resident #1's Evaluation for Bowel & Bladder Training, dated 05/01/24, indicated he/she had a score of 17 (indicating a poor candidate for scheduling or retraining), moderate cognition impairment, was incontinent of stool and had impaired mobility. Review of Resident #1's Medication Administration Record (MAR), and Physician's Orders, for July 2024, indicated he/she was being administered multiple medications daily for treatment of constipation, as follows; - Monitor bowel sounds and bowel movements every shift. - Bisacodyl Tablet Delayed Release 5 MG, Give two tablets by mouth at bedtime for Constipation. - Colace Oral Capsule 100 MG (Docusate Sodium), Give two capsules by mouth, two times a day for Constipation. - Enulose Solution 10 GM/15 ML (Lactulose Encephalopathy), Give 30 milliliters by mouth, two times a day for Constipation. - Milk of Magnesia Oral Suspension 2400 MG/30 ML (Magnesium Hydroxide), Give 30 ML by mouth, one time a day for Constipation. - Polyethylene Glycol Powder (Polyethylene Glycol 1450), Give 17 gram by mouth one time a day, Give in 8 oz of water for Constipation. - Senna Plus (Sennosides-Docusate Sodium) oral tablet 8.6-5.0 MG, Give 2 tablets by mouth, two times a day for Constipation. - Simethicone Oral Tablet 80 MG, 2 tablets by mouth ,four times a day for gas, chew with some amount of water. Resident #1's MAR, for July 2024, also indicated he/she had Physician Orders for (PRN) as needed, medications for management of his/her constipation, as follows; - Bisacodyl Suppository, 10 MG, Insert 1 Suppository rectally every 8 hours, As needed for Constipation daily. - Fleet Enema 7-19 GM/118 ML (Sodium Phosphates), Insert 1 application rectally every 8 hours, As needed for Constipation if no results from suppository. - Polyethylene Glycol Powder 3350 Powder (Polyethylene Glycol 3350 (BULK)), Give 17 gram by mouth every 24 hours, As needed for Constipation. Further review of Resident #1's Physician Orders and his/her Treatment Administration Record (TAR), indicated he/she had a new orders, for Nursing to complete the following: - 7/19/24, Insert Foley Catheter, 18 French Foley Catheter into rectum for 22 hours, one time only for abdominal pain and flatulence for one day. -7/25/24, Insert Foley Catheter, 18 French Foley Catheter, with 30 cc (balloon) into rectum for 24 hours, one time for gas relief, for one day (07/25/24) and Bladder Scan every shift for three days, if Post void residual is greater than 400 milliliters (ML), notify the provider. Review of Resident #1's Physicians Progress Note, dated 07/19/24, indicated Resident #1 had multiple medical problems, advanced dementia, ongoing parasitic Iieus (a condition that occurs when the muscles in the intestines stop working properly, preventing food from passing through and can lead to a block intestine, even though there is no physical obstruction) versus colonic pseudo-obstruction (also known as [NAME] Syndrome, a condition that causes the colon to suddenly expand, even though there's no mechanical blockage), history of chronic constipation and an extremely distended abdomen. During a telephone interview on 08/29/24 at 1:05 P.M., the Nurse Practitioner said that Resident #1's bowels do not work properly, he/she had been constipated with flatus (gas) had abdomen discomfort, and that he/she needed assistance with the aid of bowel medications and treatments. The Nurse Practitioner said Resident #1 had a distended abdomen, he/she was uncomfortable and had abdominal pain. The Nurse Practitioner said on 07/19/24 and 07/25/24, as an intervention, an order was given for Nursing to insert a Rectal Tube (Foley Catheter tube was used as rectal tube was unavailable) to provide comfort to Resident #1. During an interview on 08/29/24 at 12:20 P.M., the Nurse Manager said she was informed Resident #1 was constipated, had a distended abdomen, and he/she had abdominal discomfort. The Nurse Manager said she was aware Resident #1 had been on bowel medications for constipation and abdominal distention and he/she had a Foley Catheter placed in his/her rectum twice as an intervention to release gas and to help promote him/her to have a bowel movement. The Nurse Manager said Resident #1's Comprehensive Plan of Care did not include Resident #1's history of constipation, his/her issues with abdominal distention, regimen of bowel medications or the placement of a Rectal Tube in his/her rectum for an intervention. The Nurse Manager said the Minimum Data Set (MDS) Nurse and the Director of Nurses (DON) were responsible for reviewing and updating the Residents' Comprehensive Plans of Care. During an interview on 08/29/24 at 1:41 P.M., the Director of Nurses (DON) said Resident #1 had a history of constipation, abdominal and gas pain, he/she had been taking bowel medications and Nursing placed a Foley Catheter (as the Facility did not have a Rectal Tube in stock) in his/her rectum on two different occasions to provide Resident #1 comfort. On the day of Survey, 08/29/24, The DON reviewed Resident #1's Comprehensive Plan of Care with the Surveyor and said Resident #1's Plan of Care did not include his/her history of constipation, abdominal discomfort/pain or indicate interventions including multiple bowel medications or use of a Rectal Tube. The DON said it was her expectation that Nursing staff be knowledgeable about residents' Plans of Care and to implement goals, interventions, and outcomes accordingly. The DON said Nursing staff can implement, change, update and make any changes including interventions that need to be placed in the residents Plan of Care as needed. The DON said it is the responsibility of the Nurse Unit Managers, the MDS Nurse and herself to ensure the residents Plans of Care are accurate.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a history of constipation, and had Physician's Order on 07/19/24 and 07/25/24, for Nursing to insert an 18 French Foley Catheter (due to unavailability of a Rectal Tube) into his/her rectum to treat abdominal distention and pain, the Facility failed to ensure nursing staff were competent in the process, which included being aware of Facility Policy and Procedures and documenation requirements. Findings include: Review of the Facility's Policy titled, Nursing Documentation, dated as reviewed 08/10/23, indicated the facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice. The Policy indicated the Facility must ensure that Licensed Nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Facility Policy titled, Rectal Tube Insertion and Removal, dated as reviewed 08/24/23, indicated the Facility will provide Rectal Tube Insertion and Removal in accordance with professional standards of practice. Resident #1 was admitted to the Facility in November 2022, diagnoses included sepsis, acute renal failure, hypertension, seizures, and advanced Alzheimer's. Review of Resident #1's Physicians Progress Note, dated 07/19/24, indicated that Resident #1 was on a regimen of multiple bowel medications which were not relieving his/her abdominal distention. The Note indicated to trial Resident #1 with a Rectal Tube (if not available could use Foley Catheter tube until available) to provide comfort to Resident #1 and decompress his/her abdomen. Review of Resident #1's Physician Order, dated 07/19/24, indicated Nursing to insert Foley Catheter, 18 French Foley Catheter into rectum for 22 hours, One time only for abdominal pain and flatulence. During an interview on 08/29/24 at 12:20 P.M., the Charge Nurse said Resident #1 had a Physician's Order for a Rectal Tube to be inserted by Nursing into his/her rectum. The Charge Nurse said she did not review the Facility's Policy on Rectal Tube Insertion and Removal, that she had not performed this particular nursing skill (was not familiar with this type of intervention) and said the Nurse Practitioner assisted her with the insertion of the Foley Catheter tube (as Rectal Tube was unavailable) into Resident #1's rectum. The Charge Nurse said the Facility does not stock Rectal Tubes in their supply, and that she had used a Foley Catheter tube. The Charge Nurse said she did not write a Nurse Progress Note on 07/19/24 about the procedure, since the Nurse Practitioner said she would document on Resident #1. During a telephone interview on 09/06/24 at 1:05 P.M., the Nurse Practitioner said on 07/19/24 the insertion of a Rectal Tube (Foley Catheter tube) was done to provide Resident #1 with comfort since he/she had a lot of gas, discomfort, was constipated, had a distended abdomen and was not responding to his/her bowel medications. The Nurse Practitioner said the Facility did not have any Rectal Tubes in supply, so a Foley Catheter was used until a Rectal Tube was available. The Nurse Practitioner said she was planning to insert Resident #1's Foley Catheter Tube into his/her rectum, but the Charge Nurse had already started the procedure upon her arrival. The Nurse Practitioner said Resident #1's Physician was aware of his/her health status, had suggested the Rectal Tube be inserted to help decompress the abdomen and said the Physician had documented on Resident #1. The Nurse Practitioner said on 07/25/24 she had received a phone call from Nursing stating Resident #1's abdomen was again distended, and he/she was uncomfortable. The Nurse Practitioner said since Resident #1 had relief on 07/19/24 from the Foley Catheter tube being inserted in his/her rectum, she provided a new order for Nursing to insert a Rectal Tube for treatment. The Nurse Practitioner said the Facility did not have any Rectum Tubes in supply and Nursing inserted a Foley Catheter into Resident #1's rectum. Review of Resident #1's Physician Order, dated on 07/25/24, indicated Nursing to insert Foley Catheter, 18 French Foley Catheter, with 30 cc balloon, into rectum for 24 hours, for gas relief, for one day (07/25/24). During a telephone interview on 08/29/24 at 10:35 A.M., Nurse #1 said on 07/25/24, Resident #1 was constipated, he/she had abdominal distention and he/she was uncomfortable. Nurse #1 said Resident #1 had a Physician Order to insert a Rectal Tube into his/her rectum to provide Resident #1 comfort. Nurse #1 said she had never heard of this Nursing skill, was not sure if the Facility had a Policy and Procedure on Rectal Tubes and said she did not review or speak to any of the other Nurses regarding Rectal Tube insertion. Nurse #1 said the Facility did not stock Rectal Tubes in supply, so she used a Foley Catheter Tube. Nurse #1 said she inserted the Foley Catheter Tube into Resident #1's rectum like she would insert a Foley catheter in the urinary track, although she only inserted the tube a couple of inches into his/her rectum. During a telephone interview on 09/11/24 at 9:49 A.M., Nurse #2 said on 07/25/24, Resident #1 had a Physician Order for Nursing to insert a Foley Catheter Tube into his/her rectum to provide Resident #1 comfort. Nurse #2 said the Facility does not have Rectal Tubes in supply. Nurse #2 said he was not sure if the Facility had a Policy and Procedure on Rectal Tube Insertion and Removal and he has never heard of or performed this type of procedure. Review of Resident #1's Nurse Progress Notes, indicated there was no Nursing documentation on 07/19/24, 7/20/24, 07/25/24 or 7/26/24, to indicate which Nurse inserted and/or removed the Rectal Tube (Foley Catheter Tube), how Resident #1 tolerated the procedures or what the outcomes were. During a telephone interview on 09/06/24 at 3:28 P.M., the Staff Development Coordinator (SDC) said if a Physician orders a Rectal Tube insertion/removal, the Facility does not have any Rectal Tube supplies to manage the Rectal Tube procedure. The SDC said the Facility has not provided Nursing Staff with education or skills training related to Rectal Tubes. The SDC said the Facility does have a Policy on Rectal Tube Insertion and Removal, and that Nursing staff are able to review the Policy and Procedures on the Facility's computer system prior to any skill they perform on a resident. During an interview on 08/29/24 at 1:41 P.M., the Director of Nurses (DON) said the Facility does have a Rectal Tube Insertion and Removal Policy. The DON said the Facility does not stock Rectal Tubes in supply. The DON said it was her expectation that Nursing staff be knowledgeable about Facility's Policies and Procedures and Nursing skills prior to performing a task. The DON said it was her expectation that Nursing document any procedure in the residents Progress Note after a skilled procedure is performed. On 08/29/24, the DON reviewed Resident #1's Progress Notes (with the Surveyor) and said Nursing did not document Progress Notes on the insertion or removal of Resident #1's Foley Catheter in his/her rectum. The DON said it was her expectation that Nursing staff be knowledge and document the skill that was performed.

Based on record review, and interview, the facility failed to meet professional standards of care for one Resident (#5), out of a total sample of 21 residents. Specifically: 1. For Resident #5 the facility failed to ensure an occupational therapy assistant provided services within her scope of practice resulting in an injury. Findings include: Review of 259 CMR Board of Allied Health Professionals: 3.00 OCCUPATIONAL THERAPISTS, indicated the following: 1. Evaluation is the process of obtaining and interpreting data necessary for an intervention, including planning for and documenting the evaluation process and results. 2. Occupational Therapy Assistants (OTA) may not initiate or alter an intervention plan without prior evaluation by and approval of, the supervising Occupational Therapist (OT). 3. The OT must be directly involved in the delivery of services during evaluation and re-evaluation. Resident #5 was admitted to the facility in September 2020 with diagnoses including diabetes, Charcot's joint of the left ankle and foot (damage to the ankle and foot when nerve damage has caused a lack of sensation), displaced fracture of the left tibia (lower leg) with routine healing, lateral malleolus of left fibula (ankle) fracture with routine healing and left talus (bone that forms the ankle) fracture with routine healing. Review of the Occupational Therapy (OT) evaluation dated 7/11/23, indicated Resident #5 was referred to therapy for self-feeding due to recent weight loss with a new goal: will improve ability to feed self and efficiently perform eating tasks. Further review of the evaluation failed to indicate that Resident #5 was evaluated by the OT for transfers and the evaluation failed to include a goal for transfers or positioning. Further review failed to indicate a referral to Physical Therapy as Resident #5 was at baseline status for transfers. Review of the OT treatment note dated 7/20/23, indicated the OTA suggested (without the OT evaluating Resident #5) for Resident #5 to transfer to a wheelchair. Resident #5 said he/she was afraid to do the transfer and did not want to attempt transfer to the wheelchair. Resident #5 took two shuffles towards the head of the bed, using a rolling walker for support, and sat on the edge of the bed. The note indicated the OT was present during the transfer but did not have her hand on the Resident as the sit to stand transfer took place to evaluate the ability of the Resident to perform the task safely. A transfer to the wheelchair did not take place. Review of the OT note dated 7/25/23, indicated that Resident #5 was treated by the OTA and was transferred with a max assist of one to stand and pivot into a wheelchair. The evaluating therapist was not present during this transfer to assess the Resident's current level or safety with the transfer. The note was signed at 2:18 P.M. The OT notes failed to indicate the plan of care was modified to include a goal for positioning or transfers and that the OT had assessed Resident #5's transfer status prior to the OTA completing the transfer. Review of the care plan indicated a focus area for Activities of Daily Living (ADL) with an initiation date of 11/18/21, and an intervention of TRANSFER: The Resident requires max assistance by two staff members to move between surfaces. Review of the Progress Note dated 7/25/23, entered at 8:52 P.M., indicated that the nurse was notified by the nursing assistant that she had noted swelling with bruising of the Resident #5's left foot. The nurse assessed Resident #5's left foot and noted that the entire foot and lower leg was significantly swollen. Resident #5 denied any pain (as would be normal with Charcot foot). The nurse practitioner ordered an X-ray of the foot. Review of the X-ray dated 7/25/23, at 9:30 P.M. indicated soft tissue swelling without fracture or dislocation. Review of the progress note dated 7/26/23, entered at 8:13 A.M. indicated that the nurse observed the left foot to be worsening, felt hot to the touch and obtained an order from the nurse practitioner to send Resident #5 to the hospital. Review of the document titled [NAME] Hospital History and Physical Examination, dated 7/28/23, indicated Resident #5 was transferred from [NAME] hospital upon orthopedic evaluation because the physician felt it best to have Resident #5's condition evaluated and treated at [NAME] hospital. Further review indicated the left lower leg with significant swelling and ecchymosis (bruising). Ankle resting inverted with skin tear over the anterior distal tibia and a wound over the lateral malleolus with exposed bone. Further review indicated Resident #5 has an open left ankle fracture. Review of the document titled [NAME] hospital discharge summary dated 7/28/23, indicated the following: *The patient is a resident at a nursing home who is non weight bearing, non-mobile at baseline with a known left foot deformity who normally transfers with a Hoyer lift. At the nursing home she/he was transferred while weight bearing resulting in worsening deformity, acute swelling, blister formation and skin breakage with bone exposure. She/he has severe neuropathy at baseline and sensation is diminished on exam. Review of the facility document titled Documentation Survey Report v2 (where Certified Nurse's Aides (CNAs) document daily function of a resident and the level of assistance provided) indicated the following: *In May 2023 Resident #5 was totally dependent on 2 staff members to transfer (full staff performance to complete the task). Walk in room; activity did not occur. *In June 2023 Resident #5 was totally dependent on 2 staff members to transfer. Walk in room; activity did not occur. *In July 2023 Resident #5 was totally dependent on 2 staff members to transfer. Walk in room; activity did not occur. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #5 was totally dependent (full staff performance every time during a 7 day look back period) for transfers and required two + staff members to complete the task. Further review indicated that Resident #5 did not walk in her/his room (activity did not occur). During an interview on 9/14/23 at 7:57 A.M., Certified Nurse's Aide (CNA) #2 said a dependent transfer requires the use of a mechanical lift and a transfer with maximal assistance with 2 staff members requires the 2 staff members to lift the resident under the arms without the resident's feet touching the floor. CNA said that with either type of transfer, the resident in non-weight bearing and does not participate in the activity. CNA #2 said prior to Resident #5's injury, he/she would transfer with a mechanical lift or maximal assistance from 2 staff members. During an interview on 9/13/23, at 12:02 P.M., the Occupational Therapist said that she completes the majority of the OT evaluations in the facility. The OT said the Occupational Therapist Assistant then completes the treatments but that she treats all residents on caseload every 10th visit to ensure the plan of care is still appropriate. The OT said that it is not within the scope of practice for an occupational therapy assistant to assess a resident or to make changes to the plan of care. The OT said she completed the evaluation for Resident #5 and said she had not assessed the Resident's ability to transfer during the initial evaluation and had not made a goal for transferring. The OT said she had not modified Resident #5's treatment plan prior to the OT assistant completing the transfer and she, herself had not physically assessed the Resident's ability to transfer. The OT said that she was present during the 7/20/23 treatment session, however, did not assess Resident #5's transfer status and that she watched the assistant perform the treatment, (including the resident weight bearing). The OT said she is a newer therapist and since the OTA had more years of experience, she deferred to the assistant. The OT again said it was her responsibility to assess the Resident and develop the plan of care and it is not within the scope of practice for the assistant to do so. During an interview on 9/13/23 at 12:18 P.M., the Director of Rehabilitation (DOR) said the OT is responsible for evaluating the residents of the facility and developing the plan of care. The DOR said the evaluating therapist must continually assess the resident based on the feedback provided by the assistant and change the plan of care if appropriate. The DOR said the Occupational Therapy Assistant should not have transferred Resident #5 without the OT assessing his/her transfer status and a goal being in place. The DOR said if positioning was an issue during feeding, the nursing staff could have transferred the Resident out of bed and the OTA could have begun treatment after the transfer was complete. During a follow up interview on 9/14/23, at 7:42 A.M., the Director of Rehabilitation (DOR) said that therapists use the term dependent and maximum assist of 2 people interchanging. The DOR said that both are considered non-weight bearing but dependent implies the use of a mechanical lift. The DOR then said that when nursing documents a resident is a max assist of 2 people, the staff is lifting the resident and the resident's feet do not touch the floor. The DOR confirmed this is how Resident #5 had been transferring with the staff up until his/her injury on 7/25/23. 43846

Based on observation, record review and interview, the facility failed to ensure nursing staff implemented orders for one Resident (#5) out of a total sample of 21 residents. Staff failed to remove a leg brace as recommended by the orthopedic surgeon resulting in the worsening of a surgical wound. Subsequently, Resident #5 was hospitalized requiring debridement (a surgical procedure to remove dead tissue) of the wound and sepsis (an infection of the blood stream) with associated Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia requiring a PICC line (a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for IV antibiotics. Findings include: Review of the Treatment of Wounds policy, dated 3/31/23, indicated: It is the intent of this center that a resident having a wound receives necessary medical treatment to prevent infection, deterioration or development of wounds in keeping with the resident's medical condition. Resident #5 was readmitted to the facility in August 2023 with diagnoses including displaced fractures of the left tibia, lateral malleolus of the left fibula, and left talus. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #5 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact. On 9/12/23 at 7:55 A.M., the surveyor observed Resident #5 in bed with his/her left foot in a cast. Review of the hospital discharge paperwork dated 8/4/23 indicated: Patient has cast with window available to do regular wound checks if concerns prior to follow-up visit may come in sooner. Plan to d/c cast when incisions are healed. Review of the orthopedic clinic follow up note dated 8/15/23 indicated Resident #5's left leg was irritated by cast and was replaced with a brace. Instructions indicated: remove brace 2-3 times daily. The instructions were signed and dated by Nurse Practitioner on 8/15/23. Review of the Physicians orders for August 2023, Treatment Administration Record for August 2023, and care plans failed to indicate staff were removing the brace as ordered. Review of the nurse progress notes indicated: 8/16/23: LLE (left lower extremity) Dressing/wrap clean, dry and intact. Pending instructions from orthopedic MD. (The orthopedic MD recommendations to remove the brace 2-3 times a day had been signed and dated by the Nurse Practitioner the day before; 8/15/23) A nursing note written on 8/21/23 indicated the following: This writer, Nurse Practitioner and Director of Rehab assessed wound to left lateral ankle. Moderate amount of serous drainage noted to gauze. Wound bed 50%/50% slough and granulation. Undermining noted to be 2-6 o'clock when cleaning. Surrounding skin red and blanchable, tender to touch and warm on palpitation. Area edematous/swollen. Pt visited surgeon for follow up . Hard cast was removed and replaced with kerlix, ACE wrap and brace that was to be removed TID (three times a day) per day to observe for wound deterioration. [Nurse Practitioner] evaluated and is sending out [to hospital] for further eval. Review of the hospital paperwork dated 9/5/23 indicated Resident #5 was admitted to the hospital with diagnoses of sepsis due to left ankle infection with associated MRSA bacteremia. Resident #5's wound was debrided and a PICC line was placed during the hospitalization to treat the infection with IV antibiotics. During an interview on 9/13/23 9:12 A.M., Unit Manager #1 said that the Nurse Practitioner had signed off on the orthopedics instructions to remove Resident #5's brace 2-3 times daily and it was not carried over to the physician's orders. During an interview on 9/13/23 at 2:45 P.M., the Director of Nursing said that when the Nurse Practitioner had signed off on the orthopedic instructions to remove Resident #5's leg brace, it should have been put in as an order for nursing to follow. During an interview on 9/14/23 at 8:07 A.M Nurse #1 said that Resident #5's cast was completely managed by the orthopedics and at some point was changed. Nurse #1 said that nursing staff did not remove any device off Resident #5's leg.

Based on observation, record review and interview the facility failed to ensure that it is free from medication rates of 5% or greater. Findings include: Review of the facility policy titled Administration of Medications dated reviewed 8/24/23, indicated the facility will ensure medications are administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms. 1. Resident #25 was admitted to the facility in March 2023 with diagnoses Parkinson's disease, psychotic disorder and generalized weakness. Review of the doctor's orders dated September 2023 indicated a doctor's order for Acetaminophen oral tablet 500 mg (milligrams) give 2 tablets by mouth three times a day for pain. Further review indicated the following orders: 1. Lidocaine external patch 4% apply to mid upper back topically one time a day for pain and remove per schedule. 2. Miralax oral packet 17 GM (grams) give one packet by mouth in the morning for constipation. On 9/13/23, at 8:30 A.M., the surveyor observed Nurse #4 administer medications to Resident #25. The surveyor observed Nurse #4 give Resident #25, 2 tablets of Acetaminophen 650 mg. The surveyor did not observe Nurse #4 administer the Lidocaine patch or the Miralax as ordered. During an interview on 9/13/23, at 8:43 A.M., Nurse #4 said that she was waiting to put the Lidocaine patch on after Resident #25 took a shower. Nurse #4 then said that she thought the Acetaminophen was the 500 mg and didn't realize the bottle contained 650 mg tablets. Nurse #4 also said that she did not administer the Miralax. 2. Resident #65 was admitted to the facility in February 2023 with diagnoses including stroke, depression and anxiety. Review of the doctor's orders dated September 2023 indicated the following doctor's order: 1. Baclofen oral tablet 5 mg give one tablet three times a day. 2. Carvedilol oral tablet 12.5 mg give three tablets by mouth two times a day for hypertension with meals, to hold if heart rate below 60. On 9/13/23, at 9:11 A.M., the surveyor observed Nurse #5 dispense and administer Baclofen 5 mg 3 tablets. The surveyor did not observed Nurse #5 dispense and administer Carvedilol oral tablet 12.5 mg as ordered.

Based on observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. once opened were dated as required and 3. topical and treatment items were not stored with oral medications. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications, Biologicals, dated last revised 7/21/22, indicated the following: 1. Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals. 2. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 3. Once any medication or biological package is opened, the facility should follow manufacturer's guidelines with respect to expiration dates for opened medications. 4. If a multi-dose vial of an injectable medication has been opened or accessed the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial. A) On 9/12/23, at 8:27 A.M. the surveyor observed the following in the Woodland Unit north medication cart: 1 bottle of cranberry supplement open without a date. Review of the manufacturer's directions indicted that the supplement expires 3 months after opening. 1 vial tuberculin derivative injectable, open without a date 5 tubes of Diclofenac Sodium Treatment cream 1 tube ammonium Lactate Cream 1 tube Nystatin Cream 1 tube Ketoconazole Cream 1 tube Lidocaine cream 1 tube Hydrocortisone cream 1 tube Clotrimazole cream 1 tube Santyl ointment 1 tube Triamcinolone Acetonide cream 1 budesonide and formoterol inhaler open without a date 1 albuterol/ipratropium combavent inhaler open without a date B) On 9/12/23, at 3:40 P.M. the surveyor observed the following in the Pond View Unit south medication cart: 12 tubes of Diclofenac cream 4 bottles of nystatin antifungal powder 3 tubes nystatin antifungal cream 1 tube Solosite wound gel 1 tube of Normlgel Ag wound treatment 3 combivent inhalers open without a date. Further review indicated that the inhalers were dispensed on 12/7/22, 12/31/22, and one without a date or label. Review of the manufacturer's directions indicated to discard the inhalers three months after opening. 1 Pulmacort inhalers open without a date. Further review indicated the inhaler was dispensed from the pharmacy 2/24/23, more than six months ago. Review of the manufacturer's directions indicated to discard the inhalers six months after opening. 1 tube of Neomycin/Polymyxin B Sulfates and Bacitracin Zinc ophthalmic ointment open without a date and a dispense date of 8/8/23. 1 bottle of Latanoprost ophthalmic solution open without a date and without a date dispensed. C) During medication pass on 9/12/23, at 8:31 A.M., the surveyor observed Nurse #4 leave the medication cart and enter a residents room leaving the medication cart unlocked. During an interview on 9/12/23, at 8:35 A.M., Nurse #4 said that the medication cart should always be locked when it is not within eyesight of the nurse. During an interview on 9/12/23, at 3:44 P.M., Nurse #2 said that treatment creams belong in the treatment cart. Nurse #2 then said that all of the inhalers should have been dated when opened.

Based on observation, record review, staff, resident and family interviews, the facility failed to assess, monitor and provide the necessary care and services in order to control the pain for 1 resident (#6), out of 6 applicable residents who experienced pain, in a total sample of 18. Findings include: Resident #6 was admitted to the facility in 10/2011 with [DIAGNOSES REDACTED]. Review of the initial MDS (Minimum Data Set) dated 10/14/11, indicated that the Resident required extensive assistance for all activities of daily living and received PRN (as needed) medication for pain. Resident interview had indicated that the Resident had no pain. Review of the quarterly MDS assessment dated [DATE] indicated that the Resident received PRN pain medication in the prior 5 days and again Resident interview had indicated that the Resident had no pain. However, review of the nurses notes for the 5 day observation period prior to the assessment reference date of 1/19/12 indicated that the Resident had, on at least 7 occasions, received PRN pain medication for rectal pain. The plan of care for arthritis, general discomfort and decreased mobility due to [MEDICAL CONDITION] was dated 10/17/11. There was no plan of care for rectal pain. The approaches and interventions to deal with pain included the following: *Use diversion and distraction techniques such as activities, music and television *Reposition for comfort *Monitor, record and report pain to MD *Administer pain medication as ordered/indicated *Monitor effectiveness of pain management strategies *If pain medication is ineffective or inadequate report to MD/NP *Teach resident that pain medication s are available and to request when needed *Encourage pain medication if indicated before therapy *Assess patient for nonverbal signs/symptoms of pain as needed. Observation during the initial tour, on 4/2/12 at 10:20 A.M., revealed that the call light in Resident #6's room was on and sounding. Upon entering the room, Resident #6 looked up at this surveyor with a distressed look on his/her face, and mouthed in a soft voice "pain". This surveyor went to tell Medication Nurse #2 that the Resident reported experiencing pain. The medication Nurse #2 said that the patient had already been medicated and they were waiting for the medication to work. Review of the MAR (medication administration record) and physician order [REDACTED]. *Tylenol 650 mg as needed every 4 hours as needed for pain/discomfort *[MEDICATION NAME] 5/mg/500 mg 1 tab every 4 hours as needed for pain *[MEDICATION NAME] 2 mg every 3 hours as needed for pain *[MEDICATION NAME] 3 mg every 3 hours as needed for pain There was no further clarification as to when or which dosage of medication were to be given. In addition, there were no medications scheduled to be provided on a regular basis to treat pain and discomfort. Further review of the MAR for March, 2012 indicated that 29 times various PRN medications were given to treat pain. Review of the MAR (medication administration record) for 3/5/12 indicated that at 6:00 A.M. on 3/5/12 the Resident was administered 3 mg [MEDICATION NAME] for the treatment of [REDACTED].M., indicated that the Resident did not have any current pain reported. The Pain Assessment did not indicate that the Resident had been medicated for pain within the last 1-1/2 hours. Additional Pain Assessments, completed on 4/3/12 and 4/6/12, indicated that the Resident was stoic and could not verbally express pain. During an interview, on 4/2/12 at 3:15 P.M., Medication Nurse #2 said that the measures to decide which medication to provide the Resident were unclear. She further stated that the Resident usually asks for [MEDICATION NAME]. If the [MEDICATION NAME] does not work, the Resident would then be given the [MEDICATION NAME], however the Resident feels that the [MEDICATION NAME] does not work as well. Review of the MAR indicated [REDACTED]. Review of the record indicated that there was no documentation indicating that the Resident was assessed, using a verbal or nonverbal pain rating scale on a regular schedule to determine his/her pain level. During an interview with a family member on 4/3/12 at 1:30 P.M., the family member said that the Resident often does not ask for pain medication and could be stoic. The family member said that he/she feels that the Resident was in pain often. During observation of the Resident, on 4/5/12 at 9:00 A.M., the Resident said that he/she was in pain. Medication Nurse #2 said during an interview, that the Resident had been medicated for pain at 8:00 A.M., and waiting for the medication to take effect (both the [MEDICATION NAME] and [MEDICATION NAME] should have helped relieve the pain after 1 hour); however, there was no documentation that the nurse had conducted a follow-up assessment to determine the effectiveness of the medication. Furthermore, interview with Medication Nurse #2 failed to reveal a plan as to when and how the facility would address the Resident's current complaints of pain Review of the Pain Management policy (revised 3/2007) failed to address a system for the reassessment of pain after a medication was administered.