Every finding on record at Mary's Meadow at Providence Place

Based on record review and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse's Aides (CNA) that the RN was responsible for overseeing with provision of resident care.Specifically, the facility failed to have an RN working at least eight consecutive hours over a 24-hour period on 8/24/25.Findings include:Review of the 8/23/25 and 8/24/25 nursing schedule indicated an RN was scheduled to work on 8/23/25 from 7:00 A.M. until 3:00 P.M. Further review of the schedule indicated no RN was scheduled to work until 8/24/25 at 9:00 P.M., providing only three hours of RN coverage on 8/24/25, of the eight consecutive hours in a day that is required. During an interview on 8/26/25 at 3:15 P.M., the Scheduler said she was unaware of the RN coverage requirement and would need to review this with her manager. During an interview on 8/26/25 at 4:49 P.M., the Director of Nursing (DON) reviewed the schedule for 8/24/25 and said there was only a total of three hours of RN coverage when there should have been eight consecutive hours within a 24-hour period.

Based on observation and interview, the facility failed to ensure that medications were stored in a safe and secure manner for one unit (Hillside Unit), out of a total of four units. Specifically, the facility failed to ensure that two blister pack medication cards containing 30 tablets of Metoprolol 50 milligrams (mg) (a medication used to treat heart and circulatory conditions) each were not stored on the counter at an unlocked nurses' station where the medications were readily accessible to unauthorized individuals.Findings include:Review of the undated facility policy titled Medication Storage In The Facility indicated the following:-Medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.-All medications will be kept inaccessible to residents and visitors at all timesOn 8/27/25 at 7:46 A.M., the surveyor entered the unlocked nurses' station and observed two blister pack medication cards each containing 30 tablets of Metoprolol 50 mg. During an observation with interview on 8/27/25 at 8:25 A.M., the surveyor and Director of Nurses (DON) entered the nurses' station and observed the Metoprolol blister pack medication cards on the counter of the nurses' station. The DON said the medication should not have been left on the counter at the nurses' station and should have been locked in a secure cabinet.

Based on interview and record review, the facility failed to notify the Physician of a significant change in condition for one Resident (#1), out of a total sample of 12 residents. Specifically, the facility failed to notify Resident #1's Physician of a blood glucose level of greater than 350 milligrams per deciliter (mg/dl), as ordered.Findings include:Resident #1 was admitted to the facility in February 2020 with diagnoses that included Type 2 Diabetes Mellitus Without Complications and Atherosclerotic Heart Disease.Review of the Minimum Data Set (MDS) Assessment, dated 5/26/25, indicated Resident #1 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of a total possible score of 15.Review of the active Physician's Orders, dated 8/1/25, included the following orders:-POC (Point of Care) two times daily; call if BS (blood sugar) is greater than 350 or less than 70 two times a day related to Type 2 Diabetes Mellitus Without Complications initiated 7/10/25-Basaglar KwikPen Subcutaneous Solution Pen-Injector 100 unit/ml (unit per milliliter) Insulin Glargine (Lantus); 24 units subcutaneously one time a day related to Type 2 Diabetes Mellitus Without Complications initiated 7/18/25-Jardiance Oral Tablet 25 milligrams (mg) by mouth one time a day related to Diabetes Mellitus Type 2 Without ComplicationsReview of the August 2025 Medication Administration Record (MAR) included the following:-a BS level of 376 mg/dl entered on 8/15/25-a BS level of 355 mg/dl entered on 8/19/25Review of the clinical record and a Physician's Progress Note, dated 8/4/25, indicated the following:-Resident seems to be (a) brittle diabetic and with advanced age.we are being concerned with this. Resident had hypoglycemia (low blood sugar level) last week with Lantus dosage and experienced rebound hyperglycemia (high blood sugar level).Further review of clinical record did not indicate any evidence that the Physician had been notified of Resident #1's elevated BS levels on 8/15/25 or 8/19/25.During an interview on 8/27/25 at 10:12 A.M., the Director of Nurses (DON) said when a nurse contacts a Physician there should be documentation of that contact in the clinical record progress notes. The DON reviewed Resident #1's clinical record and said she could not provide any documented evidence that the Physician had been notified of Resident #1's BS level on 8/15/25 and 8/19/25. The DON said Resident #1's Physician should have been notified of the elevated BS on 8/15/25 and 8/19/25 as ordered.

Based on record review and interview, the facility failed to accurately execute Advance Directives for one Resident (#39), out of a total sample of 12 residents. Specifically, the facility failed to ensure that the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form was valid and reflected the signature of Resident #39's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself).Findings include:Review of the facility's policy for MOLST, dated [DATE], indicated:-A do not resuscitate form/advance directive/five wishes document must be completed and signed by the resident or legal surrogate as permitted by state law. It will be kept in the resident's medical record.-The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the residents wish to make changes to such directives.Review of the facility's policy for Cardiopulmonary Resuscitation (CPR), dated February 2018, indicated the following:- CPR is initiated unless a valid DNR (Do Not Resuscitate) order is in place. Resident #39 was admitted to the facility in [DATE] with diagnoses of Unspecified Dementia and Mood Disturbance.Review of Resident #39's clinical record included: - A MOLST form, dated [DATE], signed by a Registered Nurse per a conversation with Resident #39's HCP- A Physician's order, dated [DATE], activating Resident #39's HCP- A Physician's order, dated [DATE], of MOLST: DNR (Do Not Resuscitate), DNI (Do Not Intubate) DNTH (Do Not Transfer to Hospital); Healthcare Proxy ActivatedFurther review of the clinical record did not indicate Resident #39's HCP had signed the MOLST form as required.During an interview on [DATE] at 2:04 P.M., the Director of Nurses (DON) reviewed the MOLST form and said it was signed by a Registered Nurse as a result of a conversation with Resident #39's HCP. The DON said the Resident's MOLST form was not valid and a new MOLST form should have been completed to reflect the HCP signature.

Based on record review and interview, the facility failed to ensure all required staff members attended the scheduled quarterly Quality Assurance Performance Improvement (QAPI) meeting, as required. Specifically, the facility Infection Preventionist (IP) failed to attend three of the last four quarterly QAPI meetings. Findings Include: Review of the facility policy titled Mission Driven Quality Assurance and Performance Improvement Plan/Policy (QAPI), revised July 2023 indicated the following: -Committee membership includes the Medical Director, the Administrator, Director of Nursing, Social Services, Dietary Services, Activities, Pastoral Care, Environmental Services, Infection Preventionist, and other department managers as determined . Review of the attendance sheets from 7/18/22, 10/17/22 and 1/16/23 indicated the facility Infection Preventionist was not in attendance during the scheduled quarterly meetings held on those dates. During an interview on 7/10/23 at 11:18 A.M., the Administrator said he thought the only required members that needed to attend the QAPI meetings were the Administrator, Medical Director, and Director of Nursing (DON) and that for three of the last four quarterly QAPI Meetings, a facility Infection Preventionist was not in attendance.

Based on observations, interview, and record review, the facility failed to assess one Resident's (#138) out of a total sample of 12 residents, ability to safely self-administer medications. Findings include: Review of the facility's policy for self-administration of medications, undated, included the following: - It is the policy of this facility that individual residents may self-administer medications if they indicate a desire to do so, and the interdisciplinary team (IDT), including the resident believe this is a safe practice. - If the resident has an order to keep medication at bedside, the facility must complete a Self-Administration of Medications screen. - Self-administration of medication is to be addressed in the resident's care plan and indicated on the Medication Administration Record (MAR). - If the resident chooses to self-administer their medications the nursing staff will document the resident's usage of medication on the MAR for each shift. - If the resident has an order to keep medications at bedside, the medication must be secured in a locked box at all times to maintain the safety of other residents. - If the resident is self-administering his/her own medications, completion of the self-administration screen will be completed initially, quarterly, and with a change in condition. Resident #138 was admitted to the facility in June 2023 with a diagnosis of Congestive Heart Failure (CHF-when the heart is unable to adequately pump blood through the body resulting in the buildup of fluid in the extremeties [arms and legs], lungs and/or other organs). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Resident's chart included a Self-Administration of Medication Release form dated 6/21/23 that indicated the Resident wished for the Medication Nurse to administer his/her medications. Review of the electronic medical record (EMR) included a Self-Administration of Medication assessment dated [DATE] that indicated the Resident did not desire to self-administer medications. Review of the July 2023 Physician's orders included the following: -ProAir HFA Inhalation Aerosol Solution (also known as Albuterol- a medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness), 108 micrograms (mcg) per actuation (the action of causing a device to operate), two puffs inhaled orally every four hours as needed for shortness of breath or wheezing. -may keep at bedside, initiated 6/23/23. Review of the June 2023 MAR indicated no documented evidence that the Resident was using the ProAir Inhaler after the Physician order to keep the medication at bedside on 6/23/23. Review of the July 2023 MAR indicated no documented evidence the Resident was using the ProAir Inhaler. During an observation and interview on 7/5/23 at 3:13 P.M., the surveyor observed the Resident seated in a recliner chair at his/her bedside. The surveyor also observed an Albuterol/ProAir Inhaler (a small handheld device that allows one to breathe medicine in through the mouth directly to the lungs) on the Resident's bedside table. The Resident said he/she uses the Albuterol/ProAir a couple of times during the day and also before or after he/she gets ready for bed. Resident #138 further said, the Nurse just leaves it for me, they don't ask how often I use it - I think it is supposed to be every four hours, but I think I use it more than that. Further review of the medical record indicated no evidence the Resident's ability to self-administer medications safely had been assessed prior to leaving the Albuterol/ProAir Inhaler medication at his/her bedside. During an interview on 7/6/23 at 2:44 P.M., Nurse #3 said if a resident wished to self-administer medication, there should be a self-administration assessment completed for the resident. The surveyor and Nurse #3 reviewed the Resident's record and Nurse #3 said a self-administration assessment had not been completed for the Resident as required. She further said if the Resident initially wanted a Nurse to administer his/her medications, then changed his/her mind, a new consent and assessment should have been completed.

Based on record review and interview, the facility failed to develop and implement the Plan of Care for two Residents (#30 and #1) out of a total sample of 12 residents. Specifically, the facility failed to: 1. Implement fall prevention interventions for the two Residents. Findings include: 1a. Resident #30 was admitted to the facility in June 2023 with diagnoses including Femoral Neck Fracture and status-post fall. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS Assessment indicated the Resident required: -extensive assist of two persons for bed mobility and transfers, -had lower extremity impairment and had a history of falls and fractures, including falls prior to admission and since being admitted to the facility. Review of the Resident's Fall Risk Screener dated 6/7/23 indicated to implement high risk fall prevention interventions. Review of the Resident's Fall Risk assessment dated [DATE] indicated the Resident was at Moderate Risk for falls. Review of the medical record indicated the Resident had a fall at the facility on 6/11/23. After that fall, the facility's staff updated the Resident's care plan on 6/11/23 to include the following intervention: - Apply bed and chair alarm when unsupervised in room. Further review of the medical record included a progress note dated 6/18/23 that indicated the Resident sustained an unwitnessed fall, was found lying on his/her back between his/her recliner and his/her bed and obtained a skin tear to his/her left elbow. Review of the Fall Investigation, dated 6/18/23 indicated the following: - Elder Assistant (EA - title the facility used for Certified Nursing Assistants) #2 went into Resident's room to bring his/her supper and found him/her lying on his/her back on the floor between his/her recliner chair and the bed. The chair alarm was on the wheelchair and not the recliner. Review of the Fall SBAR (an acronym meaning situation, background, appearance, and review) form indicated the following: - What could we do together to prevent this from happening again? Chair alarm was not on the recliner. - What is the gap? What was different this time that may have led to the fall? The chair alarm was not on the recliner. His/her attempts to get up are unpredictable. - Describe actions to prevent further falls for this Resident. Assure alarms are on and functioning, assure Resident's needs are met and assure the Resident is wearing proper footwear. During an interview on 7/7/23 at 3:26 P.M., Nurse #2 said the Resident's chair alarm was not on his/her recliner where he/she was sitting before his/her fall. It had been left on his/her wheelchair, despite the care plan indicating he/she should always have a chair and bed alarm when in his/her room. During an interview on 7/7/23 at 3:30 P.M., EA #2 said the Resident did not have his/her chair alarm under him/her as required, when he/she fell from his/her recliner. During an interview on 7/7/23 at 4:31 P.M., the Director of Nursing (DON) said the Resident's chair alarm was not moved from his/her wheelchair to his/her recliner and the care plan was not followed as required. 42741 1b. Resident #1 was admitted to the facility in April 2022 with diagnoses including muscle weakness, difficulty walking, and a history of falls. Review of the Resident's medical record indicated the Resident had fallen on 10/13/22 and 3/11/23. Review of the Resident's Care Plan titled, Certified Nurse's Aide Care Plan indicated the following intervention: - .Tab alarm in chair, initiated 4/19/22 Review of the most recent MDS assessment dated [DATE], indicated: -the Resident utilized an alarm in his/her wheelchair -required extensive assistance of two persons for transfers -and had a history of falls since admission On 7/5/23 at 3:11 P.M., the surveyor observed the Resident seated in a wheelchair. He/she had a tab alarm (alarm that attaches to the Resident's clothing with a clip, that would pull away if the Resident tried to stand up, and alarm would sound) attached to his/her wheelchair but the clip was not attached to the Resident's clothing. On 7/6/23 at 9:02 A.M., the surveyor observed the Resident seated in a wheelchair. He/she had a tab alarm attached to his/her wheelchair but not attached to the Resident's clothing. During an interview on 7/6/23 at 9:07 A.M., EA #1 said the Resident's tab alarm should have been clipped to the Resident's clothing so that if he/she stood up the alarm would sound, and it was not as required.

Based on observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident (#138) out of a total sample of 12 residents. Specifically, the facility failed to maintain and store oxygen equipment in a manner to prevent contamination, sinus and respiratory infections. Findings include: Review of the facility's policy titled, Oxygen Administration, reviewed January 2023, indicated the following: - Oxygen tubing should be changed as ordered. Resident #138 was admitted to the facility in June 2023 with a diagnosis of Congestive Heart Failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS Assessment indicated the Resident was on Oxygen therapy. Review of the July 2023 Physician's orders indicated the following: -Apply supplemental Oxygen via NC (nasal cannula - a device consisting of a lightweight tube that splits into two prongs to be placed in the nostrils, for delivery of supplemental Oxygen) to keep oxygen saturation (the amount of Oxygen circulating in the blood) greater than 90 percent every shift. During an observation and interview on 7/5/23 at 3:17 P.M., the surveyor observed the Resident seated in a recliner chair in his/her room wearing a NC connected to an oxygen concentrator (a device that can purify and concentrate the room air to produce Oxygen) running at a rate of 2 liters per minute (LPM, the measurement of flow of Oxygen received from an oxygen delivery device). The surveyor observed the NC to have a piece of tape secured over the tubing with a date of 6/22/23. The surveyor also observed another NC connected to a portable oxygen concentrator hanging off the back of a wheelchair, that was undated. The undated NC was wrapped around the wheelchair with the nasal prongs resting against the back of the wheelchair. The Resident said he/she used the supplemental Oxygen all the time. Review of the medical record indicated no evidence of a care plan or Physician's orders relative to oxygen tubing changes and concentrator care. During an interview on 7/6/23 at 2:44 P.M., the surveyor and Nurse #3 reviewed surveyor photos from 7/5/23 showing the NC tubing dated 6/22/23 and the tubing draped over the back of the wheelchair. Nurse #3 said that oxygen tubing should be changed weekly and should be placed in a bag when not in use to prevent infection and this did not occur as required. During an interview on 7/6/23 at 3:10 P.M., the Director of Nursing (DON) said there should have been a Physician's order to change the oxygen tubing weekly and there was not.

Based on interview and record review, the facility failed to ensure that its staff responded to Medication Regimen Reviews (MRR) recommendations by the Consultant Pharmacist timely and documented within the clinical record for two Residents (#11 and #20), out of a total sample of 12 residents. Findings Include: Review of the Facility policy titled Medication Regimen Review, revised 03/3/2020 indicated the following: -Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. -For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained in the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 1. Resident #11 was admitted to the facility in February 2020. Review of the Resident's medical record indicated the Consulting Pharmacist completed MRRs on 3/16/23 and 5/12/23 and to see the MRR report for full note. Upon further review of the Resident's Medical Record no MRR reports were found. During an interview on 7/6/23 the Director of Nursing (DON) said she could not locate the completed MRR forms, and she would need to reach out to the Pharmacist for copies of the MRRs in question. During an interview on 7/6/23 the DON said she was unable to locate any documentation that the MRRs from 3/16/23 and 5/12/23 had been reviewed, addressed, and signed by the Resident's Attending Physician, as required. 44129 2. Resident #20 was admitted to the facility in December 2017. Review of the Resident's medical record indicated progress notes that stated the Consultant Pharmacist conducted MRRs and made recommendations on 3/16/23 and 5/12/23. Further review of the medical record indicated no evidence of the MRR forms completed by the Consultant Pharmacist. During an interview on 7/7/23 at 2:38 P.M., the Consultant Pharmacist said she was aware there were problems with the MRRs and brought it to the attention to the facility at the Quality Assurance Performance Improvement (QAPI) meeting in April 2023. She said that the Physician's response rate to the MRRs had decreased significantly. She further said that she had a discussion with the DON and thought they had made some changes to the procedure. The Consultant Pharmacist stated there had been minimal improvement in the response rate and she had planned on bringing the data to the quarterly QAPI meeting in July 2023. She further said there was no evidence the Attending Physician had been reviewing the Pharmacist's recommendations. During an interview and record review on 7/7/23 at 3:45 P.M., the DON provided newly printed copies of the MRRs dated 3/16/23 and 5/12/23 that indicated the following recommendation: -The Resident receives Lithium (a medication used to control mood). -Recommendation: To monitor for potential side effects, please consider adding monitoring for signs and symptoms of toxicity (diarrhea, vomiting, tremor, drowsiness, and muscle weakness). -Rationale: Lithium has a boxed warning describing the close relationship between serum (blood) lithium concentration and toxicity. After the surveyor reviewed the copies of the MRRs, the DON said there was no evidence the Attending Physician had reviewed the recommendations, as required.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one Resident (#11) out of a total sample of 12 residents. Specifically, the facility staff failed to document Insulin (a hormone that regulates sugar in the blood) medication administered outside of the Resident's scheduled dose. Finding Include: Resident #11 was admitted to the facility in February 2020 which a diagnosis of Type II Diabetes (when the body can no longer produce and regulate the hormone insulin resulting in abnormal blood sugar levels). Review of the July 2023 Physician's orders indicated an order started on 5/16/23 for: >the Resident to have his/her blood sugars checked four times daily >Receive Novolog (a type of Insulin) via a sliding scale (a set of instructions for administering Insulin dosages based on specific blood sugar readings) three times a day as follows: -Blood Sugar level 0-199=No coverage -Blood Sugar level 200-250=Administer 3 Units -Blood Sugar level 251-300=Administer 5 Units -Blood Sugar level 301-350=Administer 7 Units -Blood Sugar level 351-400=Administer 9 Units -Blood Sugar level 401-450=Administer 11 Units Review of the June 2023 Medication Administration Record (MAR) indicated on six days in June the Resident had blood sugars in ranges that required a corresponding dose of Novolog, but no documentation was completed on the MAR to indicate the Resident had received the required dose of Novolog based on the sliding scale. 1. 6/6/23 a blood sugar of 256 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. 2. 6/7/23 a blood sugar of 226 was recorded at 4:50 P.M. with no documentation sliding scale Novolog was provided. 3. 6/15/23 a blood sugar of 223 was recorded at 11:30 A.M. with no documentation sliding scale Novolog was provided. 4. 6/16/23 a blood sugar of 245 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. 5. 6/21/23 a blood sugar of 291 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. 6. 6/29/23 a blood sugar of 269 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. During an interview on 7/6/23 at 10:28 A.M., Nurse #1 said the Resident's blood sugars were recorded on the MAR and when the Resident had a blood sugar high enough to require his/her Novolog, then that amount of Novolog administered should be recorded on the MAR. Nurse #1 further reviewed the June 2023 MAR with the surveyor and said she would be unable to tell if the Resident had received the ordered Novolog on the dates in question as it was not recorded on the MAR. During an interview on 7/6/23 at 11:40 A.M., the Director of Nursing (DON) said documentation for the sliding scale Novolog should be documented on the MAR every time Novolog was administered. She further said she reviewed the June 2023 MAR and on the days in question she could not be sure how much Novolog and whether or not Novolog was administered as ordered, because the documentation was missing.

Based on interview and record review the facility failed to implement the Screening and Immunization Policy. Specifically, the clinical record did not include documentation that indicated the resident or resident's representative received education regarding the pneumococcal vaccine, were offered the pneumococcal vaccine on admission, or whether or not the resident had received the vaccine, for 2 residents (#11 and #124) in a total sample of 5 residents reviewed for immunizations. Findings include: Review of the undated facility policy for Screening and Immunization indicated the following: -Residents are offered immunizations when admitted . -The immunization date, or refusal, and date of counseling provided for the pneumococcal are included on the immunization tracking form in the clinical record. 1. Resident #11 was admitted to the facility in April 2022. Review of the electronic health record (EHR) immunization record did not indicate the status of the resident's pneumococcal vaccine. Review of the hard copy medical record did not indicate a consent to say whether the resident had been offered, accepted, or declined the vaccine, nor was there any documentation of resident/resident representative education of the risks and benefits. On 5/18/22 at 2:04 P.M. the Director of Nurses (DON) provided the surveyor with a fax from the resident's primary care physician indicating the resident had received the pneumococcal vaccine prior to admission to the facility. 2. Resident #124 was admitted to the facility in May 2022. Review of the EHR immunization record did not indicate the status of the resident's pneumococcal vaccine. Review of the hard copy medical record did not indicate a current consent to indicate whether or not the resident had been offered, accepted or declined the vaccine, nor was there any documentation of resident/resident representative education. On 5/18/22 at 2:04 P.M. during an interview the DON said she thought resident #124 had been offered the vaccine but had refused. On 5/19/21 at 2:00 P.M. the Infection Control Nurse said she thought the resident had refused the vaccine when admitted . A copy of an informed consent dated 5/18/22, the first day of survey, was given to the surveyor. The consent form indicated the resident had been given vaccine information on 2/4/22, which was three months prior to the resident's current admission. The Infection Control Nurse said the resident would be receiving the pneumococcal vaccine today.

Based on document review, observations and interviews, the facility failed to ensure staff followed Centers for Disease Control and Prevention (CDC) guidelines related to the use of Personal Protective Equipment, specifically eye protection, to properly prevent and/or contain COVID-19 on two of four units. Findings include: Review of the CDC guidelines, under the heading of Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic: Health Care Personnel working in facilities located in areas with moderate to substantial community spread should follow Standard Precautions and Transmission-Based Precautions and should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Review of county test positivity rates posted on the Centers for Medicare and Medicaid Services (CMS) website dated 12/2/2020 list the Hamden county positivity rate as 6.4%, indicating moderate community spread of Covid-19. On 12/02/2020 at 8:48 A.M., during observations of the facility, the surveyor observed two staff members in close proximity (less than six feet distancing), with residents during the breakfast meal, assisting with feeding on the Hillside unit. The residents were actively eating and were unmasked. Staff were wearing facemasks, but were not wearing eye protection. On 12/2/2020 at 12:50 P.M., the surveyor observed two staff members serving and assisting residents with lunch on the Garden unit. The residents were actively eating and were unmasked. The staff members were masked but were not wearing eye protection and were in close proximity of the residents, less than six feet distance. On 12/2/2020 at 1:20 P.M., during an interview, the Infection Preventionist stated that the facility follows CDC guidance related to staff use of Personal Protective Equipment (PPE). A review of the facility's Infection Control Covid-19 policy, undated, indicates that eye protection should be used in addition to face masks for care of residents who are not suspected or confirmed to have Covid-19 when there is moderate to high community spread. A review of a facility PPE training tool, dated 9/16/20, indicates when there are no resident or staff cases identified in the facility within the last 14 days, recommended PPE when providing care is Facemask and Face Shield/Goggles. On 12/2/2020 at 1:15 P.M., during an interview, the administrator stated the facility staff has used protective eyewear (Face Shield or Goggles) during feeding assistance in a resident room, but has not used the protective eyewear when giving assistance with meals outside the resident room, as required.

Based on record review and interview the facility failed to ensure 1 resident (#24) maintained their usual body weight, and failed to follow the facility Weight Policy, out of a total sample of 12 residents. Findings include: Resident #24 was admitted to the facility in 6/2019. Review of the facility's Weight Policy, dated 1/2017, indicated the purpose was to provide a process in which the resident would have their weight monitored. The process included: - If a weight variance is noted . (5% in one month): The resident is re-weighed within 48 hours. The results are documented on the resident's weight record and the licensed nurse/dietician follows up, as appropriate. Review of the Nutritional Admission care plan, date unclear, indicated the resident would maintain adequate nutritional status as evidenced by maintaining weight with in 5% in 30 days, or 10% in 180 days. The interventions included the following: - Monitor/record/report to physician as needed significant weight loss: 3 pounds in 1 week, greater than 5 % in 1 month. Record review indicated the resident weighed 113.6 pounds on 8/5/19 and 105.4 pounds on 9/20/19. The calculated weight loss was 7.2 %. Further record review indicated the above weights were the only weights obtained in the months of 8/2019 and 9/2019. During an interview on 10/3/19 at 9:37 [NAME]M., Nurse #1 said that most of the residents are weighed monthly unless otherwise ordered. She said if there was a change in the resident's weight we are supposed to re-weigh the resident, and communicate the change to the physician and the dietician. Nurse #1 reviewed Resident #24's weight and said that she was not aware that the resident had a weight loss, she said a re-weigh was not obtained, and neither the physician nor the dietician were notified.

Based on observation, record review and interview the facility failed to provide dental services for 1 resident (#5) out of a total sample of 12 residents. Findings include: Resident #5 was admitted to the facility in 3/2010. Review of the Request for Service form, dated 1/2013, indicated the resident requested dental services. Review of the Annual Minimum Data Set Assessment, dated 10/17/18, indicated the resident had severe cognitive impairment as evidenced by a score of 1 out of 15 on the Brief Interview of Mental Status, required extensive assistance for grooming, and had obvious or likely cavities or broken natural teeth. Review of a nurse's note, dated 5/19/19, indicated the resident had a chipped tooth up to the gum line. The physician had been notified for further follow up. Record review indicated no follow up related to the resident's chipped tooth. On 10/3/19 at 8:30 [NAME]M., the surveyor observed the resident seated in a specialty wheelchair. The surveyor observed that the resident had his/her own teeth, and the front tooth was chipped. During an interview on 10/3/19 at 10:41 [NAME]M., the Director of Nurses said she was unable to find any follow up related to the resident's chipped tooth.

Based on record review, observation and staff interview, the facility failed to obtain informed consent for the use of side rails for 7 residents (#8, 9, 23, 24, 27, 29 and 34) out of a total sample of 13 residents. Findings include: 1. Resident #24 was admitted in 5/2013, with [DIAGNOSES REDACTED]. The Quarterly assessment, with the Assessment Reference Date (ARD) of 6/30/18, indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 out 15 (severe cognitive loss), the resident was supervised for ambulation, was a limited assist for activities of daily living, and was independent for bed mobility. The Bed Rail/Assist Bar Evaluation, dated 6/30/18, indicated the resident requested to use side rails for support and transfer, as an enabler to promote independence. Record review indicated that there was no documentation that informed consent was obtained for the use of side rails. On 8/13/18 at 10:28 A.M., and at 11:45 A.M., Resident #24 was observed in bed with bilateral 1/4 side rails in the raised position. On 8/14/18 at 7:06 A.M., Resident #24 was observed lying in bed with bilateral 1/4 side rails in the raised position. 2. Resident #29 was admitted in 1/2016, with [DIAGNOSES REDACTED]. The Significant Change of Status assessment, with the ARD of 7/25/18, indicated the resident's BIMS score was 3 out of 15 (severe cognitive loss), was an extensive assist for activities of daily living and bed mobility, and used alarms daily. The Bed Rail/Assist Bar Evaluation, dated 7/25/18, indicated that the resident requested side rails for support and transfers as an enabler to promote independence. Review of the clinical record indicated that there was no documentation that informed consent was obtained for the use of side rails. On 8/13/18 at 9:31 A.M., Resident #29 was observed in bed, sitting in an upright position with bilateral 1/4 side rails in the raised position. On 8/14/18 at 7:05 A.M., Resident # 29 was observed lying in bed with bilateral 1/4 side rails in the raised position. 3. Resident #8 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, with an ARD date of 5/11/18, indicated a BIMS score of 11 out of 15 (moderate cognitive impairment). The resident required assist of 2 for bed mobility and transfer. Review of the Bed Rail/Assist Bar Evaluation of 5/11/18 indicated that the resident utilized bilateral quarter bed rails. Review of the Self Care Deficit CNA (Certified Nurse Assistant) Care Plan indicated: Bed rails in the forward position and bed in the low position. Observation, on 8/14/18 at 6:45 A.M., found Resident #8 lying in bed with 2 quarter bed rails in the forward position. Record review indicated that there was no documentation that the risks and benefits of bed rail use were reviewed with the resident or resident's representative, and there was no documentation that informed consent was obtained prior to installation of the bed rails. 4. Resident #9 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, with an ARD of 5/25/18, indicated a BIMS score of 14 out of 15 (intact mental status). The resident required assist of 2 with bed mobility and was dependent with transfers. Review of the Bed Rail/Assist Bar Evaluation of 4/6/18 indicated that the resident utilized bilateral quarter bed rails. Review of the CNA Care Plan indicated: Place bed rails in forward position, and bed in low position. Observation, on 8/14/18 at 6:52 A.M., found Resident #9 lying in bed. There were bilateral quarter bed rails up and in the forward position. Record review indicated that there was no documentation that the risks and benefits of bed rail use were reviewed with the resident or resident's representative, and there was no documentation that informed consent was obtained prior to installation of the bed rails. 5. Resident #23 was admitted to the facility in 3/2011 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, with an ARD of 7/19/18, indicated a BIMS score of 9 out of 15 (moderate cognitive impairment). The resident required assist of 2 with bed mobility and transfers. Review of the Bed Rail/Assist Bar Evaluation of 3/21/18 indicated that the resident utilized bilateral quarter bed rails. Review of the CNA Care Plan indicated: Bed rails in forward position to assist with bed mobility and positioning, and bed in low position. Record review indicated that there was no documentation that the risks and benefits of bed rail use were reviewed with the resident or resident's representative, and there was no documentation that informed consent was obtained prior to installation of the bed rails. Observation, on 8/13/18 at 2:07 P.M., found Resident #23 lying in a low bed on his/her back with 2 upper quarter bed rails in place. Observation, on 8/14/18 at 6:43 A.M., found Resident #23 sitting in a wheelchair in the day room. During an interview, on 8/14/18 at 6:44 A.M., CNA #1 said that Resident #23 utilized 2 upper bed rails in the forward position. 6. Resident #27 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment, with an ARD of 5/21/18, indicated a BIMS score of 15 out of 15 (intact mental status). The resident was independent with bed mobility and required supervision with transfers. Review of the Bed Rail/Assist Bar Evaluation of 7/25/18 indicated that the resident utilized one quarter bed rail. Review of the Self Care Deficit CNA Care Plan indicated: Right bed rail in the back position. Record review indicated that there was no documentation that the risks and benefits of bed rail use were reviewed with the resident or resident's representative, and there was no documentation that informed consent was obtained prior to installation of a bed rail. Observation, on 8/14/18 at 6:55 A.M., found Resident #27 sitting in a room chair. During an interview, on 8/14/18 at 6:59 A.M., CNA #1 said that Resident #27 utilized 1 upper rail in the back position. 7. Resident #34 was admitted to the facility in 10/2009 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, with an ARD of 7/29/18, indicated a BIMS score of 3 out of 15 (severe cognitive status). The resident required assist of 2 with bed mobility and was dependent with transfers. Review of the Bed Rail/Assist Bar Evaluation of 3/21/18 indicated that the resident utilized bilateral quarter bed rails. The plan of care for [DIAGNOSES REDACTED] with muscle weakness, decrease range of motion right arm and dependent for all care indicated: Use bed rails in the forward position for turning. Place rails in back position at all other times. Record review indicated that there was no documentation that the risks and benefits of bed rail use were reviewed with the resident or resident's representative, and there was no documentation that informed consent was obtained prior to installation of the bed rails. Observation, on 8/13/18 at 2:00 P.M., found Resident #34 lying in a low bed with 2 upper quarter bed rails. Observation, on 8/14/18 at 6:57 A.M., found Resident #34 lying in low bed with 2 upper bed rails in the back position. During an interview, (on 8/13/18 at 10:45 A.M.), the Director of Nurses said that for Residents #8, 9, 23, 24, 27, 29 and 34, there was no documentation that the risks and benefits of bed rail use were reviewed with the resident or resident's representative, and there was no documentation that informed consent was obtained prior to installation of bed rails.

Based on observation, record review and staff interview, the facility failed to provide a written summary of the baseline care plan for 3 residents (#26, 40 and 90) out of a total sample of 13 residents. Findings include: 1. Resident #40 (closed record) was admitted to the facility in 6/2018, with [DIAGNOSES REDACTED]. Record review indicated a baseline care plan was initiated on 6/8/18. Record review indicated that there was no documentation that a written summary of the baseline care plan was provided to the resident or resident representative. During an interview, on 8/9/18 at 12:36 P.M., the Minimum Data Set (MDS) Coordinator said that the facility has a meeting with the newly admitted residents within 48 hours of admission and the care plan is discussed at this time. The MDS coordinator said a written summary was not given to the resident or resident representative at this time. 2. Resident #90 was admitted in 8/2018 with [DIAGNOSES REDACTED]. Review of the clinical record indicated a baseline care plan was initiated on 8/6/18. Observation, on 8/8/18 at 12:25 P.M., found the resident sitting at the dining room table. The resident was assisted with the noon meal. Observation, on 8/9/18 at 8:45 A.M., found the resident sitting at the dining room table. Staff was assisting the resident with the breakfast meal. Review of the MDS Coordinator's progress note, dated 8/9/18, indicated a meeting was held on 8/9/18 to review the current plan of care. There was no indication that a copy of the baseline care plan was provided to the resident at this time. During an interview, on 8/9/18 at 12:36 P.M., the MDS Coordinator said that the facility had a meeting with the newly admitted residents within 48 hours of admission and the care plan was discussed at that time. The MDS coordinator said a written summary was not given to the resident or resident representative at the time of the meeting. 3. Resident #27 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. Record review indicated that the plan of care was initiated on 5/11/18. Further record review indicated that there was no documentation that the resident or resident's representative was provided with a written copy of the baseline care plan. During an interview, on 8/09/18 at 12:36 P.M., the MDS Coordinator said that a care plan was developed within 48 hours of admission, but a written copy was not provided to the resident or resident's representative as required.

Based on record review, observation and interview, the Facility failed to ensure that 1 of 6 residents with falls (#6), in a total sample of 10 residents, received adequate supervision and assistance devices to prevent accidents. Findings include: For Resident #6, the Facility failed to provide adequate supervision and assistance devices to prevent 12 incidents/accidents in 11 months. Resident #6 was admitted to the Facility in 5/2012 with [DIAGNOSES REDACTED]. Review of the plan of care: Risk for falls related to impulsivity, knee instability and episodes of bladder incontinence at night indicated: *Encourage to stay in Hillside after dinner. *Ensure environment is free of clutter. *Monitor blood pressure for changes. *Monitor for increased dizziness. 1. Review of the Fall Investigation indicated that on 6/25/13 at 7:40 P.M., Resident #6 sustained an unwitnessed fall. Resident #6 was found lying on the floor on his/her back in the hallway, in front of his/her bedroom. The walker was nearby. Resident #6 was unable to explain the circumstances of the fall due to confusion. There was no injury. New interventions included: push fluids and monitor orthostatic blood pressures for 3 days. The Fall Risk Assessment of 6/26/13 indicated that Resident #6 was at moderate risk for falls. 2. Review of the Fall Investigation indicated that on 7/6/13 at 4:00 A.M., Resident #6 sustained an unwitnessed fall. The elder assistant (EA) heard a loud noise from Resident #6's bedroom. Resident #6 was found lying on his/her left side in his/her bedroom. Resident #6 sustained a 3 centimeter (cm) bruise to his/her left chin. New interventions included: place alarming floor mat next to bed. 3. Review of the Fall Investigation indicated that on 7/12/13 at 8:15 A.M., the EA was making the bed in Resident #6's bedroom. Resident #6 left his/her walker behind and began ambulating towards the bed. Resident #6's knee appeared to give out, and Resident #6 began to stumble. The EA was able to catch Resident #6. There was no injury. New interventions included: Bengay patch and brace to knee before getting out of bed. 4. Review of the Fall Investigation indicated that on 7/16/13 at 4:45 A.M., Resident #6 sustained an unwitnessed fall. Resident #6 was heard calling from his/her bedroom. Resident #6 was found lying on the floor with upper body leaning on the recliner. There was no injury. The alarming floor mat was in the off position during a trial basis due to causing increased irritability. New interventions included: alarming floor mat when in bed. 5. Review of the Fall Investigation and Progress Notes indicated that on 9/3/13 at 2:27 A.M., the EA heard an alarm sounding from Resident #6's bedroom. Resident #6 was attempting to remove the floor mat which was secured in place under the night stand. Resident #6 was banging his/her right arm on the night stand during this attempt. Resident #6 sustained 2 irregular shaped skin tears with swelling and bruising to the right elbow. In addition, Resident #6 sustained a hematoma to the forehead (origin known). The plan of care was updated on 9/20/13 to include: monitor frequently during night for need to use toilet. Incontinent pads at night. 6. Review of the Fall Investigation indicated that on 9/23/13 at 12:15 A.M., Resident #6 sustained an unwitnessed fall. The EA heard an alarm sounding and found Resident #6 sitting on the floor near bed. Resident #6 was soiled with feces, and the toilet bowl contained feces. Resident #6 said that he/she was trying to shut the alarm off. There was no injury. New interventions included: frequent checks during night. Keep night light on. Tab alarm to bathroom door and pressure sensor alarm in bed at bedtime. The floor mat alarm was discontinued. 7. Review of the Fall Investigation and Progress Notes indicated that on 10/4/13 at 2:56 P.M., Resident #6 sustained an unwitnessed fall. The EA found Resident #6 kneeling on the floor in hallway, holding onto the walker. There was no injury noted. New interventions included: pressure alarm to recliner in bedroom (discontinued on 10/9/13). Review of Progress Notes of 10/9/13 indicated that Resident #6 was found to have bruises to the left scapula, left deltoid and left hip (5 days after the fall). 8. Review of the Fall Investigation and Progress Notes indicated that on 10/19/13 at 11:15 A.M., Resident #6 sustained an unwitnessed fall. Resident #6 was found kneeling on the floor in his/her bathroom. There was no indication that the alarm to the bathroom door was sounding. There was no injury. New interventions included: alarm to bathroom door (initiated after a fall on 9/23/14) and assist with all ambulation. Pressure sensor alarm to bed. Tabs alarm to recliner if used in bedroom. Review of the Fall Risk Assessment of 11/7/14 indicated that Resident #6 was at high risk for falls. 9. Review of the Fall Investigation and Progress Notes indicated that on 11/6/13 at 5:05 P.M., Resident #6 sustained an unwitnessed fall. Resident #6 was found on the bedroom floor on his/her knees with walker in front. There was no injury. New interventions included: bed moved to wall, and recliner in corner. Continue with bed and bathroom door alarms. Review of the significant change in status Minimum Data Set (MDS) assessment of 11/13/13, indicated that the resident had severely impaired cognitive status, required assist with transfer, ambulation, toilet use, bathing, dressing, was incontinent of urine and had a history of [REDACTED]. Review of the plan of care indicated that on 11/21/13, the plan was updated to include: sit in recliner in room after lunch with legs elevated, with chair sensor alarm. On 11/27/13, a Velcro alarming seatbelt in wheelchair for transport was added to the plan. 10. Review of the Fall Investigation and Progress Notes indicated that on 1/1/14 at 7:45 A.M., Resident #6 sustained an unwitnessed fall. Resident #6 was found sitting on the bedroom floor near the recliner. The tabs alarm was still attached and did not sound. There was no injury. New interventions included: chair pad alarm when sitting in recliner. 11. Review of the Fall Investigation and Progress Notes indicated that on 3/9/14 at 8:30 P.M., Resident #6 sustained an unwitnessed fall. The bed alarm sounded, and Resident #6 was found lying on his/her left side on the bedroom floor. Resident #6 had an abrasion on left mid-back. No new interventions were added. 12. Review of the Fall Investigation and Progress Notes indicated that on 5/14/14 at 5:15 P.M., Resident #6 sustained another unwitnessed fall. Resident #6 was found on the bathroom floor. The bathroom door alarm did not sound, and the wheelchair alarm did not sound. There was no injury. Interventions included: maintenance adjusted the bathroom door alarm. Resident #6 to be assisted to toilet after naps, place Velcro seatbelt on, turn on alarm, and recheck to ensure functioning. On 5/15/14 at 12:45 P.M., Resident #6 was observed sitting in a straight chair with a pressure seat alarm in place at a table in the dining room. At 2:00 P.M., Resident #6 was observed sitting in a wheelchair with an alarming Velcro seatbelt in place, near the unit kitchen. During interview on 5/15/14 at 2:30 P.M., the concern regarding Resident #6's 12 incidents/accidents in 11 months was reviewed with the Director of Nurses.

Based on record review, and interview, the facility failed to follow physician's order related to sliding scale insulin for 1 sampled resident (#1) in a total sample of 10 residents. Findings included: Resident #1 was admitted to the facility in 4/11 with the following pertinent Diagnoses: [REDACTED]. Physician's Orders of 4/20/11 indicated obtain blood sugar (BS) fingersticks three times per day. Administer [MEDICATION NAME] Insulin per sliding scale before meals. The sliding scale was as follows: BS 60 to 100 milligrams per deciliter (mg/dl) administer 4 units BS 101 to 150 mg/d, administer 5 units BS 151 to 200 mg/dl, administer 6 units BS of 201 to 300 mg/dl, administer 8 units BS of 301 to 400 mg/dl, administer 10 units BS of 401 or greater, administer 12 units Review of the April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. sliding scale [MEDICATION NAME]10 units was given. Review of the Nurse's Note of 4/28/11 at 12:15 P.M., stated, "[MEDICATION NAME] Sliding Scale - for bs 301-400: BS 401, resident states appetite not that good, does not plan to eat much, will give 10 units instead of 12." During an interview on 5/18/11 at 8:35 A.M., Nurse #1 indicated that on 4/28/11, [MEDICATION NAME]10 units was given for a blood sugar of 401 mg/dl, even though the current physician's order indicated that 12 units was to be given. At this time, Nurse #1 indicated that the physician's order was not followed and an incorrect dose of insulin was administered.

Based on observation and confirmed through staff interview, the facility failed to store medications according to Federal laws for 3 Residents (#1, #8, and #9), out of a sample of 10 residents. Findings included: 1. During the medication pass on [DATE] at 1:50 P.M., on the Woodland Unit, Resident #1's medication cabinet in this room had an opened, undated vial of Humalog insulin. Nurse #2 confirmed that this vial was not dated (if undated it is considered expired). 2. Observation of the medication storage cabinet on the Woodland Unit on [DATE] at 2:10 P.M., indicated that there was an open vial of Humalog insulin dated [DATE] (the date it was opened). The vial of Humalog insulin was 6 days beyond its expiration date. Nurse #2 confirmed that this vial was expired. 3. Observation of Resident #9's medication cabinet on the Cloister Unit on [DATE] at 2:22 P.M., indicated that there was an open, undated vial of Novolin insulin. Nurse #3 confirmed that this vial was not dated. 4. Observation of Resident #8's medication cabinet on the Garden Unit on [DATE] at 2:30 P.M., indicated that there was an open, undated vial of Novolog insulin. Nurse #3 confirmed that this vial was not dated. During an interview with the Director of Nursing on [DATE] at 2:50 P.M., it was acknowledged that it was the Facility's policy to throw away vials of insulin, 28 days after the medication was opened.