Every finding on record at NewBridge on the Charles Skilled Nursing Facility

Based on observations and interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications for Residents #24 and #62 remained in view of the nurse and were not left unattended and unsecured during the medication administration pass. Findings include:Review of the facility's policy titled Automated Dispensing Machine (ADM), dated as last revised 9/29/25, indicated but was not limited to the following:-ADMs are used to provide access to medications and to ensure medication security.-Only authorized personnel may remove medications. Review of the facility's policy titled Medication Administration, dated as last revised 7/28/25, indicated but was not limited to the following:-Medications are administered by or under the supervision of nursing in accordance with Federal or State laws and regulations.-The Nurse will remain with the patient until the medications are administered. On 5/12/26 at 9:10 A.M., the surveyor observed Nurse #1 prepare and administer medications for Resident #24 as follows:-Nurse #1 poured the following medications into the medication cup: Levothyroxine 50 micrograms (mcg) (for thyroid), Aspirin 81 milligrams (mg) (for heart), Atorvastatin 40mg (for cholesterol), Ezetimibe 10mg (for cholesterol), Proscar 5mg (for prostate), Metoprolol Extended Release 50mg (for blood pressure), and Senna 2 tabs (for bowels).-Nurse #1 left the cup of pills on top of the medication cart in the hallway and entered Resident #24's room. The medication cart was facing outward to the hallway, her back was to the doorway/medication cart, the medications were not in view, and unsecured.-Nurse #1 exited Resident #24's room and walked around the corner to the nurses' station to remove Tylenol (for pain) from the ADM. The cup of pills remained on top of the medication cart not in view and unsecured.-Nurse #1 returned to the medication cart and poured Tylenol 1000mg into the medication cup with the other pills.-Nurse #1 left the cup of pills on top of the medication cart in the hallway and entered Resident #24's room. The medication cart was facing outward to the hallway, her back was to the doorway/medication cart, the medications were not in view, and unsecured.-Nurse #1 returned to the medication cart, entered Resident #24's pain level in the computer, entered Resident #24's room and administered the medications. On 5/13/26 at 9:20 A.M., the surveyor observed Nurse #1 prepare and administer medications for Resident #62 as follows:-Nurse #1 removed Eliquis 2.5mg (anticoagulant/blood thinner), Metoprolol 25mg, Saccharomyces Boulardii 120mg (probiotic), Norvasc 5mg (for blood pressure), Vitamin B12 500mcg, Enteric Coated Aspirin 81mg, Vitamin D3 1000 units, Prilosec 20mg (for reflux), and Torsemide 10mg (diuretic for fluid) from the ADM, placed the pills in a plastic cup, and walked to Resident #62's room with the cup of pills on top of the medication cart.-Nurse #1 entered Resident #62's room to scan his/her name band. Nurse #1 left the cup of pills on top of the medication cart in the hallway. The medication cart was facing outward to the hallway, she was around the corner in the room, not in view of the doorway or medication cart, the medications were not in view, and unsecured.-Nurse #1 exited Resident #62's room and walked around the corner to the nurses' station to remove Oxycodone (narcotic pain medication) from the ADM. The cup of pills remained on top of the medication cart, not in view and unsecured.-Nurse #1 returned to the medication cart with Oxycodone 2.5mg, took the cup of pills off the medication cart, entered Resident #62's room and administered the medications. During an interview on 5/13/26 at 9:55 A.M, Nurse #1 said she should not have left the pills on top of the medication cart unattended. She said she probably should have taken them with her in and out of the room, and when she went to the nurses' station to get pain medication from the ADM. During an interview on 5/13/26 at 11:57 A.M., the Director of Nurses (DON) said medications should be removed from the ADM, brought to the resident's room on the medication cart, and then administered. She said they should not be left on the medication cart unsecured and out of the nurse's view for any period of time, especially to walk back to the nurses' station to remove additional medication. She said she should have brought the cup of pills with her or locked them in the individual lock box at the entrance to the resident's room.

Based on observation, record review and interview, the facility failed to ensure one Resident (#46) was free from restraints out of a total sample of 21 residents. Specifically, for Resident #46 the facility failed to assess the use of pillows under the fitted sheet on both sides of the bed as a potential restraint. Findings include: Review of the facility policy titled Restraints and dated as revised 2/7/22, indicated that all patients have the right to be free from restraints. The least restrictive method of restraint that meets the patient's assessed need is used. Further review indicated that the documentation of the management of medical conditions along with documentation of alternate approaches used to manage a patient's behavior should be entered in the medical record. Further review indicated that if the provider wishes to utilize restraints, a provider order shall be obtained by the nurse responsible for the care of the patient for each use of a restraint. The nurse shall document an assessment at least every 2 hours. The nurse will include the use of restraints in the patient's care plan. Resident #46 was admitted to the facility in May 2023 with diagnoses including Parkinson's disease, hip dislocation and depression. On 6/6/23 at 7:59 A.M., the surveyor observed Resident #46 lying in bed with pillows tucked under the fitted sheet on each side of the bed potentially preventing him/her from getting out of bed, the bed was in the low position and a floor [NAME] was on the floor. During an interview on 6/6/23 at 7:59 A.M., Certified Nurse's Aide (CNA) #1 said that Resident #46 has had falls and tries to get out of bed and that is why the pillows are under the fitted sheet on each side of the bed. On 6/6/23 at 9:46 A.M., the surveyor observed Resident #46 lying in bed with pillows under the fitted sheet on both sides of the bed potentially preventing him/her from getting out of bed. On 6/7/23 at 7:13 A.M., the surveyor observed Resident #46 lying in bed with pillows under the fitted sheet on both sides of the bed potentially preventing him/her from getting out of bed. Review of the care plan failed to indicate a plan of care for the use of a restraint or the use of pillows under the fitted sheet on both sides of the bed. Review of the physician's orders, dated June 2023, failed to indicate an order for the use of a restraint. On 6/7/23 at 7:45 A.M., the surveyor, the Director of Nursing (DON) and CNA # 1 observed Resident #46 lying in bed with pillows under the fitted sheet on both sides of the bed potentially preventing him/her from getting out of bed. CNA #1 said that the nurse's put the pillows under the fitted sheet but that she put another one at the bottom because Resident #46 kept swinging her/his legs over the side of the bed trying to get out. The DON said that the pillows beneath the fitted sheet would be considered a restraint. The DON then said that the pillows should not be there and instructed CNA #1 to remove them. During an interview on 6/7/23 at 10:11 A.M., the Quality Regulatory Nurse said that the medical record did not include a pre-restraining assessment or a restraint assessment for the use of pillows beneath the fitted sheet on both sides of the bed.

Based on records reviewed and interview the facility failed to complete discharge Minimum Data Set (MDS) Assessments in a timely manner for four Residents (#7, #12, #28 and #48) out of a total sample of 21 residents. Findings include: Review of the Resident Assessment Instrument (RAI) Manual 3.0 indicated the following: A discharge MDS must be completed no later than 14 days after discharge. 1. Review of the medical record indicated that Resident #7 was discharged from the facility on 3/11/23. Further review failed to indicate a discharge MDS was completed. 2. Review of the medical record indicated that Resident #12 was discharged from the facility on 2/18/23. Further review failed to indicate a discharge MDS was completed. 3. Review of the medical record indicated that Resident #28 was discharged from the facility on 1/27/23. Further review failed to indicate a discharge MDS was completed. 4. Review of the medical record indicated that Resident #48 was discharged from the facility on 1/30/23. Further review failed to indicate a discharge MDS was completed. During an interview on 6/07/23 at 8:46 A.M., the MDS coordinator said that the MDS discharge records had not been completed.

Based on observations, interviews, and test tray results, the facility failed to ensure foods provided to all residents were appetizing and served at palatable temperatures. Findings include: On 10/6/21 at 11:45 A.M., the surveyor observed food service staff preparing to serve the noon meal from the unit pantry kitchen. Multiple (25) plate warming devices (thermal unit) with plates were observed stored on the service counter prior to serving the resident meal trays. During an interview on 10/6/21 at 11:45 A.M., the Food Service Manager/ Chef said the facility food service uses a DuraTherm/Dinex system to maintain food temperatures which includes a heated base (electrical conduction), plate and insulated dome cover, and the system can hold hot food temperatures for at least 30 minutes. During an interview on 10/6/21 at 3:35 P.M., a Resident said that the breakfast is always cold, especially the eggs. The Resident revealed that he/she would ask staff to reheat the food up in the microwave. Then, the Resident said he/she just stopped ordering eggs because they were always cold. During a Resident Council meeting held with the surveyor on 10/8/21 at 10:00 A.M., 4 out of 5 residents voiced several food complaints. Specifically, residents said that the breakfast eggs on the meal tray are served cold and the toast was always a problem, being under toasted or soggy. The surveyor conducted two breakfast test trays and validated some of the residents' voiced concerns of cold eggs and limp, soggy toast. Breakfast Test Tray #1 was sampled on the North Wing on 10/8/21 at 8:48 A.M. as follows: - poached egg temperature was 92 degrees Fahrenheit (F) and was cold and unpalatable - yogurt and fruit were not chilled as temperatures registered 60-62 degrees F and 65 degrees F, respectively. The plate was cold to touch and not warm despite the presence of a thermal warming device under the plate. On 10/13/21 at 7:50 A.M., the surveyor observed that food service staff in the pantry kitchen had pre-arranged 16 thermal pellet units/plates on the counter, sitting and waiting for the food items to be plated and then placed on meal trays in the food cart. Food items on the steam table included a hotel size pan of toast. All the toast and English muffins had been toasted and placed into a steamer unit, covered with a cloth napkin. Breakfast Test Tray #2 was sampled on the North Wing on 10/13/21at 8:47 A.M. The surveyor found the hot foods palatable, with the exception of an English muffin, which was very lightly toasted, limp cold and unappetizing. During an interview on 10/8/21 at 8:55 A.M., Dietary Staff #1 said she sets up the Dinex thermal heated unit and plates before the start of breakfast and had no response for why thermal/plate was cold to touch. The warmth and moisture from holding the toast on the steam table unit, may have contributed to the limp and soggy toast condition at the time of service to residents. During an interview with the Food Service Managers on 10/13/21 at 11:30 A.M., they both said they understood if the thermal/Dinex system was not utilized properly such as plugged in timely or left set up too early sitting on the counter tops, that the end temperature result of food items could be potentially affected.

Based on observations, record review, and interview the facility failed to ensure that proper infection control practices were followed based on guidance from the Center for Disease Control and Prevention (CDC) for newly admitted residents to continue on precautions for 14 days for 5 out of 5 (Resident #1, #2, #3, #4, #5). Findings include: CDC guidance dated 4/30/20 indicated Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE (personal protective equipment). During an interview on 6/25/20 at 10:00 A.M., the Director of Nurses (DON) said residents who are admitted from the hospital are admitted on transmission based precautions. She said all residents were tested at the hospital, prior to admission to the facility, and a resident with a negative test result would be admitted to the non-COVID units at the facility and then tested for COVID-19 upon admission to the facility. She said when the COVID-19 result come back negative the residents' order for precautions was discontinued. She said based on negative test results the facility discontinued the precautions for newly admitted residents prior to the 14th day. During an interview on 6/25/20 at 11:50 A.M. the infection Preventionist said an admission guideline policy was created and implemented. She said the policy was written based on the CDC guidelines for discontinuation of transmission based precautions with a test based strategy. She said the facility policy for new admissions indicated a negative COVID-19 test must be obtained prior to admission to the facility, the resident was admitted on transmission based precautions and then tested for COVID-19 within 24 hours of admission. The policy indicated once the results were negative the precautions could be discontinued. The policy does not include information regarding the continuance of transmission based precautions for the first 14 days of admission. 1. Resident #1 admitted to the facility on [DATE] from the hospital with a [DIAGNOSES REDACTED]. A review of the medical record indicated the resident was swabbed for COVID-19 on 6/23/20 and enhanced precautions were implemented. A review of the nursing progress notes indicated that on 6/24/20 the lung sounds of Resident #1 had faint crackles and the resident had an occasional dry cough. On 6/25/20 at 9:45 A.M. the room of Resident #1 was observed to have a sign that indicate the Resident was on droplet precautions. At 11:25 A.M. the room of Resident #1 no longer had a precaution sign. On 6/25/20 at 11:25 A.M., Nurse #1 said that the COVID-19 test results were received and were negative. She said due to this, Resident #1 was removed from precautions (2 days after admission). 2. Resident #2 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. A review of the medical record indicated the hospital admitting paperwork had conflicting results from COVID-19 tests. The nursing progress note indicated the most recent COVID-19 test was listed as positive on 6/21/20. The nurse indicated Resident #2 was placed on the facilities COVID positive unit on 6/23/20. The nursing progress note from 6/24/20 indicated Resident #2 was moved off of the COVID-19 positive unit due to a negative COVID-19 test result. On 6/25/20 at 11:20 A.M.,. Resident #2 was observed in his/her room. The surveyor observed a rehabilitation staff member come out of the room. The rehabilitation staff member said that Resident #2 was taken off of precautions (1 day after admission) on 6/24/20 due to a negative COVID-19 test result. 3. Resident #3 was admitted to the facility on [DATE] from the hospital status [REDACTED]. A review of the medical record indicated a COVID-19 swab was obtained on 6/23/20 at 4:37 P.M. A review of the nursing progress note indicated on 6/24/20 Resident #3 had a low grade temperature of 99.2 and a change in mental status. A nursing progress note on 6/25/20 at 9:45 A.M. indicated COVID-19 not detected and enhanced precautions were discontinued (2 days after admission). On 6/25/20 at 1:10 P.M. the dietician was observed in the room of Resident #3 with only a face mask on, no other PPE was observed. During an interview, on 6/25/20 at 11:27 A.M., Nurse #2 said Resident #3 was removed from precautions on this day due to a negative test result for COVID-19. 4. Resident #4 was admitted to the facility on [DATE] from the hospital following a right total hip revision. A review of the medical record indicated Resident #4 was placed on enhanced contact precautions upon admission. A review of the nursing progress notes indicated that on 6/25/20 a COVID-19 test result was negative and enhanced precautions were discontinued (2 days after admission). During an interview on 6/25/20 at 11:30 A.M. Nurse #3 said the enhanced precautions for Resident #4 were discontinued due to a negative test result. 5. Resident #5 was admitted to the facility on [DATE] from the hospital. On 6/25/20 at 11:00 A.M. the room of Resident #5 was observed to have a sign indicated the Resident was on Enhanced Droplet Precautions. The sign indicated staff were to don mask, gloves, gowns, face shield/goggles prior to entering the Resident room. On 6/25/20 at 1:15 P.M. the surveyor observed Certified Nursing Assistant (CNA) #1 in the room of Resident #5. The CNA was observed to be wearing a mask, no gown, no gloves, no eye protection. CNA #1 was observed to be touching (no gloves on) the open closet of Resident #5, then picked up an article of clothing off the bed, fold it against his body and place it in the closet. The CNA then moved a rolling walker with his bare hands. The CNA then exited the room of Resident #5 and saw the surveyor. The CNA reached for the cabinet outside of the Resident room (without performing hand hygiene), opened the cabinet, obtained a gown and started putting the gown on. When the surveyor inquired about the precaution sign for Resident #5, CNA #1 said he went in to the Residents room quick to help him/her. The CNA confirmed that the sign indicating Resident #5 was on Droplet Precautions was correct.

Based on record review, resident interview and staff interview, the facility staff failed to ensure that the complete list of medications was reconciled during admission for 1 Resident (#35), from a total sample of 12 Residents. Medications are reconciled upon admission to the facility to prevent medication error from occurring. Findings include: Resident #35 was admitted to the facility in 5/2019, with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/30/19, indicated that the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated the resident was cognitively intact. During the initial tour on 6/13/19 at 8:50 A.M., resident #35 told the surveyor that her/his only concern with the stay at the facility was that her/his medications were not properly reconciled during admission resulting in her/him not receiving prescribed [MEDICAL CONDITION] medications for several days. Review of the facility medication error and reconciliation report dated (MONTH) 9, 2019 indicated: 1.) Resident #35 had inquired why he/she was not receiving [MEDICATION NAME] (used to treat [MEDICAL CONDITION], enlarged [MEDICAL CONDITION]). discharged paperwork from hospital was reviewed, which revealed that 2nd page of discharged medications were not reviewed at time of admission (page 6 of medication list were restarted, page 7 of medication list were not reviewed and fell off). The medications on the 2nd page of the medication list that were not reviewed included the following: 1. Aspirin (use to treat pain, inflammation) 81 mg 2. Atorvastatin (use to treat high cholesterol level) 80 mg 3. [MEDICATION NAME] (use to treat depression, anxiety) 60 mg 4. [MEDICATION NAME] 150 mg 6 days a week (Monday-Tuesday-Wednesday-Thursday-Friday-Saturday). Further review of the medication error report for resident #35 indicated: 1.) Facility staff apologized to Resident #35 for the medication errors. 2.) The resident was reassured that the facility would thoroughly review the event in order to improve process. 3.) Aspirin, atorvastatin and [MEDICATION NAME] were restarted 4.) Order to obtain [MEDICAL CONDITION] stimulating hormone (TSH) level 5.) Notation that the [MEDICATION NAME] not restarted per Resident request Review of Resident clinical record including progress notes and medication administration records revealed that Resident # 35 did not receive the following medications: [REDACTED] 1. Aspirin 81mg daily from 5/24/19 to 6/9/19 (17 days) 2. Atorvastatin 80 daily mg from 5/24/19 to 6/9/19 (17 days) 3. [MEDICATION NAME] 60 mg daily from 5/24/19 to 6/9/19 (17 days) 4. [MEDICATION NAME] 150 mg 6 times a week from 5/24/19 to 6/9/19 (14 days) The surveyor interviewed the facility admission's Nurse of resident #35 on 6/17/19 at 11:00 A.M. via telephone. She told the surveyor that she was not aware of 2nd page (medication list), and that she called the discharging hospital for clarification of insulin order only. She told surveyor that she met with Resident #35 to inquire information about his/her insulin only.

Based on record review, observation and resident and staff interview, the facility failed to ensure the plan of care for self administration was safe and was followed consistently and in accordance with the facility procedures for 1 resident (#8) from a total sample of 12 residents. Findings include: Resident #8 was admitted to the facility in 12/2015 and had [DIAGNOSES REDACTED]. contact [MEDICAL CONDITIONS] and status [REDACTED]. There was no Minimum Data Set assessment to review, however during the initial tour on 12/15/15 at approximately 8:30 A.M., Nurse #3 said the Resident was alert and oriented to person, place and time. During the initial tour and upon entering Resident #8's room, the Surveyor observed 2 prescription medications, one medication was observed on the Resident's night stand and the other was on the tray table in front of the Resident. The Surveyor asked Nurse #3 about the medications. Nurse #1 said she had given the Resident the medication [MEDICATION NAME] (nasal spray) for self administration and that she had planned to go back to the Resident's room to return the medication to the mediation storage container. The Surveyor inquired about the second medication and the Nurse said she was unaware of a second medication. The Nurse returned to the Resident's room and returned with 2 prescriptions, [MEDICATION NAME] and an anti-itch topical cream called Sarna. She opened the locked medication storage container and placed the 2 medications in the container. Both medications had a pharmacy label with the Resident's name on it. Nurse #2 said that the Resident did not have an order or assessment to self administer. Review of the 12/2015 physician orders included orders for [MEDICATION NAME] 0.005%, 2 sprays each nare daily and Sarna, apply topically for itch, ever 4 hours and as needed (PRN). The clinical record reviewed on 12/17/15, did not include a Resident request to self administer medications, an assessment for self administration of medications or physician's order to self administer medications. During interview on 12/17/15 at 11:30 A.M., Resident #8 said that he/she used the [MEDICATION NAME] and Sarna lotion as he/she needed it. Resident #8 said that the facility staff usually left the prescription on his/her bedside. The Resident said he/she had not requested them to leave it and had not been asked any questions about the use of the 2 medications. The Resident said he/she used the [MEDICATION NAME] several times a day sometimes (the order was for daily use). Review of the Facility policy indicated that in order for a resident to self administer any medication the resident must meet criteria that includes, able to identify the drug used must accurately state dosage, state frequency, state purpose of each medication, able to voice side-effects and when/how to communicate concerns, cooperate with plan of self administration and physically manipulate the medication and be able to secure the locked medication storage system. In addition, the facility staff must be responsible for on-going monitoring, obtain physician orders, assess the resident's ability and outline the plan in a care plan. staff are required to obtain a physician order, self administration must be care planned and the resident must be provided with a secured locked area to maintain medications.

Based on record review, interview, and observation, for 2 out of a total sample of 12 residents (#8 and #10) the Facility failed to ensure that the care and treatment of [REDACTED].>Findings include: 1. Review of the clinical record indicated Resident #10 was admitted to the Facility in 12/2015, and his/her [DIAGNOSES REDACTED]. The clinical record indicated Resident #10 had a single lumen PICC line that was used for antibiotic therapy. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. The Surveyor reviewed the Facility policy for PICC line flushing according to INS (infusion nurses society) standards, dated 2011. The policy indicated the following protocol: -for any PICC line in use, flush each lumen with 5 milliliters (ml) of normal saline followed by 5 ml of [MEDICATION NAME], an anticoagulant used to prevent occlusion of the PICC line, after the medication. The protocol indicated the [MEDICATION NAME] was a 10 unit/ml concentration (50 units). The policy indicated that the SASH (saline, antibiotic, saline and [MEDICATION NAME]) method was used for flushing PICC lines. The Surveyor observed Nurse #1 on 12/16/15 at 8:09 A.M. during medication pass. The Surveyor observed Nurse #1 flush Resident #10's PICC line with 5 ml of normal saline, and Nurse #1 flushed the PICC line with another syringe before he hung the antibiotic medication [MEDICATION NAME] via the pump. The Surveyor asked Nurse #1 what he flushed prior to the [MEDICATION NAME]. Nurse #1 said he flushed Resident #10's PICC line with [MEDICATION NAME] prior to the antibiotic because there was resistance to the PICC line. Nurse #1 said after the [MEDICATION NAME] infusion ended in an hour, he would again flush the line with normal saline and [MEDICATION NAME]. After the Surveyor questioned why two [MEDICATION NAME] flushes were required, Nurse #1 said he usually used the SASH method but Resident #10's PICC line had resistance. The Surveyor interviewed Nurse #2 on 12/16/15 at 9:30 A.M. Nurse #2 said she always used the SASH method to flush any PICC lines while the PICC line was in use. The Surveyor interviewed the interim Director of Nurses (DON) on 12/16/15 at 8:15 A.M. The Interim DON was notified by the Surveyor of the breech in Facility protocol for PICC line flushes. The Interim DON and the Surveyor reviewed the EMAR (electronic medication administration record), which indicated that Resident #10 received 50 units of the [MEDICATION NAME] flush prior to the antibiotic. The Interim DON said said she would notify the Nurse Practitioner before Resident #10 received any further [MEDICATION NAME] flushes. 2. For Resident #8, the facility failed to follow facility policy and protocol for flushing a double lumen PICC line. Resident #8 was admitted to the facility in 12/2015 and had [DIAGNOSES REDACTED]. Record review on 12/17/15 indicated the Resident had his/her left hip prosthetic removed due to infection and was admitted with a double lumen PICC line that was used for antibiotic therapy. Review of the physician orders, dated 12/11/15, included the antibiotic medication [MEDICATION NAME] 2 grams, which was administered every 4 hours via the PICC line. In addition, the orders indicated that the PICC line be flushed with 5 ml of sodium chloride (normal saline), three times per day and with 50 units of [MEDICATION NAME] (blood thinner to prevent occlusion) three times per day. In addition, the staff were to monitor the PICC line for adverse effects from IV, monitor site, every shift, monitor and measure external length of PICC line weekly and change dressing every 7 days. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR failed to indicate when the normal saline and [MEDICATION NAME] flushes were to be done and in what sequence. During interview on 12/17/15 at approximately 12:00 P.M., the Surveyor inquired about the protocol for flushes of a PICC line with Nurse #4. Nurse # 4 said that PICC lines were flushed with normal saline prior to and after administration of a medication, followed by [MEDICATION NAME]. Nurse #4 described the steps she took to administer the medications and flushes, which included reviewing the MAR indicated [REDACTED]. The Surveyor asked for Nurse #4 to review the current MAR. She could not explain the physician orders, which did not include the protocol she outlined and did not match the times the antibiotic was administered and what sequence the flushes were done. She said she could not show evidence that she did the flushes according to what she had shared with the Surveyor and did not know if flushes were being done to the second lumen. During interview on 12/17/15 at 12:40 P.M., the Director of Nurses said the Resident's orders were not complete and that although she could show that the Resident had received the antibiotic, she could not show evidence that the nursing staff were flushing the lumens according to protocol. In addition, she said that the orders should have included orders to flush the second lumen and orders for flushes for before and after blood draws (as she confirmed that the Resident had 6 blood draws through the PICC line). The Director said that the physician orders [REDACTED].

Based on observation, record review, and interview, the Facility Failed to ensure that the medication error rate was less than 5% during observation of the medication pass on 12/15/15 and 12/16/15. There were 30 opportunities with 3 errors, resulting in an error rate of 10%. Findings include: 1. On 12/15/15, a medication pass was observed at 12:10 P.M The Surveyor observed the Medication Nurse administer Humalog Insulin, 4 units subcutaneously and the oral anti-diabetic agent, Nateglinide 60 milligrams (mg) to Non-sampled Resident #1 during the lunch meal. Review of the physician's orders [REDACTED].#1's insulin should be administered either 15 minutes before or 15 minutes after a meal. Review of the physician's orders [REDACTED].#1's Nateglinide should be taken 1 to 30 minutes prior to a meal. 2. On 12/16/15, the Surveyor observed a medication pass at 8:45 A.M. The Surveyor observed Nurse #2 administer the medication [MEDICATION NAME] (a proton pump inhibitor used to prevent stomach acid reflux) 20 mg to Non Sampled Resident #2. Nurse #2 administered the medication and Non sampled Resident #2 was finished with his/her breakfast. Review of the physician's orders [REDACTED].#2's [MEDICATION NAME] was best administered before breakfast. The Surveyor reviewed the medication errors, with the Director of Nurses (DON), after the medication pass.

3. For Resident #5, the facility failed to care plan for urinary incontinence. Resident #5 was cognitively impaired and admitted to the facility on [DATE], following a hospitalization for a [MEDICAL CONDITIONS]. The initial Minimum Data Set with an assessment reference date (ARD) of 8/9/13, coded the resident as "2," frequently incontinent. The Care Area Assessment (CAA) stated, "Occasionally incontinent. Unable to hold urine until reaching bathroom. Voiding each shift without difficulty. Staff assist to toilet. Monitor." The CAA indicated that the facility would care plan urinary incontinence. The facility's Urinary Incontinence Policy dated 9/4/12, indicated: After the Admission Assessment is complete, should there be evidence of urinary incontinence at the time of admission, or a new-onset urinary incontinence develops, a comprehensive assessment of UI (urinary incontinence) will be initiated, with a voiding diary.... Nursing Staff will initiate a plan of care for each resident/patient addressing the particular incontinence etiology and specific individual needs of each resident. The assessment and initiation of treatment plan of care should be completed within: 7 days. Neither the electronic nor the paper medical record included any evidence that a care plan for urinary incontinence had been done. During interview on 8/21/13 at 3:00 P.M., the Director of Nurses (DON) was unable to provide evidence that a care plan for incontinence had been done. Based on record review and staff interviews, the facility failed to develop comprehensive care plans which includes individualized, measurable objectives and appropriate interventions for 4 sampled residents (#1, #2, #5 and #7) in a total sample of 11 residents. Findings include: 1. For Resident #1 the facility failed to develop a care plan for the treatment of [REDACTED]. Resident #1 was admitted to the facility in 7/2013 with [DIAGNOSES REDACTED]. Review of the medical record failed to reveal a care plan for the treatment of [REDACTED]. During interview on 8/22/13 at 8:45 A.M. the Director of Nurses said that the facility had not created a care plan for the care of the Foley catheter. 2. For Resident #2 the facility failed to develop a care plan for the treatment of [REDACTED]. Resident #2 was admitted to the facility in 7/2013 with [DIAGNOSES REDACTED]. Review of the medical record failed to reveal a care plan for the treatment of [REDACTED]. During interview on 8/22/13 at 8:45 A.M. the Director of Nurses said that the facility had not created a care plan for the care of the Foley catheter. 4. For Resident #7, the facility failed to develop a care plan for treatment and prevention of infection due to history of multiple infections and the treatment of [REDACTED]. Resident #7 was admitted to the facility in 7/31/13 with [DIAGNOSES REDACTED]. The resident was on contact precautions. The resident was treated with IV antibiotic through a PICC (peripherally inserted central catheter) line for the infection. On 8/17/13, the resident required a indwelling urinary (Foley) catheter due to retention. Review of the medical record failed to reveal a care plan for the treatment and prevention of infections or for the indwelling urinary (Foley) catheter. During interview on 8/21/13 at 4:15 P.M. the Northeast Unit RN#1 said that the facility had not created a care plan for the Infection or the care of the Foley catheter.

Based on record review and staff interview, the facility failed to ensure that the services being provided met professional nursing standards of quality for 3 sampled residents (#1, #2 and #7) in a total sample of 11 residents. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." 1. For Resident #1 the facility failed to ensure that the resident had a physician's orders [REDACTED]. Resident #1 was admitted to the facility in 7/2013 with [DIAGNOSES REDACTED]. Review of the medical record failed to reveal a physician's orders [REDACTED]. During interview on 8/22/13 at 8:45 A.M. the Director of Nurses said that there was no order for the catheter. The Director of Nurses further stated that the reason for the lack of an order was that the resident was admitted with the catheter. 2. For Resident #2 the facility failed to ensure that the resident had a physician's orders [REDACTED]. Resident #2 was admitted to the facility in 7/2013 with [DIAGNOSES REDACTED]. Review of the medical record failed to reveal a physician's orders [REDACTED]. During interview on 8/22/13 at 8:45 A.M. the Director of Nurses said that there was no order for the catheter. The Director of Nurses further stated that the reason for the lack of an order was that the resident was admitted with the catheter. 2. For Resident #7, the facility failed to follow the facility's policy for measuring the external length of the central line catheter. Resident #7 was admitted to the facility in 7/31/13 with [DIAGNOSES REDACTED]. The resident was ordered to receive IV (intravenous) antibiotic through a PICC (peripherally inserted central catheter) line for multiple infectious organism. The facility's policy for central line care read, at the time of dressing change the external catheter length is measured. The resident was admitted with the PICC line in place. Review on 8/21/13 of the residents clinical record revealed only one PICC line assessment containing the IV catheter length dated 8/7/13. The Northeast Unit RN#1,during an interview at 4:30 P.M. said that the PICC Line assessment containing the IV catheter length was to be obtained and documented weekly with the dressing change. The Northeast unit RN#1, stated the policy was not followed as required.

Based on record review, and staff interview, the facility failed to conduct a comprehensive assessment of bladder function and ensure that the resident received appropriate treatment and services to restore as much normal bladder function as possible for one resident (#5) in a total sample of 11 residents. Findings included: Resident #5 was cognitively impaired and admitted to the facility on [DATE], following a hospitalization for a [MEDICAL CONDITIONS]. A review of the medical record revealed an initial nursing note dated 8/2/13, indicating that the resident was continent of bladder. The initial Minimum Data Set with an assessment reference date (ARD) of 8/9/13, coded the resident as "2," frequently incontinent. Certified Nurse Aide recent documentation indicated the resident was incontinent of bladder on 8/16/13 at 9:45 P.M., 8/19 at 4:19 A.M. and 3:05 P.M. The facility's Urinary Incontinence Policy dated 9/4/12, indicated: After the Admission Assessment is complete, should there be evidence of urinary incontinence at the time of admission, or a new-onset urinary incontinence develops, a comprehensive assessment of UI (urinary incontinence) will be initiated, with a voiding diary.... If resident is incontinent on admission or becomes incontinent: Nursing staff will initiate the urinary incontinence assessment. This assessment will be initiated within ... 72 hours.... Nursing Staff will initiate a plan of care for each resident/patient addressing the particular incontinence etiology and specific individual needs of each resident. The assessment and initiation of treatment plan of care should be completed within: 7 days. Neither the electronic nor the paper medical record included any evidence that a Urinary Incontinence assessment with a voiding diary had been done. The resident did not have a care plan for urinary incontinence. The Care Area Assessment (CAA) with an ARD of 8/9/13, stated, "Occasionally incontinent. Unable to hold urine until reaching bathroom. Voiding each shift without difficulty. Staff assist to toilet. Monitor." During interview on 8/21/13 at 3:00 P.M., the Director of Nurses (DON) was asked if she could provide evidence that the resident's urinary assessment, voiding diary and care plan had been done. On 8/22/13, following this interview, the DON gave the surveyor a copy of the resident's urinary assessment, voiding diary and bladder scan that had been done on 8/22/13.

Based on record review, resident and staff interviews, the facility failed to maintain a safe, sanitary environment for 1 of 1 resident (#2) who required the use of a CPAP (continuous positive air pressure) machine out of a sample of 11 residents. Findings include: For Resident #2 the facility failed to clean the resident's CPAP machine based on the manufacturers directions for cleaning. Additionally, review of the facility's infection control policy and procedure for cleaning and sanitizing equipment and supplies dated 12/2000 and reviewed 2/2013 failed to include a policy and procedure for cleaning of a CPAP machine. Review of the policy and procedure for cleaning CPAP equipment based on the directions from the Sleep Medicine Institute of Texas, Pa. indicates the following: A) Daily Care 1. Wash your hands before handling or cleaning the CPAP machine. 2. Immerse the humidifier, tubing and mask in a sink of warm, soapy water. A mild detergent will properly clean your equipment; ensure the soap does not contain antibacterial agents, bleach, chlorine, alcohol, moisturizers or scents. Agitate the equipment in the water for several minutes. 3. Rinse the equipment in warm water until all traces of soap are gone. 4. Hang the tubing over a hanger, towel bar or shower rod and place mask and humidifier on a towel to dry. 5. Unplug the CPAP machine and wipe it down with a clean cloth dampened with water and mild soap. Go over the machine again with another clean, damp cloth to rinse away the soap. B) Weekly Care 6. Remove the filter of the machine and rinse it by running tap water through the filter. Squeeze it to ensure the dust is eliminated and allow it to dry before putting it back into the machine. 7. Disinfect your mask, tubing and humidifier after washing them by filling a sink with 1 part vinegar and 1 part water. Soak it in the sink for approximately 10 minutes. Rinse thoroughly by allowing the water to run through and over the equipment up to 3 minutes. 8. Allow the equipment to dry before reconnecting it to the machine. Resident #2 was admitted to the facility in 7/2013 with [DIAGNOSES REDACTED]. During interview at 12:25 P.M. on 8/21/13 the resident said that he/she did not remember the the CPAP machine being cleaned since his/her admission to the facility. During interview at 12:35 P.M. on 8/21/13 Nurse #3 said that after speaking to the Director of Nurse there was no policy for CPAP maintenance, because the family was responsible for providing the CPAP machine. The nurse further stated that the family was also responsible for maintaining the machine. However, there was no plan for the family to clean and no oversight planned. Additionally, the nurse said that the facility did not and had not cleaned the CPAP machine since the resident was admitted . During interview at 8:45 A.M. on 8/22/13 the Director of Nurses confirmed that the machine had never been cleaned.

Based on observation and staff interview, the facility failed to ensure that food was stored correctly to prevent the potential spread of foodborne illness. Findings include: 1. On the morning of 10/10/12 at 8:45 A.M. with the Executive Chef (EC) and Food Service Director (FSD), the Surveyor observed numerous trays of uncovered raw hamburger patties and uncovered, raw chicken breasts in the walk-in refrigeration unit referred to as the "meatbox." The Surveyor observed that the raw meats were out of their original packaging, were not covered and were not labeled or dated. When asked by the Surveyor how staff would know how long the meats had been defrosting or what the use by date was, the EC said that the staff would not know, as the meats were not labeled or dated. On the morning of 10/11/12 at approximately 7:45 A.M. with the EC, the Surveyor returned to the meatbox and observed a large brisket of beef without a label or date. The EC immediately asked the kitchen staff to label and date the brisket.

Based on record review, resident and staff interview, review of facility policy and procedures for reporting , investigating and preventing resident abuse, the facility failed to thoroughly investigate and report to the Administrator immediately, two allegations of mistreatment for one sampled resident (#2) in total sample of 10, and for one nonsampled resident (NS #A). Findings include: According to the facility Policy and Procedure for Prevention, Reporting and Investigating Abuse: Physical/Psychological injury, last revised on 7/14/2011, mistreatment is a form of abuse defined as the intentional of careless delivery of treatments that result in or are likely to result in injury pain or death, unreasonable difficulty to move around, restriction on communication with others or psychological harm. All alleged incidents of mistreatment, abuse, misappropriation of property will be investigated by the facility under the direction of the Administrator and in accordance with Federal and State Law. Any employee who suspects abuse will report to his/her immediate supervisor on duty. If department reporting is other than nursing, the employee should notify their supervisor who should notify the Director of Nursing. Assure patient safety and provide immediate treatment. If perpetrator is identified, obtain a statement and relieve him/her of duties pending investigation. Contact Human Resources for consultation as soon as possible or next business day. An occurrence report will be completed. The DON/designee will initiate an internal investigation using the Statement Interview Documentation Form. The Abuse Allegation Investigation Checklist will be used as a guide to conduct the investigation. This form directs the investigator to identify all persons involved and obtain written statements and interviews within 24 hours; review alleged perpetrator's employee file to determine if there have been any past incidents of suspected abuse allegations and review staffing schedules to identify potential witnesses, obtain statements and interview staff/patients identified. Review all documentation and make a determination if the abuse/neglect/mistreatment is substantiated and report findings to appropriate agencies, involved parties and Quality Improvement. 1. Resident #2 was admitted for short term rehabilitation following a fall at home resulting in an ankle fracture, requiring a cast and nonweight bearing status. According to the Minimum Data Set (MDS), completed on 9/29/2011, the resident scored a 15 out of 15 on the BIMS (Brief Interview for Mental Status), indicating the resident was cognitively intact. During the resident interview on 10/5/2011 at 10:30 A.M., when the resident was asked if he/she had ever been harmed mentally or physically by anyone in the facility, the resident responded that a few weekends ago, a weekend physical therapist provided treatment to the resident and the therapist "smelled like a brewery" and appeared to be under the influence of alcohol. The resident stated this caused him/her to be alarmed and uncomfortable. The resident stated he/she told the weekday physical therapist (PT) about the incident on Monday and was told the accused would not take care of the resident again. The resident stated he/she was left with the impression everything was taken care of but the resident stated he/she still sees the accused therapist working on the unit which caused concern about the safety of other residents. The resident stated no one had reported back to the resident with follow up on the complaint. Review of the occurrence report, dated 9/19/2011, revealed a physician reported the resident was treated by a weekend physical therapist who was under the influence of alcohol. The report did not say who the physician reported this to or when. The report was completed by the Director of Nursing. The report stated the resident did not want this staff person to care for her/him again and expressed concern for other residents receiving therapy. The action plan on the report stated the resident was reassured, the therapist would be removed from the resident's case, and the information would be passed on to the Rehabilitation Manager for follow-up. Review of the time-line of activities related to the incident, provided by the facility on 10/5/2011, revealed that on 9/19/2011, the DON confirmed the allegation with the resident and reported the incident to the covering Director of Rehab Services. On 9/20/2011, the Rehab Directors discussed if there were any prior complaints against the accused physical therapist. On 9/21/2011, the Rehab Directors met with Human Resources to review Drug and Alcohol policy and were counseled to ask the PT if the allegation was true. The PT denied the allegation of intoxication while on duty. The accused PT caseload was adjusted to remove Resident #2 from his assignment. The rehab managers did not follow up with the resident until 10/5/2011 after discussion with surveyor. There were no other documents for review from the investigation. Interview with the Administrator on 10/5/2011 at approximately 2:00 P.M., confirmed the Administrator was unaware of the allegations until the surveyor asked about the incident. Interview with the DON who conducted the investigation, on 10/6/2011, at approximately 11:00 A.M. confirmed no interviews of potential witnesses were conducted other than Resident #2. No written statements were taken from anyone. Other residents treated by the accused PT the same day were not interviewed. 2. Non Sampled Resident "A" was admitted to the facility 2/28/11, and discharged [DATE]. Review of a facility grievance log sheet indicated on the 3:-11: shift on 3/14/11 at approximately 8:00 p.m., non-sampled (N/S) Resident "A" reported to nursing that he/she had lost between $56.00 and $60.00 the day before. Review of the Occurrence (Incident) Report revealed Resident "A" to be cognitively intact. According to the Incident Report, Security was immediately notified and interviewed the Resident. Based on the Report, nursing staff searched the room, Resident belongings and trash without finding the money. The report refers to the Resident remaining concerned about the loss and that additional follow-up was needed. A 3/15/11 analysis and corrective action report reveals the Resident was given a key to his/her bedside cabinet to store valuables while an inpatient. There was a notation indicating Security was aware. The Daily Log Full Report simply stated that the Resident reported having lost money, that Security was called to the unit to investigate and that there were no findings. Interview with the Director of Nursing and Administrator on 10/6/11 at approximately 1:45 p.m. revealed they had been unaware of the loss and that no further investigation or action had been done. The Administrative team was unable to obtain any further information from Security, however, the surveyor was provided with a nursing note from 3/14/11. According to nursing documentation, when asked why he/she had not reported the loss earlier, the Resident figured it didn't matter since it was already lost. According to nursing documentation, Security had relayed to nursing that upon interview, the Resident's story contained inconsistencies as to the time and amount of money lost. The Nursing note concluded with the need for follow-up with the Resident and Resident's family concerning the lost money. Based on documentation and interview with the Director of Nursing and Administrator, there was no evidence any further investigation had occurred, that the facility reported the allegation, that the missing money had ever been found, or that the Resident had been reimbursed.