Every finding on record at Our Island Home

Based on observation, interview, and document review, the facility failed to provide services that met professional standards of practice for three Residents (#13, #17, and #25), out of a total sample of 33 residents. Specifically, the facility failed: 1. For Resident #13, to ensure physician's orders for opioid administration were followed; and2. For Resident #17 to ensure physician's orders for opioid administration were followed; and3. For Resident #25, to ensure physician's orders for inhaled medication were followed. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. 1. Resident #13 was admitted to the facility in March 2026 and had diagnoses including Alzheimer's disease and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, with a reference date of 3/11/26, indicated that Resident #13 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 and received medication for pain. Review of the medical record indicated but was not limited to the following Physician's Orders: -Acetaminophen (nonsteroidal anti-inflammatory drug used to treat mild to moderate pain) 500 milligrams (mg), as needed for pain/fever twice daily (3/12/26) -Acetaminophen 500 mg, give two tablets two times a day for pain (3/12/26) -Morphine Sulfate (opioid used to treat moderate to severe pain) solution 20 mg/milliliters (ml), give 0.25 ml every 2 hours as needed for pain (3/26/26) -Pain Monitoring: monitor for pain every shift and document the numeric score 0-10, every shift and as needed (3/5/26) Further review of the physician's orders failed to identify pain severity parameters for the use of each pain medication to ensure effectiveness of the pain management regime. Review of March 2026 Medication/Treatment Administration Record (MAR/TAR) indicated: -Acetaminophen as needed was administered on 3/12/26 for a pain level of 4 -Acetaminophen as needed was administered on 3/26/26 for a pain level of 2 -Morphine Sulfate as needed was administered on 3/26/26 for a pain level of 5 -Morphine Sulfate as needed was administered on 3/27/26 for a pain level of 2 -Morphine Sulfate as needed was administered on 3/27/26 for a pain level of 1 During an interview on 4/8/26 at 2:47 P.M., the Director of Nursing (DON) reviewed Resident #13's medical record and said the physician's orders for acetaminophen and Morphine Sulfate should include parameters for their use such as mild, moderate or severe pain or a numerical scale from 0-10. She said it is her expectation that acetaminophen be administered to the Resident for a mild pain level of 1 or 2 and not Morphine. During an interview on 4/9/26 at 12:12 P.M., Physician #1 reviewed Resident #13's medical record and said for mild pain, acetaminophen would be provided first and then depending on the effectiveness, the Morphine could be provided. If the pain was more significant initially, then the Morphine would be given first. She said the orders for pain medication should include parameters for their use. 2. Resident #17 was admitted to the facility in March 2026 with diagnoses including: fractured neck of right femur, cognitive communication deficit, and osteoarthritis. Review of the MDS assessment, dated 3/7/26, indicated Resident #17 was cognitively impaired as evidenced by a BIMS score of 5 out of 15. Review of the current Physician's Orders for Resident #17 indicated but were not limited to the following: -acetaminophen oral tablet 500mg, give 2 tablets by mouth two times a day for pain (3/25/26) -acetaminophen oral tablet 500mg, give 1 tablet by mouth every 4 hours as needed for mild pain/fever (3/25/26) -Oxycodone HCL oral tablet 5mg, give 2.5mg by mouth every 6 hours as needed for moderate to severe pain (3/26/25) -pain monitoring: monitor for pain every shift and document the numeric score 0-10 (3/2/26) Review of Resident #17's April 2026 MAR included but was not limited to the following: -Oxycodone HCl, give 2.5mg every 6 hours as needed for moderate to severe pain was administered on the following dates, times, and pain level: -4/6/26 at 5:35 A.M., pain level 5 -4/7/26 at 9:12 A.M., pain level 2; and 6:34 P.M., pain level 2 During an interview on 4/8/26 at 12:37 P.M., Nurse #1 said the Oxycodone was for moderate to severe pain and that would be pain of a 6 through 10 on the pain scale indicator. Nurse #1 said he assessed Resident #17's pain to be 2 out of 10 and said he should have given Resident #17 the prescribed acetaminophen because the pain was mild and should not have given Resident #17 the Oxycodone. During an interview on 4/8/26 at 1:50 P.M., the DON said it is inappropriate to have given Resident #17 an opioid medication with a pain level of 2 when the order was for moderate to severe pain. The DON said moderate to severe pain would be 6 through 10 on the pain scale and Resident #17 did not display that level of pain. During an interview on 4/9/26 at 12:17 P.M., Physician #1 said Oxycodone should not have been administered when acetaminophen was an option for mild pain and the nurses should be following orders as prescribed. 3. Review of the facility's policy titled Medication Administration Policy, revised 9/2020, indicated but was not limited to the following: -proper oral inhaler administration: -(iv) If more than one puff-wait one minute in between puffs -rinse mouth with water if using corticosteroid inhaler Resident #25 was admitted to the facility in January 2025, with diagnoses including: chronic obstructive pulmonary disease (COPD). Review of Resident #25's Physician Orders included but was not limited to the following: -Wixela Inhub inhalation aerosol powder breath activated 250-50 micrograms(mcg)/ACT, 1 puff inhale orally two times a day for COPD, rinse mouth after each use (1/30/25) -Umeclidinium bromide inhalation aerosol powder breath activated 62.5mcg/ACT, 1 puff inhale orally one time a day for COPD (10/1/25). On 4/7/26 at 12:06 P.M., the surveyor observed Nurse #1 administer two inhalation medications, Umeclidinium bromide and Wixela to Resident #25. The surveyor observed Nurse #1 administer the Umeclidinium bromide inhaler first, then immediately administer the Wixela inhaler, failing to wait at least one minute in between administration of inhaled mediations. In addition, the surveyor did not observe Nurse #1 have Resident #25 rinse his/her mouth after administration of inhaled Wixela as physician ordered. During an interview on 4/8/26 at 12:42 P.M., Nurse #1 said he should have waited in between inhaled medications and should have had Resident #25 rinse his/her mouth as ordered. During an interview on 4/8/26 at 1:50 P.M., the DON said Resident #25 should not have been given two inhalers back-to-back without waiting a period of time for medication effectiveness, and Resident #25 should have been instructed to rinse his/her mouth as ordered by the physician.

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, the facility failed to ensure their grievance policy included notification that residents and their representatives have the right to file grievances anonymously, should they choose not to alert a staff member of their concern(s), and failed to include the contact information of the grievance official with whom a grievance can be filed, that is, business address (mailing and email) and business phone number, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system.Findings include:Review of the facility's policy titled Grievance/Concerns Procedures, last revised 2/20/26, indicated:-Any resident, his or her representative, interested family member, or advocate may file a grievance or complaint concerning his or treatment, medical care, behavior of other residents, staff members, theft or (sic) property, etc., without fear of threat or reprisal in any form.You are requested to follow the procedures outlined below when filing a complaint:-Obtain a Resident Grievance Concern Form (attached). Forms are located on the bulletin board outside of the nourishment kitchen, at the nurse's station, and in the Director of Social Services and Administrator's office.-Please fill out the form as indicated and give to the Director of Social Services or Administrator. If you prefer, a staff member can assist you with filling out this form. Upon receipt of the form, an investigation of the grievance/concern will begin.-Upon completion of the investigation, you will be informed orally of the results of the investigation. Note: complaints related to abuse, harassment, or mistreatment will be immediately investigated and you will receive the findings, recommendations, and/or corrective action taken upon completion of the investigation subject to HIPPA and employee rights requirements.-Should you disagree with the findings, recommendations, or actions taken; you may meet the Administrator, or you may file a complaint with any of the agencies listed on the facility bulletin boards-It is the policy of this facility to assist you in filing a grievance. Should you feel that our staff has not assisted you in this matter, or you feel that you are being discriminated against for taking such steps, you are encouraged to report such incidents to the Administrator at once.-If you would like a copy of the facility's Freedom from Abuse, Neglect, and Exploitation policy, addressing Resident Grievance/Concerns, please see Administration. Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation, last revised 3/4/22, indicated but was not limited to:Resident Grievances/Complaints-Person with whom the resident initiates complaint will complete an incident/accident form to be given to their supervisor or designee to complete either an Investigation/Incident Summary Report form or a Resident Grievance Concern Form and will pass the information on to your Supervisor, Administrator, Director of Nurses, or Social Worker to begin the investigation process as soon as possible.-The Administrator or designee will notify the resident (if needed), the resident's representative, and employee, local law enforcement authorities and/or The Department of Public Health for those complaints which are deemed reportable.-Results of the Grievance/Complaint will be noted appropriately on the form and reported orally to the individual (especially if that is a resident or resident representative) who submitted the complaint.-All Resident Grievance Concern Forms will be kept in a binder in the Social Worker's office.-The Social Worker or designee will be the contact person for Grievance/Complaints.The policies failed to include notification that residents and their representatives have the right to file grievances anonymously, should they choose not to alert a staff member of their concern(s), and failed to include the contact information of the grievance official with whom a grievance can be filed, that is, business address (mailing and email) and business phone number, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system as required.On 4/8/26 at 11:10 A.M., the surveyor held a resident group meeting with 12 residents in attendance. Twelve of 12 residents said that they were not aware of their right to file a grievance anonymously or who the grievance official is. They said if they have an issue, they have to go to the Resident Council President or a staff member about it. The residents said sometimes they want to speak out but don't want to be identified, so they don't say anything.During an interview on 4/7/26 at 4:30 P.M., the Administrator reviewed the facility's Grievance/Concerns Procedure and Freedom from Abuse, Neglect, and Exploitation policy and said the policies do not include notification that residents and their representatives have the right file grievances anonymously and it does not include contact information of the grievance official as well as for independent entities to whom resident and their representatives can file grievances. The Administrator said at this time, there is no way for residents or their representatives to file a grievance without involving a staff member.

Based on record review and staff interview, the facility failed to ensure that a [NAME] Monitor was appointed, and treatment plan approved by the court for one Resident (#13) who was admitted to the facility and administered an antipsychotic medication, from a total sample of 12 residents. Findings include:In a [NAME] guardianship hearing, the court is being asked to authorize extraordinary treatment or care, such as administering antipsychotic medications, admitting an adult to a nursing home facility, and other medical care. This procedure was established by the Supreme Judicial Court in a decision entitled [NAME] v. Commissioner of the Department of Mental Health, 390 Mass. 489 (1983) - Massachusetts Guardianship Association (massguardianshipassociation.org).Resident #13 was admitted to the facility in March 2026 and had diagnoses including Alzheimer's disease and bipolar disorder.Review of the Minimum Data Set (MDS) assessment, with a reference date of 3/11/26, indicated that Resident #13 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 and received antipsychotic medication daily.Review of the medical record indicated Resident #13 was appointed a permanent Legal Guardian on 8/15/24 by the Commonwealth of Massachusetts Probate and Family Court. Further review of the medical record failed to indicate a Rogers Treatment Plan to authorize the administration of antipsychotic medication was obtained.Review of March 2026 admission Physician's orders indicated an order for the antipsychotic medication Seroquel 25 milligrams (mg) in the afternoon and 50 mg at bedtime.Review of March 2026 and April 2026 Medication Administration Records indicated Resident #13 was administered Seroquel as ordered by the physician.During interviews on 4/8/26 at 4:10 P.M., 4:28 P.M. and 5:09 P.M., the Administrator said Resident #13 has a Legal Guardian and should have a [NAME] Monitor and a court approved treatment plan in place for administration of antipsychotic medication. The Administrator said the facility is responsible for ensuring all residents with legal guardians and administered antipsychotic medication have [NAME] monitors and approved treatment plans but did not pick up on that need when Resident #13 was admitted but should have.

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:-Ensure staff handled medications in a sanitary manner to prevent potential transmission of infections; and-Ensure staff followed hand hygiene procedures prior to handling medication(s) and after administering medication(s).Findings include:Review of the facility's policy titled Hand Hygiene Procedures, revised 9/2020, indicated but was not limited to the following:-hand hygiene should be performed between providing care for residents, after hand contact with unclean equipment or work surfacesReview of the facility's policy titled Medication Administration Policy, revised 9/2020, indicated but was not limited to the following:-wash your hands before beginning and before contact with each residentOn 4/7/26 from 11:38 A.M. through 1:26 P.M., the surveyor observed Nurse #1 administer medications to six residents (#30, #25, #8, #15, #28, and #41). During this time, the surveyor did not observe Nurse #1 perform hand hygiene before or after administering medications. The surveyor observed Nurse #1 touching the computer, medication packages, and drawer handles between handling each residents' medications, potentially contaminating his hands. On 4/7/26 at 12:06 P.M., the surveyor observed Nurse #1 place Resident #25's nasal spray, and two inhalers in his uniform pocket then place the medications down on the Resident's bedside table without placing a protective barrier. The surveyor observed Resident #25 administer his/her inhaled medications, then place the medications back onto his/her bedside table. The surveyor then observed Nurse #1 pick up the medications and place them into his uniform pocket. The surveyor observed Nurse #1 at the completion of Resident #25's medication administration, remove the medications from his uniform pocket and place them directly onto the medication cart without a protective barrier. Nurse #1 then placed the medications back into the medication cart and failed to perform hand hygiene. On 4/7/26 at 1:13 P.M., the surveyor observed Nurse #1 administer Resident #28's eye drop mediation. Nurse #1 took the cover off the eye drops and placed the cover down on the Resident's dresser without a protective barrier. Nurse #1 completed the administration of the eye drops and he then placed the cover back on the eye drops and placed the eye drops in his uniform pocket. The surveyor observed Nurse #1 removing the eye drops from his uniform pocket and placing them back into the medication cart. During an interview on 4/8/26 at 12:42 P.M., Nurse #1 said he should have performed hand hygiene before and after each Resident's medication administration but did not. Nurse #1 said he did not place a protective barrier down to prevent the spread of infection for Resident #25 and Resident #28 when he placed medications down on their furniture, but he should have. Nurse #1 said he should not have placed Resident #25 and #28's medications inside his uniform pockets.During an interview on 4/8/26 at 1:50 P.M., the Director of Nursing (DON) said hand hygiene should have been performed before and after each Resident's medication administration. The DON said the nurse should not have placed medications in his uniform pocket, to prevent contamination and the spread of infection. The DON said the nurse should have placed a protective barrier down when medications were placed on a surface that may potentially be contaminated.

Based on observation, record review, and interview, the facility failed to ensure medications were accurately labeled and stored in accordance with acceptable professional standards. Specifically, the facility failed to:1. Ensure a treatment cart was locked when not in direct supervision of a licensed nurse;2. Ensure Resident #10's Albuterol Sulfate HFA inhaler (used to treat shortness of breath) was stored securely; and3. Ensure Resident #25's medications were stored in their original packaging.Findings include: 1. On [DATE] at 5:08 P.M., the surveyor observed two entry doors to the nursing suite (nursing station, medication room, oxygen room) wide open with no licensed staff in the vicinity of the nursing suite. The door labeled Oxygen Room was wide open and had an unlocked multi-drawer treatment cart inside that was easily accessible to all residents residing in the facility. The treatment cart contained the following items: -Multiple packets of Skin Prep (forms a protective film or barrier on the skin) -Povidone-Iodine Antiseptic pads (broad-spectrum antiseptic solution used for skin disinfection, wound care, and surgical preparation, effective against a wide range of microorganisms) -Bengay Cream (topical analgesic cream used to relieve muscle and joint pain) -Adapt Stoma Powder (absorb moisture from the skin around a stoma, helping to protect irritated skin and improve the adhesion of ostomy appliances) -(2) Diclofenac Sodium Topical Gel 1% (nonsteroidal anti-inflammatory) -Tacrolimus Ointment 1% (topical medication used to treat moderate to severe atopic dermatitis) -Preparation H Ointment (topical treatment for hemorrhoids) -(4) Triamcinolone Acetate 0.1% (steroid medication) -Fluorouracil Cream 5% (topical chemotherapy medication used to treat precancerous and certain cancerous skin lesions by preventing abnormal cell growth) -Collagenase Santyl Ointment (topical medication used to remove dead or damaged tissue from chronic wounds and severe burns, promoting healing) -Estradiol 0.01% Cream (vaginal estrogen therapy used to relieve menopausal symptoms) -Geri Care Analgesic Balm Topical Analgesic cream 10% menthol 15% methyl salicylate (topical analgesic) -(2) Ketoconazole Shampoo 2% (topical antifungal) On [DATE] from 5:10 P.M. to 5:13 P.M., the surveyor observed two residents wander by the unlocked nursing suite. On [DATE] at 5:13 P.M., the surveyor notified the Director of Nursing (DON) who accompanied the surveyor to the open and unlocked Oxygen room and observed the unlocked treatment cart and its contents. She said the treatment cart is supposed to be locked at all times when not in use and not accessible to anyone other than licensed staff, especially residents. 2. Review of the facility's policy titled Medication Administration Policy, revised 9/2020, indicated but was not limited to: -Proper storage of medications: -opened medications will be documented with open date and expiration date. Open medications will be labeled with proper stickers indicating open and expired dates. -drug storage remains the responsibility of the nursing staff. -residents who self-administer have the right to store medications in a locked drawer, cabinet, or closet, at bedside. Resident #10 was admitted to the facility in [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). Review of Resident #10's Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of Resident #10's Physician's Orders indicated but were not limited to: - [DATE]: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) MCG (micrograms)/ACT (actuation); 2 puffs inhale orally every four hours as needed for shortness of breath. Review of Resident #10's Self-Administration of Medication evaluation, dated [DATE], indicated he/she was approved for self-administration of the Albuterol Sulfate HFA inhaler and capable of storing medications in a secured location. On the following dates and times, the surveyor observed Resident #10's Albuterol Sulfate HFA inhaler on a bedside table located in the middle of the room. Resident was not in his/her room at the time. -[DATE] at 11:20 A.M.; and -[DATE] at 11:37 A.M. During an interview on [DATE] at 12:05 P.M., Resident #10 said he/she leaves the inhaler out all the time and does not have a way to lock up the medication. During an interview on [DATE] at 12:42 P.M., Nurse #1 said the inhaler should not have been left unattended and should have been locked up. During an interview on [DATE] at 1:50 P.M., the DON said Resident #10 should not have been left with medication that was kept unsecured. The DON said all medications should be locked up when not in use. 3. On [DATE] at 12:43 P.M., the surveyor, with Nurse #1 present, observed a medicine cup containing several unlabeled medications in the top right-hand drawer of the medication cart. The medication cup included 11 white pills: -three large oval tablets -two capsules -five round tablets -one small oval tablet Nurse #1 said the medications were for Resident #25 who was sleeping during the morning medication time and was going to give the medications later. Nurse #1 said he should have destroyed the medications and should not have left the pre-poured, unlabeled medications in a cup in the medication cart. During an interview on [DATE] at 1:50 P.M., the DON said Resident #25's medications should not have been left in the medication cart unlabeled. The DON said medications should be stored in the medication cart labeled.

Based on interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for one Resident (#6), out of a total sample of 12 residents. Specifically, for Resident #6, the facility failed to ensure pain medication was not administered outside of parameters identified in the Physician's orders. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility policy titled: Medication administration, dated as reviewed: 2/4/25, indicated but was not limited to the following: -medications shall be administered only upon the order of physicians who are members of the medical staff -nurses may administer medications in accordance with the regulations of the Board of Nursing Resident #6 was admitted to the facility in April 2025 with diagnoses including: fracture of the left femur, encephalopathy, and fall. Review of the most recent MDS, dated [DATE], indicated the Resident was taking opioid (narcotic) pain medication and was moderately cognitively impaired with a brief interview for mental status score of 11 out of 15. Review of the medical record indicated the Resident was their own person and capable of making their own medical decisions. Review of the physician orders for Resident #6, indicated but were not limited to the following: 4/24/25: Oxycodone (narcotic pain medication) 5 milligrams (mg), give half a tablet [2.5 mg]as needed (PRN) every four hours (Q4H) for moderate pain (discontinued (d/c) 4/30/25) 4/24/25: Oxycodone 5 mg give one tablet Q4H PRN for severe pain (d/c 4/30/25) 4/30/25: Oxycodone 5 mg give one tablet Q4H PRN for severe pain During an interview on 5/7/25 at 8:20 A.M., the Resident said they feel their pain is well managed and he/she is not interested in taking the oxy pain pills. Resident #6 further said the staff are giving the oxy pills to him/her without him/her asking for them. He/She said they were worried about becoming addicted and didn't want to stay on such a strong medication since they don't need it. The Resident said they are not having any pain that isn't manageable by other means. Review of the current pain care plan for Resident #6 indicated but was not limited to the following: -monitor and record pain characteristics PRN, severity on 1-10 scale Review of the Numerical Rating Scale for pain, indicated the following: -rating of zero indicates (=) no pain -rating of 1-3 = mild pain -rating of 4-6 = moderate pain -rating of 7-10 = severe pain Review of the Medication administration record (MAR) for both April 2025 and May 1st -7th, 2025 indicated, but was not limited to the following for Resident #6: April 2025: -Oxycodone 5 mg half tablet (2.5 mg) Q4H PRN for moderate (rating of 4 - 6) pain was administered outside of the ordered parameters four out of five times it was provided: >Twice for a rating of zero, >once for a rating of 9, >once for a rating of 7. -Oxycodone 5 mg one tab Q4H PRN for severe (rating of 7 - 10) pain was administered outside of the ordered parameters nine out of nine times: >Five times for a rating of zero, >twice for a rating of 1, >once for a rating of 3, >once for a rating of 4. May 2025: -Oxycodone 5 mg one tab Q4H PRN for severe pain was administered outside of the ordered parameters three of the four times it was provided. >Twice for a rating of 1, >once for a rating of 2. Further Review of the MARs indicated the Licensed Nurses were administering the PRN Oxycodone medication to Resident #6 outside of the prescribed parameters. During an interview on 5/7/25 at 11:25 A.M., Nurse #3 said the Resident is at the facility for rehab following a left femur fracture. Nurse #3 said she thought the Resident would not consistently participate in rehab without pain medications being given. Nurse #3 reviewed the MAR for April and May and said the Oxycodone orders are for PRN only and have parameters and the medication had been administered outside of the prescribed parameters and should not have been. Review of the skilled rehabilitation progress notes and evaluations failed to indicate that Resident #6 was limited in his/her rehab participation based on an excess of pain. During an interview on 5/7/25 at 11:56 A.M., Nurse #1 said the process is supposed to be that you ask the Resident how their pain is and you go strictly by what they say and provide the medications that are as needed, if they want them, according to the pain rating number they give you. Nurse #1 said pain is rated on a 1-10 scale and 1-3 is mild, 4-6 is moderate and 7-10 is severe. Nurse #1 reviewed the April and May MARs and said the Resident received the PRN Oxycodone multiple times outside of the ordered parameters and that should not have been happening and the Nurses should only be administering the medication in accordance with the Physician orders. During an interview on 5/7/25 at 1:01 P.M., the Occupational Therapist (OT) said she provides treatment to Resident #6 since admission and she has not ever known the Resident to refuse any therapy treatments based on pain and that is definitely something the therapists would have written in the rehab progress notes. The OT said nursing manages the residents pain and the therapists only intervene if a resident is incapable of participating in rehab because of excess pain and that did not occur for Resident #6. During an interview on 5/7/25 at 3:08 P.M., the Director of Nurses (DON) said her expectation is that the Licensed Nurses are administering medications in accordance with the Physician orders. The DON reviewed the April and May MARs for Resident #6, and said it appeared the Nurses had administered the PRN Oxycodone multiple times outside of the ordered parameters and that should not have happened.

Based on observations, document review, and interviews, the facility failed to follow infection control prevention practices to prevent the transmission of communicable diseases and infections for one Resident (#13) out of one resident on transmission-based precautions, out of a total sample of 13 residents. Specifically, the facility failed to ensure staff wore the appropriate PPE (personal protective equipment) while providing care for Resident #13, who was on droplet and contact precautions. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions, dated 4/3/24, indicated but was not limited to: -Contact Precautions: Use of PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (putting on) PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. -Droplet Precautions: Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space. On 5/6/25 at 11:22 A.M., the surveyor observed a yellow CDC Contact Precautions sign, and a dark green CDC Droplet Precautions sign posted at the doorway to Resident #13's room. A three-tiered cart containing PPE (masks, gloves, gowns, eye protection) was available below the signs. Review of the CDC Contact Precautions sign indicated the following: -Everyone must: >Clean their hands, including before entering and when leaving the room. -Providers and staff must also: >Put on gloves before room entry. Discard gloves before room exit. >Put on gown before room entry. Discard gown before room exit. >Do not wear the same gown and gloves for the care of more than one person. >Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Review of the CDC Droplet Precautions sign indicated the following: -Everyone must: Clean their hands, including before entering and when leaving the room. -Make sure their eyes, nose and mouth are fully covered before room entry. -Remove face protection before room exit. During an interview on 5/6/25 at 3:36 P.M., the Infection Preventionist said Resident #13 was started on contact and droplet precautions on 4/22/25 related to unknown respiratory illness. On 5/6/25 at 3:40 P.M., the surveyor observed CNA #3 and CNA #4 in Resident #13's room (door was open and no privacy curtain was drawn) transferring him/her in a Hoyer lift (a mechanical device used to lift and transfer patients who cannot move themselves) wearing gloves only. A yellow CDC Contact Precautions sign and a dark green CDC Droplet Precautions sign were posted at the doorway to Resident #13's room and PPE was available in a cart below the signs. During an interview on 5/6/25 at 3:50 P.M., CNA #3 and CNA #4 said they did not think that Resident #13 was still on precautions and only wore gloves when they transferred the Resident. The surveyor directed the CNAs to the precautions signs posted at the Resident's doorway. The CNAs said they should have worn a gown, gloves, mask and eye protection when assisting the Resident but did not. During an interview on 5/6/25 at 4:00 P.M., the Infection Preventionist said Resident #13 is on contact and droplet precautions and staff are to wear a gown, gloves, mask and eye protection when providing all care to the Resident. The Infection Preventionist said staff are expected to read the precaution signs posted at the Resident's doorway and follow proper PPE protocol.

Based on interview, record review, and policy review, the facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#10, #5 and #21), out of a sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended Pneumococcal vaccine 20-valent (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria). Findings include: Review of the facility's policy titled Resident Immunization Policy, dated as last revised on 1/17/23, indicated but was not limited to the following: -Vaccines against tetanus and diphtheria, influenza, pneumonia, COVID-19 will be available to all residents. Residents and their Responsible Party will be educated and encouraged to consent to receiving immunizations as recommended by the Massachusetts Immunization Program unless medically contraindicated. -All residents will have their immunization status assessed upon admission and annually thereafter. Review of the Massachusetts Immunization Program indicated vaccine administration and clinical guidelines followed the Centers for Disease Control and Prevention (CDC) guidance. Review of the CDC guidelines for Pneumococcal Vaccine indicated the following: -Persons age [AGE] years or older who have previously received both PCV13 (Pneumococcal vaccine 13-valent) and PPSV23 (pneumococcal polysaccharide vaccine), AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 1. Resident #10 was admitted to the facility in February 2024 and was over the age of 65 at the time of the survey. Review of the medical record indicated the Resident/Representative signed the Resident Immunization Informed Consent form for Prevnar 13, 15, 20 (PCV 13, 15, 20) whichever is due based on CDC recommendation. Review of the immunization history for Resident #10 indicated the Resident had received PPSV23 in 2008 and had received PCV13 in 2012. Further review of the medical record failed to indicate Resident #10 was provided with PCV20. 2. Resident #5 was admitted to the facility in January 2010 and was over the age of 65 at the time of the survey. Review of the immunization history for Resident #5 indicated the Resident had received PPSV23 in 2010 and received PCV13 in 2015. Further review of the medical record failed to indicate Resident #5 was provided with PCV20. 3. Resident #21 was admitted to the facility in May 2021 and was over the age of 65 at the time of the survey. Review of the immunization history for Resident #21 indicated the Resident had received PPSV23 in 2014 and received PCV13 in 2017. Further review of the medical record failed to indicate Resident #21 was provided with PCV20. During an interview on 5/8/24 at 1:05 P.M., the Infection Control Preventionist said the process for immunizations was that the immunization history was reviewed on admission. She said when a resident is admitted she reviews the Massachusetts Immunization Information System (MIIS) and when most residents were admitted they had received the PPSV23 and the PCV13. She said she thought if the residents had both the PPSV23 and PCV13 they were fully vaccinated and were not eligible for PCV20. She said she did not know that residents who had previously been vaccinated greater than 5 years ago were eligible to receive the PCV20 vaccine. During an interview on 5/8/24 at 1:50 P.M., the Infection Control Preventionist said she had located the CDC guidance on PCV20 eligibility. She said the facility had not been offering or providing education on PCV20 to residents who had the vaccine series more than 5 years ago.

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility for one Resident (#17), out of a total sample of 12 residents. Specifically, the facility failed to implement enhanced barrier precautions for a Resident who has a tracheostomy stoma and is at high risk for infection. Findings include: 43935 Review of the facility's policy titled Enhanced Barrier Precautions, dated as reviewed 4/26/24, indicated but was not limited to the following: - enhanced barrier precautions (EBP) will be implemented for residents with wounds and indwelling medical devices at especially high risk for both the acquisition of and colonization with multi-drug resistant organisms (MDRO) - the decision to implement EBP will be made by the infection control nurse and healthcare leadership team - compliance with EBP will be monitored by the infection control nurse and healthcare leadership team - signage will be placed on the door of the resident's room and information will be documented in their care plan Review of the Centers for Disease Control and Prevention (CDC) guidance titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated as last reviewed 7/28/21, indicated that examples of indwelling medical devices include . tracheostomy/ventilator. Resident #17 was admitted to the facility in December 2020 with diagnoses including: malignant neoplasm of the larynx (tumorous cancer of the throat), malignant neoplasm of the right upper bronchus or lobe of the lung, and tracheostomy status (a surgically created opening into the windpipe to allow air flow into the lungs). Review of the most recent Brief Interview for Mental Status, dated 3/6/24, indicated Resident #17 was cognitively intact with a score of 13 out of 15. During an interview on 5/7/24 at 10:08 A.M., Resident #17 said the tracheostomy was long ago and now he/she just has a trach stoma (permanent opening in the throat for air passage). The surveyor observed the Resident to have a trach mask (device for delivering oxygen) over the stoma connected to an oxygen concentrator with humidified oxygen flowing at 2 liters per minute. On 5/7/24 at 10:08 A.M., the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room and no personal protective equipment was available outside or inside the room for staff to use in the event the Resident should require assistance. Review of the medical record including progress notes, orders, and care plans for Resident #17 failed to indicate the Resident was on EBP. Review of the care Kardex for Resident #17, as of 5/8/24, indicated but was not limited to the following: Bathing: - Provide sponge bath when a full bath or shower cannot be tolerated, Resident can require continual supervision to limited assist when bathing. During a follow up interview on 5/7/24 at 4:58 P.M., Resident #17 was in his/her room and said when he/she is at the hospital they are on special precautions since having the tracheostomy and the facility does not follow those or provide any additional safety barriers to protect the Resident from potential exposure to germs even though he/she is high risk to contract infections related to their medical diagnoses. On 5/7/24 at 4:58 P.M., the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room and no personal protective equipment was available outside or inside the room for staff to use in the event the Resident should require assistance. During an observation on 5/8/24 at 8:39 A.M., the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room and no personal protective equipment was available outside or inside the room for staff to use in the event the Resident should require assistance. During an interview on 5/8/24 at 8:49 A.M., the Director of Nurses reviewed the EBP policy for the facility with the surveyor. She said Resident #17 is not on EBP, but realizes that they should be since they have a trach stoma and is at high risk for infections. She said the Resident is mostly independent and only requires staff assistance at times but is rapidly declining and staff need to be aware of the potential infection risk to the Resident and EBP should have been implemented based on the facility policy.

Based on observation, interview, record review, and policy review, the facility failed for one Resident (#12), of 12 sampled residents, to maintain their catheter drainage bag below the level of the bladder at all times to prevent potential complications. Findings include: Review of the facility's policy titled Indwelling Urinary Catheter: insertion, routine care and removal, dated as effective 9/21/22, indicated but was not limited to the following: - always keep the drainage bag below the level of the individual's bladder, to prevent urinary tract infections caused by urinary reflux (urine flowing back up into the bladder) Resident #12 was admitted to the facility in August 2022 with diagnoses including: hydronephrosis (a condition in which urine cannot drain from the kidneys resulting in kidney swelling) and protein calorie malnutrition. Review of the most recent Brief Interview for Mental Status (BIMS), dated 3/12/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an observation with interview on 5/7/24 at 10:18 A.M., the surveyor observed Resident #12 lying in bed. Resident #12 said they had a cystoscopy (procedure in which a small camera is inserted through the urethra to investigate the urinary system) and has had the catheter since that time. The surveyor did not observe a catheter urine drainage bag anywhere. The Resident said the staff had placed a leg bag (a catheter drainage bag that attaches to the leg for use when out of bed) on them in case they were to get up for some reason they wouldn't need to worry about maneuvering the regular drainage bag. Review of Resident #12's care plan for Indwelling catheter, initiated 1/12/24, indicated but was not limited to the following: - position catheter drainage bag and tubing below the level of the bladder On 5/7/24, the surveyor made the following observations of Resident #12: - 1:59 P.M., Resident lying in bed, catheter drainage leg bag in place - 4:12 P.M., Resident lying in bed, catheter drainage leg bag in place During an interview on 5/7/24 at 4:43 P.M., Nurse #2 said Resident #12 is not capable of changing the catheter drainage bag from a leg bag to a regular drainage bag independently and the staff swap out the drainage bags. She said the Resident was in bed and should not have the leg bag on as it would not allow for proper drainage, since it does not sit below bladder level, and could cause potential complications. Review of the Resident care Kardex, dated 5/8/24, indicated but was not limited to the following: - Resident is bedbound as of 5/1/24 - Catheter: indwelling, position catheter drainage bag and tubing below the level of the bladder During an interview on 5/8/24 at 12:13 P.M., the Director of Nurses said Resident #12 should not have had a leg bag on while they were in bed, as it would prevent proper urine drainage, and the standard and care plan were not followed.

Based on interview, the facility failed to implement and maintain an effective training program for all staff, which included laundry personnel, training on standards, policies, and procedures for the facility's infection prevention and control program as it relates to handling contaminated laundry. Findings include: According to the Centers for Disease Control and Prevention (2024), best practices for personal protective equipment (PPE) for laundry staff include but are not limited to: -If there is risk of splashing, for example, if laundry is washed by hand, laundry staff should always wear gowns or aprons and face protection (e.g., face shield, goggles) when laundering soiled linens. According to the American Healthcare Association (2023), Tips for Meeting the Linen Requirements in Skilled Nursing Facilities include but are not limited to: Linen and Laundry Handling: Staff should handle all used laundry as potentially contaminated and use standard precautions (e.g. gloves, gowns when sorting and rinsing). During an interview on 5/8/24 at 11:20 A.M., Laundry Staff #1 said she handles all linens with gloved hands and no other PPE. She said she has never been educated to utilize any other PPE for handling soiled infectious linen. During an interview on 5/8/24 at 1:00 P.M., the Maintenance/Housekeeping Director said he is responsible for the laundry department. He said a mask and gloves should be worn for sorting, handling and processing contaminated linens. He said he does not provide education to laundry staff on infection control related to laundry. During an interview on 5/8/24 at 2:30 P.M., the Infection Preventionist (IP) said she is responsible for providing all staff education on all aspects of infection control, including laundry staff, but she has not done it.

Based on record review, policy review, and staff interview, the facility failed to ensure for seven Residents (#24, #27, #11, #19, #20, #1, #12), out of a total sample of 14 Residents, that each Resident's drug regimen was free from unnecessary drugs to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #24, an as needed (PRN) psychotropic medication was limited to 14 days; 2. For Resident #27, a PRN psychotropic medication was limited to 14 days; 3. For Resident #11, to monitor for side effects of Lexapro (antidepressant) and Trazodone (antidepressant and sedative); 4. For Resident #19, to monitor for side effects of Fluoxetine (antidepressant); 5. For Resident #20, to monitor for side effects of Duloxetine (antidepressant); 6. For Resident #1, to monitor for side effects of Zoloft (antidepressant); and 7. For Resident #12, to monitor for the side effects of Risperdal (antipsychotic), Ativan (antianxiety), Trazodone, and Zoloft (antidepressant). Findings include: Review of the facility's policy titled Psychotropic Medications, dated January 2023, indicated but was not limited to the following: -Based on comprehensive assessment of residents, the residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record -The resident's need for the psychotropic medication shall be monitored, as well as when the resident has received optimal benefits from the medication and when the medication dose can be lowered or discontinued -Psychotropic drugs may be ordered by a physician when medically necessary to treat a specific condition or behavior, when indicated by an assessment of the resident, after non-pharmacological interventions have been tried and at the lowest possible dose -Behaviors for which these drugs are used must present a danger for residents or others, interfere with the staff's ability to provide care, or cause the resident frightful distress due to paranoia, hallucinations, or delusions -Licensed nurses shall be aware of potential side effects of psychotropic medications and report any side effects to the resident's attending physician 1. Resident #24 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease. Review of the MDS assessment indicted Resident #24 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15 and received psychotropic medication daily. Review of the April 2023 Physician's Orders included but was not limited to the following: -Lorazepam (antianxiety) 0.5 mg, give 1 tablet every 2 hours as needed for mild to moderate anxiety (3/9/23) -Lorazepam 0.5 mg, give 2 tablets every 2 hours as needed for severe anxiety (3/9/23) The physician's order failed to include a stop date or a re-evaluation date. 2. Resident #27 was admitted to the facility in May 2021 with diagnoses including dementia. Review of the April 2023 Physician's Orders included but was not limited to the following: -Lorazepam (antianxiety) 0.5 mg, give 1 tablet every 2 hours as needed for mild to moderate anxiety (3/24/23) -Lorazepam 0.5 mg, give 2 tablets every 2 hours as needed for severe anxiety (3/24/23) The physician's order failed to include a stop date or a re-evaluation date. During an interview on 4/26/22 at 8:48 A.M., the Director of Nurses said as needed psychotropic medications need to have a stop date and be re-evaluated for continued use. 42742 3. Resident #11 was admitted to the facility in March of 2023 with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, unspecified psychosis, schizoaffective disorder bipolar type, and dementia. Review of current Physician's Orders indicated the following: -Lexapro (Escitalopram Oxalate) Tablet 5mg (milligram), give 3 tablets by mouth one time a day for depression, 9/10/22 -Trazodone (antidepressant and sedative) HCL tablet, give 25mg by mouth at bedtime for insomnia, 3/1/23 The physician's orders failed to include monitoring of side effects for the use of the psychotropic medications as required. Review of the March 2023 and April 2023 Medication Administration Records (MAR) indicated Resident #11 received the medications as ordered by the physician. During an interview on 4/25/23 at 3:26 P.M., Nurse #3 said there was no order to monitor for side effects for the Lexapro and Trazodone and, if no order, then it would not be carried over to the MAR or Treatment Administration Record (TAR) for nurses to document monitoring. 4. Resident #19 was admitted to the facility in December 2020 with diagnoses including major depressive disorder. Review of the current Physician's Orders included the following: -Fluoxetine HCL Capsule 40mg, give 1 capsule by mouth one time a day related to major depressive disorder, 3/23/21 The physician's orders failed to include monitoring of side effects for the use of psychotropic medication as required. Review of the April 2023 MAR indicated Resident #19 received the medication as ordered by the physician. During an interview on 4/25/23 at 9:24 A.M., Nurse #3 said there was no order to monitor for side effects for the use of Fluoxetine and it was not being monitored on the MAR or TAR. 5. Resident #20 was admitted to the facility in May 2018 with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, unspecified psychosis, and schizoaffective disorder bipolar type. Review of the current Physician's Orders included the following: -Cymbalta (Duloxetine) capsule delayed release particles 60mg, give 1 capsule by mouth one time a day related to major depressive disorder, 6/21/19 The physician's orders failed to include monitoring of side effects for the use of psychotropic medication as required. Review of the April 2023 Medication Administration Record indicated Resident #20 received the medication as ordered by the physician. During an interview on 4/25/23 at 3:29 P.M., Nurse #3 said there was no order to monitor for side effects for Cymbalta, so it was not carried over to the MAR or TAR for monitoring. During an interview on 4/26/23 at 8:47 A.M., the Director of Nursing (DON) said residents on psychotropic medications should be monitored for side effects. 27189 6. Resident #1 was admitted to the facility in February 2021 with diagnoses that included diabetes mellitus and major depressive disorder. Review of the April 2023 Physician's Orders indicated the following: -Zoloft 25 milligram (mg) tablet, Give 3 tablets (75 mg) by mouth one time a day (9:00 A.M.). Review of the comprehensive care plan included but was not limited to the following: Problem-Resident uses anti-depressant medication (Zoloft) related to depression Goal-Resident will be free from adverse reactions related to antidepressant Interventions-Monitor/document/report as needed (PRN) any adverse reactions to anti-depressant therapy-change in behavior/mood/cognition: hallucinations/delusions; social isolation; suicidal thoughts, withdrawal, decline in Activities of Daily Living(ADL) ability continence, no voiding, constipation fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, Dartmouth dry eyes. Further medical record review failed to indicate a physician's order or documentation by the staff for monitoring for signs or symptoms of adverse side effects related to the administration of the anti-depressant Zoloft. During an interview on 4/25/23 at 2:31 P.M., Nurse #3 reviewed the MAR, care plans, and TAR, and confirmed that the Resident was on an antidepressant and that no monitoring of these medications for side effects/adverse reactions or effectiveness was completed. 7. Resident #12 was admitted to the facility in September 2014 with diagnoses including frontotemporal dementia with behavioral disturbances, depression, anxiety, and mood disorder. Review of the April 2023 Physician's Orders indicated the following psychotropic medications: Lorazepam (anti-anxiety) Tablet 0.5 mg, Give one tablet by mouth in the afternoon Lorazepam Tablet 1 mg, Give one tablet by mouth in the morning Zoloft (anti-depressant) Tablet 25 mg, Give 4 tablets by mouth one time a day Risperdal (anti-psychotic) Tablet 0.5 mg, Give 0.5 mg tablet (dose is 0.25 mg) by mouth in the evening Trazodone (anti-depressant) Tablet 100 mg, Give one tablet by mouth in the evening Review of the comprehensive care plans indicated but was not limited to the following: -Problem- Resident is at risk for adverse reaction related to polypharmacy -Goal- Resident will be free of adverse drug reactions. -Interventions- Monitor for possible signs and symptoms of adverse drug reaction, falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression, poor appetite, constipation, gastric upset. -Problem- Resident uses psychotropic medications -Goal- Resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. -Interventions- Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report as needed any adverse reactions of psychotropic medications, unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Further medical record review failed to indicate a physician's order or documentation by the staff for monitoring for signs or symptoms of adverse side effects related to the administration of Lorazepam, Trazodone, Zoloft, and Risperdal. During an interview on 4/25/23 at 2:24 P.M., Nurse #3 reviewed the MAR, care plans and TAR, and confirmed that the Resident was on anti-depressants, anti-anxiety and anti-psychotics medications and that no monitoring of these medications for side effects/adverse reactions or effectiveness was completed.

Based on record review, policy review, and interview, the facility failed to ensure that the resident's drug regimen was free from unnecessary drugs without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications for seven Residents (#11, #19, #7, #12, #5, #1, and #39), in a total sample of 14 residents. Specifically, the facility failed to ensure that: 1. Residents #11, #19, #7, #12, and #5 were monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant; 2. Resident #1 was monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-diabetic agent; and 3. Resident #39 was monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant and anti-diabetic agent. Findings include: 1. Review of the facility's policy titled Anticoagulation Therapy and International Ratio (INR) Testing (revised August 2020) indicated but was not limited to the following: -Residents on anticoagulation therapy (Warfarin, Low Molecular Weight Heparin, etc.) will have ongoing monitoring of therapy to assure safety and effectiveness of medications. -Residents on anticoagulation therapy will be monitored for any increased bleeding. A. Resident #11 was admitted to the facility in March 2023 and had diagnoses including a personal history of pulmonary embolism (PE- condition in which one or more arteries in the lungs become blocked by a blood clot). Review of the current Physician's Orders indicated the following: -Eliquis (Apixaban) Tablet 2.5 milligrams (mg), give 1 tablet by mouth two times a day for anticoagulant, 8/11/22 Review of the Bristol-[NAME] Squibb Eliquis (Apixaban) package insert, revised September 2021, indicated the following: -Eliquis is a factor Xa inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation and for the prophylaxis of DVT (deep vein thrombosis), which may lead to pulmonary embolism. Warnings and Precautions: -Eliquis can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. Review of the April 2023 Medication Administration Record (MAR) indicated the following: -Eliquis Tablet, administered daily from 4/1/23 through 4/23/23 Further review of the medical record failed to indicate Resident #11 was being adequately monitored for signs and symptoms of bleeding related to the use of a blood thinner. During an interview on 4/25/23 at 3:26 P.M., Nurse #3 said there was no order to monitor for signs and symptoms of bleeding, so it would not be carried over to the MAR or Treatment Administration Record (TAR) to be monitored. B. Resident #19 was admitted to the facility in December 2020 with diagnoses including a personal history of pulmonary embolism and chronic embolism and thrombosis of other specified veins. Review of the current Physician's Orders indicated the following: -Xarelto Tablet (Rivaroxaban) 15mg, give 1 tablet by mouth in the evening for anticoagulation therapy, 12/29/20 Review of the [NAME] Pharmaceuticals Xarelto packet insert, revised February 2023, indicated the following: -Xarelto is a factor Xa inhibitor indicated for the treatment of deep vein thrombosis and pulmonary embolism Warnings and Precautions: -Risk of bleeding: Xarelto can cause serious and fatal bleeding Review of the April 2023 MAR indicated the following: -Xarelto Tablet, administered daily from 4/1/23 through 4/30/23 Further review of the medical record failed to indicate Resident #19 was being adequately monitored for signs and symptoms of bleeding related to the use of a blood thinner. During an interview on 4/25/23 at 3:24 P.M., Nurse #3 said there was no order to monitor for signs and symptoms of bleeding, so it would not be carried over to the MAR or TAR to be monitored. C. Resident #7 was admitted to the facility in January 2010 and recently diagnosed with an aortic thrombosis related to atrial fibrillation. Review of the April 2023 Physician's Orders indicated the following: Apixaban (Eliquis) Oral Tablet, 5 mg, Give one tablet by mouth two times a day (start date 4/12/23). The physician's orders failed to include monitoring of potential complications/adverse consequences for the use of Eliquis. Review of the April 2023 MAR indicated that the Resident was receiving the anticoagulant medication twice a day as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: -Problem-Resident is taking Anti-Coagulation Therapy Eliquis to prevent thrombus from Afib -Goal-Resident will show no signs/symptoms of bleeding (date initiated 4/13/23) -Interventions-Evaluate for blood in stools; Evaluate for bruising; Evaluate for signs and symptoms of bleeding Further medical record review failed to indicate the staff were monitoring for signs or symptoms of bleeding/potential adverse side effects related to the administration of the anticoagulant Eliquis. During an interview on 4/25/23 at 2:35 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of bleeding/potential adverse side effects related to Resident #7 receiving an anticoagulant. D. Resident #12 was admitted to the facility in September 2014 with diagnoses including frontotemporal dementia with behavioral disturbances, depression, anxiety, and mood disorder, pulmonary emboli, and deep vein thrombosis. Review of the April 2023 Physician's Orders indicated the following: -Xarelto tablet 20 mg, Give 20mg by mouth in the evening for treatment to prevent reoccurrence of blood clot in the lung. The physician's orders failed to include monitoring of potential complications/adverse consequences for the use of Xarelto. Review of the April 2023 MAR indicated that the Resident was receiving the anticoagulant medication daily as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: Problem:Resident has a deep vein thrombosis related to immobility and takes Xarelto Goal- Resident will remain free of complications related to anticoagulation therapy Interventions- Monitor for signs and symptoms of bleeding due to the use of a blood thinner Further medical record review failed to indicate the staff were monitoring for signs or symptoms of bleeding/potential adverse side effects related to the administration of the anticoagulant/blood thinner Xarelto. During an interview on 4/25/23 at 2:35 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of bleeding/potential adverse side effects related to Resident #12 receiving an anticoagulant/blood thinner. E. Resident #5 was admitted to the facility in April 2022 with diagnoses including atrial fibrillation. Review of the 1/18/23 Minimum Data Set (MDS) assessment indicated Resident #5 received anticoagulant medication daily. Review of the April 2023 Physician's Orders included the following anticoagulant medication: Apixaban 2.5 mg two times a day (4/20/22) The physician's orders failed to include monitoring for signs and symptoms of adverse consequences of taking anticoagulant medication. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed Resident #5's medical record and said the Resident did not have an order for monitoring for side effects for the use of an anticoagulant medication such as increased bleeding. During an interview on 4/26/23 at 8:48 A.M., the Director of Nursing said it was her expectation that staff should be monitoring for signs and symptoms of adverse effects of anticoagulant medications. 2. Resident #1 was admitted to the facility in February 2021 with diagnoses that included diabetes mellitus and depression. Review of the April 2023 Physician's Order indicated the following: -Trajenta Tablet 5 MG (linaGLIPtin), Give 1 tablet by mouth one time a day, Hold if does not eat breakfast (8:00 A.M.) -Levemir Subcutaneous Solution 100 UNIT/Milliliter (ML) (Insulin Detemir) Inject 12 units subcutaneously in the morning at 6:00 A.M. -Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 999 = 8 units and notify MD, subcutaneously before meals at 6:30 A.M., 11:30 A.M., and 4:30 P.M. The physician's orders failed to include monitoring of potential complications/adverse consequences and for the monitoring for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Review of the April 2023 MAR indicated that the Resident was receiving the anti-diabetic medication and insulin as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: Problem- Metabolism altered- Resident has diabetes mellitus Goal-Resident will be free from any signs and symptoms of hypoglycemia and hyperglycemia. Interventions-Monitor/document/report as needed (PRN) any signs and symptoms of hypoglycemia; sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Diabetes medication as ordered by doctor. Monitor for/document side effects and effectiveness. Further medical record review failed to indicate the staff were monitoring for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to the administration of the anti-diabetic medication and insulin. During an interview on 4/25/23 at 2:35 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to Resident #1 receiving an anti-diabetic medication and insulin. 3a. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, and dementia. Review of the April 2023 Physician's Orders indicated the following: Apixaban Tablet (Eliquis), 2.5 mg, Give one tablet by mouth two times a day. The Physician's orders failed to include monitoring of potential complications/adverse consequences for the use of Eliquis. Review of the April 2023 MAR indicated that the Resident was receiving the anticoagulant medication daily as ordered by the physician. Further medical record review failed to indicate the staff were monitoring for signs or symptoms of bleeding/potential adverse side effects related to the administration of the anticoagulant/blood thinner Eliquis. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of bleeding/potential adverse side effects related to Resident #39 receiving an anticoagulant/blood thinner. b. Review of the April 2023 Physician's Orders indicated the following: Lantus SoloStar Subcutaneous Solution Pen-Injector 100 Unit/ml, Inject 8 units subcutaneously at bedtime. Metformin HCL tablet 1000 mg, Give one tablet by mouth twice a day. The physician's orders failed to include monitoring of potential complications/adverse consequences and for the monitoring for hypoglycemia and hyperglycemia. Review of the April 2023 MAR indicated that the Resident was receiving the anti-diabetic medication and insulin as ordered by the physician. Review of the comprehensive care plan indicated but was not limited to the following: Problem- Metabolism altered- Resident has diabetes mellitus Goal-Resident will be free from any signs and symptoms of hypoglycemia and hyperglycemia. Interventions-Monitor/document/report as needed (PRN) any signs and symptoms of hypoglycemia; sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait; Diabetes medication as ordered by doctor. Monitor for/document side effects and effectiveness. Further medical record review failed to indicate the staff were monitoring for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to the administration of the anti-diabetic medication and insulin. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said that the facility failed to monitor for signs or symptoms of hypoglycemia/hyperglycemia and potential adverse side effects related to Resident #39 receiving an anti-diabetic medication and insulin. 42742 34145

Based on interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for six Residents (#14, #27, #1, #39, #19, and #20), out of a total sample of 14 residents. Specifically, the facility failed: 1. For Resident #14, to ensure a Physician's order was obtained for psychotherapy; 2. For Resident #27: a. to ensure Physician's orders were in place for monitoring hyper/hypoglycemia and treatment interventions to address the potential for hyperglycemia, and b. to ensure Physician's orders were in place for fingerstick blood sugars (FSBS) in order to implement hypoglycemic protocol; 3. For Resident #1, to ensure orders were in place for FSBS to correlate with orders for sliding scale insulin; 4. For Resident #39, a. to ensure a range/instructions were identified for physician notification of either a low blood sugar or a high blood sugar and protocols/interventions for hyperglycemia, and b. to ensure weights were obtained according to physician's orders; 5. For Resident #19, to ensure orders were in place for FSBS to correlate with orders for sliding scale insulin; and 6. For Resident #20, to ensure orders were in place to monitor for signs and symptoms of hyper/hypoglycemia. Findings include: 1. Resident #14 was admitted to the facility in January 2023 with diagnoses including major depressive disorder. Review of the 3/6/23 Minimum Data Set (MDS) assessment indicated Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15, had mild depression as evidenced by a depression score of 8 out of 27, and received antidepressant medication. Review of the medical record indicated Resident #14 received one to one (1:1) psychotherapy from the consultant psychiatric provider since admission to the facility. During an interview on 4/24/23 at 2:04 P.M., the Social Worker said that Resident #14 has 1:1 psychotherapy sessions every two weeks utilizing Zoom (a communication platform that allows users to connect with video, audio, phone, and chat) on a computer. Further review of the medical record failed to indicate a Physician's Order for the provision of psychotherapy. During an interview on 4/25/23 at 11:55 A.M., Nurse #3 said there was no Physician's order in place for 1:1 psychotherapy. 2. Review of the facility's policy titled Diabetic Management, dated 1/2023, included but was not limited to: Signs and symptoms of hyperglycemia: -increased thirst; -dry mouth; -increased urination; -headache; -lethargy; -restlessness; and -loss of appetite. Diabetic ketoacidosis (a serious complication of diabetes that can be life-threatening) or hyperosmolar (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances) coma includes the following symptoms: -high blood sugar; -ketones in the urine; -nausea and/or vomiting; -lethargy Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: -restless and/or muscle twitching; -tachycardia (increased heart rate) -pale, cool, moist skin -excessive perspiration; -irritability or bizarre changes in behavior; -blurred or impaired vision; -headaches; -numbness of the tongue and lips/thick speech; -stupor, unconsciousness and/or convulsions; and -coma Resident #27 was admitted to the facility in May 2021 with diagnoses including type 2 diabetes mellitus. Review of the April 2023 Physician's Orders included but was not limited to: -Glucagon (a hormone that your pancreas makes to help regulate your blood glucose (sugar) levels) 1 milligram (mg) inject 1 mg intramuscularly as needed for capillary blood glucose (CBG) less than 60 and if resident unresponsive/unable to swallow (5/25/21) -Glucose Gel 15 grams (gm) geltube, give 15 grams by mouth as needed for signs/symptoms of hypoglycemia and/or CBG less than 60, may repeat times 1 in 15 minutes if no improvement (5/25/21) The physician's orders failed to indicate an order to monitor for signs and symptoms of hyper/hypoglycemia (high/low blood sugar), failed to include an order for fingerstick blood sugars to obtain the capillary blood glucose level to implement the hypoglycemic protocol, and failed to include interventions for the potential of hyperglycemia. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 said residents with diabetes should have orders in place to monitor for hyper and hypoglycemia as well as interventions. She said without orders in place to test the residents' capillary blood sugar, staff are not able to implement the hypoglycemic protocol. 27189 3. Resident #1 was admitted to the facility in February 2021 with diagnoses that included diabetes mellitus and depression. Review of the April 2023 Physician's Orders indicated the following: -Tradjenta Tablet 5 MG, Give 1 tablet by mouth one time a day. Hold if does not eat breakfast. -Levemir Subcutaneous Solution 100 UNIT/ML (Insulin-Detemir) Inject 12 units subcutaneously in the morning -Novolog Solution 100 UNIT/ML (Insulin-Aspart) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 999 = 8 units and notify MD, subcutaneously before meals at 6:30 A.M., 11:30 A.M. and 4:30 P.M. Further record review did not indicate a physician's order to obtain/perform Capillary Blood Glucose (CBG)/Finger Stick Blood Sugar (FSBS) checks at 6:30 A.M., 11:30 A.M., and 4:30 P.M. that correlated with the administration of the sliding scale insulin. During an interview on 4/25/23 at 2:31 P.M., Nurse #3 said that there should be an order for obtaining/performing the CBG/FSBS to correlate with the sliding scale and there was not. 4a. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, and dementia. Review of the April 2023 Physician's Orders indicated the following: Capillary Blood Glucose (CBG) via fingerstick one time a day every Wednesday, Friday, Sunday related to Type 2 Diabetes Mellitus with other circulatory complications. The order start date was 12/12/23 at 8:00 A.M. Record review indicated on 4/12/23 the above order was discontinued, and the following order was initiated: Fasting Capillary Blood Glucose (CBG) via fingerstick one time a day every Wednesday, Friday, Sunday related to Type 2 Diabetes Mellitus with other circulatory complications at 6:00 A.M. Further review of the April 2023 Physician's Orders failed to indicate a range/instructions for physician notification of either a low CBG or a high CBG or protocols/interventions for hyperglycemia. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said the CBG results should have specific ranges for physician notification with protocols for low/high blood sugar interventions and there was not. b. Review of the April 2023 Physician's Orders indicated the following: Monitor weight; Notify physician if gain of 3 pounds in one day or 5 pounds in one week; In the morning every other day (start date 2/17/23). Review of the March 2023 and the April 2023 Medication Administration Records (MAR) and Treatment Administration Records (TAR) indicated the following weights were not obtained every other day as ordered by the physician: -3/5/23, 3/9/23, 3/11/23, 3/15/23, 3/21/23, 3/23/23, 3/25/23, 3/27/23, 4/4/23, 4/6/23, and 4/22/23. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 confirmed that the Resident's weights had not been obtained every other day as per the physician's orders. 42742 5. Resident #19 was admitted to the facility in December 2020 with diagnoses including Type 2 diabetes mellitus with hyperglycemia and stage 1 through stage 4 chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 3/14/23, indicated Resident #19 received insulin injections daily. Review of current Physician's Orders indicated the following: -Novolog Solution (Insulin Aspart) (fast acting insulin to control blood sugar around mealtimes) 100 Units/Milliliter (ml), inject as per sliding scale (varies the dose of insulin based on blood glucose level) if: 200-250 = 2 units, Inject 2 units subcutaneously (SC) 251-300 = 3 units, Inject 3 units SC 301-350 = 4 units, Inject 4 units SC 351-400 = 5 units, Inject 5 units SC 401-999 = 6 units, Inject 6 units SC and call MD, SC one time a day related to Type 2 Diabetes Mellitus with hyperglycemia, 7/19/22 -Levemir Solution 100 Unit/ml (Insulin Detemir), 14 units subcutaneously in the morning related to Type 2 Diabetes Mellitus with hyperglycemia, 4/20/23 The physician's orders failed to include an order to monitor for signs and symptoms of hypo/hyperglycemia. Further review of physician's orders failed to indicate an order to perform CBG testing to correlate with the administration of sliding scale insulin and Levemir insulin and failed to indicate instructions/ranges for when the physician was to be notified of a low CBG result. During an interview on 4/25/23 at 2:59 P.M., Nurse #3 said there was no physician's order to monitor for signs and symptoms of hypo/hyperglycemia and it was not being done. She said if there was no order, then it would not be on the MAR or TAR for staff to document. 6. Resident #20 was admitted to the facility in May 2018 with diagnoses including Type 2 diabetes mellitus with ketoacidosis (serious diabetes complication where the body produces excess blood acids, ketones) without coma. Review of the current Physician's Orders indicated the following: -Metformin HCl ER Tablet, Extended Release 24 hour, give 500mg by mouth two times a day for Diabetes Mellitus Type 2, 7/19/21 The physician's order failed to include an order to monitor for signs and symptoms of hypo/hyperglycemia. Further review of physician's orders failed to indicate instructions/ranges for when the physician was to be notified of a high or low CBG result. During an interview on 4/25/23 at 3:28 P.M., Nurse #3 said there was no order to monitor for signs and symptoms of hypo/hyperglycemia so it would not be on the MAR or TAR for nurses to document. During an interview on 4/26/23 at 8:37 A.M., the Director of Nursing (DON) said side effects should be monitored for all high-risk medications including diabetic agents. She said staff should be monitoring for signs and symptoms of hypo/hyperglycemia.

Based on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for four Residents (#39, #5, #24, and #38), out of a total sample of 14 residents. Specifically, the facility failed to ensure that: 1. Resident #39 had a care plan developed for anticoagulant therapy; 2. Resident #5 had a care plan developed for the use of Risperdal (antipsychotic); 3. Resident #24 had a care plan developed for the use of Ativan (antianxiety) and Remeron (antidepressant); and 4. Resident #38 had a care plan developed for substance use disorder (SUD). 1. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, and dementia. Review of the April 2023 Physician's Orders indicated the following: -Apixaban (Eliquis) Tablet (blood thinner/anticoagulant) 2.5 milligrams (mg); Give one tablet by mouth two times a day. Review of the April 2023 Medication Administration Record (MAR) indicated that the Resident was receiving the anticoagulant medication daily as ordered by the physician. Further medical record review of the comprehensive care plans failed to indicate that a care plan had been developed for the Resident addressing the administration of the anticoagulant/blood thinner Eliquis. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 reviewed the comprehensive care plans and said that the facility failed to have an individualized comprehensive care plan for Resident #39 addressing the administration of the anticoagulant/blood thinner Eliquis. 34145 2. Resident #5 was admitted to the facility in April 2022 with diagnoses including congestive heart failure, type 2 diabetes mellitus, and adjustment disorder with mixed anxiety and depressed mood. Review of the 1/18/23 Minimum Data Set (MDS) assessment indicated Resident #5 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, had mild depression as evidenced by a depression score of 6 out of 27, and received antidepressant medication daily. Review of April 2023 Physician's Orders included the following psychotropic medication: -Risperdal (antipsychotic) 0.5 mg at bedtime (4/14/23) Review of comprehensive care plans included but was not limited to: -Problem: The Resident uses the psychotropic medication Risperdal related to disease process, diagnosis of bipolar disorder (4/13/23) -Interventions: Administer psychotropic medications as ordered. Monitor side effects and effectiveness. Monitor/document/report any adverse reactions of the medication (4/13/23) -Goal: The Resident will be/remain free from psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date (4/13/23) Further review of the care plan failed to identify Resident specific targeted signs and symptoms for the use of Risperdal and any specific non-pharmacological approaches and measurable goals to meet the Resident's needs. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed Resident #5's medical record. She said the care plans don't include Resident specific targeted behaviors, non-pharmacological interventions and measurable goals for the use of Risperdal but should. 3. Resident #24 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease. Review of the 3/15/23 MDS assessment indicated Resident #24 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15, had mild depression as evidenced by a depression score of 8 out of 27, and received antidepressant medication daily. Review of April 2023 Physician's Orders included the following psychotropic medication: -Lorazepam 0.5 mg, give one tablet every two hours as needed for mild to moderate anxiety (3/9/23) -Lorazepam 0.5 mg, give two tablets every two hours as needed for severe anxiety (3/9/23) -Mirtazapine 7.5 mg, give 7.5 mg in the evening for depression (3/17/23) Review of comprehensive care plans included but was not limited to: -Problem: Resident has depression related to dementia (3/16/23) -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/document/report any signs/symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness (3/16/23) -Goals: Resident will remain free of signs/symptoms of distress, symptoms of depression, anxiety or sad mood through review date (3/16/23) Further review of the care plan failed to identify Resident specific targeted signs and symptoms for the use of Lorazepam and Remeron and any specific non-pharmacological approaches and measurable goals to meet the Resident's needs. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed Resident #24's medical records. She said the care plans don't include Resident specific targeted behaviors, non-pharmacological interventions and measurable goals for the use of Lorazepam but should. 4. Resident #38 was admitted to the facility in November 2022 with diagnoses including opioid abuse with unspecified opioid-induced disorder. Review of the 2/15/23 MDS assessment indicated Resident #38 was cognitively intact as evidenced by a BIMS score of 11 out of 15, and had a diagnosis of opioid abuse with unspecified opioid-induced disorder. Review of the April 2023 Physician's Orders included but was not limited to: -Methadone HCI, 10 mg every eight hours for history of opioid abuse (11/9/22) Review of the medical record failed to indicate a person-centered care plan had been developed for the Resident's diagnosis of opioid abuse with unspecified opioid-induced disorder and use of Methadone that included interventions, measurable objectives and timeframes to meet the Resident's needs. During an interview on 4/24/23 at 3:50 P.M., the Director of Nursing (DON) said she did not develop a specific care plan for the Resident's opioid use disorder but added the diagnosis to another care plan. The DON said she should have developed a care plan to address the Resident's opioid use disorder that included interventions and measurable goals.

Based on observation, interview, policy review, and record review, the facility failed to treat one Resident (#19) with dignity and respect, out of a total sample of 14 residents, by not allowing the Resident to exercise his/her right to smoke without supervision and outside of the scheduled smoking times. Findings include: Review of the facility's policy titled Resident Smoking Policy, revised February 2023, indicated but was not limited to the following: -All residents who wish to smoke will be assessed by nursing for safety using the Assessment in the Electronic Health Record, upon admission, as identified with regards to safety and/or status changes and quarterly. A physician's order is required. -Resident smoking schedule is to be determined by the Risk Committee and visibly posted for all residents to view. -Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Resident #19 was admitted to the facility in December 2020. Review of the Smoking-Safety Screen, dated 7/26/21 through 3/24/23, indicated Resident #19 was safe to smoke independently without supervision and had no cognitive loss. Review of the Smoking Agreement, signed by the Resident on 11/22/22, indicated but was not limited to the following: -Residents with smoking privileges requiring monitoring will require supervision. Review of the current Physician's Orders indicated the following: -Resident may smoke in designated smoking areas in accordance with OIH [Our Island Home] smoking policy, independently with supervision (2/17/23) During an interview on 4/23/23 at 11:50 A.M., Resident #19 said he/she felt his/her rights were being violated related to smoking times. Resident #19 said the scheduled smoking times were five hours apart and he/she was not allowed to go out to smoke outside of those times and had to be supervised/monitored. Review of the Resident Smoking Times and Location document posted in the facility indicated the following designated smoking times: Daily Times: 6:00 A.M. 9:30 A.M. 2:00 P.M. 6:30 P.M. 9:00 P.M. During an interview on 4/24/23 at 1:54 P.M., Resident #19 said, They treat me like a mental case and It's supervised. On 4/24/23 at 2:00 P.M., the surveyor observed Certified Nursing Assistant (CNA) #1 lead Resident #19 and three other residents outside onto the back patio to smoke. CNA #1 stayed outside for the duration supervising the residents. CNA #1 said the smoking times are scheduled and residents don't go out in between. She said they have to be supervised and do not come out independently. During an interview on 4/25/23 at 12:48 P.M., Nurse #3 said she wasn't sure why the physician's order said supervision or why the Resident can't go outside to smoke when he/she wants if he/she's independent without supervision and would have to ask the Director of Nurses (DON). On 4/25/23 at 1:22 P.M., the surveyor observed Resident #19 approach the nurses' station and ask Nurse #3 to go outside to smoke. Nurse #3 said we just don't have anyone to go outside with you right now. Resident #19 shook his/her head and walked away. During an interview on 4/26/23 at 8:04 A.M., Resident #19 said he/she wants to go outside to smoke by him/herself and asks staff but is told no. During an interview on 4/25/23 at 4:40 P.M., Physician #2 said she was asked by the facility to write a facility wide smoking mandate order but there was no reason as far as she was concerned that Resident #19 would need supervision for smoking. She said Resident #19 was more independent than all the other smokers and should be able to exercise his/her right to smoke. During an interview on 4/26/23 at 8:09 A.M., the Administrator said he sat down with the smoking residents, and they agreed to the smoking times, but the program is a work in progress and the times are not etched in stone. He said if there's staff availability, they'll try to allow residents to smoke outside of those times but no promises. He said the program is still fluid and can be changed. During an interview on 4/26/23 at 8:19 A.M., the DON said Resident #19 can smoke independently and can go out independently. She said staff don't need to go out with him/her but need to keep eyes on him/her for safety reasons.

Based on record review, policy review, and interview, the facility failed to provide an environment that would remain free of accidents and hazards for two Residents (#39 and #38), in a total sample of 14 residents. Specifically, the facility failed to ensure: 1. Resident #39's wander guard device was checked weekly to ensure proper functioning; and 2. Resident #38 had a quarterly smoking assessment completed. Findings include: 1. Review of the facility's policy titled Wandering Monitoring Device Policy, dated 11/2020, included but was not limited to: -All residents assessed to be a wandering/elopement risk will wear a monitoring transmitter at all times. -The proper functioning of transmitters will be checked weekly by the nursing staff and as needed if malfunction is noted or suspected. -Transmitter checks will be documented on the log. -The wandering monitoring device will be checked for placement every shift by the nursing team. Resident #39 was admitted to the facility in December 2022 with diagnoses that included chronic atrial fibrillation, diabetes mellitus, dementia, and history of elopement. Review of the April 2023 Physician's Orders indicated the following: -Wander guard bracelet; Check placement every shift; Location right ankle (expiration date 7/23/23) -Check wander guard function every week Review of the Treatment Administration Record (TAR) for February, March, and April 2023 did not indicate that the wander guard had been checked weekly to ensure it was functioning per the physician's order and facility policy. During an interview on 4/25/23 at 2:40 P.M., Nurse #3 said the order to check the functioning of the wander guard weekly had been incorrectly entered into the Electronic Medical Record (EMR) and that the order for the weekly checks to ensure functioning was not carried over to populate onto the TAR. Nurse #3 said there was no documentation indicating the weekly checks were completed as ordered by the physician and per the facility policy and that it was not monitored to ensure proper functioning. 34145 2. Review of the facility's policy titled Resident Smoking Policy, dated 9/2021, indicated but was not limited to the following: -All Residents who wish to smoke will be assessed by nursing for safety using the Assessment in the electronic medical record, upon admission, as identified with regards to safety and/or status changes, and quarterly. Resident #38 was admitted to the facility in November 2022 with diagnoses including chronic obstructive pulmonary disease. Review of documentation provided by the facility indicated Resident #38 was one of five smokers in the facility. Review of the medical record indicated smoking assessments were completed on 11/10/22, 11/15/22, and 11/22/22. No other assessments were in the medical record. According to facility policy, Resident #38 should have had a quarterly smoking assessment conducted in March 2023. During an interview on 4/25/23 at 11:52 A.M., Nurse #3 reviewed the Resident's medical record and said only the original smoking assessment was conducted in 11/2022. She said a schedule was not set up and the quarterly smoking assessment was not done.

Based on record review, policy review, and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required for two Residents (#24 and #27), from of a total sample of 14 residents. Specifically, the facility failed to ensure an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff. Findings include: Review of the facility's policy titled Hospice, undated, included but was not limited to: -Coordinated care plans for residents receiving Hospice services will include the most recent Hospice plan of care as well as the care and services provided by our facility, including the responsible provider and discipline assigned to specific tasks to maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Resident #24 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease. Review of the April 2023 Physician's Orders included but was not limited to: -Admit to Hospice services (3/9/23) Review of Hospice documentation indicated Resident #24 received Hospice skilled nursing once a week for 13 weeks (3/9/23 - 6/3/23) and 4 as needed visits for 13 weeks (3/9/23 - 6/3/23). Review of interdisciplinary care plans included but was not limited to: Problem: Resident has a terminal prognosis and was admitted to Hospice on 3/9/23 (3/13/23) Interventions: Adjust provision of activities of daily living to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate (3/13/23); Encourage support system of family and friends (3/13/23); Keep the environment quiet and calm (3/13/23); Observe resident closely for signs of pain, administer pain medications as ordered (3/13/23); Work cooperatively with Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (3/13/23); Work with nursing staff to provide maximum comfort for the resident (3/13/23) Goal: The Resident's comfort will be maintained through the review date (3/13/23) The care plan was not integrated and failed to include a description of the facility and Hospice services provided to the Resident. 2. Resident #27 was admitted to the facility in May 2021 with diagnoses including dementia. Review of the April 2023 Physician's Orders included but was not limited to: -Admit to Hospice services (3/24/23) Review of Hospice documentation indicated Resident #27 received Hospice skilled nursing twice a week for 14 weeks (3/24/23 - 6/21/23), 4 as needed visits for 14 weeks (3/24/23 - 6/21/23) and 3 Hospice Aide visits every week for 14 weeks (3/24/23 - 6/21/23). Review of interdisciplinary care plans included but was not limited to: -Problem: Resident has a terminal diagnosis (3/24/23) -Interventions: Keep the environment quiet and calm (4/3/23); Observe resident closely for signs of pain, administer pain medications as ordered (4/3/23); Work cooperatively with Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (4/3/23); Work with nursing staff to provide maximum comfort for the resident (4/3/23). The care plan was not integrated and failed to include a description of the facility and Hospice services provided to the Resident. During an interview on 4/25/23 at 11:52 A.M., the surveyor and Nurse #3 reviewed Residents #24 and #27's medical records. She said the comprehensive care plans are not integrated and do not include a description of Hospice services and facility services provided to the Residents.

Based on observations, interviews, and record review, the facility failed to ensure the Physician was notified of a Hospice recommendation for a change in treatment for one Resident (#27), in a total sample of 14 residents. Findings include: Resident #27 was admitted to the facility in May 2021 with diagnoses including a history of a stroke without residual deficits and atrial fibrillation. Review of the medical record indicated a 3/24/23 Physician's Order to admit to Hospice services. Review of Hospice documentation indicated a 4/14/23 Hospice Nurse progress note: -Observations: edema in both hands/forearms; very painful to the touch -Consider towel/washcloth rolls to both hands -Consider Tramadol (opioid analgesic) for pain in hands, 25 milligrams (mg) every six hours as needed (PRN) Review of the medical record failed to indicate the Hospice's Nurse's recommendations for towel/washcloth rolls to both hands and Tramadol for pain in hands was communicated to the Physician and addressed. On 4/23/23 at 3:00 P.M., the surveyor observed Resident #27 sitting in a Broda (positioning) chair in the unit hallway. The Resident's hands were contracted resting on pillows. There were no towels or washcloth rolls in either of his/her hands. During an interview on 4/25/23 at 10:30 A.M., Hospice Nurse #1 said she sees Resident #27 weekly and writes notes and recommendations in a communication book. The process is that facility staff inform the Resident's attending Physician of her recommendations for approval. The Nurse said she recommended bilateral rolled towels or washcloths for the Resident's hands and Tramadol last week because of painful contractures. The surveyor and Hospice Nurse #1 reviewed her 4/14/23 note with recommendations for towel/washcloth rolls for both hands and she said it had not been addressed by the Physician yet. On 4/25/23 at 11:15 A.M., the surveyor observed Resident #27 seated in a Broda chair in the dayroom. Both of the Resident's arms were elevated on pillows and no towel or washcloth rolls were in the Resident's hands. During an interview on 4/25/23 at 11:52 A.M., the surveyor and Nurse #3 reviewed Resident #27's medical record and Hospice communication book. She said the Hospice Nurse's recommendations for towel or washcloth rolls for the Resident's hands and Tramadol were not communicated to the Physician by facility staff. She said the Physician should have been notified timely so interventions for the Resident's contractures and pain could be implemented right away.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was assessed by nursing to be at high risk for falls, and required the use of a fall mat on the floor on the left side of the bed (right side of his/her bed had been positioned up against the wall) while in bed for safety, the Facility failed to ensure that staff consistently implemented and followed interventions identified in his/her plan of care related to safety. On 12/30/22, Restorative Nurse Aide (RNA) #1, who was assigned to care for Resident #2, left him/her sitting up bed in with the bedside table in front of him/her, however prior to leaving the room, RNA #1 did not place the fall mat on the floor next to the left side of his/her bed, per the plan of care. Resident #2 fell out of bed, and was found with his/her head and shoulders on the floor, with his/her feet still on the bed, he/she was noted to be bleeding from his/her forehead and was transferred to the Hospital Emergency Department for evaluation. Findings include: Review of the Facility's Policy, titled Resident Care Planning, revision date as 5/8/2017, indicated that all residents will have an Interdisciplinary Care Plan developed that includes measurable goals to meet each, individual's medical, physical, mental, and psychosocial needs. The Policy indicated that resident Care Plans will be reviewed and updated to ensure the highest obtainable level of care and quality of life for each resident. Resident #1 was admitted to the Facility in September 2022, diagnoses Dementia, Alzheimer's disease, Heart failure, Conductive Hearing Loss, Chronic kidney disease, Urinary incontinence, and Polyosteoarthritis (arthritis that affects five or more joints). Review of Resident #2's Morse Fall Scale, dated 9/01/22, indicated that he/she was assessed by nursing as being a high risk for falls. Review of Resident #2's Fall Risk Care Plan, dated as 9/02/22, indicated that he/she required a fall mat (assistive/safety device) to be placed on the floor next to the left side of his/her bed, when in bed. The Care Plan indicated Resident #2 was at high risk for falls related to confusion, gate and balance problems, poor comprehension, and was unaware of his/her safety needs. Review of Resident #2's Admission Minimum Data Set (MDS) Assessment, dated 9/07/22, indicated that Resident #2 had severe cognitive impairment, with his/her daily decision making noted as severely impaired. Review of Resident #2's Significant Change Minimum Data Set (MDS) Assessment, dated 10/22/22, indicated that Resident #2 had been placed on Hospice Services related to end of life care needs. Review of the Facility's Investigative Report, dated 12/30/22, indicated that at approximately 7:15 P.M., Resident #2 had a fall from his/her bed after the assigned Certified Nurse Aide (CNA) (later identified as Restorative Nurse Aide #1) left Resident #2 sitting in an upright position in bed and did not place the fall mat on the floor next to the left side of his/her bed before she left the room (right side of bed was positioned up against the wall). The Report indicated Resident #2 was found with his/her head and shoulders on the floor and his/her feet still on the bed. The Report indicated Nurse #4 and Nurse #5 lowered Resident #2's legs to the floor and assessed him/her. The Report indicated that Nurse #3 called 911 and Resident #2 remained on the floor until Emergency Medical Services (EMS) arrived and he/she was transferred to the Hospital Emergency Department (ED) for evaluation. The Report indicated that Resident #2 sustained a laceration to his/her forehead and a left elbow skin tear. The Report indicated that both areas required steri-strips (low profile adhesive strip used for wound support) and that Resident #2 also had abrasions to his/her left scalp and left shoulder. During an interview on 02/07/23 at 2:26 P.M., Nurse #5 said that she heard CNA #2 yell for help because Resident #2 had fallen out of bed. Nurse #5 said she and Nurse #4 went into Resident #2's room and observed that his/her head and shoulders were on the floor and his/her feet were still on the bed. Nurse #5 said she and Nurse #4 lowered Resident #2's feet off the bed onto the floor, did not move his/her head or neck, and noted that he/she had a laceration on the left side of his/her forehead. Nurse #5 said they initiated 911, and Emergency Medical Services (EMS) arrived and transported Resident #2 to the Hospital ED for evaluation. During an interview on 02/07/23 at 1:09 P.M., Nurse #3 said that Resident #2 was at high risk for falls, and that when Resident #2 was in bed, he/she required a fall mat to be placed on the floor next to the left side of his/her bed. Nurse #3 said RNA #1 told her that she had been assisting Resident #2 with drinking his/her shake and she left Resident #2's room to redirect another resident. Nurse #3 said RNA #1 told her that she had not put the fall mat next to Resident #2's bed before leaving his/her room. During an interview on 02/06/23 at 12:15 P.M., Restorative Nurse Aide (RNA) #1 said that on 12/30/22, she was assigned to care for Resident #2, and he/she did not want to get out of bed for dinner. RNA #1 said she folded the fall mat up, put it to the side in the room, and then raised the head of Resident #2's bed. RNA #1 said she placed the bedside table in front of Resident #2, and said she had to raise the height of the bed itself up high enough to get the bedside table under the bed to position it in front of him/her. RNA #1 said while she was assisting Resident #2 with drinking his/her shake, another resident tried to enter his/her room. RNA #1 said she put the shake on the bedside table in front of Resident #2 and went to redirect the other resident out of the room. RNA #1 said when she went back to Resident #2's room she saw him/her lying on the floor. RNA #1 said that she did not put the fall mat on the floor next to his/her bed before she left his/her room. RNA #1 said that she had provided care to Resident #2 several times before, and said she knew that when he/she was in bed that the fall mat was supposed to be on the floor next to his/her bed. RNA #1 said that she did not follow his/her plan of care interventions. During an interview on 02/07/23 at 11:05 A.M., the Director of Nurses (DON) said that Resident #2's plan of care indicated that he/she was a high risk for falls, and required a fall mat to be in place on the floor next to the left side of his/her bed when he/she is in bed. The DON said that RNA #1 did not follow the intervention, per Resident #2's plan of care in order to maintain his/her safety.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was assessed by nursing to be at high risk for falls, had decreased safety awareness, and required the use of a fall mat on the left side of his/her bed when in bed, the Facility failed to ensure he/she was provided with adequate safety measures in an effort to maintain his/her safety to prevent incidents and/or accidents resulting in an injury. On 12/30/22, Restorative Nurse Aide (RNA) #1 who was assisting Resident #2, who was in bed, with dinner time intake, left the room to redirect another resident, leaving him/her unattended. RNA #1 left Resident #2 sitting upright in bed, with the bed in a raised position, and RNA #1 also did not put the fall mat (which she had removed earlier) back on the floor next to the left side of his/her bed before leaving the room. Resident #2 was found by staff, after falling out of bed, with his/her head and shoulders on the floor and his/her feet still on the bed. Resident #2 was noted to be bleeding from his/her forehead, and was transferred to the Hospital Emergency Department ED) for evaluation. As a result of the fall, Resident #2 sustained a contusion to his/her left forehead with an overlying skin tear, an abrasion to the back of his/her head, and a skin tear to his/her left elbow. Resident #2's skin tears were repaired with steri-strips (low profile adhesive strip used for wound support), covered with dressing, and was also noted to have abrasions to his/her left scalp and left shoulder Findings include: Review of the Facility's Policy, titled Fall Protocol, revision date as 11/5/2020, indicated that the resident's environment will be maintained to maximize their safety and wellness and residents will be assessed to determine fall risk using the Morse Fall Scale. The Policy indicated that residents identified as being 'at risk' a plan of safety will be developed, and interventions/ measures will be implemented and the committee will review/update the Care Plan to ensure appropriate interventions are in place. The Policy indicated that the purpose of fall/accident mats is to reduce the severity of the injury of a resident. Review of the Facility's Investigative Report, dated 12/30/22, indicated that at approximately 7:15 P.M., Resident #2 had a fall from his/her bed after the assigned Certified Nurse Aide (CNA) (later identified as Restorative Nurse Aide #1) left Resident #2 sitting in an upright position in bed and did not place the fall mat on the floor next to the left side of his/her bed before she left the room. The Report indicated Resident #2 was found with his/her head and shoulders on the floor and his/her feet still on the bed. The Report indicated that Nurse #4 and Nurse #5 lowered Resident #2's legs to the floor and assessed him/her. The Report indicated that Nurse #3 called 911 and Resident #2 remained on the floor until Emergency Medical Services (EMS) arrived and he/she was transferred to the Hospital Emergency Department (ED) for evaluation. The Report indicated Resident #2 sustained a laceration to his/her forehead and a left elbow skin tear. The Report indicated that both areas that required steri-strips (low profile adhesive strip used for wound support), and that Resident #2 also had abrasions to his/her left scalp and left shoulder. Resident #1 was admitted to the Facility in September 2022, diagnoses Dementia, Alzheimer's disease, Heart failure, Conductive hearing loss, Chronic kidney disease, Urinary incontinence, and Polyosteoarthritis (arthritis that affects five or more joints). Review of Resident #2's Morse Fall Scale, dated 9/01/22, indicated that he/she was assessed by nursing as being a high risk for falls. Review of Resident #2's Fall Risk Care Plan, dated as 9/02/22, indicated that he/she required a fall mat (assistive/safety device) to be placed on the floor next to the left side of his/her bed, when in bed. The Care Plan indicated Resident #2 was at high risk for falls related to confusion, gate and balance problems, poor comprehension, and was unaware of his/her safety needs. Review of Resident #2's Admission Minimum Data Set (MDS) Assessment, dated 9/07/22, indicated that Resident #2 had severe cognitive impairment, with his/her daily decision making noted as severely impaired. Review of Resident #2's Significant Change Minimum Data Set (MDS) Assessment, dated 10/22/22, indicated that Resident #2 had been placed on Hospice Services related to end of life care needs. During an interview on 02/07/23 at 12:00 P.M., CNA #2 said that as she walked by Resident #2's room, she saw him/her lying on the floor and that she called for the Nurses. During an interview on 02/07/23 at 2:26 P.M., Nurse #5 said that she heard CNA #2 yell for help because, Resident #2 had fallen out of bed. Nurse #5 said she and Nurse #4 went into Resident #2's room and observed his/her head and shoulders were on the floor and his/her feet were still on the bed. Nurse #5 said that she and Nurse #4 lowered Resident #2's feet off the bed onto the floor, did not move his/her head or neck, and noted that he/she had a laceration on the left side of his/her forehead. Nurse #5 said that they initiated 911, Emergency Medical Services (EMS) arrived, and Resident #2 was transported to the Hospital Emergency Department for evaluation. During an interview on 02/07/23 at 1:44 P.M., Nurse #4 said when she went into Resident #2's room, she saw that his/her head and shoulders on the floor, his/her feet were still on the bed, and that there was blood on the left side of his/her forehead. Nurse #4 said that she and Nurse #5 assessed Resident #2, and lowered his/her legs onto the floor. Nurse #4 said Resident #2 had sustained a laceration to his/her forehead. Review of a Nurse Progress Note, dated 12/30/22, indicated that the Nurse (identified as Nurse #3) was notified about 7:15 P.M. and was needed immediately in Resident #2's room, when she arrived there were two other Nurses and a Certified Nurse Aide (CNA) in his/her room and noticed Resident #2 on the floor with blood on his/her forehead and he/she said, ooh it hurts, help me up, please. The Note indicated EMS was called for immediate transfer to the Hospital Emergency Department. The Note indicated the first nurse on arrival (Nurse #5) to Resident #2's room, lowered him/her to the floor after noticing he/she was hanging head down and his/her legs were still on the bed, but did not move Resident #2's head until the EMS arrived and applied a neck collar to him/her. During an interview on 02/07/23 at 1:09 P.M., Nurse #3 said that after Resident #2 fell out of bed, in addition to wanting to know why Resident #2's fall mat had not been placed back on the floor beside his/her bed, said she asked Restorative Nurse Aide (RNA #1) why Resident #2's bed was left up in a high position and why the head of his/her bed had been left up when she left him/her unattended. During an interview on 02/06/23 at 12:15 P.M., Restorative Nurse Aide (RNA) #1 said that on 12/30/22, she was assigned to care for Resident #2, and he/she did not want to get out of bed for dinner. RNA #1 said she folded the fall mat up, put it to the side in the room, and then raised the head of Resident #2's bed. RNA #1 said she placed the bedside table in front of Resident #2, and said she had to raise the height of the bed itself up high enough to get the bedside table under the bed to position it in front of him/her. RNA #1 said while she was assisting Resident #2 with drinking his/her shake, another resident tried to enter his/her room. RNA #1 said she put the shake on the bedside table in front of Resident #2, who was seated upright in the bed, and went to redirect the other resident out of the room. RNA #1 said she did not lower the head of Resident #2's bed and said she did not put the fall mat in place on the floor next to his/her bed, before she left his/her room. RNA #1 said that she had provided care to Resident #2 several times before, and said she knew that when he/she was in bed that the fall mat was supposed to be on the floor next to his/her bed. RNA #1 said when she went back to Resident #2's room she saw him/her lying on the floor. Review of a Hospital Emergency Department (ED) Report, dated 12/30/22, indicated that Resident #2 was seen in the ED after an unwitnessed fall out of his/her bed and the left side of his/her head/face struck the ground. The Report indicated that Resident #2 sustained a contusion to his/her left forehead with an overlying skin tear, an abrasion to the back of his/her head, and a skin tear to his/her left elbow. The Report indicated that Resident #2's skin tears were repaired with steri-strips and dressings were placed. Review of a Nurse Progress Note, dated 12/31/22, indicated that Resident #2 returned to the Facility with a laceration to the left side of his/her forehead with a dressing in place. Review of Resident #2's Skin Observation Tool, dated 12/31/22, indicated that Resident #2 had a laceration to the left side of his/her head with small amount of bloody drainage with steri-strips and a bandage in place. During an interview on 02/07/23 at 11:05 A.M., the Director of Nurses (DON) said that RNA #1 was assisting Resident #2 with drinking his/her shake while he/she was in bed. The DON said that RNA #1 left Resident #2 in an upright position with the bedside table in front of him/her and did not place the fall mat on the floor next to his/her bed when she left his/her room. The DON said that Resident #2's plan of care indicated that he/she required a fall mat in place on the floor next to the left side of his/her bed, when he/she is in bed and said that Resident #2 was not provided with appropriate safety measures including ensuring the fall mat was in place in order to maintain his/her safety.

Based on record review, document review, and staff interview, the Facility failed to ensure that for one Resident (#10), of a total sample of 10 Residents, that a dying Resident's pain was adequately assessed and treated with the narcotic [MEDICATION NAME], in accordance with accepted Professional Standards of Nursing practice, a physician's orders [REDACTED]. Findings included: Resident #10 was admitted in ,[DATE] with [DIAGNOSES REDACTED]. According to the most recent MDS, signed as being completed [DATE], the Resident experienced short and long-term memory deficits and severely impaired cognitive skills for daily decision making. The MDS indicated that the Resident was totally dependent for all ADLs (activities of daily living), was incontinent of bowel and bladder, and received scheduled pain medications. Record Review revealed that on [DATE], the Physician ordered a consult for Palliative Care for end of life comfort measures, [MEDICATION NAME] sulfate 1 mg sc (subcutaneously) every 1 hour PRN (as needed) for moderate pain or respiratory distress, and [MEDICATION NAME] sulfate 2 milligram (mg) sc every 1 hour PRN for severe pain or respiratory distress. The Resident's discharge record, and the Facility's investigation of alleged neglect of the Resident's pain, and other actions by the Charge Nurse on [DATE], were reviewed on [DATE] during the Facility's annual recertification survey. The Facility's investigation, dated [DATE], indicated the Charge Nurse failed to properly assess/document the Resident's pain and respiratory status and refused to administer [MEDICATION NAME] sulfate when approached by the family regarding their concern over the Resident being in acute pain/respiratory distress. The investigation indicated on [DATE] at 9:30 P.M., the family returned to the Facility to be with the Resident and requested that the Charge Nurse administer [MEDICATION NAME] sulfate to the Resident due to the Resident's increased restlessness and discomfort. The investigation indicated that the Charge Nurse told two family members that the Resident did not need [MEDICATION NAME] and she refused to administer it. The investigation indicated that the Charge Nurse did not go into the room to assess the Resident. The Charge Nurse brought in a Tylenol suppository sometime around 10:00 P.M. but the administration was not documented on the MAR (Medication Administration Record). The investigation indicated that at 10:15 P.M., a family member arrived at the Facility and requested to speak with the Charge Nurse. The family member asked the Charge Nurse to give the Resident [MEDICATION NAME] sulfate for pain control. The Charge Nurse again refused the family member's request saying the Resident received Tylenol and did not need [MEDICATION NAME] because he/she was not using accessory muscles and she would not give any medication. The investigation indicated the Charge Nurse refused to call the Physician when requested by the family member. The Charge Nurse refused to call the Resident's Physician and told the family member, the phone is right there, you can call the doctor. The investigation indicated that a CNA (certified nursing assistant) on duty at the time asked the family member what the problem was. The family member said, I feel my dying (family member) is suffering and not getting the care he/she needs. The Charge Nurse told the family member that the Resident did not need [MEDICATION NAME] because she was not in distress. There was no documented evidence that the Charge Nurse went into the Resident's room to assess his/her pain level or clinical status. The Facility investigation indicated that more verbal exchanges occurred between the family member and the Charge Nurse, at which time the Charge Nurse yelled at the family member to stop questioning her nursing judgment. The Charge Nurse reportedly kicked the family member out of the nurses station. The family member said to the Charge Nurse, I am the patient's family member; I should call the cops. The family member went back to the Resident's room. Another family member then went to the nurse's station to speak to the Charge Nurse about pain control for the Resident. The investigation indicated that the Charge Nurse ignored the other family member's request for pain control. Again, there was no evidence that the Charge Nurse went back to the Resident's room to assess the Resident, or to address the other family member's concern over the Resident's pain, and request for pain medication. The investigation indicted the other family member then called the Acting DON (Director of Nursing). The Acting DON instructed the other family member to contact the Resident's Physician, which she did. The Physician told the other family member that she would call the Charge Nurse. The investigation indicated that the Police arrived to the Facility and informed the family member that the nursing staff had requested she be removed from the building. The Police advised the family that the Resident may get better care if he/she went to the Hospital. The investigation indicated that the family decided to transfer the Resident to the Hospital since they had lost confidence in the Facility's ability to provide adequate care to the Resident. The investigation also indicated that from the time the two family members arrived at 8:20 P.M., until 12:00 midnight, a CNA did not come to help with the care of the Resident. Review of the MAR on [DATE], revealed that no Tylenol or [MEDICATION NAME] sulfate were administered on [DATE]. On [DATE] from 3:00 P.M. to 7:00 P.M., the nurse on duty prior to the Charge Nurse wrote, Significant Change in condition, ,[DATE] % (oxygen saturation) on RA (room air). 2 liters per minute oxygen initiated with oxygen saturation over 92%. PR (per rectum) [MEDICATION NAME] given per MD order [MEDICAL CONDITION] vs. muscle rigidity/spasm. The Nursing Supervisor and Administrator were made aware of the Resident's condition by the nurse. The nurse wrote that at that time the family were not willing to add [MEDICATION NAME] or [MEDICATION NAME] to the plan of care. On [DATE] to [DATE] from 7:00 P.M. to 7:00 A.M., the Charge Nurse wrote that Tylenol 650 mg suppository was administered at 9:30 P.M. for a temp of 99 and congestion. The Charge Nurse wrote that increase request for [MEDICATION NAME] denied d/t (due to) no s/sx (signs or symptoms) of use of accessory muscles, increase respiratory rate, adventitious breath sound or facial grimacing. The Charge Nurse failed to document what time she assessed the Resident, whether additional clinical assessments were performed, the Resident's vital signs, to include the Resident's respiratory rate, oxygen saturation, use of oxygen, mental status, skin color and appearance, or other signs and/or symptoms of pain or respiratory distress typically performed by a nurse during an assessment for pain and/or respiratory status. The investigation indicated that on [DATE] at 12:20 A.M., the Resident was transferred to the local hospital where he/she was assessed with [REDACTED]. The Resident was given a [MEDICATION NAME] (used to decrease oral secretions) and administered [MEDICATION NAME]. The Resident expired at the Hospital on [DATE]. Interview with the Administrator on [DATE] at 1:30 P.M., confirmed that the Charge Nurse was terminated for her actions on [DATE] and [DATE], and for not following multiple Facility Policies, including her failure to provide adequate assessment, pain control/nursing care to the Resident, and for failing to show care and [MEDICATION NAME] to the dying Resident's family.

Based on interviews, records reviewed and observations, the Facility failed to ensure water temperatures in resident shower rooms was maintained at a safe level. On 6/1/16, following a shower, Resident #1 was observed to have a reddened area from his/her hairline to right brow area. On assessment, Resident #1 was found to have a 1 centimeter (cm) circular open area, on the right side of his/her forehead and a 1 cm open area above his/her right brow. Resident #1 required treatment of [REDACTED]. Findings Include: Resident #1 was admitted to the Facility in July 2010, with a medical [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 4/20/16, indicated Resident #1's Brief Interview for Mental Status (BIMS) denoted Resident #1 was severely cognitively impaired, had long and short term memory deficits and was rarely understood. The MDS indicated Resident #1 required total dependence of one staff person for bathing. Resident #1 was unable to be interviewed due to impaired cognition. The Facility Resident Incident/Accident Report, dated 6/1/16 and timed at 10:30 A.M., indicated following Resident #1's shower, his/her forehead was observed from the hairline to the brow, to be very red. The report indicated Resident #1's scalp and remainder of his/her face was within normal limits. The report indicated Resident #1 had a 1 cm circular open area noted on the right side of his/her forehead (top layer of skin) and also a 1 cm open area above Resident #1's right brow. The Resident Incident/Accident Report indicated the incident occurrence type was classified as a burn. A Nurse Progress Note, dated 6/1/16, indicated as Certified Nurse Aide (CNA) #3 was pushing Resident #1 in the wheelchair through the hall, Nurse #1 observed Resident #1's forehead area was reddened, and observed two 1 cm circular abrased areas. Nurse #1 observed one abrasion above Resident #1's right eyebrow, and one abrasion on the right side of his/her mid forehead. The Surveyor interviewed Nurse #1 at 12:05 P.M., on 11/10/16. Nurse #1 said, and her undated signed witness statement indicated, that on 6/1/16, she observed Resident #1's forehead was very red, and warm to touch. Nurse #1 said that on assessment, Resident #1 was found to have two 1 cm circular abrased areas, one above Resident #1's right eyebrow and one on the right side of his/her forehead. The Surveyor interviewed CNA #3 at 10:45 A.M., on 11/16/16. CNA #3 said, and her witness statement, signed and dated 6/1/16, indicated she entered the shower room to assist CNA #1 and CNA #2 with Resident #1. CNA #3 said Resident #1's shower was complete and Resident #1 was dressed. CNA #3 said she observed an area over Resident #1's right eye which appeared to be red and circular and Resident #1's forehead appeared to be red. The Surveyor interviewed CNA #2 at 11:15 A.M., on 11/15/16. CNA #2 said, and her witness statement, signed and dated 6/4/16, indicated as she entered the shower room to assist CNA #1 dress Resident #1, she observed a very red area on Resident #1's forehead that appeared to be missing skin, or words to that effect. The Surveyor was unable to interview CNA #1 despite attempts to contact her via telephone calls and letter. CNA #1's Resident Incident/Accident Report, signed and dated 6/1/16, indicated she observed that Resident #1's face was red after she completed Resident #1's shower but did not observed Resident #1 with any type of reddened areas on his/her forehead. CNA #1's statement indicated Nurse #2 had completed Resident #1's weekly skin check during Resident #1's shower and was assessed with [REDACTED]. The Surveyor interviewed Nurse #2 at 11:03 A.M., on 11/10/16. Nurse #2 said, and her witness statement, signed and dated at 9:30 A.M., on 6/1/16, indicated that on 6/1/16, she assessed Resident #1 during his/her shower for weekly skin assessment, and did not note any skin issues. Nurse #2 said that approximately 30 minutes after completing Resident #1's weekly skin assessment, Resident #1 was seated in the wheelchair at the Nurses' station. Nurse #2 said she was asked by Nurse #1 to assess the reddened areas noted on Resident #1's forehead and entered the additional assessment information on Resident #1's Treatment Record. Review of the Facility's Domestic Hot Water Logs from 3/24/16 through 11/3/16, indicated water temperatures were checked every 5 to 7 days and the water temperatures on the resident units ranged between 97 degrees Fahrenheit (F) to 106 degrees Fahrenheit F. The Surveyor interviewed the Plant Supervisor at 12:30 P.M., on 11/10/16. The Plant Supervisor said the Facility monitored and maintained a domestic hot water log for temperatures on the resident units. The Plant Supervisor said each shower room had a temperature valve connected to the shower which was monitored and adjusted by staff as needed during showers to maintain the appropriate water temperature. The Plant Supervisor said although he was aware the safe temperature range for hot water was between 100 degrees F to 110 degrees F, the shower water temperatures varied. The Plant Supervisor said the Facility had an old heating and boiler system and the hot water temperatures in the showers could vary, and reach as high as 120 degrees F. The Plant Supervisor said Resident #1 was showered in the East Wing shower room on the day of the incident. The Plant Supervisor was unable to provide the Surveyor with any domestic hot water logs for monitoring of resident shower rooms. At approximately 12:55 P.M., the Surveyor and the Plant Supervisor proceeded to the resident units to check hot water temperatures. The water temperatures were checked on each resident unit in various resident bathrooms and both resident shower rooms. The water temperatures in the resident bathrooms registered between 104 degrees F and 105 degrees F. The water temperatures registered in both resident shower rooms between 110 degrees F (West Wing) and 117 degrees F (East Wing). The Surveyor interviewed the Director of Nurses at 9:40 A.M., and throughout the day on 11/10/16. The Director of Nurses said, and the Incident Report Form filed with the Massachusetts Department of Public Health, dated 6/7/16, indicated Resident #1's injuries were result of being burned in the shower. The Director of Nurses said the Facility internal investigation indicated Resident #1 received some type of burn in the shower as water temperatures vary and the staff need to watch and adjust the water, or words to that effect.

Based on record review, interview with staff and observation, the facility failed to follow safety interventions to ensure, for 1 sampled resident (#4), from a total sample of 10, to avoid falls and prevent accidents. Findings include: For Resident #4, the facility failed to ensure the plan of care clearly identified all devices and interventions for fall prevention and that interventions were consistently implemented for this resident at high risk for falls. The medical record was reviewed on 4/23/14 at 11:40 A.M. Record review of Resident #4 includes [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment completed on 2/23/14, indicates the resident is alert, oriented with cognitive limits, and memory losses, with mood indicators, and requires assistance from staff for dressing, bathing, and toileting. The resident requires limited assistance with transfers and ambulation. The MDS indicates the resident has pain issues, experienced falls with injury, uses a walker device and has no restraints. The plan of care with a revision date of 9/19/13, that addressed the resident's fall risk and potential for injury, impulsiveness and lack of safety awareness, included the following interventions: - Educate as needed safety awareness/orient resident to room; - Remind to use the call light if resident wants to get up, tends to forget; - Keep call light and frequently used items in close proximity/reach; ask if resident needs anything before leaving room; Anticipate needs, especially toileting to reduce attempts to rise on own; - Keep well fitting shoes or gripper socks on feet when ambulating; keep room clutter free; - Toilet frequent and regular intervals, ambulate with assist, gait belt and rolling walker to all destinations. A review of the nurses' notes indicated the resident had several falls without injury. - On 12/6/13 the resident's knees buckled during ambulation with staff. - On 12/10/13, the resident's alarm in the room sounded and staff responded to find that the resident had disconnected the alarm, and was seen walking unsteadily and fell toward staff who was able to break the fall. -On 12/20/13, the resident attempted to stand after removing shoes while in the bathroom and sat on the floor. After the above falls the resident's plan of care for fall prevention was updated in December 2013 and indicated that alarms (personal, bed and chair sensors, and motion sensors) were in use as interventions and that the alarm devices had been altered or removed by the resident despite staff attempts to rearrange the locations and keep out of reach to avoid detachment. The resident's fall assessment dated [DATE], indicates the resident is a high (greater than 16 points) risk for falls with a score of 22 points. The resident prefers to spend time in his/her room. Safety interventions include the use of a personal infrared laser sensor (PIR) alarm to alert staff when the resident rises up from a his/her chair in the room, or motions toward the bathroom or door way exit. Floor mat beside the bed and a bed sensor alarm were also in use. Although the resident's written plan of care did not clearly identify the fall mat or bed sensor as devices in use, these items were included on the Quarterly 2/13/14 Safety/Restraint Tool. A review of the nurses' note dated 2/25/14, indicates safety meeting concerns of the resident's ambulation ability, frequency of toileting needs and increased fall risk. New approaches were added to address the resident's voiding pattern and to provide restorative ambulation. An important quality of life goal was to allow the resident to ambulate in his/her room with a walker and a PIR sensor alarm to alert staff for assistance in the event the resident forgets to call for help. The additional intervention of a personal infared (PIR) laser alarm, affixed to the wall to alert staff when the resident attempts to rise, self transfer or walks toward the door or enters the bathroom. After a loss of balance on 3/5/14, while ambulating toward the bathroom, innovative wall grab bars were installed near the resident's room chair and outside the bathroom. The fall prevention plan of care was revised to include the wall grab bars. A review of the nurses' note of 3/19/14, indicates the resident had a fall which required medical treatment for [REDACTED]. Documentation of the incident report indicated the resident was transported to the living room area for an activity and socialization. The incident documentation indicated other residents, a volunteer and activity staff were present at the time the nurse aide escorted and left the resident in the living room. The activity staff person left the room to go to a nearby office, and during that time Resident #4 got up out of his/her seat and walked around the immediate corner out of the living room area and fell backwards hitting his/her head. There was no alarm and no staff present at the time of the fall. The resident was transferred to the emergency room for treatment. Hospital discharge report of 3/19/14 indicates the resident was treated for [REDACTED]. The resident returned to the facility. Review of this fall incident investigation indicates that staff failed to follow established care interventions to use an alarm on the chair, when out of the resident's room and left unsupervised. Review of the (undated) Nurse Aide Care Card on 4/23/14 incorrectly indicated the resident as a low fall risk and not a high risk as assessed. The care card indicated the use of a chair alarm and this was not followed at the time of the fall on 3/19/14. During the tour of the facility on 4/22/14 at 8:30 A.M., the resident was observed seated in his/her room in a comfortable chair, resting. The Charge Nurse explained the laser (PIR) alarm system attached to the wall/door area that would sound if the resident motioned or attempted to stand up from the chair. On 4/23/14 at 7:30 A.M., the resident was observed in a wheelchair during breakfast in the dining room with a personal alarm attached to the chair and a seatbelt which was released during this observation. Staff was present and the resident was in a supervised setting. Interview on 4/24/14 at 12:10 P.M., the Director of Nurses' said that after the resident's 3/19/14 fall, an investigation was completed and staff were provided with re-education on fall safety for this resident.