Every finding on record at Spaulding Nursing and Therapy Center - Brighton

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically, the facility failed to ensure medication carts were locked while a nurse was not present. Findings include: Review of the facility policy titled Medication Storage, dated revised 8/2/24, indicated that carts, cabinets and other areas containing medications must be kept locked at all times when not in use. Further review indicated that all medications on the nursing units are stored securely in the med (medication) carts. On 3/11/25 at 7:42 A.M., the surveyor observed a medication cart unlocked and unattended in the hallway of the 2nd floor nursing unit. At 7:44 A.M., Nurse #1 arrived at the medication cart and said she was not aware the cart was unlocked and then locked it. On 3/11/25, at 8:33 A.M. the surveyor observed a medication cart open on the second floor. The surveyor was able to access the medication cart and open the drawers. The surveyor also observed several nurses and other staff members down the hall, not paying attention to the medication cart with the drawer wide open. The surveyor observed 2 staff members walk towards the medication cart, look at the open drawer, and then enter resident's rooms to deliver food trays. During an interview on 3/11/25, at 8:38 A.M., Unit Manager #1 said the medication cart was not supposed to be unlocked. During an interview on 3/11/25 at 8:42 A.M., Nurse #2 said she should not have left the medication cart open and should have locked it when she left. On 3/12/24 at 12:19 P.M. the surveyor observed a medication cart unlocked on the 2nd floor and unattended and accessible to others in the area. The nurse exited a resident room, walked down the hallway, passed the cart and went behind the nurse's station. The medication cart was equipped with an automatic locking mechanism which engaged at approximately 12:21 P.M. During an interview on 3/12/25, at 1:30 P.M. the Director of Nursing said that some of the medication carts are equipped with a timer that automatically lock the cart after 4 minutes of being idle.

Based on record review and interview, the facility failed to ensure that an as needed (PRN) order for psychotropic medication was limited to 14 days for one Resident (#7) out of a total sample of 20 residents. Findings include: Review of facility policy titled 'Procedure for Psychotropic Consent' dated February 2017, indicated the following but not limited to: -PRN (as needed) orders for psychotropic medications which are not for antipsychotic medications are limited to 14 days, unless the attending physician/prescribing practitioner documents a rationale to extend the medication. Resident #7 was admitted to the facility in October 2017 with diagnoses including anoxic brain damage. Review of the current physician order indicated the following: -Date modified 2/18/25, Lorazepam (ativan) tablet 0.5 mg (milligram). Give one tablet by gastrostomy tube route three times a day as needed for anxiety/agitation. Review of the pharmacy recommendation dated 3/5/25 indicated the following:' Please evaluate the continued need for this medication. A rationale could not be located on the progress note. If it is to be extended please document the rationale for the extended time period in the medical record and indicate specific duration. Review of the Nurse Practitioner note dated 3/11/25 indicated the following: Recommendations reviewed and no changes made based on the following rationale: LT (Long Term) care patient -using for agitation with good effects. Review of the Nurse Practitioner note failed to indicate a specific duration for the PRN Lorazepam. Review of the Medication Administration Record indicated the Resident had received the Lorazepam 17 times from 2/19/25 through 3/11/25. During an interview on 3/12/25 at 10:23 A.M., the Director of Nursing said PRN psychotropics should have a 14 day stop date.

Based on observation, interview and policy review, the facility failed to ensure a resident was assessed for the ability to self-administer medications, failed to observe a resident take prescribed medication, and left the medication at the bedside, unsecured. Findings include: Review of the facility policy Medication Administration dated 5/28/24, indicated: - Observe the patient taking the medication and no medications are left at bedside. On 3/11/25 at 8:46 A.M., the surveyor observed a resident in his/her room sitting in a chair located in front of a breakfast tray. On the tray was a medicine cup which contained 8 pills of various sizes and colors. The Resident said that about five minutes ago a nurse left the medicine on his/her breakfast tray and then left the room. The Resident said that some nurses watch him/her take the medication while others leave the medication on the tray for him/her to take later. Review of the resident's medical record indicated he/she had not been screened for medication self-administration and did not have a physician's order to self-administer medications. During an interview with the Nursing Supervisor on 3/12/25 at 9:30 A.M., she said the resident did not have an order for medication self-administration. The Nursing Supervisor said nurses are not allowed to leave medications unsecured in resident bedrooms.

Based on observation, record review and interview the facility failed to implement a treatment order timely for an identified pressure injury for one Resident (#184), out of a total sample of 20 residents. Specifically, for Resident #184, a treatment order was not implemented until 72 hours after the facility first identified his/her pressure injury. Findings include: Review of the facility's Skin and Wound Care Policy, with a current revision date 3/4/2025 includes but is not limited to the following: Purpose: to outline how skin assessment and wound care is delivered safely and effectively within the facility. Policy Statement *Two nurses will provide a comprehensive skin assessment for all patients on admission ('four eyes skin check). *Comprehensive skin assessments will be completed a minimum once per day. Any undocumented or worsening pressure injuries, atypical, deteriorating or otherwise clinically concerning wounds warrant an order for IP Consult to Wound Nurse. *A validated tool to assess the risk of pressure ulcer development will be utilized to help determine treatment and preventative interventions. (Braden/Braden Q) *All pressure injuries will be categorized on admission by the wound care nurse or the designee using National Pressure Injury Advisory Panel staging system (NPIAP 2016) Review of the National Pressure Injury Advisory Panel (NPIAP) indicted the following definition for a Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Resident #184 was admitted to the facility in February 2025 and has diagnoses that include but not limited to failure to thrive in adult, rheumatoid arthritis, pneumonia, and breast cancer. Minimum Data Set Assessment information was not available at the time of survey for Resident #184. Review of the Brief Interview for Mental Status Exam, dated 3/2/25 indicated Resident #184 had a score of 13 out of 15, indicating he/she has intact cognitive status. Further review of the medical record indicated Resident #184 requires partial to moderate assistance from staff for toileting hygiene and supervision/touching assistance with dressing, and receives enteral nutrition (tube feeding, a way of providing nutrition directly into the gastrointestinal tract through a tube). Review of the Braden Scale for Predicting Pressure Injury Risk dated 2/27/25 indicated Resident #184 had a score of 17, which indicates he/she as being mild risk for developing a pressure injury. During an observation and interview on 3/11/25 at 8:32 A.M., Resident #184 was sitting up in a chair. Resident #184's bed was equipped with an air mattress. Resident #184 said he/she has a wound on his/her buttock and that he/she did not come in with it. Review of the LDA (Lines/Drains/Airways - a field in the electronic health records) and wounds flowsheets indicated the following: Wound Pressure Injury date first assessed 2/28/25 primary wound stage 2 PI (pressure injury), present on admission, location left buttocks, Wound description Stage 2 PI. Review of the physician's orders indicated: Daily dressing to left buttocks PI, cleanse with normal saline and pat dry, cover with TRIAD hydrophilic wound dressing apply in a dime-thickness and cover with bordered dressing. Do not scrub old Triad off with force, just cleanse with gray bath wipes and if doesn't all have to be removed prior to reapplying, change daily, initiated 3/3/25. The physician's orders indicated a treatment was not implemented for Resident #184's pressure injury until 3/3/25; three days after it was first identified. Review of the facility's incident report, titled Event: Skin/Tissue, dated 3/3/25 indicated the event occurred on 2/28/25. Event type Pressure Ulcer. Objectively describe the event: On 3/3/25 I was asked to review a 2nd day skin check photo of patient has a pressure injury (sic) small stage 2 PI noted on left buttocks. Actual Ulcer Stage, Stage 2, Ulcer Location: Left buttocks. Where was ulcer acquired? Noted on admission. During an interview on 3/12/25 at 9:22 A.M., Nurse #3 said the order for Resident #184's pressure injury was put in place on 3/3/25 and that there was no other treatment to the pressure injury prior to 3/3/25. During an interview on 3/12/25 at 9:28 A.M., Charge Nurse #1 said Resident #184 is at risk for developing pressure ulcers due to poor appetite and is on enteral feeding. Charge Nurse #1 reviewed Resident #184's medical record and said Resident #184 has a left buttock pressure injury. Charge Nurse #1 reviewed the record and said the Pressure injury on Resident #184's left buttock was identified on 2/28/25. Charge Nurse said there was no measurement of the wound, but it was noted as a Stage 2 Pressure injury. Charge Nurse #1 said when a pressure injury is identified the wound nurse is made aware, the MD (medical doctor) is notified, and a treatment is obtained. Charge Nurse #1 said a treatment for Resident #184's wound did not get placed until 3/3/24, three days after the pressure area was identified. During an interview on 3/12/25 at 9:53 A.M., Unit Manager #1 said a treatment for a pressure injury should be in place when it is identified. During an interview on 3/12/25 at 10:05 A.M., the Wound Nurse, said she did not see the resident's pressure injury and that if the area was identified on 2/28/25 that the provider should have been notified, and a treatment order should be obtained, and should not have waited until 3/3/25. During an interview on 3/12/25 at 10:17 A.M., the Director of Nursing said a treatment order should have been obtained for the pressure injury when it was identified.

Based on observation and interviews, the facility failed to ensure infection control practices were maintained to prevent spread of infection during medication pass. Findings include: During medication pass observation on 3/12/25 at 8:40 A.M., on the 3rd floor unit. Nurse #2 was observed touching pills with her bare hands as she poured the medications from the blister pack and the bottles. During an interview on 3/12/25 at 8:56 A.M., Nurse #2 said she was touching the pills with her bare hands because she had sanitized her hands. During an interview 3/12/25 at 9:44 A.M., the Infection Control Nurse said nurses should not touch medications with bare hands during medication administration.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure staff implemented and followed their abuse policy, when on 2/29/24 Certified Nurse Aide (CNA) #2 reported Resident #1's allegation that someone had hurt him/her a couple days ago at the facility to Nurse #1, however Nurse #1 did not report the allegation to the Executive Director, Director of Nursing or designee, per Facility policy. Administrative Staff were not made aware until 3/04/24, of Resident #1's allegation. Findings include: Review of the Facility's Abuse Policy, revised dated 05/16/18, indicated that all employees will identify events, such as but not limited to suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse, immediately report them and the Executive Director, Director of Nursing or designee will determine the direction of the investigation. This also includes resident to resident abuse. A. Anyone who witnesses an incident of suspected abuse which includes unauthorized photographs of residents that has been taken, kept, and/or distributed on social media or transmitted through multimedia messaging by staff, neglect, involuntary seclusion, or misappropriation of resident's property is to tell the abuser to stop immediately and is to report the incident to a supervisor immediately. Resident #1 was admitted to the Facility in August 2023, diagnoses included coronary artery disease, chronic obstructive pulmonary disease, pulmonary embolism, and rectal cancer. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 01/22/24, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), was able to make his/her needs know, was his/her own decision maker, and was dependent on staff for mobility and activities of daily living. Review of the Facility's Internal Investigation, dated 03/04/24, indicated that CNA #2 reported to Nurse #1 on 2/29/24 that Resident #1 had told her that someone had hurt him/her a couple of days ago at the facility. The Investigation indicated that a telephone interview with Nurse #1 was conducted on 03/04/24 by the Director of Nursing (DON), and during the interview Nurse #1 confirmed that CNA #2 had told her about Resident #1's allegation. The Investigation indicated Nurse #1 went to speak to Resident #1 and he/she reported that someone hurt him/her, and that Nurse #1 told Resident #1 that she would tell the doctor. The Investigation indicated that DON told Nurse #1 that she should have immediately reported the allegation, per the facility abuse policy and training. During an interview on 03/19/24 at 1:00 P.M., CNA #2 said on 02/29/24 while providing him/her care, Resident #1 had told her that someone had hurt him/her a couple of days ago at the facility. CNA #2 said she immediately reported what Resident #1 told her to Nurse #1, who was the nurse assigned to care for Resident #1 that day. During a telephone interview on 03/21/24 at 3:10 P.M., Nurse #1 said that she was no longer an employee at the Facility and declined to be interviewed by the Surveyor. During an interview on 03/19/24 at 12:50 P.M., the Director of Nursing (DON) said their Investigation findings concluded that Nurse #1 had failed to report an alleged incident of CNA #1 being inappropriate with a resident while providing care immediately, per facility policy. The DON said Nurse #1 had not followed the Facility's Abuse Policy. On 03/19/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was immediately assessed for any sign of injury or distress, none were noted, staff provided support and will continue to do so as needed. B. 03/04/24, all residents on CNA #1's assignment were immediately assessed and were asked if there were any other concerns related to care and/or treatment provided by CNA #1. C. 03/04/24 through 03/18/24, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) completed house-wide staff re-education and training on the Facility's Abuse Policy, which included reporting immediately. D. Area of concern presented at the facility's monthly Quality Assurance Performance Improvement (QAPI) Committee Meeting. It will continue to be reviewed by the committee monthly to ensure substantial compliance. E. The facility terminated CNA #1's employment. F. The Administrator, the Director of Nursing, and/or their designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure he/she was provided adequate supervision to maintain his/her safety to prevent an incident/accident resulting in an injury. On 11/27/22 during the overnight shift, the nurse applied a hot pack to Resident #1's abdominal area, however, the nurse did not follow hot pack instructions when she applied it to Resident #1, and Resident #1 was left unattended with the hot pack in place. When the nurse returned to remove the hot pack, Resident #1 was found to have a second degree burn (burn that affects both the outer and underlying layer of skin, they cause pain, redness, swelling and blistering) to the mid- lower quadrant of his/her abdomen. . Findings include: Review of the Facility Policy titled, Applying a Commercial Dry Heat Pack, dated August 2022, indicated the following; -consult the manufacturer's instructions before applying the dry heat pack; -position the resident as appropriate to ensure that the treatment area is accessible; -apply the dry heat pack to the treatment area as indicated by the practitioner or manufacture; and -monitor the condition of the skin and assess for redness and discomfort in the treatment area. Review of the Facility's Chemical Medi-Choice Hot Pack, undated, indicated the following; -place hot pack in sleeve or wrap in towel to avoid direct contact with the skin; -supervise children and the elderly during use; -peak temperatures may reach 120 degrees once activated; -do not apply to patients with circulatory problems unless prescribed by a physician; and -do not use with sensory impaired patients. Resident #1 was admitted to the facility in November 2022, diagnoses included diabetes mellitus, lower extremity weakness with neuropathic pain, falls, and urinary retention with an indwelling catheter (tube inserted into the bladder to drain urine) in place. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/27/22, indicated that at 3:30 A.M., Resident #1 was administered a single use hot pack to his/her abdomen in attempt to assist him/her to urinate. The Report indicated that Resident #1 sustained a second degree burn with blisters to the lower quadrant of his/her abdomen from the application of the hot pack by the 11:00 P.M. to 7:00 A.M. (overnight shift) nurse. The Report indicated that the nurse left Resident #1 on the toilet to get the bladder scanner and an indwelling catheter kit. The Report indicated that the nurse found the burn at 3:40 A.M. The Report indicated that the there was no indication to apply a hot pack to Resident #1 to assist with urinary retention, that the resident must have a physician's order to use a hot pack, and that the nurse must monitor and assess the area before, during and after the application of a hot pack. During an interview on 12/19/22 at 1:10 P.M. (and review of her written witness statement dated, 11/28/22), Nurse #1 said Resident #1 was having difficulty urinating and failed previous voiding trials. Nurse #1 said she was trying to think of anything that might help him/her urinate without having to re-insert an indwelling Foley catheter again. Nurse #1 said she did not realized Resident #1 did not have a Physician's Order for a hot pack and she said she did not pay attention to the rules. Nurse #1 said while Resident #1 was on the toilet, she got a hot pack, placed it in the bunched-up material from his/her house gown, and left Resident #1 in the bathroom to get the bladder scanner and a new indwelling catheter insertion kit. Nurse #1 said when she returned to Resident # 1, the hot pack was directly on his/her abdominal area. Nurse #1 said the area was already pink. Nurse #1 said by the time she got Resident #1 back into bed, performed the bladder scan, and re-inserted his/her indwelling catheter, that his/her abdominal area was red and blistering. Review of Resident #1's Physician Progress Note, dated 11/17/22, indicated he/she had erythema (reddening of the skin) four by six centimeters (cm) and a 1.5 cm by 2 cm blister with clear contents in the middle of the erythematous area. Review of Resident #1's Physician Orders, dated 11/27/22 through 12/10/22, indicated to apply Silver Sulfadiazine (a topical antibiotic used to treat and/or prevent infection to second and third degree burns) one percent (%) daily, topically (on the skin) to suprapubic wound. Review of Resident #1's Treatment Note, dated 12/09/22, indicated the application of the Silver Sulfadiazine was completed by nursing and his/her abdominal area continued to be pink and fragile at that time. During an interview on 12/19/22 at 11:36 A.M., the Unit Manager said she had interviewed Resident #1 on 11/28/22, about the use of the hot pack. The Unit Manager said she asked Resident #1 if Nurse #1 educated him/her on the use of the hot pack and that Resident #1 said no. During an interview on 12/19/22 at 3:45 P.M., the Director of Nurses said Nurse #1 did not have a Physician's Order to apply a hot pack to Resident #1's abdomen. The DON said it is the expectation of the Facility that all treatments provided to Residents have a Physician's Order, any use of heat or cold pack that there is a barrier placed between the skin and the pack, the nurse should educate the Resident on the use of the pack, remain with the resident, and frequently check the affected area for any adverse reactions. On 12/19/22, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidence by; A) On 11/27/22 Resident #1 was immediately assessed by Nurse #1 after removing the hot pack, Resident #1's Physician was notified, treatment orders were provided, and administered. B) On 11/27/22 through 12/02/22, the DON re-educated all nursing staff on the proper use of hot packs including; -Physician or Nurse Practitioner Order must be present and treatment is to only be performed by a licensed nurse or therapist; -Do not leave a resident unattended while using a hot pack if the resident has cognitive or sensory deficits; -Ensure there is a barrier between the hot pack and the residents skin, such as a towel or pillowcase; -Educated the resident not to place the hot pack directly onto the skin; and -Monitor the skin under the hot pack frequently during the treatment. C) On 11/29/22, a Facility wide audit was conducted by the Nurse Directors (equivalent to Unit Managers) to ensure all resident utilizing a hot pack had a Physician's Order in place. D) Weekly, the Nurse Directors will complete audits of five resident medical records. Any resident with a hot pack order will be assessed by the Nurse Director for proper use of the hot pack. E) Nurse Directors will survey nursing staff, once per week to determine if any resident is receiving heat therapy and will review the medical record to ensure a Physician's Order is in place. F) Any non-compliance or opportunity for education will be addressed immediately by the Nurse Directors. G) Audit results will be reported to the DON or designee weekly and brought to Quality Assurance and Performance Improvement (QAPI) meeting monthly until 100 percent compliance is achieved for three consecutive months. H) The Director of Nurses and/or designee is responsible for to report findings to the QAPI committee. I) The Director of Nurses and/or designee is responsible for overall compliance.

Based on observation, interview and record review the facility failed to ensure that one Resident (#211) was free from the use of a restraint out of a total 16 sampled residents. Findings include: The facility policy titled Restraint Management, revised 12/19/19, indicated the following: * Non-Violent/Non-Self-Destructive Restraint)is defined as any manual method, physical or mechanical device, equipment, or material that meets all the following criteria: - Is attached or adjacent to the resident body; - Cannot be easily removed by the resident; and - Restricts the resident's freedom of movement or normal access to his/her body. * Non-Behavioral Restraints require an individual order by a Licensed Independent Practitioner (LIP). * A non-behavioral restraint is used only after an assessment is completed, the interdisciplinary team discusses least restrictive options including alternatives to restraints. * Care plans will be updated to reflect restraint intervention and any reduction strategies. Resident #211 was admitted to the facility in September 2021, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 10/3/21, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #211 scored a 4 out of a possible 15 indicating moderately impaired cognition. The MDS further indicated Resident #211 had no behaviors, and did not use a restraint. During an observation on 10/26/21 at 7:56 A.M., Resident #211 was observed in bed with pillows pushed under the sheets on both sides of Resident #211's body. Resident #211's legs were hanging over the left side of the bed. During an observation on 10/27/21 at 7:26 A.M., Resident #211 was observed in bed with pillows stuffed under sheets on both sides of Resident #211's body. Resident #211 was attempting to throw his/her legs over the left side pillows and his/her legs were dangling off the left side of the bed. Resident #211 was not interviewable and when asked how he/she was doing, the Resident only responded it's hard as he/she moved his/her legs up and down over the pillows on the left side of the bed . Resident #211 could not explain further what was hard. During a record review on 10/27/21 at 8:06 A.M., the record failed to indicate: * an order for [MEDICAL RECORD OR PHYSICIAN ORDER] * Documentation in the clinical notes indicating a restraint had been considered by the interdisciplinary team; * A restraint assessment for the use of a restraint. * A care plan regarding the use of a restraint. During an interview on 10/27/21 at 9:24 A.M., Resident #211's Personal Care Attendant (PCA) #1 said that she was responsible to care for Resident #211. According to PCA #1, Resident #211 was always trying to get out of bed when he/she was in bed. PCA #1 said we have the pillows under the sheets, to stop him/her from getting out of bed and falling. During an interview on 10/27/21 at 9:57 A.M., Nurse #1 said that she was aware that the staff put pillows under the sheets to prevent Resident #211 from getting up out of bed and from falling and that is sort of like a restraint. Nurse #1 said that a restraint assessment should have been completed and she reviewed Resident #211's record but could not find one. Nurse #1 said that Resident #211's most recent fall risk assessment also do not indicate that a restraint was used. During an interview on 10/27/21 at 10:09 A.M., the Director of Nursing (DON) explained her expectation regarding the use of a restraint: * The completion of an interdisciplinary assessment in the medical record; * Obtaining an order for [MEDICAL RECORD OR PHYSICIAN ORDER] * Nurses are to document at the end of each shift that they've checked on the resident every two hours. The DON further said in this case a restraint assessment should have been done, because by Resident #211 throwing his/her legs over the pillows he/she was demonstrating he/she wanted to get up.

Based on observations, interview and facility policy review, the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases including COVID-19 by failing to (1.) perform hand hygiene when indicated on three of three patient units (2.) remove gloves and perform hand hygiene prior to exiting a patient room and (3.) keep soiled items off of the floor in communal corridors. Findings include: The facility policy titled Hand Hygiene, reviewed 11/15/21, indicated: * Perform hand hygiene before and after contact with equipment or other items in the patient's room. * Perform hand hygiene before and after using gloves. Review of the Centers for Disease Control (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: *Hand Hygiene-Health Care Personnel (HCP) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. *Put on clean, non-sterile gloves upon entry into the patient room or care area. *Change gloves if they become torn or heavily contaminated. *Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. On 1/27/21 at 8:30 A.M., during an initial interview with the facility's Director of Nursing (DON), Executive Director (ED) and the Infection Preventionist Nurse (IPN) they said: * The facility was admitting patients to the facility that are COVID-19 positive. * The facility was primarily comprised of short term rehabilitation patients. All patients that were admitted were placed on a COVID-19 14 day admission quarantine. A sign outside their room indicated the date that their quarantine would be completed. * The most recent COVID-19 positive case was on 1/19/21. * The facility was testing both patients and staff for COVID-19 twice a week. On 1/27/21 at 9:10 A.M., the surveyor observed the facility's 2nd Floor unit. The following observations were made: * At 9:14 A.M., a Nurse #1 was observed standing outside a patient room. A sign outside the room indicated that the patient was on contact precautions. Nurse #1 was observed to put on an isolation gown, then without performing hand hygiene, put on a pair of gloves, contaminating the gloves surface. Nurse #1 entered the patient room, wearing the contaminated gloves, and carrying medication, that she provided to the patient. * At 9:19 A.M., a Personal Care Attendant (PCA) #1 stood in the corridor, and without performing hand hygiene, put on a pair of gloves, contaminating the gloves. PCA #1 then crossed the hall, and with a gloved hand, opened the linen closet, contaminating the gloves further and the door handle. She retrieved several items of linen, contaminating the linen and items in the closet. * At 9:20 A.M., PCA #1, wearing the same gloves, closed the closet's door, contaminating its surface, and crossed the hall. PCA #1 knocked on a patient room door, contaminating its surface and entered. In the room, PCA #1, without performing hand hygiene and without removing the gloves, put on an isolation gown, contaminating its surface and shut the room door. A sign outside the room indicated that the patient in the room was on a 14 day admission quarantine until 2/5/21 for COVID-19. * At 9:28 A.M., Nurse #2 stood at her medication cart opening and shutting multiple drawers, retrieving medications, and scanning medication cards with a scanner. Then, without performing hand hygiene, Nurse #2 put on a pair of gloves, picked up the medication with the contaminated gloved hand and entered a patient room to administer the medication. On 1/27/21 at 9:54 A.M., the surveyor observed the facility's 3rd Floor unit. The following observations were made: * At 10:00 A.M., PCA #2 exited a resident room wearing a glove on each hand. He removed a large bag of soiled linen from a cart in the room, and placed the bag on the floor, contaminating the floor. Then, with the gloved hands, PCA #2 picked up the bag and carried it down the corridor to the soiled utility closet. There, with a gloved hand, he entered a code in a keypad, contaminating the keypad and opened the closet's door, contaminating its handle and entered. * At 10:03 A.M., a Housekeeper (HK) #1 stood in the corridor putting on an isolation gown. She then pushed her housekeeping cart to a patient room doorway. There, HK #1, without performing hand hygiene, put on a pair of gloves, contaminating the gloves and entered the patient room. A sign outside the room indicated that the resident in the room was on a 14 day admission quarantine until 2/2/21 for COVID-19. * At 10:06 A.M., HK #2 exited a patient room. A sign outside the room indicated that the patient in the room was on a 14 day admission quarantine until 1/27/21 for COVID-19. HK #2 pushed her housekeeping cart to the room next door. Then, without performing hand hygiene she put a glove on one hand, contaminating the gloves surface, and wiped down her mop and broom with a disinfectant wipe. * At 10:08 A.M., HK #2 put on an isolation gown, then pushed her cart outside another patient's room. There, without performing hand hygiene, she put on a pair of gloves, contaminating the gloves surface and entered the patient room. A sign outside the room indicated that the patient in the room was on a 14 day admission quarantine until 2/3/21 for COVID-19. * At 10:14 A.M., Nurse #3 was observed at her medication cart opening and shutting multiple drawers, retrieving medication. Nurse #3 put on an isolation gown. Then, without performing hand hygiene, Nurse #3 put on a pair of gloves, picked up the medication in the contaminated gloved hand and entered a patient room to administer the medication. On 1/27/21 at 11:25 A.M., the surveyor observed the facility's 1st Floor unit. The following observations were made: * At 11:27 A.M., HK #3 was standing at a computer with a glove on typing. * At 11:28 A.M., HK #4, wearing a glove on each hand carried a bag of trash down the corridor. He briefly exited the unit, through a door, and moments later returned carrying the gloves balled up in one hand. HK #4 walked back up the corridor and threw the gloves in the trash. Then, without performing hand hygiene, he took his keys out of his pocket, contaminating the keys and pocket, and unlocked a housekeeping closet, contaminating its surface. * At 11:30 A.M., HK #3, wearing a glove on each hand, pushed her housekeeping cart down the corridor, and turned the corner out of view. During an interview with the IPN on 1/27/21 at 11:37 AM she said: * Staff are expected to sanitize their hands immediately before putting on gloves and after taking off gloves. * Staff should not be wearing gloves in the corridor at any time due to the risk of having contact with the environment and spreading pathogens. * Staff should not place soiled linen bags on the floor. CMS (Centers for Medicare and Medicaid Services) considers CMS and CDC (Center for Disease Control) COVID-19 guidance to be a national standard. The facility failed to abide by the standard and transmission-based precautions identified in its own policies and procedures, thus increasing the potential for transmission of COVID-19 in the facility.

Based on observation, interview, and policy review, the Facility staff failed to ensure proper infection control practices were maintained during wound care for 1 Resident (#23) out of a total sample of 21 residents. Findings include: Resident #23 was admitted to the Facility in 1/2019 with [DIAGNOSES REDACTED]. Review of Resident #23's 4/2019 Treatment Administration Record indicated physician orders [REDACTED]. - Right great toe: wash with normal saline and paint with [MEDICATION NAME] (an antiseptic) daily - Right second toe: wash with normal saline and paint with [MEDICATION NAME] daily - Right heel: wash with normal saline and apply [MEDICATION NAME] dressing (an absorbent foam dressing) Review of the Facility infection control policy titled Hand Hygiene 10/2017 indicated hand hygiene should be performed: - before and after donning and removing gloves On 4/26/19 at 10:21 A.M., the Surveyor observed Nurse #1 perform wound care to the right foot of Resident #23 and noted the following: -Nurse #1 cleansed the second toe with normal saline and changed her gloves without performing hand hygiene, therefore contaminating her new gloves. -Nurse #1 painted the right great toe with [MEDICATION NAME] and changed her gloves without performing hand hygiene, therefore contaminating her new gloves. -Nurse #1 cleansed the right heel with normal saline and changed her gloves without performing hand hygiene, therefore contaminating her new gloves and proceeded to cover the wound with a foam dressing. -Nurse #1 changed her gloves without performing hand hygiene, therefore contaminating her new gloves and proceeded to apply cream to the right foot and lower leg. On 4/26/19 at 10:50 A.M. the Surveyor conducted an interview with Nurse #1. She said Facility policy is to perform hand hygiene each time gloves are changed. She further said she forgot to perform hand hygiene a few times during wound care for Resident #23. On 4/26/19 at 11:40 A.M. the Surveyor conducted an interview with the Director of Nursing (DON). She said Facility policy is to perform hand hygiene after glove changes and before and after starting wound care.

Based on record review and interview, the Facility staff failed to complete an investigation of injuries of unknown source to determine the cause of multiple skin tears, for 1 Resident (#20) from a total sample of 21 residents. Resident #20 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. During a review of Resident #20's medical record 4/25/19 at 12:42 P.M. nursing notes evidenced a skin tear to the right foot, a skin tear to the right hand and a skin tear to the left wrist occurring in 3/2019 and 4/2019. The Surveyor requested the related incident reports and investigations regarding the skin tears from Unit Manager #1. Unit Manager #1 later informed the Surveyor that incident reports had not been completed. She further explained that the resident's skin is very fragile due to a medication he/she is prescribed, but no investigation was initiated. Review of the Facility policy titled Accident/Incident and dated 10/2017 indicated that it is the responsibility of all staff to report all incidents and accidents that occur in the facility. All occurrences are investigated in a timely manner and preventative measures initiated. The Facility's failure to complete an incident report and a subsequent investigation prevented the Facility from determining the exact cause of the multiple skin tears, prevented the development of interventions to prevent further skin tears and prevented review and analysis of the incident by the Administrator, Director of Nurses and Quality Assurance Committee, as described in the Facility policy.

Based on record review and interview the Facility staff failed to provide licensed pharmacist services and ensure pharmacist recommendations were reviewed by the physician for 2 Residents (#46 and #30) out of 21 sampled residents. Findings include: 1. For Resident #46 the Facility staff failed to ensure the drug regimen was reviewed at least once a month by a licensed pharmacist. Resident #46 was admitted to the Facility in 3/2019 with [DIAGNOSES REDACTED]. Review of Resident #46's Minimum Data Set ((MDS) dated [DATE] indicated Resident #46 had short term memory impairments. Review of Resident #46's Physician order [REDACTED]. Review of a Psychiatry Note dated 3/7/19 indicated Resident #46 was seen for shouting/screaming out loudly and frequently, and frequent agitation. Resident #46 reported to the Psychiatrist I can't sit still, leave me alone and feeling terrible, like he/she is jumping around inside. Medication at the time of the Psychiatry visit included: [MEDICATION NAME], and [MEDICATION NAME]. Psychiatry recommended consulting nutrition to check if [MEDICATION NAME] deficient, to decrease dose of [MEDICATION NAME] to 10mg and observe then continue taper, to increase [MEDICATION NAME] from 100mg twice a day to three times a day, and consider a low dose of [MEDICATION NAME] 0.25mg every 6 hours as needed. Review of a Psychiatry note dated 4/23/19 indicated Resident #46 was seen to assess behaviors and Medication Side Effects (MSE) of [MEDICATION NAME]. Resident #46 reported Feeling fine. to the psychiatrist. The note indicated [MEDICATION NAME] was recently started and appears to be helping. Staff reporting resident is doing better, calmer, less irritable, sleeping better, and more interactive. Resident does continue to shout out but not as frequently. Current medications at time of assessment included: [MEDICATION NAME] 250mg twice a day and [MEDICATION NAME] 10mg daily. Recommendations at the time of visit indicated if Resident #46 continues to do well would not increase, would periodically check [MEDICATION NAME] level and monitor (Liver Function Test) LFT and mental status. Review of the medical record failed to find documentation that Resident #46 was seen by the pharmacist. During an interview with the Director of Nurses (DON) on 4/26/19, at 11:06 A.M., she reviewed Resident #46's medical record and was unable to locate a note indicating resident was seen by the pharmacist, she said when pharmacist sees a resident and has no recommendations sometimes he just provides a list of who he sees. During an interview with Unit Manager #1 on 4/26/19, at 11:26 A.M., she said that the pharmacist does all of his documentation electronically. She said that it would be in the Electronic Medical Record (EMR). She reviewed Resident #46's EMR and did not find a consult from the pharmacist. She then reviewed the paper record to ensure a paper recommendation was not filed, she did not find a consult from the pharmacist. During an interview with Unit Manager #1 on 4/26/19 at 11:46 A.M., she said that she called the pharmacist and he reviewed his log and said that he didn't know how or why but he had not seen Resident #46 since his/her admission. 2. For Resident #30 the Facility failed to ensure the attending physician was made aware, reviewed and took action if any to address the pharmacist's identified irregularity made during the monthly medicine regimen review. Resident #30 was admitted to the Facility in 10/28/17 with [DIAGNOSES REDACTED]. On 4/25/19 at 11:03 A.M., the medical record indicated in a pharmacy consultation report dated 2/25/19 with the recommendation to consider discontinuation of the PRN (as needed) [MEDICATION NAME] (an anitnausea medication) and PRN [MEDICATION NAME] (a medication administered through a nebulizer to expand the airway). Review of the medical record failed to indicate that the physician responded to the pharmacist recommendation. Review of Resident #30's physician orders [REDACTED]. During an intervew on 4/25/19 at 11:29 A.M., the Director of Nursing (DON) said when the pharmacist makes a recommendation the physician signs an attestation on the bottom of the document with the recommendation and documents whether they agree or disagree and the plan. The DON reviewed the document and said it was not present on the form and would have to go check a different view on the electronic medical record (EMR). During an interview on 4/25/19 at 2:26 P.M., the DON said she did not find that the recommendation was addressed by the physician. She said if the recommendation was a significant medication recommendation it would be addressed that day and for others she would expect the pharmacy recommendation to be addressed within 72 hours.

Based on observation, record review and interview the Facility Staff failed to electronically transmit resident assessments within 14 days of completion for 3 residents (#4, #5, and #8) out of 21 sampled residents. Findings include: 1. Resident #4 was admitted to the Facility in 10/2018, review of the medical record indicated Resident #4 was discharged from the Facility in 11/2018 with a target Minimum Data Set (MDS) completion date of 11/6/18 and target transmission date of 11/13/18. Resident #4's MDS was not transmitted till 4/25/19. 2. Resident #5 was admitted to the Facility in 10/2018, review of the medical record indicated Resident #5 was discharged from the Facility in 11/2018 with a target MDS competition date of 11/3/2018 and target transmission date of 11/8/2018. Resident #5's MDS was not transmitted till 4/25/19. 3. Resident #8 was admitted to the Facility in 12/2018, review of the medical record indicated Resident #8 was discharged in 12/2018 with a target MDS completion date of 12/16/19 and target transmission date of 2/15/2019. Resident #8's MDS was not transmitted until 4/25/19. During an interview with MDS Nurse #1 on 4/25/19, at 8:09 A.M., she researched Resident #4, Resident #5, and Resident #8's medical record and indicated the MDS had been completed by not transmitted. She said that the MDS should have been transmitted.

Based on interview and record review, the facility failed to ensure that [MEDICATION NAME] (insulin medication for the management of diabetes), was administered per the physician's orders [REDACTED].#17 and #13) out of a total sample of 21 Residents. Findings include: 1. For Resident #17 the Facility failed to ensure that insulin was administered per the physican order. Resident #17 admitted to the Facility in 5/2018 with a [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set, dated dated [DATE], Resident #17 required assistance with activities of daily living and was cognitively intact, scoring a 15/15 on the Brief Interview of Mental Status. Review of the clinical record indicated that Resident #17 had an order for [REDACTED]. The order included the following sliding scale instructions: for a blood glucose level less than 70 call the physician and administer 15 grams of carbohydrates for a blood glucose level between 70-150 administer 0 units for a blood glucose level between 151-180 administer 1 unit for a blood glucose level between 181-200 administer 2 units for a blood glucose level between 201-240 administer 3 units for a blood glucose level between 241-280 administer 4 units for a blood glucose level between 281-320 administer 5 units for a blood glucose level between 321-360 administer 6 units for a blood glucose level between 361-400 administer 7 units for a blood glucose level greater than 400 administer 8 units and call the physician. Review of the medical record with the Informatics Nurse indicated that from 5/15/18 to 6/4/18 there were 3 times when [MEDICATION NAME] was not administered per the ordered sliding scale. On 5/17/18 at 7:55 A.M., a blood glucose level of 195 was obtained and 1 unit was administered instead of the 2 units as ordered. On 5/18/18 at 8:49 P.M., a blood glucose level of 153 was obtained and 0 units were administered instead of the 1 unit as ordered. On 6/3/18 at 12:46 P.M., a blood glucose level of 329 was obtained and 7 units were administered instead of the 6 unit as ordered. 2. For Resident #13, the facility staff failed to document a blood glucose level and failed to administer the correct dose of insulin as per the physician orders. Resident #13 was admitted to the facility in 5/2015 with a [DIAGNOSES REDACTED]. Review of the clinical record indicated a physician's orders [REDACTED]. The order included the following sliding scale instructions: for a blood glucose level between 70 - 150 no coverage for a blood glucose level between 151 - 200 administer 2 units for a blood glucose level between 201 - 250 administer 4 units for a blood glucose level between 251 - 300 administer 6 units for a blood glucose level between 301 - 350 administer 8 units for a blood glucose level between 351 - 400 administer 10 units for a blood glucose level >400 administer 12 units and call physician Review of the MAR (medication administration record) from 5/31/18 to 6/5/18 indicated that on 6/2/18 at 9:00 A.M. nursing staff administered 2 units of [MEDICATION NAME] (insulin). There was no documented blood glucose level to indicate that the insulin dose administered was in compliance with the sliding scale instructions. Further review of the MAR indicated [REDACTED].M. the blood glucose level was 253. Nursing staff administered 4 units of [MEDICATION NAME] (insulin). Review of the sliding scale instructions for insulin coverage indicated that 6 units should have been administered. During a review of the MAR from 5/31/18 to 6/5/18, the Informatics Nurse acknowledged the 1 time on 6/2/18 when the blood glucose level was not recorded and the 1 time on 6/3/18 when the Insulin [MEDICATION NAME] ([MEDICATION NAME]) dose was not administered according to the sliding scale instructions.

Based on record review, observation and interview, the facility failed to measure upper arm circumference and external length of a peripherally inserted central catheter (PICC) line, upon admission and during subsequent dressing changes, in accordance with the facility policy, for 3 sampled Residents (#31, #91 and #190) with a PICC, out of a total of 21 sampled Residents. Findings include: The facility's policy on Infusion Maintenance for PICC included the following instructions for site maintenance: Transparent Dressing Changes are to be done 24 hours post insertion or on admission, then every week and as needed. Measure upper arm circumference and external catheter length on admission, with each dressing change and prn (as needed). 1. Resident #31 was admitted to the facility in 10/2017. Resident #31's medical [DIAGNOSES REDACTED]. Review of Resident #31's medical record indicated a PICC line was inserted during a hospitalized from [DATE] to 3/19/18. Upon the resident's return, the facility failed to ensure that an accurate initial baseline and external PICC line measurements were documented as completed on admission and on subsequent weekly dressing changes in accordance with the facility's infusion maintenance policy. Documentation of the upper arm circumference and PICC external catheter length were missing 3/19, 3/26, 5/10, 5/17, 5/24 and 5/31/18. Unit Manager #2 was present as the above data was reviewed and noted the missing documentation regarding the measurements of the external catheter length and upper arm circumference. The facility failed to follow the infusion maintenance guidelines adapted for the care of PICC line. 2. Resident #190 was admitted to the facility 5/24/18. Resident #190 medical [DIAGNOSES REDACTED]. Review of Resident #190's medical record indicated a PICC line was inserted prior to admission on 5/19/18. The facility failed to ensure that an accurate initial baseline and external PICC line measurements were documented as completed on admission and on subsequent weekly dressing changes in accordance with the facility's infusion maintenance policy. Documentation of the upper arm circumference and PICC external catheter length was missing 5/24 and 5/31/18. Unit Manager #2 was present as the above data was reviewed and noted the missing documentation regarding the measurements of the external catheter length and upper arm circumference. The facility failed to follow the infusion maintenance guidelines adapted for the care of PICC line. 3. Resident #80 was admitted to the facility in 5/18. Resident #80's medical [DIAGNOSES REDACTED]. The Resident was receiving intravenous antibiotics through a PICC line that was inserted at the hospital prior to admission. Review of the Resident's Medication Administration Record [REDACTED]. Charge Nurse #1 was present as the above data was reviewed and she noted the missing documentation regarding the measurements of the external catheter length. The facility failed to follow the infusion maintenance guidelines adapted for the care of PICC line.

Based on observation, documentation review and interview, the facility failed to follow proper procedures to ensure safety in the use of the commercial dryer. Findings include: 1. On 6/4/18 at 1:41 P.M., during tour of the facility's laundry, the surveyor observed one commercial dryer in use drying microfiber mop heads. A sign on the dryer read: Warning Do not dry mop heads. Another sign on the dryer read: Personal Safety Rules to avoid the possibility of fire, including spontaneous combustion, do not dry items containing foam rubber or similarly textured rubberlike materials or any material on which you have used a cleaning solvent or which contains flammable liquids or solids (such as gasoline, kerosene, vegetable or cooking oils, waxes, etc. The Laundry Director said that the facility dries microfiber mop heads and microfiber cleaning cloths in the dryer on the A, C and E settings. The surveyor inquired about drying microfiber mop heads and cleaning cloths in the dryer as the practice conflicts with the warning signs on the dryer. Mop heads and cloths absorb chemicals from cleaning solutions which are flammable. The surveyor then requested to review the manufacturer's guidelines and the facility's policy on microfiber laundering and drying. 2. Review of the manufacturer's Microfiber Laundering Recommendations read limited drying and avoid using heat-only extraction & tumble needed. All micro fiber - MAX 140 degrees F. The laundry's policy read as follows: microfiber mops and rags may be put into the dryer but only on cycle A which is set at 140 degrees, 25 minutes per manufacturer's recommendation for microfiber materials. Cycle C is set at 160 degrees and cycle E is set at 180 degrees which exceed the manufacturer's recommendations. 3. On 6/4/18 at 2:45 P.M., during an interview, the Laundry Director provided the Material Safety Data Sheet of a cleaning solution used with the microfiber cloths that indicated the flashpoint of the product was 187 degrees F. well below the recommended drying temperature of 140 degrees F. However, the facility does not consistently follow the manufacturer's Microfiber Laundering Recommendations for limited drying and to avoid using heat-only extraction & tumble needed - MAX 140 degrees F. as the Laundry Director said that the microfiber is also dried on the C and E temperature settings.

Based on observations and interviews, the Facility failed to ensure that expired medications were not available for administration in 2 of 2 medication rooms inspected. The Facility also failed to ensure that medications were not stored in an open space that was accessible to non-clinical persons Findings include: 1. During observation of the first floor medication room on 6/01/18 at 1:49 P.M. with Charge Nurse #1, one box of expired flu medications - high dose with 10 pre-filled syringes in the box with an expiration date of (MONTH) 25,2018 was found in the medication refrigerator. The Charge Nurse noted the box of expired syringes and removed them for disposal. 2. During observation of the third floor medication room on 6/01/18 at 1:59 P.M. with Unit Manager #1, one [MEDICATION NAME]open multi use vial with no open or exp. date and one [MEDICATION NAME] multi use vial with no open or expiration dates on bottle were found in the medication refrigerator. The Unit Manager noted the bottles and removed them for disposal. 3. On 6/05/18 at 12:22 P.M., the Surveyor observed 2 medication cards of [MEDICATION NAME] (a medication used to treat nerve pain related to diabetes): one card of 15 pills and one card of 30 pills that were left unattended at the nursing station desk, tucked into a space between the phone and computer, with non-clinical persons in the area. The Surveyor noted the unit secretary, maintenance staff and visitors in the area at the time of the observation. The Surveyor observed the medications unattended for 7 minutes and then notified Unit Manager #2, who was not aware the medications were there. Unit Manager #2 said this was not the appropriate place to store medications and noted they were for a resident who was discharged . Unit Manager #2 removed the medications to the locked medication room.

Based on records reviewed and interviews for one of five sampled residents (Resident #1), the Facility failed to ensure there was a system in place for the reconciliation of medications when on 10/30/17, Resident #1 was prescribed Eliquis (an anticoagulant medication) in error. Resident #1, who did not have a [DIAGNOSES REDACTED]. On 11/02/17 Resident #1 was noted to have blood in his/her stools, was transferred to the Hospital where her/she was diagnosed with [REDACTED]. Findings include: Resident #1 was admitted to the Facility in (MONTH) (YEAR), medical history included [DIAGNOSES REDACTED]. Review of Resident #1's Physician admission orders [REDACTED]. An Electronic physician's orders [REDACTED]. The order indicated Resident #1 had no history of Interaction Warnings. The Order was electronically signed as prescribed by the Physician and acknowledged by Nurse #3. The Electronic Medication Administration Record [REDACTED]. A Nurse Practitioner's Progress Note, dated 10/31/17, indicated Resident #1 had a recent history of diverticular (tiny sacs that develops in the tissue that lines the bowels) bleed and current medications included Eliquis. There was no documentation to indicated the Nurse Practitioner questioned the order for Eliquis. A Nurse Practitioner's Progress Note, dated 11/2/17, indicated Resident #1 had multiple bowel movements with bright red blood (BRB), has history of GI bleed, on an anticoagulant medication, will send to Emergency Department (ED) for emergent evaluation. A Nurse Progress Note, dated 11/02/17, indicated that during the morning Resident #1 was noted to have blood tinged stools, the Nurse Practitioner was notified and an order was given for a stool guaiac (a fecal occult blood sample to determine if blood in stool) which was performed and tested positive. The Progress Note indicated that as the day progressed Resident #1's stools were noted with increasing amounts of blood and blood clots, and an order was obtained to transfer Resident #1 to the Hospital Emergency Department (ED) for evaluation. The Hospital ED Report, dated 11/02/17, indicated Resident #1's presentation was concerning for large volume of GI blood loss with the potential for life threatening hypovolemic shock (a life threatening condition that results when loss of 20 percent or one-fifth of body's blood or fluid supply, which makes it impossible for the heart to pump a sufficient amount of blood to the body). The ED Report indicated Resident #1 was transfused with packed red blood cells to maintain his/her circulatory volume and oxygen carrying capacity, and he/she was admitted to inpatient status for further medical evaluation. A Hospital Discharge Summary, dated 11/08/17, indicated Resident #1 had two days of hematochezia (the passage of fresh blood through the anus, usually in or with stools) in the setting of recently starting Eliquis via a medication error, and he/she was transfused with four units of packed red blood cells. The Facility's Root Cause Analysis Medication Error Report, undated, indicated that on the morning of 11/03/17, the Physician reviewed Resident #1's medical record and identified that there was a prescribing error and that Eliquis was ordered incorrectly for Resident #1. The Root Causes included the following information: - Human error occurred in entering the order on the wrong resident. The error occurred two days after going live with a new electronic record and moving into a new building. - The environment was new to everyone (people, place and technology) and a lot of uncertainty about systems and working relationships. - The resident (Resident #1) received seven doses of Eliquis without nursing questioning why he/she was taking an anticoagulant. The Surveyor interviewed the Director of Nurses (DON) at 9:15 A.M. on 4/09/18 and throughout the day of the survey. The DON said the Facility did not have a Policy in place for the reconciliation of medications. The Surveyor interviewed the Physician at 9:30 A.M. on 4/09/18. The Physician said he became aware of the medication error on 11/03/17, after Resident #1 was admitted to the Hospital for treatment of [REDACTED]. The Surveyor interviewed Nurse #3 at 2:20 P.M. on 4/09/18. Nurse #3 said that on 10/30/17, she was acting as the Charge Nurse on the Unit, said she had not taken care of Resident #1 and was not familiar with his/her [DIAGNOSES REDACTED]. Nurse #3 said she saw a pop up screen on the electronic medical record indicating that the Physician had prescribed a new medication for Resident #1 which then automatically pre-populates to the MAR. Nurse #3 said she was not familiar with the electronic medical record and said she hit the acknowledgement button on the electronic medication order without verifying the order with the physician or checking to see if there was an appropriate [DIAGNOSES REDACTED]. The Surveyor interviewed the Nurse Practitioner at 2:50 P.M. on 4/09/18. The Nurse Practitioner said that although he did evaluate Resident #1 during the period of time he/she received Eliquis, he had no explanation as to why he did not identify the medication error other than, words to the effect, listed medications that appear on the electronic medical record progress notes are pre-populated, and in all honesty he did not pay much attention to the listed medications.

Based on observation, interview and record review, the facility failed to ensure that for 1 sampled resident (#9), in a total sample of 15, received adequate supervision to prevent injury. Findings include: For Resident #9 the facility failed to provide adequate supervision and as a result, the resident fell on [DATE] at 7:30 P.M. and fractured her left hip requiring acute hospitalization and surgical repair. Review of Resident #9's clinical record on 3/1/16 and 3/2/16 indicated that the resident was admitted in 1/2016. The resident's [DIAGNOSES REDACTED]. The Morse Falls Scale Document, an assessment that determines resident fall risk, was dated 1/15/16 and indicated that Resident #9's risk score was 60, which identified a high risk for falls. Review of the resident's Admission Minimum Data Set (MDS) assessment dated [DATE], identified the resident as having a Brief Interview of Mental Status (BIMS) score of 13/15 (meaning the resident's cognition was intact) and required extensive assistance of one person for transfers, dressing and toilet use. The Admission MDS assessment further indicated that the resident's balance during moving on and off the toilet was not steady and was only able to stabilize with staff present. The MDS Care Area Assessment Documenation (CAA) indicated; Falls, CAA triggered due to impaired balance, receives antidepressant meds as ordered. Contributing factors include Left side weakness status [REDACTED]. Morse Fall Risk assessment is high at 60. He/she has bed, body alarms. He/She is at risk for fall, injury. Will proceed to fall care plan and monitor and maintain safety, call light within reach, assist with Activities of Daily living (ADLS) toileting and mobility. Review of Interim Care Plan dated 1/15/16, indicated; Falls/Safety Risk with Goal: Patient will remain free of injuries and falls. Interventions on document indicate: * Keep call light in reach * Respond Promptly to call for assistance, * Anticipate and meet needs * Assess for fall risk/cause of falls and intervene to prevent * Initiate fall protocol routine moderate low * Pt eval and treat as ordered or PRN ( as needed) * Encourage activities that minimize potential for falls * Evaluate/Supply adaptive device/equipment as needed * Provide education/safety reminders. Additionally written in hand indicated; Morse 60, S/P (status [REDACTED]. Review of the of nursing note dated 2/1/2016, indicated that Pt (patient) ambulates with quad cane with CG (contact guard) assist with gait belt, gait continues to be unsteady, No c/o ( complaints of) pain this shift; Family/friends to visit: Pt is a fall risk, call bell placed within reach and pt reminded to call when getting OOB (out of bed), bed/body alarms maintained will continue to monitor. During interview on 3/2/16 at 11: 45 A.M., the Occupational Therapist #1 said that Resident #9 required up to 50 percent help with her activities of daily living. She said that the resident's current functional status was posted on a white board (a tool to communicate a resident's functional status to Certified Nursing Assistants (CNAs) located in the resident's room.) She further said when asked by surveyor #1, that she would never leave the resident unattended in the bathroom and therefore, was never left alone during occupational therapy treatments. Occupational therapist #1 said that on 2/2/16 she put a bedside commode in the Resident's room due to the resident experiencing weakness. During interview on 3/2/16 at 11:45 A.M., the Physical Therapist said that during treatment on 2/2/16, Resident #9 was experiencing orthostatic hypotension ( blood pressure drops suddenly with change of position. This is an increased risk for falls.) and that nursing staff was made aware. Interview with Nurse #1 on 3/2/16 at 2:30 P.M., she said that Patient Care Cards were used to communicate resident care needs to the CNAs. She further said that Resident #9's Patient Care Card on the date of the fall was checked off with instructions not to leave Resident #9 in the bathroom alone. She said, and put in writing, that she updated the Patient's Care Card with information to use the bedside commode on 2/2/16. Nurse #1 further said, the Patient Care Card for 2/2/16 could not be reviewed, as it does not stay in the permanent medical record after the resident was discharged to the hospital. Review of Resident #9's current Patient Care Card dated 3/1/16, from his/her readmission, did state; Do not leave alone in bathroom/commode. On 3/2/16 at 2:15 P.M., an interview was held with CNA #1. She said she had cared for Resident #9 prior to her fall and knew his/her status by looking at the whiteboard in the resident's room and Patient Care Card. She further said that when she cared for Resident #9 she did not leave him/her in the bathroom because she/he was a fall Risk and tries to get up on his/her own. During interview with CNA #2 on 3/2/16 at 3:15 P.M., she said that she was the CNA who cared for Resident #9 on 2/2/16 the evening that the resident fell . She said that she knew that Resident #9 was a fall risk and she would run fast if the resident put on his/her call light. CNA #2 said she did not get any additional report about Resident #9's condition on the day of the fall. She said she would use the white board and Patient Care Card to know the resident's needs. CNA #2 said that on the evening of the fall on 2/2/16 she went to Resident #9's room and Nurse #2 had already assisted Resident #9 on to the bedside commode. Then CNA #2 said she returned to the resident's room and took over for the Nurse #2, who then left the room. CNA #2 said that she placed a wheelchair in front of the resident, and left the room to get a johnny. She said when she returned to the room, the resident (who was identified as a high fall risk and should not have been left unattended), was on the floor. CNA #2 said the resident was trying to remove her socks. On 3/2/15 review of the facility's Fall Investigation Form Section II Unavoidable status indicates: This section is completed by the nurse manager or designee within 72 hours of the fall. A) A determination that a fall was unavoidable may be made only if routine preventive care is provided including ( check if documentation verifies): *care plan followed *Therapy recommendations followed *Supervision done as established None of the above was reviewed as being checked off. On 3/3/16 review of a document labeled: Spaulding, West Roxbury Educational Counseling Record, dated 2/4/16 indicated that CNA #2 was Counseled via discussion to Ask a co-worker to get you supplies if think a patient should not be left alone on the commode or in the bathroom. You can call for help by ringing the call bell if needed.

Based on observations, interviews and record review, the facility failed to follow the plan of care for 1 resident (#4) out of a total sample of 15. Findings include: For Resident #4, the facility failed to notify the physician (MD) of weight gain of either 2 pounds (lbs) or greater than 3 lbs, per the plan of care. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual minimum data set assessment ((MDS) dated [DATE], indicated the resident was cognitively intact and dependent for activities of daily living (ADL). Record review on 3/1/16 and 3/2/16, indicated that Resident #4's nursing care plan, dated 10/19/15, for [MEDICAL CONDITION] included: Notify MD if [MEDICAL CONDITION] continues, labs are abnormal, weight increases 2 lbs in 1 week. Record review on 3/1/16 and 3/2/16, indicated that Resident #4's nursing care plan for [MEDICAL CONDITION], dated 10/19/15, included: Obtain weekly weight. Report gain of >3 lbs to the MD. Resident #4's weekly weight chart indicated the following: For the week of 11/16/15, there was a documented weight gain of 6.3 lbs; twice the amount of weight gain indicated in his/her careplan to notify the MD for [MEDICAL CONDITION]. For the week of 1/18/16, there was a documented weight gain of 2.2 lbs. For the week of 2/29/16, there was a documented weight gain of 2.6 lbs. There was no documentation indicating that the physician was notified of these weight gains, per care plans. During an interview with the Director of Nursing, (DON) on 3/2/16 at 1:30 P.M. and 1:50 P.M. she could not explain why the resident's MD was not notified of the weight gains and was unable to provide evidence that the MD was notified,per the plan of care.