Ayer Valley Rehab and Nursing

Inspectors wroteBased on observation, records reviewed, and interviews, the facility which is licensed for a total of 123 beds, and admits residents with psychosocial care needs associated with, but are not limited to, mental illness, substance use disorder and behavioral issues, failed to ensure that they employed a full-time qualified Social Worker (SW), from 5/28/26 after terminating their SW, up to and including the dates of survey, to adequately meet and provide the necessary and appropriate services for each residents individual psychosocial care needs. therefore, placing their current resident census of 99 residents, at risk for unmet psychosocial care needs due to the lack of having a qualified SW in place, as required.

Inspectors wrote3. Resident #12 was admitted to the facility in May 2022 with diagnoses including Dementia and COPD. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. -the Resident had received oxygen therapy. Review of the Resident's comprehensive medical record indicated: -No Physician's orders for oxygen administration or oxygen and respiratory equipment maintenance. -Physician's orders to keep the head of the bed elevated at 30 degrees as needed for shortness of breath. -a Care Plan indicating that the Resident was at risk for respiratory complications related to COPD. -a Care Plan intervention to observe the Resident's respiratory status and assess for changes. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide Physician visits at the required frequency for five Residents (#10, #28, #45, #51 and #68) for an applicable sample of six residents, out of a total sample of 23 residents. Specifically, the facility failed to provide alternating routine 60-day visits between the Physician and the Nurse Practitioner (NP) for Resident's #10, # 28, #45, #51 and #68, as required.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for two Residents (#9 and #11), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #11, act upon the Consultant Pharmacist recommendation dated 11/27/23, to monitor serum Dilantin levels routinely every six months, putting the Resident at risk for elevated serum Dilantin levels and resulting in hospitalization to manage Dilantin toxicity. 2. [...]

Inspectors wroteBased on record review, and interview, the facility failed to notify the Physician of a change in condition for one Resident (#114) for a sample of three closed resident records reviewed. Specifically, the facility failed to notify Resident #114's Physician of the Resident's change in condition when the Resident died in the facility.

Inspectors wroteBased on record review, and interview, the facility failed to resolve a grievance timely for one Resident (#66), out of a total sample of 23 residents. Specifically, for Resident #66, the facility failed to ensure that a reported grievance by the Resident, the Resident's Representative (RR), and the Nurse Practitioner (NP), regarding two missing hearing aids was documented and the grievance process initiated to resolve the concern within a reasonable timeframe.

Inspectors wroteBased on record review, and interview, the facility failed to provide care and services in accordance with professional standards of practice for one Resident (#27) out of a total sample of 23 residents, who required a vascular access device (device that provides access to the veins for the delivery of medications or fluids). Specifically, the facility failed to obtain Physician orders for the care and maintenance of Resident #27's midline catheter (a flexible tube inserted through a peripheral vein above the elbow that ends just below the axilla [armpit]) and monitor for catheter related complications.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#2), out of a total sample of 23 residents. Specifically, for Resident #2, the facility failed to complete an assessment and ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of Post-Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that three Licensed Nurses (Nurse #3, ADON [Assistant Director of Nurses] and SDC [Staff Development Coordinator]) out of three Nurses, had the specific competencies and skills sets necessary to provide respiratory care and services that were consistent with professional standards of practice for one Resident (#66), out of a total sample of 23 residents. Specifically, for Resident #66, the facility failed to ensure that Nurse #3, the ADON and the SDC had the knowledge, competency and skills necessary to: [...]

Inspectors wroteBased on record review, and interview, the facility failed to complete a performance review at least once every 12 months for one Certified Nurses Aide (CNA) #2 out of a sample of five CNAs reviewed. Specifically, the facility failed to ensure that a performance review was completed as required, for CNA #2 when CNA #2 had been employed at the facility for greater than 12 months.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one Resident (#104) out of a total sample of 23 residents, was free from a significant medication error when an anticoagulation medication was not administered and monitoring laboratory testing of the medication was not completed as ordered by the Physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food and drink at a safe and appetizing temperature to residents on the North One Unit and for two Residents (#77 and #76) residing on the South Two Unit. Specifically, facility failed to: -Provide residents on the North One Unit with hot food, at a safe an appetizing temperature, when the food was meant to be hot. -Provide Resident #77 and Resident #76 with hot food and cold drinks at safe and appetizing temperatures, when the food was meant to be hot, and the drinks were meant to be cold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was designed to meet the individual needs of one Resident (#10) out of a total sample of 23 residents. Specifically, the facility failed to ensure that Resident #10 was provided with the Physician's prescribed diet consistency of Nectar/Mildly thickened liquids (diet in which a thickening agent is added to thin liquids making them safer for a resident to swallow) when the Resident was at risk for aspiration and was offered thin consistency liquids with a breakfast meal.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that specialized rehabilitation services were provided to one Resident (#51) out of a total sample of 23 residents. Specifically, for Resident #51, the facility failed to ensure that a speech and language therapy evaluation was completed timely, when it was identified that the Resident had an unintended weight loss.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain accurate medical records relative to the application of Continuous Positive Airway Pressure (CPAP - type of non-invasive device that administers a predetermined level of pressure through a mask worn over the nose and/or mouth to keep the airways open) for one Resident (#66) out of a total sample of 23 residents. Specifically, the facility staff documented that CPAP therapy was being applied to Resident #66 at hours of sleep when the Resident was not being provided the CPAP treatment nightly as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for two Residents (#44 and #75) out of a total sample of 23 residents, increasing the risk of contamination and the spread of infection to other residents within the facility. Specifically, the facility failed to: 1. For Resident #44, ensure that staff appropriately followed Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact care for an indwelling urinary catheter. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to offer pneumococcal immunizations in accordance with Centers for Disease Control (CDC) guidance to one Resident (#28) of five applicable residents, out of a total sample of 23 residents. Specifically, the facility failed to offer an up-to-date Pneumococcal Vaccine to Resident #28 when Resident #28's pneumococcal immunization was not up to date, and administration of the Pneumococcal Vaccine was not documented as clinically contraindicated for the Resident.

Inspectors wroteBased on interview, and record review, the facility failed to offer updated COVID-19 immunizations for three Residents (#45, #51, and #10) of five applicable residents, out of a total sample of 23 residents. Specifically, the facility failed to provide evidence that the 2024-2025 COVID-19 immunization was offered to Residents #45, #51, and #10 when the Residents were not up to date with their COVID-19 immunizations and the immunizations were not documented as contraindicated for the Residents increasing the Residents' risk for acquiring COVID-19 associated illness.

Inspectors wroteBased on record review, and interview, the facility failed to have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the facility failed to ensure that a written transfer agreement was updated when the Local Area Hospital listed on the facility transfer agreement was closed 8/31/24, increasing the risk for residents of the facility not to be admitted timely and appropriately to a hospital when transfer was determined by the attending Physician to be medically appropriate.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), the facility failed to ensure nursing notified the Physician, per facility policy, when all three of these residents sustained a weight loss of greater than 5 pounds, and their physicians were not made aware.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), the Facility failed to ensure nursing services provided met professional standards of quality related to obtaining a Physician's Order, when on 12/30/24, a nurse wrote a verbal order to decrease the frequency of Resident #3's weight monitoring without speaking to and obtaining an Order from the Physician/Provider, as required.

Inspectors wroteBased on record reviewed and interviews, for three of three sampled residents (Resident #1, #2 and #3), who were assessed by nursing to be at risk for altered nutritional status which included the potential for weight loss, the Facility failed to ensure 1) Resident #3 was assessed and monitored by a Registered Dietician in the presence of an on-going significant weight loss and 2) Resident #1 and Resident #2 were adequately assessed and monitored by a Registered Dietician, and nutritional interventions were put in place in a timely manner, following previously identified significant weight loss, in an effort to help them maintain acceptable parameters of nutrition to prevent unplanned/undesired weight loss. Findings Include: The Facility Policy titled Weight Assessment and Interventions, dated as revised 11/19/24, indicated: [...]

Inspectors wroteBased on observations, interviews and records reviewed, for one of three nursing units (North 2), the Facility failed to ensure they provided and maintained a sufficient number of Certified Nurse Aides (CNAs) so that 1) that each resident's individual care needs were provided in a timely manner and as needed, and 2) so that each resident received their meal while food items were still palatable.

Inspectors wroteBased on records reviewed and interviews, the Facility failed to ensure they implemented their Quality Assurance Performance Improvement (QAPI) plan of action to monitor, assess, and document the data related to staffing to identify if improvements were made.

Inspectors wroteBased on observation, interviews and records reviewed, for one of three sampled residents (Resident #3) who's comprehensive care plan indicated he/she required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 06/05/24, Certified Nurse Aide (CNA) #3 transferred Resident #3 from his/her bed into the wheelchair with a Hoyer lift, without another staff member present to provide assistance.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to notify the Physician/Non Physician Practitioner (NPP: Nurse Practitioner) of changes in condition related to a pressure wound for one Resident (#60) out of a total sample of 26 residents, who was identified to be at risk for skin breakdown. Specifically, the facility staff failed to notify the Physician/NPP when: 1. The Resident developed a pressure injury (PI: localized damage to the skin and/or underlying soft tissue usually over a bony prominence presenting as intact skin) on his/her left hip on 2/6/24. 2. The Resident's pressure injury deteriorated to a pressure ulcer (PU: open ulcer, the appearance of which occurs as a result of intense and/or prolonged pressure or pressure in combination with shear) on 2/19/24.

Inspectors wroteBased on record and policy review, and interview, the facility failed to provide necessary pressure ulcer (PU: localized damage to the skin and/or underlying soft tissue usually over a bony prominence) treatment and services, consistent with professional standards of practice, to promote healing for one Resident (#60), out of a total sample of 26 residents. Specifically, the facility staff failed to: 1. Adequately assess Resident #60's change in skin condition when the Resident was identified to have a PU on his/her left hip. 2. Consult with the Physician/Non Physician Practitioner (NPP: Nurse Practitioner [NP]) when the Resident was identified to have a PU on his/her left hip, and obtain treatment orders from the Physician/NPP for Resident #60's left hip PU, to prevent further deterioration of the PU.

Inspectors wroteBased on review of the facility's Licensed Nurse staff schedule and interviews, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, facility staff failed to provide at least eight consecutive hours of RN services in the facility over one 24-hour period, when no nurse staffing waivers were in place.

Inspectors wroteBased on interview, record and policy review, the facility failed to implement an infection control and prevention program to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to implement a water management program to minimize the risk of Legionella and other opportunistic waterborne pathogens. Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) QSO-17-30 memo titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease (LD), last revised 7/6/18, indicated the following Facility Requirements to Prevent Legionella Infections: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure timely completion as required of the Minimum Data Set (MDS) Assessments for 14 Residents (#93, #15, #56, #70, #73, #32, #55, #5, #47, #35, #94, #67, #7, and #64) out of 14 applicable residents, out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that the components of the Quarterly and Annual MDS Assessments were completed within the required timeframes.

Inspectors wrote3. Resident #47 was admitted to the facility in December 2017 with a diagnosis of Dementia. Review of Resident #47's Health Care Proxy (HCP) Invocation Form, dated 12/21/17, indicated the Resident's HCP was invoked on 12/21/17 due to Dementia. Review of Resident #47's clinical record indicated Minimum Data Set (MDS) Assessment, dated 1/25/24, had been completed. Further review of the clinical record indicated no evidence that Resident #47's care plan was reviewed and revised to the extent practicable, with participation of the Resident's HCP after the MDS Assessment was completed. 4. Resident #54 was admitted to the facility in April 2019 with a diagnosis of Dementia. Review of Resident #54's HCP Invocation Form, dated 4/30/19, indicated the Resident's HCP was invoked on 4/30/19 due to Dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment that is free of accidents and hazards for one Resident (#59) out of a total sample of 26 residents, for one of two elevators used by residents, staff, and visitors and one Unit kitchenette. Specifically, the facility staff failed to: 1. Ensure that a damaged baseboard heating element in an elevator used by residents, staff, and visitors was maintained in safe working condition. 2. For Resident #59, ensure potentially hazardous smoking materials were stored in a secured area. 3. Ensure that instructions for re-heating resident foods in the kitchenette microwave and a thermometer for checking food and beverage temperatures were available to decrease the risk of accidental burns.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide sufficient staffing to coordinate and carry out resident care required on the North Two Unit. Specifically, the facility staff failed to ensure that: 1. Sufficient staffing levels to conduct the Unit breakfast meal pass timely for three consecutive days during the survey period and assist one Resident (#24) with his/her breakfast meal in a timely manner. 2. Sufficient staffing levels to provide showers for two Residents (#36 and #86) who required assistance to shower and the appropriate number of Certified Nurses Aides (CNA) to work the evening shift and provide the required care and services to the Residents

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food and drink that was palatable, at a safe and appetizing temperature to residents on the North Two Unit. Specifically, facility staff failed to provide residents on the North Two Unit with hot food, that required to be served hot, and cold drinks that were required to be served cold.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee meets at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program are necessary. Specifically, the facility failed to provide evidence that three out of four quarterly meetings QAPI had been conducted as required.

Inspectors wroteBased on observation, record review, and interview the facility failed to respect the rights and ensure the dignified treatment of one Resident (#89) out of a total sample of 26 residents. Specifically, the facility staff failed to: -knock and obtain permission before opening the door to Resident #89's room when the Resident was receiving personal care, resulting in the Resident being exposed to individuals in the hallway.

Inspectors wroteBased on interview and record review, the facility failed to notify seven Residents (#89, #75, #28, #46, #41, #80, and #81) out of a total sample of 26 residents, and/or their Representatives and the Office of the State Long-Term Care Ombudsman, in writing, of the Residents' transfer from the facility. Specifically, the facility staff failed to provide a written Notice of Transfer or Discharge to the seven Residents and/or Resident Representatives and notify the Office of the State Long-Term Care Ombudsman of the Residents' transfers from the facility to the hospital.

Inspectors wroteBased on interview, policy and record review, the facility failed to re-submit a Level I Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability (ID), 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#77) out of a total sample of 26 residents, had a serious mental illness (SMI).

Inspectors wroteBased on interview and record review, the facility failed to develop a discharge plan for one Resident (#304) out of a sample of 26 residents. Specifically, the facility staff failed to develop a discharge plan who required assistance with applying for housing programs and alternative options for discharge.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that activities of daily living (ADL's- activities related to personal care which include bathing, dressing, grooming and eating) were provided for one Resident (#2), who was dependent on staff for care, out of a total sample of 26 residents. Specifically, the facility failed to ensure that personal care relative to grooming needs was provided for Resident #2.

Inspectors wroteBased on interview, policy and record review, the facility failed to implement weight monitoring to maintain the nutritional status for one Resident (#28) out of a total sample of 26 residents. Specifically, For Resident #28, the facility staff failed to obtain weekly weights as ordered by a Physician for a Resident identified at nutritional risk resulting in a significant weight loss (7.6%) in 90 days.

Inspectors wroteBased on interview, policy and record review, the facility failed to ensure that residents who are trauma survivors receive culturally-competent and trauma-informed care for one Resident (#304) out of a total sample of 26 residents. Specifically, the facility staff failed to identify Resident #304's past history of trauma and/or triggers which may cause re-traumatization. Findings Include: Review of the facility policy titled Trauma-Centered Care, revised 11/5/19, indicated the following: A. Early screening and Comprehensive Assessment of Trauma: The initial (upon admission) intake, assessment and documentation process includes questions designed to sensitively and respectfully explore prior .and current trauma related experiences. B. Consumer-Driven Care and Services: Residents will receive information about their rights and program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two Licensed Nurses (Nurse #2 and Unit Manager [UM] #2) out of three Licensed Nurses reviewed possessed the specific competencies and skills necessary to care for the needs of one Resident (#60). Specifically, the facility staff failed to ensure that Nurse #2 and UM #2 were assessed for competency relative to the care of PUs when Resident #60 developed a PU and required PU care from both Licensed Nurses.

Inspectors wroteBased on record and policy review, and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regime Review (MRR) were reviewed by the Physician and responded to as required, for one Resident (#25) out of a total sample of 26 residents. Specifically, for Resident #25, the facility staff failed to respond to the Pharmacist Consultant's request to monitor for signs and symptoms of bleeding for a Resident receiving anticoagulant (medication used to thin out the blood) therapy.

Inspectors wroteBased on record review and interview, the facility failed to monitor for side effects and adverse reactions to medications for one Resident (#25) out of a total sample of 26 residents. Specifically, for Resident #25, the facility staff failed to monitor for side effects and adverse reactions related to the use of an anticoagulant (medication used to thin out the blood) medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule a follow-up dental appointment for one Resident (#77) out of a total sample of 26 residents. Specifically, for Resident #77, the facility staff failed to re-schedule a dental appointment to have teeth extracted after the Resident was assessed by the Dental Consultant, extractions were recommended, and medical approval for the procedure was obtained.

Inspectors wroteBased on interview and record review, the facility failed to provide Notice of Bed-Hold Policy at the time of transfer to a hospital or shortly thereafter for four Residents (#89, #75, #28, and #46) and/or their Representatives, out of a total sample of 26 residents. Specifically, the facility staff failed to provide Resident's #89, #75, #28, and #46 and/or their Representatives with written notification relative to Bed-Holds when the Residents were transferred from the facility to the hospital and were expected to return to the facility.

Inspectors wroteBased on observations, records reviewed, and interviews for one of three sampled residents (Resident #1) and one non-sampled resident (Non-Sampled Resident (NS-RT) #11, the facility failed to treat the residents with dignity and respect and provide them assistance with grooming and meals and provide consistent meal service. Additionally, for three of three resident care areas (North 1 Unit, North 2 Unit, and South 2 Unit), the facility failed to provide residents with adequate supplies for personal care use.

Inspectors wroteBased on observations, records reviewed, and interviews, for three of three nursing units (North 1 Unit, North 2 Unit, and South 2 Unit), the Facility failed to provide sufficient staffing to ensure they maintained a sufficient number of Certified Nurse Aides (CNAs) on the units so that all residents received the necessary care and services to meet their individual care needs.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records including but not limited to medication administration, refusal of care, and documentation of care provided by Certified Nurse Aides to residents.

Inspectors wroteBased on observations, records reviewed and interviews, the Facility failed to ensure it provided a sanitary environment in an effort to prevent contamination and transmission of infections.

Inspectors wroteBased on observations, records reviewed, and interviews, for one of three resident care units (North 2 Unit), the facility failed to ensure the call system button was accessible and within reach for Residents to call for assistance, per facility policy.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3) and 11 non-sampled residents (Non-Sampled Residents (NS-RT) #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14), the Facility failed to ensure that individualized plans of care were developed and identified interventions that were consistently implemented by staff that met each residents' individualized care needs.

Inspectors wroteBased on observations, records reviewed, and interviews, for one of three sampled residents (Resident #1), who required extensive physical assistance to total dependence on staff to meet his/her care needs, and for Non-Sampled Resident (NS-RT) #5, who also required physical assistance from staff with care, the Facility failed to ensure Activities of Daily Living (ADL) care was consistently provided by staff.

Inspectors wroteBased on observations, records reviewed, and interviews, for one of three sampled residents (Resident #3), who was cognitively impaired and wandered, the Facility failed to ensure they implemented a meaningful and engaging activity to support Resident #3's physical, mental, and psychosocial well being.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure nursing care met professional standards or practice, when on 12/25/23, Nurse #1 failed to administer medications in a timely manner, failed to notify his/her physician of the late medication administration, and failed to document that the medication was administered later than the scheduled time.

Inspectors wroteBased on records reviewed, interviews, and observations, the Facility failed to ensure that meals prepared for and delivered to each resident, were served at an appropriate temperature.

Inspectors wroteBased on interview and license review, the facility failed to ensure the Administrator was licensed in Massachusetts, as required.

Inspectors wroteBased on observations, records reviewed, and interviews, the Facility failed to ensure it provided a safe, functional, and sanitary environment, in the basement level of the Facility where laundry services and central supply was located, there was an ongoing problem with waste water and sewage drainage.

Inspectors wroteBased on observations, records reviewed, and interviews, the Facility failed to ensure they maintained an effective pest control program, when from October 2023 to the end of December 2023, the basement level of the Facility, where laundry services and central supplies was located, there was an infestation of small gnat-like flying insects.

Inspectors wroteBased on records reviewed, review of facility surveillance camera video footage, and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from abuse from a staff member. Review of the surveillance camera video footage from 08/24/23 during the evening shift, showed Resident #1 pick up a cup containing yellow-tinted liquid off a medication cart, put it up to his/her mouth, Nurse #1 quickly goes over to him/her, grabs the cup of liquid from Resident #1's hand and throws the liquid into Resident #1's face, and Nurse #1 also engaged in a verbal altercation with him/her, the incident was witnessed by another staff member who stepped into intervened. Resident #1 was visibly upset after the incident, was crying, and was cleaned up and comforted by staff.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 08/24/23 at 10:50 P.M., Certified Nurse Aide (CNA) #1 witnessed Nurse #1 throw a cup of liquid (later identified as juice and Risperidone) into Resident #1's face, and did not notify Nursing Supervisor #1 until after she told the story to the 11:00 P.M. to 7:00 A.M. Nurse, who instructed her to do so. Nurse #1 continued to work on Resident #1's unit until 12:11 A.M. on 08/25/23, placing other residents at risk for potential abuse, and Resident #1 at risk for the potential of continued abuse.

Inspectors wroteBased on records reviewed, review of surveillance camera video footage, and interviews. for one of three sampled residents (Resident #1), the Facility failed ensure medications were stored properly, when on 08/24/23 during the 3:00 P.M. to 11:00 P.M. (evening) shift, Nurse #1 (who was seated at the nurses' station) left a cup of liquid containing an antipsychotic medication on her unattended medication cart and Resident #1 attempted to drink it.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff notified the physician of: (1) A change in the treatment plan, specifically a missed hemodialysis (procedure used to remove waste and fluid from the blood when the kidneys stop working) visit, for one Resident (#205) out of one applicable sampled resident, and (2) A change in condition, specifically a new pressure ulcer, for one Resident (#88) out of three applicable sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide appropriate care and services for two Residents (#88 and #69) out of a total sample of 23 residents, by failing to obtain and implement physician's orders and provide appropriate assessment of existing wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided dialysis services; specifically, failed to (1) provide transportation to a dialysis treatment appointment, (2) obtain post dialysis weight from dialysis center, (3) monitor hemodialysis catheter site, and (4) obtain physician's order for dialysis treatments for one Resident (#205) out of one applicable sampled resident.

Inspectors wroteBased on observation, interview and document review the facility staff failed to maintain infection control standards to prevent the further spread of COVID-19 in the facility by ensuring all visitors and employees were screened for signs and symptoms of COVID-19 and exposure to others with suspected or confirmed SARS-CoV-2 infection. The facility also failed to ensure staff assessed residents for signs and symptoms of COVID-19 on every shift as required during an outbreak on two out of two applicable units.

Inspectors wroteBased on observations, interviews and record reviews, the facility staff failed to: (1) Follow Physician's orders for weekly skin checks, use of seat belts, and dressing changes, (2) Develop care plans for dementia and behavioral symptoms, and (3) To implement care plans.and dressing changes for seven residents (#13, #31, #35, #61, #84, #88, and #96) out of a total sample of 23 residents

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide sufficient nurse staffing for two out of three days (7:00 A.M. - 3:00 P.M.) shifts, during the survey period, on the South Two Unit. Specifically, the facility provided one nurse for the care of 41 residents which resulted in late medication administration to residents on the Unit.

Inspectors wroteBased on record review and interview, the facility failed to offer a pneumococcal immunization to two Residents (#55 and #93) and the influenza (flu) immunization (during the October 1, 2021 to March 30, 2022 flu season) for one Resident (#93) in a sample of five residents, when there was no documentation that indicated the vaccines were medically contraindicated or administered before admission to the facility.

Inspectors wroteBased on record review and interview the facility staff failed to: 1) perform COVID-19 outbreak testing for three Residents (#18, #55 and #93) at the required frequency, between 5/3/22 and 6/8/22, during an outbreak on the North One Unit. 2) perform contact tracing and subsequent outbreak testing of healthcare personnel (HCP) and residents on the South Two Unit after a resident tested positive for COVID-19 on 5/28/22. 3) perform required weekly surveillance testing on one out of three sampled staff members.

Inspectors wroteBased on observation, interview and record review the facility staff failed to obtain a physician's order for the treatment of an open wound for one Resident (#69) out of 23 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards, specifically related to storage of smoking materials, for one Resident (#34) out of four applicable sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#88) was assessed for risk of entrapment from bed rails, failed to ensure the risks and benefits of bed rails were reviewed with the resident or resident representative prior to the use of bed rails, and failed to obtain informed consent for the use of bed rails, out of a total sample of 23 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide individualized meaningful approaches relative to behavioral health care for one Resident (#13) out of 23 total sampled residents when the Resident demonstrated verbal behavioral symptoms during the survey period.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain an accurate medical record relative to the application of thrombo-embolic deterrent (TED; compression stockings used to reduce the risk for blood clots) stockings for one Resident (#35) out of a total sample of 23 residents. Specifically, facility staff recorded that TED stockings were applied to Resident #35's lower extremities on two out of three days during the survey period, but the Resident did not have the stockings on. Resident #35 was admitted to the facility in July 2021 with the following diagnosis: venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Review of the June 2022 Physician Orders included an order, initiated 4/5/22, for TEDs to both lower extremities to be applied in the morning and removed at bedtime daily. On 6/14/22 at 8:58 A. [...]

Inspectors wroteBased on interview and review of facility audits and reports, the facility failed to develop a Quality Assurance Performance Improvement (QAPI) plan in a good faith effort to address the deficient practice relative to administration of the pneumococcal vaccination which had been identified on previous Department of Public Health surveys.

Inspectors wroteBased on record review and interview, the facility failed to a offer one Resident (#91) a Covid-19 booster when eligible, out of a total of five sampled residents.