Embassy of Cambridge

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the ice machine was maintained in a sanitary condition. This had the potential to affect 61 of 61 residents who receive ice from the facility. The facility census was 70.

Inspectors wroteBased on observations of the facility, staff interview, and policy review, the facility failed to maintain a safe, clean, homelike environment. This affected four residents (#4, #5, #13, and #14) of seven residents reviewed for environment and had the potential to affect 35 residents on the north unit. The facility census was 70.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a sanitary laundry room. This had the potential to affect 68 of 68 residents who have their laundry done at the facility. The facility census was 70.

Inspectors wrote4. Review of Resident #69's medical record revealed he was admitted to the facility 05/23/25 with diagnoses including malignant neoplasm of lower third ossiphageous, severe protein calorie malnutrition, malignant neoplasm of the brain, cardiomyopathy, heart failure, depression, constipation, gastroesophageal reflux, chronic pain, cardiac defibrillator, and hypertension. Review of Resident #69's minimum data set (MDS) completed 05/28/25 revealed a brief interview for mental status score of 15 indicating no cognitive impairment. Review of Resident #69's smoking assessment completed on 5/23/25 and revealed the resident was a smoker, had no cognitive loss impairing their ability to smoke safely, the resident had no visual deficit, the resident smokes two to five times per day during the morning, afternoon, evenings, and nights. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions for a missing glasses lens and provide timely vision services for a resident. This affected one resident (#69) of two residents investigated for communication and sensory concerns. The census was 70.

Inspectors wroteBased on review of the medical record and interview, the facility failed to provide care without causing a skin tear for Resident #67. This affected one resident (#67) of three residents reviewed for skin conditions. The facility census was 70.

Inspectors wroteBased on record review and interview the facility failed to acquire post dialysis vital signs as ordered for one resident(#55). This had the potential to affect one resident (#55) of one resident on dialysis in the facility. The census was 70.

Inspectors wroteBased on review of the medical record and interview, the facility failed to ensure a resident had a thorough medication regimen review completed by the pharmacist. This affected one resident (#39) of five residents reviewed for medication review. The facility census was 70.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication error rate was less than five percent. There were a total of 36 medication opportunities observed with two medication errors resulting in a 5.55% medication error rate. This affected one resident (#4) of three residents observed for medication administration. The census was 70.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate documentation in the medical record for treatments for a resident. This affected one resident (#1) of 25 residents reviewed for documentation. The facility census was 70.

Inspectors wroteBased on observation and interview, the facility failed to ensure an ice machine was clean and sanitary. This had the potential to affect all residents residing in the facility. The census was 76.

Inspectors wroteBased on record review, review of personal inventory sheets, review of grievance/concern logs, review of email correspondence between a resident representative and the facility, interviews, and policy review, the facility failed to ensure resident representative reports of missing personal items were addressed in a timely manner. This affected one (Resident #2) of three residents reviewed for missing personal items.

Inspectors wroteBased on record review, and interviews the facility failed to ensure a resident, who was dependent on staff for personal care, received appropriate incontinence products needed for proper incontinence care and was assisted up in her chair daily as per her normal routine. This affected one (Resident #2) of three residents reviewed for incontinence care.

Inspectors wroteBased on record review, observation, and interviews the facility failed to ensure administrative staff maintained sufficient supplies to adequately care for the residents residing in the facility. This affected one (Resident #2) of three residents reviewed for incontinence and enteral tube feedings.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to implement an effective pain management program, including the administration of scheduled and as needed opioid medication for Resident #7. Actual Harm occurred on 11/09/24, when Resident #7, who was identified with chronic pain and a new onset of acute pain related to a fall resulting in a fractured sternum, did not receive her scheduled or as needed Percocet (narcotic pain medication) as requested, resulting in uncontrolled pain that affected the resident's ability to participate in activities of daily living and required the administration of a one-time emergent dose of Percocet to re-gain control of the resident's pain. This affected one resident (#7) of five residents reviewed for pain.

Inspectors wroteBased on medical record review, review of the facility concern log, review of a facility soft file, interviews, and policy review the facility failed to ensure timely and appropriate efforts were implemented to achieve resolution regarding Ombudsman, resident representatives, and/or resident concerns. This had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on personnel file review, review of the facility Bureau of Criminal Identification (BCI) log, review of employee time sheets, interview, and policy review the facility failed to ensure staff were not permitted to work in a direct care capacity with a disqualifying offense. This had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on review of concern log, review of food committee meeting minutes, observation, interviews, and policy review the facility failed to ensure dietary staff were competent to carry out functions of food delivery. This had the potential to affect all 72 residents, except Resident #51, whom the facility identified as nothing by mouth (NPO).

Inspectors wroteBased on review of the concern log, review of the food committee meeting minutes, interview, observation, and policy review the facility failed to ensure meals were provided per menu and resident preferences. This had the potential to affect 71 of 72 residents who receive meals from the facility kitchen. The facility identified one resident(Resident #51)to receive nothing by mouth.

Inspectors wroteBased on review of mealtimes, observation, and interview, the facility failed to ensure meals were delivered timely. This had the potential to affect 71 of 72 residents receiving meals from the facility kitchen. The facility identified one resident (Resident#51) to receive nothing by mouth.

Inspectors wroteBased on medical record review, review of controlled drug receipts, review of the medication administration audit report, review of controlled medication shift change logs, review of staff schedules, review of the facility investigation, review of a self-reported incidents (SRI), interviews, and policy review the facility failed to ensure resident narcotics were not misappropriated. This affected four (Resident #7, #12, #51, and #56) of five records reviewed for misappropriation. The facility had identified 46 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #19, #21, #22, #23, #24, #24, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #48, #51, #52, #53, #54, #55, #56, #57, #58, #500, and #501) that had medication/treatment errors. [...]

Inspectors wroteBased on medical record review, review of concern log and report, interview, and policy review the facility failed to ensure a resident was treated with respect and dignity. This affected one (Resident #4) of three residents reviewed for respect and dignity.

Inspectors wroteBased on medical record review, review of controlled drug receipts, review of the medication administration audit report, review of controlled medication shift change logs, review of staff schedules, review of the facility investigation, review of a self-reported incidents (SRI), interviews, and policy review the facility failed to thoroughly investigate an allegation of misappropriation. This affected two resident (#51, #56) of five residents reviewed for misappropriation. The facility census was 72. The facility identified eight residents affected by misappropriation (#7, #12, #13, #16, #21, #22, #31, and #37).

Inspectors wroteBased on closed record review, review of hospital records, review of hearing results, review of the facility assessment, interviews, and policy review the facility failed to ensure Resident #1 was permitted to return to the facility after an emergency room evaluation. This affected one resident (Resident #1) of three residents reviewed for discharge.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure residents received assistance and supervision during lunch dining. This affected one (Resident #62) of three residents reviewed for meal assistance.

Inspectors wroteBased on medical record review, review of concern form, review of pharmacy communication, interview, and policy review the facility failed to ensure medication were readily available and administered as ordered. This affected one (Resident #4) of three residents reviewed for pain management.

Inspectors wroteBased on medical record review, review of a facility Self-Reported Incident (SRI) and investigation, interviews with staff and residents, the facility failed to take reasonable precautions, including providing adequate supervision, to prevent a resident-to-resident altercation. This affected one resident (Resident #3) of three residents reviewed for abuse. The facility census was 72. Findings Include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right humerus, asthma, diabetes mellitus, multiple fractures of ribs, fracture of right femur, heart disease, and history of cerebral infarction. The resident was moderately cognitively impaired and was dependent on staff for activities of daily living (ADLs) assistance. [...]

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure ice water was provided to residents in their rooms, consistent with their preferences, to maintain hydration. This affected one (Resident #3) of three residents reviewed for hydration. The facility census was 72.

Inspectors wroteBased on review of information submitted to the state survey agency, interview, resident council minutes review, review of the concern log, and policy review the facility failed to ensure adequate staffing to answer call lights timely and provide care timely. This had the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on review of daily nurse staff posting, review of staffing schedule, review of time sheets, review of the facility assessment, policy review, and interview the facility failed to provide a registered nurse (RN) for at least eight consecutive hours daily on 08/04/24. This had the potential to affect all 69 residents residing in the building.

Inspectors wroteBased on review of photos, review of daily food temperature logs, interview, observation, and policy review the facility failed ensure food was palatable. This had the potential to affect all 69 residents residing in the building.

Inspectors wroteBased on review of submitted concerns to the state survey agency, interviews, and policy review the facility failed to ensure residents were treated with respect and dignity. This affected four residents (#3, #33, #41, and #49) of nine residents reviewed for respect and dignity.

Inspectors wroteBased on medical record review, review of timecards, review of the facility investigation, review of self-reported incidents (SRI), interviews, and policy review the facility failed to ensure resident narcotics were not misappropriated. This affected two residents (#42 and #51) of three records reviewed.

Inspectors wroteBased on medical record review, review of timecards, review of the facility investigation, review of self-reported incidents (SRI), interviews, and policy review the facility failed to ensure misappropriation of resident narcotics was reported to the state survey agency within the required timeframe. This affected two residents (#42 and #51) of three records reviewed.

Inspectors wroteBased on medical record review, review of timecards, review of the facility investigation, review of self-reported incidents (SRI), interviews, and policy review the facility failed to ensure misappropriation of resident narcotics was thoroughly investigated. This affected two residents (#42 and #51) of three records reviewed.

Inspectors wroteBased on closed medical record review, staff interview, and policy review the facility failed to ensure all required information upon transfer was communicated and/or documented in the resident's medical record. This affected one resident (#74) of three residents reviewed for transfer and discharge.

Inspectors wroteBased on closed medical record review, staff interview, and policy review the facility failed to ensure the resident and resident representative received a transfer notice as soon as practicable prior to being transferred to the hospital. This affected one resident (#74) of three residents reviewed for transfer and discharge.

Inspectors wroteBased on closed medical record review, staff interview, and policy review the facility failed to ensure the resident and resident representative received a bed hold notice when the resident was transferred. This affected one resident (#74) of three residents reviewed for transfer and discharge.

Inspectors wroteBased on closed medical record review, review of information submitted to the state survey agency, staff interview, and policy review the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) documents accurately reflected the resident's diagnoses. This affected one resident (#74) of three residents reviewed for PASARR assessment.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure fall interventions were implemented for a resident at risk of falls. This affected one resident (#51) of three residents reviewed for falls.

Inspectors wroteBased on review of narcotic control sheets, interview, and policy review the facility failed to ensure staff followed the systems in place for managing narcotic medications to assist in the prevention of narcotic diversion. This had the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure a resident received their diet as ordered. This affected one resident (#41) of three records reviewed.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure a resident received fluids as ordered. This affected one resident (#41) of three records reviewed.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure resident medical records including medication administration records and narcotic administration records were complete and accurate. This affected three residents (#31, #37, and #42) of 28 residents residing on Northwest.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure a resident's call light was functional at the resident's bedside. This affected one resident (#51) of three residents reviewed for falls.

Inspectors wroteBased on medical record review, review of hospital records, staff interview, and policy review, the facility failed to ensure fall interventions were implemented and residents were provided the appropriate level of assistance to prevent falls. This affected one (Resident #27) of six residents reviewed for accidents. The facility census was 68. Actual Harm occurred on 04/29/24 at approximately 4:30 A.M. when Resident #27, who was assessed to have severely impaired cognition, required physical assistance of one staff member for lower body dressing and was identified as a high fall risk, fell after having been instructed by staff (while in the shower room with the resident) to stand up and remove his pants, without staff assistance on a wet floor. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the laundry room was maintained in a safe, functional and sanitary conditon. This had the potential to affect all the residents in the facility. The facility census was 68.

Inspectors wroteBased on observation, staff interview and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene while distributing meal trays to the residents. This affected eight (Resident #3, #20, #30, #37, #38, #52, #57, and #65) out of the 26 residents (#3, #13, #15, #20, #21, #25, #30, #35, #37, #38, #41, #43, #44, #46, #48, #50, #51, #52, #54, #57, #58, #60, #61, #65, #67, and #224) residents residing on the Northwest Unit who ate their meals in their rooms. Additionally, the facility failed to ensure residents were not provided milk that was past the best by date. This affected one resident (Resident #3) out of 67 residents who received food from the facility kitchen. Resident #270 was identified as not receiving meals from the kitchen. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to notify physicians of significant weight changes. This affected one (Resident #50) of five residents reviewed for nutrition. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents accurately reflected resident diagnoses. This affected one (Resident #27) of two residents reviewed for PASARR documents. The facility census was 68 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a care plan that addressed palliative care. This affected one (Resident #43) out of one resident reviewed for hospice. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure comprehensive resident care plans were updated with changes in treatment. This affected two (Residents #32 and #33) of 24 residents reviewed for care plans. The facility census was 68.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview and review of the facility policy, the facility failed to provide proper nail care to dependent residents. This affected two (Residents #23 and #32) of five residents reviewed for activities of daily living (ADL) care. The facility census was 68 residents.

Inspectors wroteBased on medical record review, review of a tray ticket, observation, staff interview, and policy review, the facility failed to ensure residents who were not supposed to receive liquids by mouth were not provided liquids by mouth and failed to ensure nutritional supplements were provided as ordered. This affected one resident (#50) out of five residents reviewed for nutrition. The facility census was 68.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to label, date, and initial an enteral formula for a resident receiving enteral nutrition. This affected one (Resident #62) of three facility-identified residents who received tube feedings. The facility census was 68 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure resident oxygen flow rates were set as ordered by the physician and failed to ensure the humidifier bottles were emptied and changed weekly. This affected one (Resident #32) of three residents reviewed for respiratory care. The facility identified seven residents receiving oxygen therapy. The facility census was 68 residents.

Inspectors wroteBased on medical record review, staff interview and review of the facility policy the facility failed to residents were assessed for the safe use of bed rails prior to implementation. This affected one (Resident #50) of two residents reviewed for skin impairment. The facility census was 68 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were not left at the bedside unattended. This affected two (Resident #3 and #37) of six residents reviewed for accidents. The facility census was 68 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents received timely dental care. This affected one (Resident #15) of one residents reviewed for dental services. The facility census was 68 residents.

Inspectors wroteBased on medical record review, review of a meal ticket, observation, and staff interview, the facility failed to ensure residents received adaptive equipment with meals as ordered. This affected one (Resident #48) of five residents reviewed for nutrition. The census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure medications were accurately documented as administered. This affected one resident (#50) of six residents reviewed for behaviors and/or medications. The facility census was 68.

Inspectors wroteBased on observation, medical record review, policy review, and interview, the facility failed to initiate enhanced barrier precautions as required. This affected one resident (#48) of three residents sampled. The census was 70.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure dependent residents received assistance with personal hygiene. This affected one resident (#27) of three residents sampled. The census was 70.

Inspectors wroteBased on observation, medical record review, manufacturer guideline review, policy review and interview, the facility failed to ensure medications were administered as ordered. This affected two residents (#10 and #17) of five residents observed, four observed errors during 38 medication opportunities resulting in a medication error rate of 10.52%. The facility census was 70.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure residents were free of significant medication errors when a resident was administered intravenous antibiotics not in accordance with physician orders. This affected one resident (#1) of four sampled residents. The census was 70.

Inspectors wroteBased on medical record review, policy review, transportation calendar review and interview, the facility failed to be administered in a manner to ensure residents were able to be transported to scheduled appointments. This affected one resident (#1) of four residents sampled. The census was 70.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of the facility incident log, review of a facility investigation, review of the facility elopement policy and interview, the facility failed to provide adequate supervision to Resident #58, who had a developmental disability, exhibited severe cognitive impairment (with a Brief Interview for Mental Status score of four), had exit seeking behaviors and required the use of a wander guard device (a special bracelet to alert staff when a resident exits the facility), to prevent the resident from exiting the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death on [DATE] at 4:30 P.M. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure treatments were completed as ordered. This affected two residents (#123 and #141) of three residents reviewed for treatments. The facility census was 73.

Inspectors wroteBased on medical record review, transportation calendar review, dialysis contract review, policy review and interview, the facility failed to ensure residents were transported to dialysis as scheduled. This affected one resident (Resident #141) of three residents reviewed for transportation to appointments. The facility census was 73.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure medications were administered as ordered. This affected two of two residents (#127 and #130), three observed errors during 28 medication opportunities resulting in a medication error rate of 10.71%.

Inspectors wroteBased on medical record review, policy review, transportation calendar review, and interview, the facility failed be administered in a manner to ensure residents were able to be transported to scheduled appointments. This affected two residents (#25 and #141) of three residents reviewed for transportation. The census was 73.

Inspectors wroteBased on medical record review and interview, the facility failed to maintain accurate resident records. This affected one resident (#141) of three individuals reviewed for treatments. The census was 73.

Inspectors wroteBased on observation, policy review and interview, the facility failed to utilize appropriate handwashing and gloving during medication administration. This affected two residents (#127 and #130) of two residents observed for medication administration. The census was 73.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure appropriate signage was posted at the main entrance to notify residents, families, and visitors of active Covid-19 cases in the building, what symptoms of Covid-19 were, encouragement not to visit if having symptoms of those symptoms, importance of hand hygiene, and respiratory/ cough etiquette to follow when in the facility. This had the potential to affect all residents residing in the facility. The facility's census was 71.

Inspectors wroteBased on closed medical record review, policy review, and interview, the facility failed to timely identify a change in condition and failed to address and manage complaints of pain following a fall with injury for Resident #8 that occurred on 09/18/23. Actual Harm occurred on 09/22/23 when Resident #8, who was assessed to have severe cognitive impairment, was observed by staff moaning in pain while being turned and repositioned during personal care. The staff failed to notify the resident's nurse of her signs/symptoms of pain and failed to pursue pain relief for the resident. On 09/23/23 the resident was sent to the emergency room for further evaluation and was found to have an obvious deformity of the right leg and diagnostic imaging revealed thoracic, rib, sacral, and hip fractures. The resident was transferred to a trauma center. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Tuberculin and insulin were discarded once the vials were open greater than 30 days. The facility also failed to ensure the Southwest medication cart was locked when unattended to prevent unauthorized access. This affected one resident (#21) who had insulin that was outdated, had to potential to affect all residents who could require the use of Tuberculin for Mantoux/TB testing and had the potential to affect eight residents (#7, #8, #9, #15, #21, #31, #40, and #197) who were independently mobile, cognitively impaired and who did not reside on the locked memory care unit. The facility census was 52. Findings Include: 1. On 08/08/22 at 2:40 P.M. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure the Medical Director (MD) attended Quality Assurance and Performance Improvement (QAPI) meetings as required. This had the potential to affect all 52 residents residing in the facility. Findings Include: Review of an undated QAPI member list revealed the MD was a member of the facility QAPI committee. Review of the staff sign in sheets for the facility QAPI meetings, dated 05/24/22, 06/24/22 and 07/28/22 revealed no signature for the MD to indicate the MD was in attendance at any of the meetings held during this time period. On 08/15/22 a 2:51 P.M. interview with the Administrator, Director of Nursing (DON) and Registered Nurse (RN) #200 revealed the following facility staff/positions were part of the QAPI committee: [...]

Inspectors wroteBased on review of time card punches, staff COVID-19 testing logs, review of website data and information communicated from the facility, facility policy and procedure review and interview the facility failed to provide timely notification of positive COVID-19 cases to staff, residents and family/esponsible parties. This had the potential to affect all 52 residents. Findings Include: Review of [NAME] #158's time card punches revealed on 07/25/22 she clocked in for work at 6:30 A.M. and out (on 07/25/22) at 12:38 P.M. Review of staff COVID-19 testing logs revealed [NAME] #158 tested positive for COVID- 19 on 07/25/22. On 08/09/22 9:00 A.M. interview with Director of Nursing (DON) revealed staff tell residents personally when there were positive or suspected cases of COVID-19 and families were notified through Care Feed. Human Resources (HR) tracked notifications. [...]

Inspectors wroteBased on record review, review of medication information, review of the Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual, review of facility policy and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for all residents. This affected six residents (#4, #15, #33, #40, #41, and #43) of 17 residents whose assessments were reviewed. Findings Include: 1. Review of Resident #4's medical record revealed diagnose including atrial fibrillation, heart disease and diabetes mellitus. Review of the physician's orders revealed an order, dated 04/30/22 for delayed release Aspirin 81 milligrams (mg) once a day. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/03/22 revealed the assessment was coded the resident received an anticoagulant all seven days of the assessment reference period. On 08/09/22 at 5:13 P.M. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide a call light to accommodate Resident #193's needs and ability to obtain staff assistance upon his request. This affected one resident (#193) of 24 residents reviewed for call light function/accessibility. Findings Include: Record review revealed Resident #193 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, essential hypertension, type two diabetes mellitus with hypoglycemia with coma, acute respiratory distress syndrome and Lennox-Gastaut syndrome. Resident #193's admission Minimum Date Set (MDS) 3.0 assessment, dated 08/03/22 revealed the resident's cognition was not assessed but Resident #193 had a problem with short-term and long-term memory. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #21's physician was notified when blood glucose (sugar) results were outside ordered parameters (blood sugar less than 60 or greater than 500). This affected one resident (#21) of five residents reviewed for medication administration.

Inspectors wroteBased on review of the Skilled Nursing Facility Beneficiary Protection Notification Review Sheet and staff interview the facility failed to ensure residents who received Medicare Part A Services, did not exhaust skilled days and remained in the facility received a Centers for Medicare and Medicaid Services (CMS)-10055 form as required. This affected three residents (#4, #7 and #19) of three residents reviewed for beneficiary notices. Findings Include: Review of the Skilled Nursing Facility Beneficiary Protection Notification Review Sheet for Resident #4, #7 and #19 revealed all three residents were discharged from Medicare Part A Services, had not exhausted their skilled days and remained in the facility. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the ombudsman was notified of Resident #2's transfer to the hospital as required. This affected one resident (#2) of one reviewed for hospitalization. Findings Include: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation and kidney stones. Review of Resident #2's progress note, dated 04/12/22 revealed the resident was admitted to the hospital with atrial fibrillation with rapid ventricular rate and chest pain. Further review of Resident #2's progress note, dated 07/24/22 revealed the resident was admitted to the hospital for kidney stones. On 08/08/22 at 2:54 P.M. interview with Resident #2 confirmed she had been admitted to the hospital twice in the last four to five months for atrial fibrillation and kidney stones. On 08/15/22 at 9:05 A.M. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure the admission Pre-admission Screening and Resident Review (PASARR) form for Resident #4 was accurate to reflect the resident's mental health and psychotropic medication use in the last six months. This affected one resident (#4) of two residents reviewed for PASARR. Findings Include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, depression, anxiety and substance abuse. Review of Resident #4's PASARR, dated 04/29/22 indicated the resident had no mental health disorders and had not taken any prescribed psychotropic (anti-depressants or anti-anxiety) medications in the past six months. [...]

Inspectors wroteBased on observation, record review, review of ancillary service records of resident visits and interview the facility failed to ensure Resident #6's hearing aid was in working condition and Resident #12 received new glasses timely. This affected two residents (#6 and #12) of two residents reviewed for hearing/vision. Findings Include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of hearing deficit. The resident's payor source was Medicaid. Review of Resident #6 ancillary consent, dated 05/13/22 revealed the resident had Medicaid and signed a consent for audiology services. Review of Resident #6's admission orders, dated 05/12/22 and current orders (for 08/2022) revealed orders for ancillary services including hearing (audiology) services. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure fall interventions were in place for Resident #16 as care planned to prevent falls and failed to ensure the resident's responsible party was notified timely of a fall. This affected one resident (#16) of two residents reviewed for accidents.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed the ensure oxygen tubing was dated and changed per physician order, failed to ensure residents who were receiving oxygen had a physician's order for use and/or failed to ensure a resident's oxygen saturation was maintained above 92% as ordered. This affected three residents (#13, #17, and #193) of four residents reviewed for respiratory care. Findings Include: 1. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery and legal blindness. Review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/07/22 revealed the resident had moderately impaired cognition and did not use oxygen. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure medication orders were accurately transcribed upon admission and failed to obtain laboratory testing for medication monitoring to ensure all medications were justified and administered at the most effective dose. This affected two residents (#21 and #194) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #21's medical record revealed diagnoses including type 2 diabetes mellitus, hyperlipidemia, and bipolar disorder. Record review revealed Resident #21's medication regimen included physician's orders for Lipitor (antihyperlipidemic), Novolog insulin per sliding scale, Basaglar insulin, Depakote (bipolar therapy agent) and Trulicity insulin. [...]

Inspectors wroteBased on observation, record review, review of axillary service records and interview, the facility failed to ensure residents received routine dental services. This affected two residents (#6 and #12) of three residents reviewed for dental care. Findings Include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including nicotine dependence and gastric reflux disease. The resident's payer source was Medicaid. Review of Resident #6's progress note, dated 05/12/22 revealed the hospital called report and indicated the resident had no teeth or dentures. Review of Resident #6's admission orders, dated 05/12/22 and current orders dated 08/2022 revealed orders for ancillary services including dental services. Review of Resident #6 oral assessment, dated 05/15/22 revealed the resident had no natural teeth and had one tooth on the bottom of his mouth. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure pureed food was the correct consistency for Resident #296. This affected one resident (#296) of one resident identified to receive a pureed diet. Findings Include: Review of a list of resident diets, dated 08/08/22 revealed Resident #296 was the only resident identified to receive a pureed diet. On 08/11/22 at 9:40 A.M. observation of pureed meal preparation revealed Dietary [NAME] (DC) #154 attempted three times to prepare pureed chicken. Following the first two attempts there were chunks of chicken still visible and after the third attempt the chicken was stringy. When tasting the chicken after the third attempt, the chicken balled up in the surveyor's mouth when placed on the roof of the pallet. On 08/11/22 at 10:10 A.M. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain a sanitary and comfortable environment and failed to ensure a mold like organism was not growing in a resident room. This affected one resident (#22) of three residents whose rooms were observed on the Northwest hall of the facility. The facility census was 52. Findings Include: On 08/15/22 at 9:33 A.M. observation of Resident #22's closet nearest the corner revealed a dark spotted substance on the ceiling and approximately 24 inches down the walls. An interview with Resident #22 at the time of the observation revealed he was unaware of the substance. On 08/15/2022 at 9:37 A.M. interview with Maintenance Director (MD) #128 revealed the facility had a problem with the sprinkler system and there had been leaking water from the system. [...]