Medford Multicare Center for Living

Inspectors wroteBased on record review and staff interviews during the survey, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents. This was identified for one (Resident #111) of three residents reviewed for falls. Specifically, Resident #111 was totally dependent on two staff members for bed mobility and for personal hygiene as per the comprehensive care plan. On 12/09/2025, Certified Nursing Assistant #1 did not follow the resident's plan of care and provided toileting care by themselves while the resident was in bed. The resident fell out of bed and sustained a fracture to the right lower leg bones. This resulted in actual harm to Resident #111 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (Resident #260) of five residents reviewed for infection control; two (Unit 1C medication cart and Unit 3C medication cart low side) of nine medications carts reviewed during the Medication Storage Task; and for two residents (Resident #75 and Resident #234) during the lunch meal dining observation. Specifically, 1) Resident #260 had a physician's order for contact precautions related to an infection with a carbapenem-resistant organism. Certified Nursing Assistant #3 was observed in Resident #260's room assisting the resident in the bathroom and to the wheelchair without wearing the required personal protective equipment; [...]

Inspectors wroteBased on record review and staff interviews during the survey, the facility failed to ensure that injuries of unknown origin were thoroughly investigated to rule out abuse, neglect, and mistreatment. This was identified for one (Resident #141) of five residents reviewed for accidents. Specifically, Resident #141 was observed on the floor secondary to an unwitnessed fall. The facility investigation did not include statements from all involved staff to determine the root cause and rule out abuse, neglect, and mistreatment.

Inspectors wroteBased on observations, record review, and interviews during survey, the facility failed to ensure that a comprehensive person-centered care plan was implemented for each resident to meet each resident's medical and nursing needs. This was identified for one (Resident #310) of five residents reviewed for Accidents. Specifically, Resident #310 had a physician's order for padded half side rails with for seizure precautions. On two separate occasions, Resident #310 was observed without the padded side rails.

Inspectors wroteBased on observations, record review, and interviews during survey, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles. This was identified for one (Unit 3 C, low side Medication Cart) of nine medication carts reviewed for the Medication Storage Task and for one (Resident #194) of five residents reviewed for Accident Hazards. Specifically, 1) a Novolog FlexPen (insulin medication to control high blood sugar) was observed unopened and stored in the medication cart. The manufacturer's guidelines indicated that the Novolog FlexPen should be stored in the refrigerator before opening. 2) Resident #194 was observed on multiple occasions with Biotin supplement (helps the body convert food into energy) bottles at their bedside.

Inspectors wroteBased on observation, interview, and record review during the survey, the facility failed to accurately document the resident population, the overall acuity, the care required by the resident population, and the resources needed, in the facility assessment. This was identified for one (Unit 1C) of eight nursing units reviewed for sufficient and competent nurse staffing task. Specifically, the facility has a dedicated ventilator unit with certified ventilator beds, occupied by ventilator dependent residents who receive ventilator-related respiratory care. The facility assessment did not include the ventilator dependent residents to determine what resources were necessary to care for those residents including the use of competent and qualified Respiratory therapists.

Inspectors wroteBased on record review and interviews during the Abbreviated Survey (NY00377991) initiated on 6/2/2025 the facility did not ensure that all incidents including allegations of abuse were thoroughly investigated. This was identified for one (Resident #1) of three residents reviewed for abuse. Specifically, on the morning of 4/14/2025 Resident #1 stated they had been punched in the ribs by nursing staff. There was no documented evidence that the facility obtained statements from the overnight staff to rule out abuse. The finding is: The facility's policy titled, Abuse Prevention Program with a revised date of September 2024 documented the residents have the right to be free from abuse and all alleged or suspected incidents will be thoroughly investigated and findings documented in a report format. [...]

Inspectors wroteBased on observation of the facility videotape, record review and interviews, during an abbreviated survey (Complaint # NY00378355), the facility did not ensure one of three residents (Resident#1) ) reviewed for abuse were free from physical abuse by a staff member. The review of video surveillance dated 04/09/25 at 11:00:56 AM showed Certified Nursing Assistant #1 using both hands to hold Resident #1's shoulders while seated in wheelchair and the Certified Nurse's Aide was pulling the resident back and forth in a shaking motion. There was no other staff or resident present in view of the surveillance video at the time of the incident.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025 the facility did not ensure that a Baseline Care Plan for each resident included instructions needed to provide effective person-centered care that meets professional standards of quality care. This was identified for one (Resident #519) of three residents reviewed for Infection Control. Specifically, Resident #519 was admitted with Coronavirus (COVID-19) positive infection and had a physician's order for Droplet and Contact Precautions for ten days. There was no care plan developed and implemented for the Droplet and Contact Precautions. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025 the facility did not ensure parenteral fluids were administered consistent with current professional standards of practice, physician orders, and the comprehensive person-centered care plan. This was identified for one (Resident #242) of three residents reviewed for Hydration. Specifically, Resident #242 was admitted to the facility with a Peripheral Inserted Central Catheter (PICC) in their right arm from the hospital. There was no documentation the facility was Monitoring the Peripheral Inserted Central Catheter (PICC) site or measuring the length of the external catheter. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #32) of three residents reviewed for Respiratory Care. Specifically, Resident #32 was observed receiving oxygen therapy without a Physician's order. The finding is: The facility's policy titled Oxygen Administration dated February 2024 documented to ensure adequate oxygenation of the body's vital organs. Residents with a clinical diagnosis or clinical indication will receive concentrations of oxygen in doses higher than those found in the atmosphere. [...]

Inspectors wroteBased on observation, record review, and interview during the Recertification survey initiated on 2/24/2024 and completed on 2/28/2025, the facility did not ensure the Physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was identified for one (Resident #32) of five residents reviewed for Respiratory care. Specifically, Resident #32 received Oxygen therapy without a physician's evaluation and physician's order. The finding is: The facility's policy titled Oxygen Administration dated February 2024 documented to ensure adequate oxygenation of the body's vital organs. Residents with a clinical diagnosis or clinical indication will receive concentrations of oxygen in doses higher than those found in the atmosphere. Oxygen [therapy] is administered by licensed nursing staff on the written order of the attending Physician. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #521) of three residents reviewed for the Infection Control Task, and one (Resident #147) of five residents reviewed for Respiratory Care. Specifically, 1) Resident #521 had a physician's order for Contact Precautions due to Clostridium difficile infection. On 2/25/2025 at 8:09 AM, Certified Nursing Assistant #3 was observed coming out of Resident#521's room carrying two meal trays without wearing any Personal Protective Equipment including a gown or gloves. [...]

Inspectors wroteBased on interviews and record review during a Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility failed to ensure that allegations of sexual abuse were reported to the Administrator or other officials immediately (or within two hours) after the allegations were made. This was identified for one (Resident #26) of seven residents reviewed for abuse. Specifically, on 3/30/2024 Resident #26, with intact cognition, reported to Licensed Practical Nurse #1 they were sexually abused by Certified Nursing Assistant #1. Licensed Practical Nurse #1 failed to report the allegations to the facility Administrator/designee or other officials. Resident #26 again reported the same allegation of sexual abuse to Certified Nursing Assistant #3 on 4/01/2024. Certified Nursing Assistant #3 informed Registered Nurse #1 of the allegation. [...]

Inspectors wroteBased on interviews and record review during a Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility failed to ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated. This was identified for one (Resident #26) of seven residents reviewed for abuse. Specifically, on 3/30/2024 Resident #26 reported to Licensed Practical Nurse #1 that they were sexually abused by Certified Nursing Assistant #1. There was no documented evidence Licensed Practical Nurse #1 took steps to initiate an investigation into the allegation. On 4/1/2024, Resident #26 reported the same allegation to Certified Nursing Assistant #3. Certified Nursing Assistant #3 informed Registered Nurse #1 of the allegation. There was no documented evidence Registered Nurse #1 took steps to initiate an investigation into the allegation. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified in three (Unit 1C, Unit 3C, and Unit 3B) of seven nursing units reviewed for Medication Storage. Specifically, 1) the daily control drug count sheet on Unit 1C was not signed by two Licensed Nurses to reflect a physical count of the available controlled medications. Additionally, the daily control drug count sheet was not reconciled to reflect the available controlled medications in the medication blister pack for Resident #130 (Unit 1C). 2) the daily control drug count sheet on Unit 3C was not signed by two licensed nurses to reflect a physical count of the available controlled medications. [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024 the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner that promotes or enhances the resident's quality of life. Specifically, on two separate occasions, Resident #92 was observed in bed from the hallway with their urinary bag attached to the bed frame. The urinary bag had no privacy bag and was observed to contain urine. The finding is: The facility policy and procedure on Resident Privacy revised 4/2024 documented the goal of the policy is to ensure that all residents' right to privacy is respected and maintained in all aspects of care delivery and that all staff members respect the privacy and dignity of residents at all times. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (Resident #186) of five residents reviewed for choices. Specifically, resident #186 was observed with multiple inhalers (Ventolin, Atrovent, Breo Ellipta) medications, on top of their room dresser. There was no documented assessment by the interdisciplinary team to determine if the resident could safely self-administer and store these medications in their room. The finding is: A facility policy and procedure titled, Medication: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This was identified for 1) one (Resident #114) of two residents reviewed for rehabilitation and restorative services; 2) one (Resident #227) of four residents reviewed for respiratory care; and 3) one (Resident #186) of five residents reviewed for unnecessary medications. Specifically, there was no documented evidence that the comprehensive care plans for Resident #114, Resident #227, and Resident #186 were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly review assessment. The finding is: The facility's policy and procedure titled, Comprehensive Care Planning: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024 the facility did not ensure each resident's environment was free from accident hazards and each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #226) of four residents reviewed for accident hazards. Specifically, Resident #226 was assessed as at risk for falls and had a history of falls. The resident's comprehensive care plan indicated a high floor mat as an intervention and a Dycem non-slip mat under the floor mat to prevent the high floor mat from slipping away from the resident's bed. During multiple observations, the Dycem non-slip mat was not observed under the high floor mats in Resident #226's room as indicated in the resident's comprehensive care plan. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024 the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. This was identified for two (Resident #148 & Resident #69) of three residents reviewed for Tube Feeding. Specifically, 1) on 4/17/2024 at 10:49 AM and again on 4/25/2024 at 12:05 PM Resident # 148's tube feeding bottles were not labeled including nursing's initials, date, and time the feeding was initiated. 2) Certified Nursing Assistant #7 was observed providing care to Resident #69 while the resident was lying flat on their back in the bed. The resident was receiving the tube feeding while the lying flat.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #152) of two residents reviewed for dialysis. Specifically, the dialysis center recommended holding Resident #152's blood pressure medications before the dialysis treatments. The facility staff did not follow the recommendations made by the dialysis center and did not notify the resident's Physician of the recommendations. The finding is: The Policy and Procedure for Hemodialysis: [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey initiated on 4/17/24 and completed on 4/26/24, the facility did not ensure that residents are free of any significant medication errors. This was identified for two (Resident #79 and Resident #143 ) of seven residents reviewed for choices. Specifically, 1) Resident #79 did not receive their physician-ordered Insulin injection timely 2) Resident #143 had a physician's order to check blood sugar via a fingerstick before meals. The blood sugar via a fingerstick was not performed in the ordered time frame, and Insulin was not administered according to the Physician's order before meals. The finding is: 1) Resident #79 was admitted with diagnoses that included Type II Diabetes Mellitus and Hypertension. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024 the facility did not ensure each resident in a semi-private room had ceiling suspended curtains, which extend around the bed to provide total visual privacy. This was identified for two (Resident #108 and Resident #111) of two residents reviewed for privacy. Specifically, Resident #108 and Resident #111 shared a semi-private room. The privacy curtain separating Resident #108 and Resident #111 was not long enough to allow full visual privacy. The finding is: The facility's policy titled, Privacy Curtains effective 4/2024 documented the purpose of this policy is to establish guidelines for the use and maintenance of privacy curtains in our nursing facility to ensure the privacy and dignity of our residents. [...]