Salem Rehab Center

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to follow proper thawing practices when defrosting clams, to ensure that food was dated in the main kitchen and in one of two unit kitchenette refrigerators.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#15) was not left with pills to self-administer without first determining if it was safe, out of a total sample of 19 residents. Specifically, staff left pills at Resident #15's bedside for self-administration without completing a self-administration of medication assessment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#71) out of a total sample of 19 residents. Specifically, for Resident #71, the facility failed to revise the comprehensive care plan relating to the need for a geri chair (a sturdy, padded chair on wheels that can recline which is designed to be more supportive and comfortable than a standard wheelchair, especially for people who have limited mobility and spend a lot of time sitting) for comfort and skin integrity concerns upon the care plan review following the completion of the last quarterly assessment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that staff accommodated food preferences for one Resident (#66), out of a total sample of 19 residents. Specifically, the facility failed to honor Resident #66's preferences and served the Resident fortified cream of wheat, which he/she disliked, instead of fortified super oatmeal as he/she requested.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure food is stored, prepared and distributed in accordance with professional standards in food safety and sanitation to prevent the spread of pathogens, which could result in foodborne illness for the residents. Specifically, 1. food stored in the dry storage area, and walk-in refrigerator were not labeled and dated, and 2. Staff failed to ensure safe food handling during the lunch meal distribution.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure three Residents (#39, #25 and #38) received care in accordance with professional standards of practice, out of a total sample of 23 residents. Specifically, 1. For Resident #39, the facility failed to ensure a physician's order was developed for the use of a hand orthotic before it was in use. 2. For Resident #25, the facility failed to ensure a wound physician recommendation was implemented. 3. For Resident #38, the facility failed to implement physician's orders for daily dressing changes to the left elbow.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that for two Residents (#10 and #1) who are unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal and oral hygiene out of a total sample of 23 Residents. Specifically, 1. For Resident #10, the facility failed to ensure incontinence care was provided timely and in accordance with the standards of care and the Resident care plan. 2. For Resident #1, the facility failed to remove unwanted facial hair.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure for one Resident (#37), out of a total sample of 23 resident, interventions related to fall, and injury prevention were implemented in accordance with the medical plan of care. Specifically, the facility staff failed to ensure bedside fall mats were in place.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (a tube surgically inserted through the abdominal wall directly into the stomach with the purpose of delivering food, typically in the form of liquid formula) was provided according to professional standards for one Resident (#36) out of a total sample of 23 Residents. Specifically, the facility failed to ensure a tube feeding was running according to physician orders for Resident #36.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#26 and #42), out of a total sample of 23 residents. Specifically, 1. For Resident #26, the facility failed to administer oxygen appropriately and change oxygen tubing as ordered. 2. For Resident #42, the facility failed to ensure continuous oxygen was provided when the Resident left the facility.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#70) out of a total sample of 23 residents. Specifically, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #70. Findings Include: Review of facility policy titled Change in Condition, dated as revised 10/2022, indicated the following: -Our facility shall promptly notify the resident, his or her Attending physician, and representative of changes in the resident's medical, mental condition and/or status. Resident #70 was admitted to the facility in May 2024 with diagnoses including major depressive disorder, post traumatic dress disorder and visual hallucinations. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a current hospice care plan was present in the medical record and coordinated with facility staff for one Resident (#71) out of a total sample of 23 residents.

Inspectors wrote5.) Resident #3 was admitted to the facility September 2023 with diagnoses including a stroke, acute inflammatory demyelinating polyneuropathy (AIDP) (weakness and sensory loss in limbs), and anemia. Review of the Minimum Data Set (MDS) assessment, dated 7/4/24, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 which indicated she is not cognitively impaired and requires total assist with all activities of daily living. Review of nursing skin evaluation, dated 7/6/24, indicated Resident #3 had no skin issues. Review of consultant wound physician notes, dated 7/9/24, indicated initial evaluation of Resident #3's right lateral ankle wound, documented duration of wound as greater than 50 days. [...]

Inspectors wrote4.) Resident #3 was admitted to the facility September 2023 with diagnoses including a stroke, acute inflammatory demyelinating polyneuropathy (AIDP) (weakness and sensory loss in limbs), and anemia. Review of the Minimum Data Set (MDS) assessment, dated 7/4/24, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 which indicated she is not cognitively impaired and requires total assist with all activities of daily living. Review of nursing skin evaluation, dated 7/6/24, indicated Resident #3 had no skin issues. Review of consultant wound physician notes, dated 7/9/24, indicated initial evaluation of Resident #3's right lateral ankle wound, documented duration of wound as greater than 50 days. [...]

Inspectors wrote4. Resident #103 was admitted to the facility in March 2024 with diagnoses that include diabetes, pressure ulcer of the right buttock (stage IV) and bacteremia. Review of Resident #103's most recent Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating that the resident had moderate cognitive impairment. The MDS further indicated that the Resident had one stage IV pressure ulcer that was present on admission to the facility and was at risk for the development of pressure ulcers. Review of Resident #103's most recent Norton Assessment (a tool designed to help clinicians evaluate a patient's risk of developing pressure injuries), dated 6/15/24, indicated a score of 9, placing Resident #103 at high risk for the development of pressure injuries. [...]

Inspectors wroteBased on interview, record review, and observation the facility failed to ensure seven residents maintained acceptable parameters of nutritional status out of a total sample of 39 residents. Specifically, the facility failed to: 1) For Resident #85 the facility failed to assess the nutritional status of and implement pertinent interventions for the Resident who developed a necrotic skin area which worsened to two unstageable wounds and experienced significant weight loss. 2) For Resident #68 the facility failed to address a significant weight loss in a timely manner. 3) For Resident #16 the facility failed to obtain weights as ordered, and address a significant weight loss for in a timely manner. [...]

Inspectors wroteBased on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically: 1.) The facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care, treatment administration, transcribing orders, pressure ulcer prevention, change in condition, and communication. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: 1.) The facility failed to provide nursing staff education and training to provide competent, safe, and effective wound care management. [...]

Inspectors wroteBased on interview, record review and the Facility Assessment, the facility failed to ensure the Governing Body provided oversight and accountability for effective operational management and quality of care related to the clinical status of residents. Specifically: 1.) The governing body failed to ensure the facility provided consistent and effective nursing staff education and training to provide competent quality of care and effective wound care management, as per the Facility Assessment. 2.) The governing body failed to allocate resources and obtain a Dietitian for the facility, as per the Facility Assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences was provided for two Residents out of a total sample of 39 residents. Specifically: 1) For Resident #85, the facility failed to utilize as-needed (PRN) pain medication for breakthrough pain and wound dressing changes as directed by the physician. 2) For Resident #75, the facility failed to ensure nursing provided pain management in accordance with professional standards of practices. Specifically for Resident #75 the facility failed consistently administer his/her physician's ordered pain medication on time.

Inspectors wroteBased on interviews and record reviews the facility failed to employ a qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis.

Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interviews, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident.

Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory effective communication training for 17 direct care staff.

Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interviews, the facility failed to ensure that staff members were educated on the rights of the resident on hire for 14 out of 17 direct care staff education files reviewed.

Inspectors wroteBased on review of the Facility Assessment, employee education record review, policy review and interviews, the facility failed to implement mandatory training on Quality Assurance and Performance Improvement (QAPI) for 17 employees.

Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory infection control training upon hire for 15 out of 17 direct care staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure at least 12 hours of required in-service training hours, that included dementia management training, were provided for 5 of 5 Certified Nurse Aides (CNAs) education files reviewed.

Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interviews, the facility failed to provide behavioral health training consistent with the requirements at §483.40 to 17 out of 17 direct care employees reviewed.

Inspectors wroteBased on observations and interviews, the facility failed to provide a dignified existence to residents. Specifically, the facility failed to ensure that staff did not refer to residents who require assistance as feeds or feeders, that staff did not speak in a foreign language to each other in the presence of residents, that staff did not stand while providing feeding assistance to residents, that staff did not transport a resident while he/she was facing backwards, and that a foley catheter drainage container was covered and wasn't visible from the hallway. Findings Include: Review of the facility policy, titled Quality of Life - Dignity, created in October 2022, indicated, but was not limited to, the following: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. [...]

Inspectors wroteBased on Resident Council Meeting minute review, interviews, and record review, the facility failed to ensure grievances addressed by the Resident Council Group had sufficient follow-up to prevent recurrence and provide residents with rationale for actions taken by the facility to resolve grievances.

Inspectors wroteBased on interview and record review, the facility failed to allow residents privacy when opening packages.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on three of three nursing units.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to develop and implement a person- centered comprehensive care plan for three Residents (#76 #106 and #92) out of a total sample of 39 residents. Specifically, 1. For Resident #76, the facility failed to develop a person-centered care plan for a behavior of wandering. 2. For Resident #106, the facility failed to develop a person-centered care plan for obstructive sleep apnea and the use of a continuous positive air pressure (CPAP) machine. 3. For Resident #92 the facility failed to develop a person-centered care plan for obstructive sleep apnea and the use of a continuous positive air pressure (CPAP) machine. Findings Include: Review of facility policy titled Care Plan- Comprehensive, dated as revised 10/22/22, indicated the following: Policy: [...]

Inspectors wroteBased on observations, record review and interviews, for three Residents (#51, #76, and #85) out of a total sample of 29 residents the facility failed to provide assistance with activities of daily living (ADLs). Specifically, 1. For Resident #51, the facility failed to provide the necessary services to maintain good nutrition (assistance with meals as per the plan of care). 2. For Resident #76, the facility failed to provide the necessary services to maintain nail grooming.

Inspectors wrote5. Resident #13 was admitted to the facility in April 2024 with diagnoses including asthma, obstructive sleep apnea, schizoaffective disorder, bipolar disorder, and post-traumatic stress disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/18/24, indicated that Resident #13 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 and he/she required oxygen. On 7/23/24 at 8:06 A.M., the surveyor observed Resident #13 in his/her bed, he/she was wearing oxygen at 8 liters per minute (LPM) via nasal canula. Resident #13 said he/she does not adjust his/her own oxygen settings. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure services consistent with professional standards were provided for two Residents (#22 and #65) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 39 residents. Specifically, the facility failed to follow physician's orders to ensure that blood pressure readings were not taken on the arm where the dialysis shunt (an access point from the dialysis machine to a blood artery) is located.

Inspectors wroteBased on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for four Residents (#13, #83, and #35), who were admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD) out of a total sample of 42 residents. Specifically, 1. For Resident #13, who was assessed by nursing as a trauma survivor, the facility failed to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident. 2. For Resident #83 the facility failed to develop a plan of care for trauma-informed care related to a diagnosis of PTSD. 3. For Resident #35 the facility failed to develop a plan of care for trauma-informed care related to a diagnosis of PTSD. Findings Include: [...]

Inspectors wroteBased on personnel file review and interviews, the facility failed to ensure that 2 of 5 Certified Nurse Assistants (CNA's) reviewed were not employed as CNA's for more than four months after hire without having completed the competency evaluation program approved by the State of Massachusetts.

Inspectors wroteBased on personnel file review and interview, the facility failed to ensure annual performance reviews were completed at least every 12 months for 2 of 3 Certified Nurse Aides (CNAs) personnel files reviewed.

Inspectors wroteBased on record review and interviews the facility failed to ensure recommendations from the Monthly Medication Review conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for five Residents (#13, #41, #50, #92, #35) out of a total sample of 39 residents. 1.) For Resident #13, the facility failed to ensure the attending physician and nursing reviewed and acted on the monthly pharmacy recomendations for ativan (an antianxiety medication) re-evaluation. 2.) For Resident #41, the facility failed to ensure the attending physician and nursing reviewed and acted on the monthly pharmacy recomendations to indicate duration of an as needed clonazepam (an antianxiety medication). [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure that PRN [as needed] ordered psychotropic drugs were limited to 14 days for four Residents (#13, #50, #41, #92) out of a total sample of 42 residents. Specifically, 1. For Resident #13, the facility failed to implement a 14 day stop date for PRN ativan (an antianxiety medication). 2. For Resident #41, the facility failed to implement a stop date or re-evaluation for use of PRN clonazepam (an antianxiety medication). 3. For Resident #50, the facility failed to implement a stop date or re-evaluation for use of PRN ativan (an antianxiety medication). 4. For Resident #92, the facility failed to implement a stop date or re-evaluation for use of PRN Klonopin (an antianxiety medication) and PRN Ambien (a hypnotic medication). Findings Include: [...]

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 4 out of 5 nurses observed made 9 errors out of 30 opportunities, resulting in a medication error rate of 30%. Those errors impacted four Residents (#75, #86, #20 and #80), out of five residents observed. 1. For Resident #75, Nurse #1 failed to administer his/her medications within the one-hour time frame. 2. For Resident #86, Nurse #2 failed to administer his/her medications within the one-hour time frame and failed to administer the correct form of iron. 3. For Resident #20, Nurse #3 failed to administer his/her medications within the one-hour time frame. 4. For Resident #80, Nurse #4 failed to administer his/her medications within the one-hour time frame and failed to follow manufactures guidelines.

Inspectors wroteBased on record review and interviews for one Resident (#24) out of 39 sampled residents, the facility failed to ensure that the Resident was free from a significant medication error. Specifically, the facility failed to ensure a blood pressure medication (midodrine) was scheduled to be administered in accordance with the physician's order which indicated that the medication be administered before meals.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1.) Ensure medications with shortened expiration dates were dated once opened. 2.) Ensure medication and treatment carts were locked when unattended. 3.) Ensure medications were stored in the original, labeled containers. 4.) Ensure medications were stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel. 5). For Resident #38, the facility failed to ensure that self-administered medications were stored securely when not in use.

Inspectors wroteBased on observations and interviews the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature.

Inspectors wroteBased on observations, policy review, record review, and interviews the facility failed to ensure one Resident (#24) out of a total sample of 39 residents, was provided the therapeutic diet in accordance with physician orders. Specifically, Resident #24 was not provided with his/her diet as ordered by the physician.

Inspectors wroteready for final edit- please delete once done Based on observations, record review, policy review, and interviews, for one Resident (#51) of 39 sampled residents, the facility failed to provide adaptive equipment. Specifically, the facility failed to ensure Resident #51 was consistently provided with a lip plate and sippy cups for use during his/her meals to maximize food intake.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled, that employees did not store their drinks with resident food/ingredients, that staff discarded produce with visible signs of decomposition, that staff discarded dairy products that were past their expiration date, and that food was not stored on the floor.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility staff failed to ensure medical records were complete and accurately documented in accordance with professional standard of practice for three Residents (#88, #263, and #35) out of 39 total sampled residents. The facility also failed to maintain complete medical records in accordance with professional standards of practice for one of three sampled discharge records. Specifically: 1.) For Resident #88, nursing documented a peripherally inserted central catheter (PICC) dressing change as implemented, when it was not. 2.) For Resident #263, nursing documented a PICC dressing change as implemented, when it was not. 3.) For Resident #35, nursing did not complete skin checks in the electronic health record when it was signed off on Treatment Administration Record (TAR) as complete. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically: 1.) The facility failed to ensure precaution gowns were appropriately implemented during wound care for residents on enhanced barrier precautions. 2.) The facility failed to ensure staff performed appropriate hand hygiene after removing gloves during wound care. 3.) The facility failed to ensure nursing implemented infection control standards for blood glucose cleaning.

Inspectors wroteBased on policy review, observation and interviews, the facility failed to ensure its staff implemented the facility smoking policy for one Resident (#44) out of a total of 39 residents sampled. Specifically, the facility failed to ensure staff stored Resident #44's smoking materials in a locked area.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for one Resident (#62), out of a total sample of 39 residents. Specifically, for Resident #62, the facility failed to ensure that Advanced Directives (Massachusetts Medical Order for Life-Sustaining Treatment form (MOLST)) were consistently documented in the medical record.

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify and assess the use of pillows tucked underneath a fitted sheet on both sides of the bed as a potential restraint for one Resident (#105) out of a total sample of 39 residents.

Inspectors wroteBased on record review and interviews, the facility failed to implement their abuse prohibition policy for one Resident (#81) out of a total sample of 39 residents. Specifically, for Resident #81, the facility failed to ensure facility staff immediately reported an allegation of physical abuse to the Director of Nursing or Administrator, as required.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an injury of unknown origin (a fracture), for one Resident (#3) out of a total sample of 39 residents.

Inspectors wroteBased on record review and interviews the facility failed to develop a baseline plan of care that included instructions needed to provide effective and person-center care for one Resident out of a total sample of 39 residents. Specifically, for Resident #27, who was assessed upon admission by nursing as a fall risk, the facility failed to develop and implement a plan of care related to falls and Resident #27 subsequently experienced a fall, 4 days after he/she admitted to the facility. Findings Include: Review of the facility policy, titled Care Plans - Baseline, revised October 2022, indicated, but was not limited to, the following: - A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Resident #27 was admitted to the facility in March 2024 with a diagnosis of dementia. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for two Residents (#3 and #24) out of a total sample of 39 residents. Specifically, 1. For Resident #3 the facility failed to review and revise the plan of care related following the removal of a foley catheter (a urinary catheter that is inserted into the bladder). 2. For Resident #24 the facility failed to review and revise the plan of care related to wound care.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to meet professional standards of quality for two Residents (#16 and #27) out of a total sample of 39 residents. Specifically: 1) For resident #16 the facility failed to implement physician's orders for prevalon boots and an air mattress for a resident with potential for skin breakdown. 2) For Resident #27 the facility failed to ensure medication orders included a correlating medical diagnosis.

Inspectors wroteBased on observation, record review and interviews the facility failed to provide services to ensure that proper treatment to maintain vision and hearing ability were provided for two Residents (#24 and #62) out of a total sample of 39 residents. Specifically, 1. For Resident #24 the facility failed to follow up on recommendations from 12/19/23 for an outside ophthalmology consult. 2. For Resident #62, the facility failed to follow up on an ear nose and throat (ENT) appointment for hearing loss.

Inspectors wroteBased on record review, policy review, observations and interviews the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one Resident (#35), out of a total sample of 39 Residents. Specifically, for Resident #35, the facility failed to apply left wrist splint daily to left upper extremity.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide adequate supervision to Residents on one of three units. Specifically, staff were observed sleeping on the [NAME] unit during the overnight shift (11:00 P.M. to 7:00 A.M.) on 7/24/24. Findings Include: Review of the General Code of Conduct, dated as revised November 16, 2022, indicated the following: -At [this facility], we expect that the high degree of skill and dedication is shown by our staff will make disciplinary actions necessary only on rare occasions. -Listed below are some examples of behavior and conduct that would result in some form of disciplinary action up to and including immediate termination. *Sleeping on the job. During initial screening on 7/23/24, four Residents on the [NAME] unit, a sub acute unit per the facility assessment, reported that staff are sleeping on the overnight shift. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#41) out of a total sample of 39 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed directly on the floor.

Inspectors wroteBased on observation, record review, and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach) for one Resident (#313) out of a total sample of 39 residents. Specifically, for Resident #313 the facility failed to implement physician's orders for his/her head of bed to be elevated, the facility failed to implement physician's orders for water flushes, and the facility failed to label the enteral feeding bag with the contents inside, and with time the enteral feeding was hung, and therefor staff were unable to identify the formula and staff were unable to determine the expiratory date of the formula based on manufactures guidelines. Findings Include: Review of facility policy titled Enteral Feedings, dated as revised 10/2022, indicated the following: -Policy: [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) consistent with professional standards of practice for two Residents (#263 and #85) out of a total sample of 39 residents. Specifically: 1.) For Resident #263, the facility failed to ensure nursing implemented a PICC line dressing change as ordered by the physician and failed to ensure nursing dated intravenous (IV) tubing. 2.) For Resident #85, the facility failed to ensure that a PICC line dressing was changed within seven days, and that the nursing failed to obtain a physician's order for PICC line dressing changes.

Inspectors wroteBased on observations, record review and interviews, the facility failed to assess one Resident (#103) for the use of side rails. Specifically, the facility failed to assess the risk of entrapment from side rails, review the risks and benefits of side rails and obtain informed consent from the resident prior to installation of side rails. Findings Include: Review of facility policy, titled Side Rails, undated, indicated the following: -Each resident will be assessed for functional status on admission, readmission, quarterly, for any significant change and as needed. Side rails will only be used by a resident to assist with his or her bed mobility. -Side rails will be analyzed for safety and prevention of entrapment. -5. the staff shall obtain consent for the use of side rails/ enabler form the resident or the resident's legal representative prior to their use. 6. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide routine medications to two Resident (#86 and #92) out of a total sample of 39 residents. Specifically, 1. For Resident #86, the facility failed to provide eliquis (anticoagulant medication) as ordered by the physician. 2. For Resident #92, the facility failed to provide two scheduled doses of klonopin (an antianxiety medication) as ordered by the physician. Findings Include: Review of the facility policy titled Unavailable Medications, dated as revised December 2019, indicated that medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure for one Resident (#47), out of a total sample of 39 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to complete a gradual dose reduction (GDR) of his/her physician's ordered Lexapro (antidepressant medication).

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to ensure laboratory services were provided for one Resident (#62) out of a sample of 39 residents. Specifically, the facility failed to ensure a 24-Hour urine was obtained.

Inspectors wroteBased on interview and record review the facility failed to obtain routine and 24-hour emergency dental care for one Resident (#16) out of a total sample of 39 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to assess for eligibility, and offer pneumococcal and influenza vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for four Residents (#47, #24, #48 and #81) out of a total of five residents reviewed.

Inspectors wroteBased on record review, policy review and interviews the facility failed to provide written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for one Resident (#35), out of a total sample of 39 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide an accurate estimated cost of services to Resident's or their representatives, for two Residents (#7 and #62) out of three records reviewed, to ensure they were informed of their potential financial liabilities of the cost of items and services provided in addition to the daily per diem room rate.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide written transfer/discharge notification for two Residents (#52 and #88) out of 39 total sampled residents when transferred to the hospital. Specifically: 1.) For Resident #52, the facility failed to provide written transfer/discharge notification when emergently discharged to the hospital. 2.) For Resident #88, the facility failed to provide written transfer/discharge notification when emergently discharged to the hospital on three separate occasions. Review of the facility policy titled Discharge/Transfer Process, revised 10/2022, indicated: - For transfers to the hospital, the nurse will ensure the appropriate details of the hospital transfer are documented in the resident's medical record. [...]

Inspectors wrote3. Resident #83 was admitted to the facility in April 2024 with diagnoses that include alcohol abuse, post- traumatic stress disorder (PTSD) and type 2 diabetes. Review of Resident #83's most recent Minimum Data Set (MDS) Assessment, dated 7/4/24, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating that the Resident is cognitively intact. Review of the Resident #83's clinical record indicated that he/she was transferred to the hospital on 5/24/24 and 7/6/24. Additional review of the clinical record failed to indicate the facility provided Resident #83 with a bed hold notice for either transfer, as required. During an interview on 7/25/24 at 9:31 A.M., Nurse #2 said that when a resident is sent out to the hospital the nurse sends a face sheet, medication orders and a summary of why he/she is being sent to the hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for four Residents (#88, #58, #92, and #3) of 39 total sampled residents. Specifically: 1.) For Resident #88, the use of restraints was inaccurately coded in the MDS. 2.) For Resident #58, the use of oxygen was inaccurately coded in the MDS. 3.) For Resident #92, the use of non-invasive mechanical ventilation was inaccurately coded on the MDS. 4.) For Resident #3, the development of a fracture was inaccurately coded in the MDS.

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, when documentation by nursing related to the conduction of weekly skin assessment was incomplete, and documentation that was to be completed by Certified Nurse Aides related to completion of Activities of Daily Living (ADL) was also incomplete.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1) the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 02/09/24 at approximately 1:45 P.M., the Administrator was witnessed interacting with Resident #1 in a demeaning, embarrassing and insulting manner, as he yelled (screamed) at Resident #1 about the cluttered and unsanitary conditions of his/her room.

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #1), who's Physician Orders included the need for Continuous Positive Airway Pressure (CPAP, uses mild air pressure to keep breathing airways open while sleeping) machine and the use of Lymphedema (swelling in the legs) compression machine, both of which were to be applied by Nursing and used by Resident #1 daily, the Facility failed to ensure nursing staff notified his/her Physician when treatments were not being completed daily as ordered.

Inspectors wroteBased on records reviewed and interviews for one out of four sampled residents (Resident #3), the Facility failed to ensure they maintained a complete and accurate medical records including but not limited to completion of Resident Assessments upon admission.

Inspectors wroteBased on records reviewed and interviews for 9 of 9 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8 and #9) the Facility failed to ensure staff complete all sections of the Resident's admission Assessment as required.

Inspectors wroteBased on records reviewed and interviews for two of nine sampled residents (Resident #3 and Resident #4) the facility failed to ensure they developed and implemented baseline care plans within 48 hours of admission, that provided information at a minimum so that staff could provide the necessary care and services to properly meet their care needs.

Inspectors wroteBased on observation, records reviewed and interviews, for one of nine sampled residents (Resident #8) whose diagnoses included high blood pressure, multiple sclerosis, anxiety and recent gastric sleeve surgery, the facility failed to ensure that medication administration was consistent with accepted standards of quality, when Resident #8 was observed ambulating independently down the hallway towards his/her room with a medicine cup containing two pills in hand.

Inspectors wroteBased on records reviewed an interviews for one of nine sampled residents (Resident #1) who was admitted to the facility with an infection that required treated with intravenous antibiotic medication, the Facility failed to ensure they obtained his/her physician ordered antibiotic medication timely, as a result Resident #1 was not administered an antibiotic as ordered, and his/she missed multiple doses of his/her intraveous antibiotic, placing him/her at increased risk for worsening of his/her infection.