Saugus Center

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for four Residents (#4, #5, #62 and #68) out of a total sample of 21 residents. Specifically: 1. For Resident #4 the facility failed to implement physician's orders to monitor and evaluate orthostatic blood pressures (orthostatic blood pressure is assessed to detect orthostatic hypotension, which is defined as a drop in systolic blood pressure of 20 mmHg (millimeters of mercury) or more or a stop in diastolic blood pressure of 10 mmHg or more within three minutes of standing from a supine position during a head-up tilt or at least 60 degrees. This drop can lead to symptoms such as dizziness, lightheadedness, fainting, headache, visual disturbances, and neck or shoulder discomfort due to inadequate blood flow to the brain and other organs) . 2. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure referrals for outside services were implemented for three sampled Residents (#1, #33, and #2). Specifically:1. For Resident #1 the facility failed to ensure that Resident #1 attended a scheduled orthopedic appointment, and after the scheduled orthopedic appointment was missed the facility failed to reschedule the orthopedic appointment. 2. For Resident #33 the facility failed to set up an appointment with urology for a suprapubic (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow.) tube placement evaluation.3. For Resident #2 the facility failed to ensure a referral was replaced for neurology.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medical records were accurate for five Residents (#3, #5, #55, #62 and #10) out of a total of 21 sampled Residents. Specifically,1. For Resident #3 the facility failed to ensure that advance directives were consistently and accurately documented throughout the medical record.2. For Resident #5 the facility failed to ensure that only medical information related to Resident #5 was in the medical record. Specifically, another resident's MOLST (Medical Orders for Life-Sustaining Treatment- a medical form that documents a patient's preferences for life-sustaining treatments and translates them into actionable medical orders signed by a licensed healthcare professional) form was located in his/her medical record.3. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically,1. The facility failed to establish an infection prevention and control program that includes a system for appropriate infection surveillance.2. For one Resident (#10) out of a total sample of 21 residents, the facility failed to implement Enhanced Barrier Precautions (EBP) during the administration of a tube feed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff treated residents with dignity and respect for three Residents (#55, #14 and #16) out of a total of 21 sampled Residents. Specifically, the facility failed to ensure the Nurse Supervisor: 1. spoke appropriately about Resident #55 in a public setting, 2. responded appropriately to Resident #14's concerns, and 3. spoke appropriately about Resident #16 in a public setting.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure one Resident (#12) was free from unnecessary psychotropic medications by ensuring a stop date was included in the physician's order for an as needed (PRN) dose of Ativan (medication used to treat anxiety) out of a total sample of 21 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#7) out of a total sample of 21 residents, after each assessment. Specifically, the facility failed to review and revise the care plan (eating status) after a quarterly assessment was completed to reflect the current status of the Resident.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the environment remained free of accidental hazards and was safe for one Resident (#67), out of a total sample of 21 residents. Specifically, for Resident #67, the facility failed to ensure that nursing consistently implemented Resident #67's plan of care related to smoking.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of a urinary catheter for one Resident (#33) out of a total sample of 21 residents. Specifically, for Resident #33 the facility failed to change a urinary drainage bag and failed to document urinary output as ordered by the physician.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#33) out of sample of 21 residents. Specifically, for Resident #33, the facility failed to have a physician's order for oxygen administration and failed to maintain Resident #33's oxygen level in accordance with the plan of care.

Inspectors wroteBased on record review and interview the facility failed to ensure for one Resident (#3), out of five applicable residents, out of a total sample of 21 residents, that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician/nurse practitioner response to the recommendations.

Inspectors wroteBased on observations, interviews, and record reviews for two Residents (#68 and #38) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of three nurses observed made two errors out of 28 opportunities resulting in a medication error rate of 7.14%. Specifically,1. For Resident #68 the facility failed to ensure Nurse #1 primed an insulin pen prior to administering the medication resulting in the incorrect dose. 2. For Resident #38 the facility failed to ensure Nurse #2 administered the correct dose of cholecalciferol (vitamin d).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one Residents (#68) was free from a significant medication error, out of a total sample of 21 residents. Specifically, for Resident #68, the facility failed to ensure insulin (an injectable hormone that lowers the level sugar in the blood) was administered in accordance with professional standards of practice (did not perform a safety test/ prime the insulin pen) resulting in Resident #68 not getting an incorrect dose of insulin.

Inspectors wroteBased on observations and interview the facility failed to store drugs and biologicals in accordance with currently accepted professional principles on one of two units. Specifically,The facility failed to ensure unattended medication carts were locked on one of two units. The facility failed to ensure over the counter medications were not left out and unsecured at the nurse's station accessible to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were provided timely for one sampled Resident (#5), out of a total sample of 21 residents. Specifically, the facility failed to obtain a urine for urinalysis and culture as indicated in physician's orders.

Inspectors wroteBased on observation, interview and test trays, the facility failed to provide meals at a palatable temperature on two of two nursing units.

Inspectors wroteBased on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring for Infection Control. Findings Include:Review of the facility policy titled Quality Assurance and Performance Improvement ( QAPI) Policy and Procedure, dated 2024, indicated but was not limited to the following: It is the policy of the Facility to develop, implement and maintain and effective, comprehensive, data driven QAPI program that focuses on indicator of the outcomes of care and quality of life. -Role of the Infection Preventionist on the QAA (Quality Assessment and Assurance) Committee. A. [...]

Inspectors wroteBased on record review and interview, the facility failed to administer the Influenza vaccine during influenza season to one Resident (#55) who consented to receive the flu vaccine out of a sample of five residents. Specifically, the facility failed to administer the influenza vaccine to a resident who consented to receiving it.

Inspectors wroteBased on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to one (#55) out of five sampled Residents. Specifically, the facility failed to offer a COVID-19 vaccination upon admission or seasonally for residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to notify one Resident's (#172) physician and legal guardian of a change in condition out of a total sample of 27 residents. Specifically, the facility failed to notify the physician of Resident #172's refusing medication, exit seeking behavior, an elopement from the facility and multiple other attempts of elopements from the facility, including through a second story window, resulting in Resident #172 from falling out of a second-floor window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to keep three Residents (#172, #56 and #35 free from accidents while at the facility. Specifically, 1. For Resident #172, with a known history of elopement from a window, the facility failed to ensure it provided appropriate supervision and safety resulting in the Resident falling from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs; 2. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure licensed nursing staff were trained and competent in managing wandering behavior and elopement, subsequently, one Resident (#172) eloped and fell from a second-floor bedroom window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs.

Inspectors wroteBased on record review and interviews, the facility failed to ensure it provided appropriate administrative oversight, specific to clinical management and building safety, when one Resident (#172) fell from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Specifically, the facility administration failed to: 1. Ensure the facility's environment was safe for a Resident with a known risk of elopement from a window; 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete annual performance reviews for 10 of 10 sampled staff.

Inspectors wrote2. During an observation on 6/8/25 at 10:29 A.M., the surveyor observed a pink sticky substance on the floor between the beds in room [ROOM NUMBER]. There was a significant amount of napkins, food particles and food wrappers on the floor next to the bed. While walking in the area the surveyors shoes would stick to the floor. On 6/10/25 at approximately 8:20 A.M., the surveyor observed the floor in room [ROOM NUMBER] still had the pink sticky substance on the floor. A resident in the room said he/she would like the room clean and for the mess on the floor to be cleaned up. During observations on 6/10/25 at 1:58 P.M. and 6/11/25 at 6:42 A.M., the surveyor observed the floor of room [ROOM NUMBER] to continued to be sticky and the pink substance was still visible. During an interview on 6/11/25 at 7:35 A.M., the Director of Housekeeping said that resident rooms are cleaned and mopped daily. [...]

Inspectors wrote3. Review of the facility policy titled Enhanced Barrier Precautions, undated, indicated the following: - It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. - Implementation of Enhanced Barrier Precautions: - a. Make gowns and gloves available immediately near or outside of the resident's room. - b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. - High-contact resident care activities include: Device care or use: feeding tubes Resident #7 was admitted to the facility in January 2018 with diagnoses including muscle wasting, depression and dysphagia. [...]

Inspectors wroteBased on record review and interview the facility failed to establish an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use.

Inspectors wroteBased on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to five out of five sampled Residents, (#35. #17, #68, #60, and #28) Specifically, the facility failed to offer COVID-19 vaccinations upon admission or seasonally for residents.

Inspectors wroteBased on record review and interview the facility failed to accurately complete the Minimum Data Set (MDS) assessments for three Resident (#26, #33 and #2) out of a total sample of 27 residents. Specifically: 1. for Resident #26, the facility failed to code his/her vision status accurately. 2. for Resident #33, the facility failed to code assistance provided for transfers accurately. 3. for Resident #2, the facility failed to code assistance provided for transfers accurately.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement care plans for two Residents, (#40 and #17), out of a total of 27 sampled residents. Specifically: 1. For Resident #40, the facility failed to develop and implement a care plan related to elopement. 2. For Resident #17, the facility failed to develop and implement a care plan related to smoking.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for three Residents (#16, #35 and #56) out of a total of 27 residents. Specifically, the facility failed: 1. For Resident #16, who was assessed as being at risk for developing pressure ulcers, the facility failed to ensure an air mattress was at the setting prescribed by the physician as well as ensure weekly skin checks were completed as ordered. 2. For Resident #35, the facility failed to ensure weekly skin checks were completed as ordered. 3. For Resident #56, who was assessed as being at high risk for developing pressure ulcers, the facility failed to ensure weekly skin checks were completed as ordered.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for two Residents (#24 and #44) out of a total sample of 27 residents. Specifically, 1. For Residents #24, who has a history of choking, the facility failed to provide supervision during meals. 2. For Resident #44, the facility failed to provide incontinence care.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide quality activity programming for one Resident (#15) out of a total of 27 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide oral mouth care to one Resident (#7) who does not receive food or drink by mouth resulting in oral thrush (a fungal infection of the mouth) developing out of a total sample of 27 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure that the necessary vision services were provided for one Resident (#26) out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nursing implemented a splinting device as ordered for contracture prevention for one Resident (#16) out of a total sample of 27 residents. Specifically, the facility failed to ensure Resident #16 was wearing a hand roll as ordered and recommended by the therapy department.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#32) was receiving oxygen at the correct flow rate and failed to ensure there was water in the humidifier bottle while the Resident was receiving oxygen, out of a total sample of 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to develop a trauma care plan related to Post Traumatic Stress Disorder (PTSD) or identify triggers for one Resident (#48) out of a total of 27 sampled Residents.

Inspectors wroteBased on observation, interview and record review the facility staff failed to ensure a care plan was developed with individualized-person centered interventions for one Resident (#12), who has a diagnosis of dementia, out of a total sample of 27 residents.

Inspectors wroteBased on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1. The facility failed to ensure the high side medication cart was locked while a nurse was not present on the first floor unit. 2. The facility failed to ensure treatment carts were locked while a nurse was not present on the second floor unit.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure laboratory services were obtained timely for three Residents (#60, #68, #40), out of a total 27 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure follow-up dental services were provided for two Residents (#22 and #24) out of a total of 27 sampled residents. Specifically, the facility failed to ensure recommendations related to the fabrication of dentures for Resident #22 and Resident #24 were implemented.

Inspectors wroteBased on record review and interview, the facility failed to provide the appropriate diet texture for one Resident (#56) out of a total sample of 27 residents. Specifically, Resident #56, who has a known history of choking at the facility, was given a peanut butter and jelly sandwich while being prescribed a puree diet.

Inspectors wroteBased on interview and document review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility developed QAPI plans related to staff education and infection control once these concerns were identified by the Administrator.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3), who were admitted to the Facility with pressure injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence which can present as intact skin or an open ulcer and may be painful) the Facility failed to ensure that nursing adequately assessed and documented their wounds, including but not limited to measurements of each wound, as well as notification of and obtaining orders for wound care treatments from the provider.

Inspectors wroteBased on record reviews and interviews for one of three sampled residents (Resident #1), whose Hospital Discharge Summary included orders for insulin administration and blood glucose monitoring, the Facility failed to ensure he/she was free from significant medication errors, when the physician's orders were not accurately reconciled by nursing, he/she was not administered insulin and his/her blood glucose levels were not monitored for three days.

Inspectors wroteBased on records reviewed and interviews, the facility failed to have sufficient staffing. Specifically, the facility failed to provide sufficient staffing, particularly on the weekend shift, during FY 24 (fiscal year) Quarter 2.

Inspectors wroteBased on observation and interview, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the transmission of disease and infection. Specifically: 1. the facility failed to develop a water management program to prevent the spread of water borne diseases and, 2. failed to disinfect reusable medical equipment between residents.

Inspectors wrote2a. For Resident #15 the facility failed to provide dignity by failing to remove chin hair. Resident #15 was admitted to the facility in August of 2023 with diagnoses that include but are not limited to Alzheimer's disease, lupus anticoagulant syndrome, muscle weakness, and unsteadiness on feet. Review of Resident #15's MDS dated [DATE] indicated staff assessed Resident #15 as having severely impaired cognition and required supervision/or touching assistance as resident completes the activity for personal hygiene and had one to three days of rejecting care. Review of Resident #15's care plans failed to indicate he/she resisted care or resisted having assistance with removing his/her chin hair. On 7/2/24 at 7:15 A.M., Resident #15 was observed, dressed in clothes resting on his/her bed. Resident #15 was observed to have thick hair approximately over one-half inch on his/her chin. [...]

Inspectors wrote3. Resident 21 was admitted to the facility in January of 2016 and with diagnoses that include but are not limited to type 2 diabetes mellitus, chronic obstructive pulmonary disease, dementia, and anxiety. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] indicated Resident #21 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating severely impaired cognition, is dependent on staff for toileting, bathing, dressing and hygiene and receives hospice services. Review of Resident #21's medical record indicated the following: -A physician's order to admit to hospice for care and comfort on 2/4/22. Review of Resident #21's care plans indicated the following: [...]

Inspectors wrote3. The surveyor made the following observation: - On 7/2/24 at 1:25 P.M., the door to the medication storage room was left opened, the surveyor was able to push it open, no staff were in the medication room. On the door was a sign that said 1/1/23 Please lock the med room at all times. During an interview, Nurse #1 said the medication room should be locked at all times. - On 7/3/24 at 8:20 A.M., the surveyor observed an unattended medication cart on the first floor, no staff were within sight of the cart. The surveyor was able to pull open the drawers of the medication cart containing medication. Nurse #3 came back to the cart and said the cart should be locked when unattended. Nurse #3 proceeded to lock the cart but the surveyor was able to open the cart when it was locked. Nurse #3 said it is not locking properly. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide dental services to one Resident (#22) out of a total sample of 27 Residents.

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure one Resident (#13), out of 27 total sampled residents, was assessed for the ability to self-administer medications. Specifically, for Resident #13 the facility failed to ensure he/she was assessed to self-administer Centrum vitamins and Nystatin powder (used to treat fungal infections of the skin).

Inspectors wroteBased on record review and interview for one Resident (#32), out of a total sample of 27 residents, the facility failed to ensure advanced directives were implemented consistently in the medical record in accordance with the resident's/health care agent wishes.

Inspectors wroteBased on record review and interview for one Resident (#120) out of three discharged resident records reviewed, out of a total sample of 27 residents, the facility failed to implement their abuse prohibition policy. Specifically, for Resident #120 the nurse failed to report an allegation of neglect to the Director of Nursing or Administrator as required.

Inspectors wroteBased on record review and interview for one Resident (#120) out of three discharged resident records reviewed, out of a total sample of 27 residents, the facility failed to report an allegation of neglect, no later than two hours after the abuse allegation was received, to the Department of Public Health.

Inspectors wroteBased on observation, record review and interview for two Residents (#20 and #32) out of a sample of 27 Residents, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the resident's status. Specifically,1. The MDS failed to indicate Resident #20 was at risk for developing a pressure ulcer/injury, and 2. The MDS failed to indicate Resident #32 had a significant weight gain, resulting in no further assessment of the accuracy of the weight gain and care planning process.

Inspectors wroteBased on observation, record review and interviews, the facility failed to meet professional standards of nursing practice for one Resident ( #221) out of a sample of 27 Residents. Specifically, the facility failed to obtain a leave of absence physician's order for a resident with a history of drug dependence and recent relapse.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to adhere to quality standards of care for one Resident (#20), out of a total sample of 27 residents. Specifically, the facility failed to identify skin injuries on Resident #20.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure for one Resident (#20) out of a total sample of 27 residents that professional standards of practice were adhered to for the prevention of developing pressure ulcers/skin injuries. Specifically, the facility failed to implement physician's orders for weekly skin evaluations.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards for one Resident (#34) out of a total sample of 27 residents. Specifically, the facility failed to ensure that the smoking policy was adhered to, resulting in Resident #34 having numerous smoking materials in his/her room and smoking in his/her room.

Inspectors wroteBased on observation, record review and interview for two out of two applicable residents (#15 and #9) out of a total sample of 27 residents and one out of one applicable discharged Resident (#120), out of a total of three discharge residents, the facility failed to implement professional standards of practice for residents who have a colostomy or ileostomy. Specifically: 1. For Resident #15 the facility failed to have physician's orders for the care of his/her ileostomy including changing the appliance, 2. For Resident #9 the facility failed to have orders or documentation to indicate when the colostomy appliance was changed. and 3. The facility failed to ensure orders to indicate when the colostomy appliance is to be changed.

Inspectors wroteBased on observation, record review and interview, the facility failed to address the nutrition and hydration status of three Residents (#57, #32, #34) out of a total sample of 27 residents. Specifically, the facility failed to: 1. Ensure a physician's order for an altered diet was obtained and appropriate for Resident #57. 2. Ensure the physician's orders were implemented for weekly weights and a re-weigh was obtained for Resident #32 whose recorded weight had a gain of 5% more than the previous month weight. 3. Obtain weights for pre and post dialysis treatment for Resident #34.

Inspectors wroteBased on observation, policy review, record review, and interview the facility failed to ensure staff provided professional standards of care related to replacing the oxygen tubing as ordered by the physician and maintaining the nasal cannula in a sanitary condition for one Residents (#22) out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure services consistent with professional standards were provided for one Resident (#34) 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 27 residents. Specifically, the facility failed to keep an updated communication book for dialysis care and ensure it was accompanying Resident #34 to and from dialysis care.

Inspectors wroteBased on interviews and record review, the facility failed to provide substance use services for one Resident (#221) out of a sample of 27 Residents. Specifically, the facility failed to: 1. Provide mental health services for Resident #221, who had a recent substance use relapse. 2. Offer and provide Resident #221 support programs that include Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings. 3. Have qualified staff to manage the support program meetings, AA and NA in the facility.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to 1. properly store food items in the kitchen to prevent the risk of foodborne illness and in accordance with professional standards for food service safety and 2. failed to ensure food was stored in the meal carts to prevent the risk of foodborne illness and in accordance with professional standards for food service safety.

Inspectors wroteBased on record review, observations and interview, the facility failed to maintain accurate medical records. Specifically, staff signed off on the Treatment Administration Record (TAR) that oxygen tubing was changed, when it had not been changed, for one Resident (#22) out of a total sample of 27 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure one Resident (#9), out of a total sample of 27 residents had a bed that was in operating condition. Specifically, Resident #9's top part of his/her bed was leaning toward his/her left side and was not level.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she required two staff members for assistance with bed mobility, which included turning and repositioning when in bed, and for incontinence care, the Facility failed to ensure staff implemented and followed interventions identified in his/her care plan, when on 03/11/24 Certified Nurse Aide (CNA) #1 provided care to Resident #1 unassisted by another staff member, Resident #1's upper body rolled off the bed, and his/her head hit the floor. Resident #1 was transferred to the Hospital Emergency Department and diagnosed with a sinus fracture and subdural hematoma (pool of blood between the brain and the outermost covering)

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members for assistance with bed mobility which included turning and repositioning, and required assistance of two with incontinence care, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety, when on 03/11/24, Certified Nurses Aide (CNA) #1 provided care for and repositioned Resident #1 in bed without assistance from another staff member, Resident #1 rolled off the side of the bed, and his/her head struck the floor. Resident #1 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with a sinus fracture and subdural hematoma (pool of blood between the brain and outermost covering).