Every finding on record at Cape Heritage Rehabilitation & Health Care Center

Based on record review and interview, for one of three sampled residents (Resident #1), whose admission diagnoses included aphasia (brain disorder that affects how you speak and understand language) the Facility failed to ensure his/her Minimum Data Set (MDS) assessment accurately reflected his/her cognitive status regarding his/her Brief Interview for Mental Status (BIMS) score. Findings include: Review of the Resident Assessment of Cognitive Patterns Policy, dated 6/30/25, indicated it was the policy of the Facility to use the MDS properly in order to determine the resident's attention, orientation, and ability to register and recall new information. The Policy indicated a structured cognitive test will be conducted, the BIMS will be used as the structured cognitive test and the results of the BIMS will be documented on the MDS.The BIMS is a 0 to 15 scale used in nursing homes and long-term care facilities to evaluate a person's memory, learning and orientation. Higher scores mean better cognitive function with 13 to 15 points indicating the individual is cognitively intact, 8 to 12 points indicating moderate cognitive impairment and 0 to 7 points indicating severe cognitive impairment. A score of 99 is used when the BIMS interview could not be completed. Review of Resident #1's clinical record indicated he/she was admitted to the Facility in December 2025 and his/her diagnoses included aphasia (brain disorder that affects how you speak and understand language) following a cerebral infarction (stroke), hemiplegia, hemiparesis and altered mental status.During a telephone interview on 8/11/26 at 10:30 A.M., the Surveyor asked Resident #1's Guardian about arranging a telephone interview with Resident #1 (who had been discharged from the Facility during July 2026) however, the Guardian did not arrange an interview.Review of the Director of Social Service's Progress Note, dated 7/02/26, indicated that the Director of Social Service met with Resident #1 on 7/02/26 to complete a quarterly assessment and he/she was laying bed with a blanket over his/her entire body and would not wake up. The Note indicated that the Director of Social Service was unable to complete Resident #1's assessment.During an interview on 8/11/26 at 1:00 P.M., the Director of Social Service said that she was unable to complete a BIMS for Resident #1 on 7/02/26 because when she met with him/her, he/she was in bed, with a blanket pulled up over his/her head and was essentially non-responsive. Review of the BIMS Assessment, dated 7/02/26 completed by the Director of Social Service, indicated that the BIMS was not completed for Resident #1.Review of the MDS assessment, dated 7/03/26, indicated Resident #1's BIMS score was documented as a 15 out of 15, therefore indicating he/she had intact cognitive function. The Director of Social Service said that the BIMS score of 15/15 entered on Resident #1's MDS Assessment. dated 7/03/26, was not accurate.During an interview on 8/11/26 at, the Administrator said that the Clinical Reimbursement Specialist documented the BIMS score of 15/15 on Resident #1's MDS assessment dated [DATE].Review of the written Witness Statement, dated 8/11/26 (on the day of the survey) and signed by the Clinical Reimbursement Specialist, indicated that she completed Resident #1's MDS assessment dated [DATE] and mistakenly entered the BIMS score of 15/15. The Statement indicated that she should have entered a BIMS score of 99 to indicate that Resident #1 was unable to complete the BIMS interview.

Based on records reviewed, interviews and observations, for one of three sampled residents (Resident #1) who during his/her admission assessments informed staff that his/her dietary preference was skim milk, the Facility failed to ensure that he/she received his/her drink of preference as identified on his/her care plan and nutritional assessment.Findings include:Review of the Facility Policy titled Resident Rights, dated as revised January 2001, indicated that each resident has the right to be fully informed in advance of their care or treatment, to be fully informed in advance of any changes in their care or treatment and to participate in planning their health care and treatment.The Policy further indicated that each resident has the right to reside and receive services with reasonable accommodation of their needs and preferences.Resident #1 was admitted to the Facility in February 2026, diagnoses included but not limited to fracture of the right and left pelvis, major depressive disorder, cerebral infarction, generalized anxiety disorder, hypothyroidism, gastro-esophageal reflux disease (GERD), hypertension and hyperlipidemia.Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 03/24/26, indicated he/she was alert, oriented, was his/her own decision maker, and had scored a 15/15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact).During a telephone interview on 06/29/26 at 12:25 P.M., Resident #1 said that while he/she was a resident at the facility, he/she spoke with the dietician multiple times about his/her preference for skim milk and never received skim milk. Resident #1 said that when he/she asked facility staff for skim milk, staff informed him/her that the facility does not have skim milk and only had low-fat milk.Review of Resident #1's Nutrition Evaluation, dated 3/02/26, indicated that he/she was prescribed a low-fat low sodium diet, understood the therapeutic diet, that preferences were obtained and that he/she drinks skim milk.Review of Resident #1's Therapeutic Diet Care Plan, dated 3/02/26, indicated that he/she was at potential risk for nutritional decline and interventions included: provide meals per physician's diet order - low fat low sodium and preferences included skim milk only.During a telephone interview on 7/02/26 at 10:07 A.M., the Dietician said that Resident #1 preferred skim milk according to his/her care plan and nutritional assessment. The Dietician said that she believed the facility had skim milk. The Dietician said that low fat milk and skim milk are not exactly the same and if Resident #1 preferred skim milk then he/she should have received it while she/she was a resident at the facility.Review of Dietary Department Services related to food orders and deliveries, specific to Milk Invoices, dated 02/25/26 and 03/03/26, indicated that whole milk and 1% milk was delivered to the facility.Further review of the Invoice indicated that skim milk was not included in either delivery order.During an onsite observation on 6/29/26 at 1:50 P.M., the Surveyor toured the Kitchen and observed 1% low-fat milk and whole milk in the refrigerator. There was no skim milk observed in the Kitchen refrigerator. During an interview on 6/29/26 at 2:00 P.M., the Food Service Director (FSD) said that the facility orders milk once a week from the supplier. The FSD said that the facility has whole milk and 1% low-fat milk. The FSD said that he thought that 1% low-milk and skim milk were the same thing.During an interview on 6/29/26 at 3:30 P.M., the Administrator said that she thought that the facility had skim milk available. The Administrator said that if the milk invoices indicated that skim milk was not ordered or delivered, then the facility did not have skim milk because the facility did not order Milk products from any other supplier. The Administrator said that if Resident #1 notified facility staff that he/she wanted skim milk, then the facility should have ordered skim milk and said that her expectation was that Resident #1 receive his/her preference of skim milk.

Based on a resident group meeting, staff interviews, and record review, the facility failed to ensure grievances and concerns from the Resident Council were acted upon to resolve the identified nursing concerns related to call light response times, customer service, and use of cell phones/earbuds by staff during care/shifts. Findings include:Review of the facility's policy titled Resident Council, dated as revised in 10/2015, indicated but was not limited to the following:- It is the policy of this home that the Recreation Department will provide support and assistance in the formation of a Resident Council.- The residents will have an opportunity to express their concerns or grievances, contribute ideas and make recommendations regarding the operation of the home.- Maintain written minutes including residents in attendance, opening and adjournment times, discussions and/or actions that take place.- Notify Department Heads in writing of concerns that come up during the meeting. Review of the Resident Council Minutes, dated 3/19/26, indicated but were not limited to the following concerns:- Certified Nursing Assistants (CNAs) were reported to be wearing earbuds and frequently using their cell phones during shifts.- Staff were noted to be speaking in different languages around residents.- Concerns were raised about limited assistance being provided when help is requested.- The Director of Nursing (DON), who was an invited guest, thanked the residents for expressing their concerns and said disciplinary action would be taken to address the concerns. Review of the Resident Council Minutes, dated 4/16/26, indicated but were not limited to the following concerns:- CNAs can be rude, unapproachable and call light times seem to be longer. Review of the Resident Council Minutes, dated 5/21/26, indicated but were not limited to the following concerns:- Delayed response times to call bells.- Communication challenges related to showers/daily care routines.- Concerns regarding consistency of care during second and third shifts. On 6/17/26 at 11:02 A.M., the surveyor held a Resident Group Meeting with 18 residents in attendance. The residents said every month they bring up concerns related to call light wait times, staff interactions, and customer services as well as concerns related to staff using phones/earbuds during care. They said they do not understand how staff are being informed of their concerns and want staff to be held accountable and for changes to occur. Review of the Resident Council Follow-Up form, dated 3/19/26, indicated the following response to resident concerns: education remains to be the solution in addition to write-ups with the CNAs who continue to disregard facilities (sic - facility's) policies. The form was dated resolved on 4/6/26. Attached to the Resident Council Concern Follow-Up form was a meeting sign in sheet with seven CNA's names on the form. No signatures were completed on the form. Review of the Resident Council Follow-Up form, dated 4/16/26, indicated the following response to resident concerns: 1:1 (one to one) education with CNAs regarding cellphones/earbuds, attitudes, call lights and name badges. The form was dated resolved on 4/23/26. Attached to the Resident Council Concern Follow-Up form were in-service attendance sheets dated 4/22/26 and 4/24/26 with a total of 10 nursing staff signatures. No Resident Council Follow-Up form was provided for the concerns from the Resident Council Meeting held on 5/21/26. On 6/17/26 at 12:57 P.M., the Activities Director said after the Resident Council meetings she follows up with the Administrator and the Department Heads to discuss any concerns the resident's brought up during the meeting. The Activities Director said she completes a Resident Council Follow-Up form and gives it to the appropriate Department Head based on where the concern originated. The Activities Director said when she gets the forms back she reviews the information with the Resident Council President and the information is shared in the next Resident Council meeting. The Activities Director said the nursing concerns are the same each month. The Activities Director said she did not receive a response from the DON for the concerns expressed during the 5/21/26 meeting. The Activities Director said she has not followed up with any of the nursing staff regarding the concerns. On 6/17/26 at 1:36 P.M., the DON said she recently took over the position until the new DON starts next week. The DON said she had not received any information regarding nursing concerns from the most recent or previous Resident Council meetings. The DON said usually information like that would go to the Assistant Director of Nursing (ADON) or the Administrator. On 6/17/26 at 1:52 P.M., the ADON said she would hear about information regarding concerns brought up in the Resident Council meetings, but the old DON was responsible for designating education to the Staff Development Coordinator (SDC). The ADON said the SDC would be responsible for completing education with staff related to the concerns brought up in Resident Council. On 6/17/26 at 2:13 P.M., the SDC said she would get information from the old DON regarding concerns from the Resident Council meetings. The SDC said sometimes education would be delegated to her to complete but she could not recall being asked in the past three months to complete any staff education. The SDC said Resident Council concerns have been consistent and the same for a long time in relation to nursing staff. The SDC and the surveyor reviewed the in-service and meeting sheets provided. The SDC said she was not involved in any of the education and did not have any additional documentation. The SDC said she would expect the in-service and meeting sheets to be signed off by all staff in the building. On 6/17/26 at 2:45 P.M., the Administrator said the facility completes education and in-service training in regard to concerns brought up during Resident Council meetings. The Administrator said education was completed with nursing staff, but no further audits were completed regarding the concerns. The Administrator said they are looking into completing audits of the concerns indicated by the Resident Council when the new DON starts. The Administrator said she would expect more nursing staff to have been educated regarding the Resident Council concerns. The Administrator said she would look for more in-service training related to the concerns brought forward by the Resident Council. Prior to exit, no further information regarding in-service training, education or audits were provided by the facility to the surveyor in relation to Resident Council concerns.

Based on observation, record review, and interview, the facility failed to ensure three Residents (#8, #89, and #87), out of a total sample of 22 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, to achieve the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #8, to transcribe and implement wound care treatment to a non-pressure wound to the Resident's right hip per recommendations by the Wound Care Physician for 10 days;2. For Resident #89, to monitor and assess (including wound description, shape, measurements and condition) multiple non-pressure wounds; and3. For Resident #87, to ensure effective monitoring and medication changes for edema management were implemented. Findings include:1. Review of the facility's policy titled Consultant Services, dated April 2015, indicated but was not limited to:- Identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident/patient through consultant services.- The consultant should document findings and recommendations.- The charge nurse will then notify the attending physician of findings, and he/she can then order specific treatments as outlined by the consultant. Resident #8 was admitted to the facility in June 2018 with diagnoses including right hip post-surgical wound. Review of the Minimum Data Set (MDS) assessment, dated 5/29/26, indicated Resident #8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had a surgical wound. Review of Resident #8's Wound Physician's documentation indicated but was not limited to:- 5/20/26, Post-Surgical wound of right hip with light serosanguinous (a type of bodily fluid or wound drainage that is thin, watery, and pale red or pink in color) exudate (drainage). - Plan: Discontinue Collagen Matrix (advanced wound care products that provide a structural scaffolding to support new tissue growth). - Apply nickel thick Santyl Ointment (prescription topical ointment used to remove dead tissue from a wound) to wound bed of right hip wound daily followed by Calcium Alginate (highly absorbent, non-adherent wound dressing) cut to fill wound space and cover with foam adhesive dressing and change daily. -5/27/26, Post-Surgical wound of right hip with light serosanguinous exudate. - Continue nickel thick Santyl Ointment to wound bed of right hip wound bed followed by Calcium Alginate cut to fill wound space and cover with foam adhesive dressing, change daily.- 6/3/26, Post-Surgical wound of right hip with light serosanguinous exudate. - Continue nickel thick Santyl Ointment to wound bed of right hip wound bed followed by Calcium Alginate cut to fill wound space and cover with foam adhesive dressing, change daily. Review of Resident #8's Physician's Orders indicated but were limited to:- Right hip: Apply nickel thick Santyl to wound bed, cover with foam dressing daily, dated 5/21/26, discontinued 6/4/26.- Right hip: Apply nickel thick Santyl to wound bed, cut Calcium Alginate to fit wound bed, cover with foam dressing daily, dated 6/4/26 Review of Resident #8's Medical Record failed to indicate why the recommendation from 5/20/26 to initiate Calcium Alginate was not implemented until 6/4/26, 14 days after the initial recommendation. During an interview on 6/22/26 at 9:18 A.M., Resident #8 said he/she is being seen weekly by the Wound Physician for a chronic wound on his/her right hip. During an interview on 6/22/26 at 11:05 A.M., Nurse #3 said the Wound Physician is at the facility every Wednesday and all recommendations go to the unit managers to follow up with the physician. During an interview on 6/23/26 at 11:29 A.M., the Assistant Director of Nursing (ADON) said the Wound Physician sends her recommendations over and the Wound Nurse distributes them to the unit managers for follow-up. She said the expectation was for the unit managers to review the recommendations, verify the recommendation and order match, and notify the physician if any changes were made. The ADON reviewed Resident #8's medical record and said she could not find any documentation as to why the Calcium Alginate had not been initiated on 5/20/26 per the Wound Physician's recommendations until 6/4/26. She said the Calcium Alginate should have been initiated on 5/20/26. During a telephonic interview on 6/23/26 at 2:01 P.M., the Wound Physician reviewed the recommendations, dated 5/20/26, and said the order for Calcium Alginate should have been implemented on 5/20/26 to help with absorption of exudate. During an interview on 6/23/26 at 2:30 P.M., the Physician said he always defers to the Wound Physician about residents' wounds and treatments. He said the Wound Physician's recommendation, from 5/20/26, for Calcium Alginate should have been implemented as recommended by the Wound Physician. 2. Review of the facility's policy titled Non-Pressure Wound Assessment, undated, indicated but was not limited to:- The facility strives to provide the residents with high quality, consistent, timely wound assessment. If a resident presents with a venous, arterial, or diabetic ulcer, the wound will be assessed on a weekly basis. Ongoing monitoring and evaluation are provided to ensure optimal resident care outcomes.- Resident with non-pressure wounds are assessed, documented, and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes.- Documentation of non-pressure ulcers include:- Location, measurement, type, thickness, presence of tunneling or undermining, drainage amount, color of drainage, odor, appearance of wound bed, appearance of wound edges, appearance of peri wound, pain, and effectiveness of treatment. Resident #89 was admitted to the facility in December 2025 with diagnoses including abscess (localized pocket of pus) of the perineum (soft tissue and skin at the bottom of the pelvis between the scrotum and the anus) and open wound of external genital organs. Review of the MDS assessment, dated 3/29/26, indicated Resident #89 was cognitively intact as evidenced by staff interview. Further review of Resident #89's MDS assessment indicated he/she had non-surgical dressings. During an interview on 6/16/26 at 9:59 A.M., Resident #89 said he/she had an excoriated (damage or tear away the outer layer of skin) area on his/her scrotum and a wound on his/her bottom from a cyst (a closed, sac-like pocket of tissue filled with fluid, air, or pus). Review of Resident #89's Physician's Orders indicated but was not limited to:- Weekly skin checks weekly on Friday, dated 4/20/26- Wound consult as needed, dated 4/20/26- Left Lateral Scrotum: Apply Iodoform packing strip (sterile, woven cotton gauze impregnated with iodoform) using a cotton tipped applicator and cover with abdominal pad daily and as needed, start date 4/23/26- Right Scrotum: Use generous amount of Skin Prep (protective barrier), followed by Silvasorb Gel (antimicrobial hydrogel used to treat partial- and full-thickness wounds), cover with foam dressing daily and as needed, start date 4/23/26- Perineum: Use generous amount of Skin Prep, followed by Silvasorb Gel, cover with foam dressing daily and as needed, start date 4/23/26 Review of Resident #89's medical record failed to indicate he/she had a Non-Pressure Wound Evaluation completed for his/her left lateral scrotum, right scrotum, and perineum. Further review of the medical record failed to indicate assessment and monitoring for Resident #89's perineal wound, right scrotum wound, and left scrotum wound specific to:- Size;- Type of wound; and,- Effectiveness of treatment. During an interview with observation dated 6/17/26 at 2:19 P.M., Nurse #1 said Resident #89 has multiple open areas that require daily dressing changes. The surveyor, with Nurse #1 present, observed Resident #89's open areas:- Left scrotum wound- Right scrotum - Right groin dressing covered with boarded gauze- Perineal wound During an interview on 6/17/26 at 2:37 P.M., Unit Manager #3 said residents who have an open area must have a non-pressure wound evaluation completed weekly for each open area. She said Resident #89 has four open areas one on their perineum, one to the left scrotum, one to the right scrotum, and one on the right groin. She said Resident #89 was not seen weekly by the Wound Physician. She said either her or the Wound Nurse would do wound rounds and document the wound measurements, description of wound, and effectiveness of the treatment on the on the non-pressure wound evaluation. Unit Manager #3 reviewed Resident #89's record and said he/she did not have any non-pressure wound evaluations from 4/23/26 to 6/17/26. She also said Resident #89 did not have an order for treatment to his/her right groin but should have. During an interview with record review on 6/17/26 at 11:05 A.M., the Assistant Director of Nursing (ADON) said any resident with a non-pressure open area must have a Non-Pressure Wound Evaluation completed on admission and then weekly to monitor if the wound is improving or not and if the treatment is effective or needs to be changed. She said during weekly wound rounds each wound must be evaluated and measured then the findings for each open area be documented on the Non-Pressure Wound Evaluation. She said Resident #89 did not have any Non-Pressure Wound Evaluations but should have. 3. Review of the facility's policy titled Nursing Documentation, dated February 2016, indicated but was not limited to the following: -Notes should be clear, concise, and not subject to misinterpretation. -A narrative note is written for any change in condition and frequency of this documentation is dependent on individual resident/patient condition. A every shift nursing note is required until the situation is resolved. -Treatments: the type and resident response, if appropriate. -Request for Physician services must be documented. -Document all untoward reactions to medications, feeding, treatments, therapy, and changes in environment. -Notification of family must be documented. -Recording of action taken by the nurse and resident/patient response. Review of the facility's policy titled Condition: Significant Change, dated April 2015, indicated but was not limited to the following: -The physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition. -This notification shall be documented in the clinical record. Review of the facility's policy titled Physician Orders-Transcription, dated April 2015, indicated but was not limited to the following: -All written physician orders or telephone orders must be duly noted and accurately transcribed by a licensed nursing staff. -Carefully transcribe orders as written to the Medication Administration record (MAR) and/or Treatment Administration Record (TAR). -Repeat order back to Physician to ensure accuracy. Review of the facility's policy titled Medication Administration-Oral, dated June 2015, indicated but was not limited to the following: -Verify medication order on the MAR. -Assess the resident/patient condition to determine the need for the medication and effectiveness of previous dose. Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize errors. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Resident #87 was admitted to the facility in December 2025 with diagnoses which include chronic systolic (congestive) heart failure (CHF-ineffective blood flow causing fluid to back up in lungs, liver, abdomen, and extremities), localized edema, pleural effusion (fluid in lung/chest wall membranes, and hypertension (HTN-high blood pressure). Review of the MDS Assessment, dated 4/28/26, indicated Resident #87 scored 7 out of 15 on the BIMS indicating he/she had cognitive impairment, CHF, HTN, heart disease, and was taking a diuretic (medication to remove extra salt and fluid from the body). Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Resident has edema in: Upper extremities related to pulmonary artery hypertension. INTERVENTIONS: Administer cardiac medications and diuretics as ordered, keep arms elevated on pillows, notify physician of skin breakdown, signs/symptoms of infection, or pain in extremities, notify physician of worsening upper extremity edema, and observe for complications related to edema. On 6/18/26 at 1:02 P.M., the surveyor observed Resident #87 sitting in his/her wheelchair with their feet down on the footrests. He/she had bilateral upper and lower extremity edema. On 6/22/26 at 1:02 P.M., the surveyor observed Resident #87 sitting in his/her wheelchair with their feet down on the footrests with bilateral lower extremity edema. His/her left arm and hand were edematous and resting on the overbed table in front of them and his/her right arm was resting in his/her lap, swollen but less than the left arm. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Diagnosis: CHF -Follow up with cardiologist for ongoing monitoring of CHF with recently increased Lasix. -Patient reported upper extremity swelling, spouse indicated swelling had been present for 1-2 weeks and the patient was typically managed with Furosemide (Lasix) outpatient. Serologies (Lab work) showed B-Type Natriuretic Peptide (BNP-indicating if heart is working too hard often caused by heart failure) level was 127 (normal range is less than 100). -Medications: Change How you take these Medications: Furosemide 20 milligram (mg) tablet take 1.5 tablets (30mg) by mouth in the morning and before bedtime. Review of the Cardiologist Appointment After Visit Summary and Progress Note, dated 1/2/26, indicated but was not limited to the following: -Current Medications: Furosemide 20mg tablet take 1.5 tablets (30mg) by mouth in the morning and before bedtime. -Recommend maintaining current medical therapy without change. During an interview on 6/16/26 at 2:02 P.M., Resident #87's Health Care Proxy (HCP) said Resident #87 had edema on 6/13/26 and they were told the physician would see him/her on 6/16/26. She said she was not aware of the change to his/her Lasix on 6/11/26 for the edema and the nurses say he/she has edema all the time. Review of the Physician's Orders indicated but were not limited to the following: -Furosemide 20 mg tablet (Lasix) – give one half tab by mouth two times a day for CHF. (6/11/26) Review of the Nursing progress notes indicated but were not limited to the following: -5/15/26: Patient has increased swelling to right arm. MD notified and recommended to monitor. There were no orders to monitor extremities for edema. There were no other nurse's notes assessing his/her edema/swelling, CHF, symptoms related to CHF, medication changes, plan of care, or HCP notification. Review of the Physician progress notes indicated but were not limited to the following: -5/20/26: Left wrist and elbow mild swelling, Palpable mass distal upper arm, 2+ pitting edema (swelling caused by excess fluid trapped in the body's tissues, the deeper the dent when pressed the more severe the condition; 2+ takes 10-15 seconds to disappear) left wrist. -5/26/26: Left wrist and elbow mild swelling, Palpable mass distal upper arm, mild edema of wrist now improved. Ultrasound to rule out Deep Vein Thrombosis (DVT-blood clot) negative and X-Rays negative. -5/28/26: Patient with increased leg swelling and shortness of breath at mild exertion. Extremities: 3+ pitting edema to mid-shins (3+ takes 30 seconds to disappear), Increased Edema/CHF, Will get a BNP, On Lasix 10mg twice daily (BID), will increase to 20mg BID for one week, then return to 10mg BID. Continue to monitor, any sudden changes will send to hospital. -6/2/26: Extremities: 2+ pitting edema to mid shins, Increased Edema/CHF, BNP 243, Continue increased Lasix dose 20mg BID until Thursday and will re-evaluate. Continue to monitor, any sudden changes will send to hospital. -6/16/26: Extremities: 2+ pitting edema to mid shins, Increased Edema/CHF, BNP 243, Continue increased Lasix dose 20mg BID until Thursday and will re-evaluate. Continue to monitor, any sudden changes will send to hospital. Review of the Physician Communication Book indicated but was not limited to the following: -5/15/26: REASON: Right Arm has 2+ pitting edema, this is new, please look at. NEW ORDERS: Continue to monitor Right Hand, slightly swollen and pitting. INITIAL WHEN ADDRESSED: (left blank) -5/19/26: REASON: Left Arm very swollen. NEW ORDERS: Will See. INITIAL WHEN ADDRESSED: initialed by provider. -5/27/26: REASON: Having Shortness of Breath (SOB) with minimal exertion. Increase Lasix?? NEW ORDERS: (left blank) INITIAL WHEN ADDRESSED: (left blank) The facility failed to document these findings in a nurse's progress note in the medical record and failed to write orders to monitor the right arm. Review of the MAR indicated but was not limited to the following: -Furosemide 20mg tablet-Give half tab 10mg two times daily. Half Tab = 10mg - Give three tabs to equal 30mg. (12/2/25 – 5/28/26) -Furosemide 20mg tablet-Give one tablet by mouth two times a day for one week. Half Tab = 10mg – Give three tabs to equal 30mg. (5/28/26-6/4/26) -Furosemide 20mg tablet-Give half tablet two times a day. (6/5/26-6/11/26) -Furosemide 20mg tablet-Give half tablet two times a day. (6/11/26 -> active order) During an interview on 6/18/26 at 1:02 P.M., Resident #87 said their arms and legs have been swollen lately and it is taking a while for them to get better. He/she said they thought their medication was adjusted, but they have been swollen for a while now. During an interview on 6/18/26 at 1:12 P.M., Nurse #2 said Resident was on Lasix 30mg twice a day, then 20mg twice a day for about a week, and now only 10mg twice a day. She said she did not know why the medication was decreased, she said maybe he/she was dehydrated or something. She said the Unit Manager (UM) might know more because she writes most of the orders. She said they use a communication book to let the Doctor know who to see and the UM usually goes through it with the Doctor when they come in. She said all the orders are not usually written in the log because most of them are verbal orders. During an interview on 6/22/26 at 1:44 P.M., UM #3 said she does rounds with the Physician and writes the new orders. She said they have been monitoring Resident #87's arm because of the swelling. She said they ruled out a DVT, but it is still swollen. She said she was not aware of the leg edema. She said they did labs and the BNP was high, but the Doctor was not that concerned about it. She said he wanted to increase the Lasix for a week and then resume previous dose to get rid of the edema. The UM reviewed the MAR with the surveyor and said they decreased his/her Lasix when the new orders were written. She said she must not have read the entire order and thought he/she was only on 10mg twice a day not 30mg twice a day and she must have given the Doctor the wrong information. She said there were no orders to monitor his/her edema either and there probably should be. She said she would have to call the Doctor because the medication change was not done correctly and Resident #87 still had edema. During an interview on 6/22/26 at 2:14 P.M., the ADON said Resident #87 had been getting Lasix 30mg twice a day since December 2025. She said she was not sure why they would have decreased the dose because the Doctor's note said to increase it for the edema. She said she would have to reach out to the Doctor because that dose change doesn't make sense. Additionally, she said the nurses should be getting information during report about med changes and what they should be monitoring a resident for. She said the nurses should know if the medication was increased or decreased and why and they should have been monitoring the edema in arms and legs and there were no orders written to do so. She said it was concerning the nurse did not know why the medication was changed and no one questioned the dose or the edema. She said she would follow up with the Doctor because he intended to increase the dose to decrease the edema and that is not what happened. During an interview on 6/23/26 at 2:38 P.M., Physician #1 said he was told Resident #87 was on Lasix 10mg twice a day, which is why he said to increase it to 20mg twice a day for a week and then back down to 10mg twice a day. He said the order that was entered was not what was intended. He said Resident #87 should not have had the Lasix reduced from 30mg twice a day to treat the edema, the orders were wrong.

Based on record review and interview, the facility failed to ensure treatment orders, consistent with professional standards of practice, were in place to promote the healing of pressure ulcers for one Resident (#8), out of a total sample of 22 residents. Specifically, the facility failed to ensure physician's order for wound treatment were re-ordered for a stage two pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) upon readmission to the facility following Resident #8's hospitalization.Findings include:Review of the facility's policy titled Treatments, dated April 2015, indicated but was not limited to:-An order is written for each treatment indicating type, frequency, and location.-Treatments are reviewed daily. Resident #8 was admitted to the facility in June 2018 with diagnoses including pressure ulcer of the left hip stage two.Review of the Minimum Data Set (MDS) assessment, dated 5/29/26, indicated Resident #8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had a stage two pressure ulcer.During an interview on 6/22/26 at 9:18 A.M., Resident #8 said he/she had a chronic pressure ulcer on his/her left hip. Resident #8 said the nurses change the dressing to his/her left hip daily.Review of Resident #8's current Physician's Orders failed to indicate he/she had a treatment to his/her left hip pressure ulcer. Review of Resident #8's discontinued Physician's Orders indicated but was not limited to:-Treatment Order: Apply generous amount of skin prep (protective barrier) to peri-wound (skin surrounding a wound). Soak gauze with Vashe (saline-based wound cleanser containing pure hypochlorous acid) and apply to wound bed. Let soak for 10 minutes. Cut collagen matrix (advanced wound care products that provide a structural scaffolding to support new tissue growth) to fit wound bed, apply and cover with foam adhesive. Location: left hip every day. Start date 3/26/2026, discontinue dated 5/3/2026Review of Resident #8's medical record indicated he/she was readmitted to the facility on [DATE] after a hospitalization. Review of Resident #8's Wound Physician's documentation indicated but was not limited to:-5/20/26: -Wound #4: Stage 2 Pressure Injury of left hip -Wound measurements 0.2 centimeters (cm) by 0.7 cm, wound of left hip is stable without sign and symptoms of infection. -Plan: -Continue wash with Vashe hypochlorous acid solution daily followed by Vashe moistened gauze to wound bed and leave in place for 10 minutes with dressing change. -Continue Collagen Matrix cut to fit to wound of left hip daily and cover with dry protective dressing daily.-5/27/26 -Wound #4: Stage 2 Pressure Injury of left hip -Wound measurements 0.2 cm by 0.7 cm, wound of left hip is stable without sign and symptoms of infection.-6/3/26 -Wound #4: Stage 2 Pressure Injury of left hip -Wound measurements 0.2 cm by 0.7 cm, wound of left hip is stable without sign and symptoms of infection. -Plan: -Continue wash with Vashe hypochlorous acid solution daily followed by Vashe moistened gauze to wound bed and leave in place for 10 minutes with dressing change. -Continue Collagen Matrix cut to fit to wound of left hip daily and cover with dry protective dressing daily.-6/10/26 -Wound #4: Stage 2 Pressure Injury of left hip -Wound measurements 0.2 cm by 0.7 cm, wound of left hip is stable without sign and symptoms of infection. -Plan: -Continue wash with Vashe hypochlorous acid solution daily followed by Vashe moistened gauze to wound bed and leave in place for 10 minutes with dressing change. -Continue Collagen Matrix cut to fit to wound of left hip daily and cover with dry protective dressing daily.-6/17/26 -Wound #4: Stage 2 Pressure Injury of left hip -Wound measurements 0.2 cm by 0.4 cm, wound of left hip is stable without sign and symptoms of infection. -Plan: -Continue wash with Vashe hypochlorous acid solution daily followed by Vashe moistened gauze to wound bed and leave in place for 10 minutes with dressing change. -Continue Collagen Matrix cut to fit to wound of left hip daily and cover with dry protective dressing daily. Review of the Medication Administration Record and the Treatment Administration Record for May 2026 and June 2026 failed to indicate Resident #8 had treatment orders in place for his/her left hip pressure area. During an interview on 6/22/26 at 9:52 A.M., Nurse #3 said Resident #8 had a pressure injury to his/her left hip and was being seen by the Wound Physician.During an interview with Nurse #3 and Unit Manager #3 on 6/22/26 at 10:35 A.M., Nurse #3 said Resident #8 did not have an order in place for his/her left pressure area. Unit Manager #3 reviewed the Wound Physician's wound consults, dated 5/20/26, 5/27/26, 6/3/26, 6/10/26, and 6/26/26 and said Resident #8 did not have an order in place for the pressure ulcer on his/her left hip, but the nurses have been applying a treatment to it every day. Unit Manager #3 said the order for the treatment to Resident #8's pressure ulcer was not reinstated upon his/her return from the hospital, but it should have been. Further review of Resident #8's medical record indicated he/she had not had an order in place for 45 days, from 5/8/26 to 6/22/26, until the surveyor brought it to the facility's attention.During an interview on 6/22/26 at 11:05 A.M., Nurse #3 said the Wound Physician is at the facility every Wednesday and all recommendations go to the unit managers to follow up with the physician.During an interview on 6/22/26 at 11:07 A.M., the Assistant Director of Nursing said the Wound Physician sends her recommendations over to the Wound Nurse who will distribute them to the unit managers for follow-up. She said the expectation was for the unit managers to review the recommendations, fill out a Pressure Injury Evaluation, verify the recommendation and order match, and notify the physician if any changes were made. She said Resident #8 did not have an order in place for his/her left hip pressure ulcer and the treatment for it should have been initiated upon return from the hospital. On 6/22/26 at 10:22 AM, the surveyor observed Nurse #3 perform a dressing change to Resident #8's left hip. Nurse #3 and the surveyor did not observe a dressing to his/her left hip upon initiation of the dressing change and Resident #8's left hip wound was open to air.During a telephonic interview on 6/23/26 at 2:01 P.M., the Wound Physician said Resident #8 was seen weekly for multiple chronic wounds. She said Resident #8 should have had an order in place for a treatment to the pressure ulcer on his/her left hip.During an interview on 6/23/26 at 2:30 P.M., the Physician said the treatment to Resident #'8s left hip should have been restarted on 5/8/26 upon their return from the hospital.

Based on interview and record review, the facility failed to ensure medication was not administered for an excessive duration for one Resident (#8), out of a total sample of 22 residents. Specifically, the facility failed to ensure Zinc Sulfate (an essential trace mineral and chemical element) was discontinued after the intended nine doses were administered, resulting in Resident #8 receiving 36 additional doses.Findings include:Review of the facility's policy (untitled), last revised 8/4/22, indicated but was not limited to:-Medication Reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay.-admission Process: -Compare orders to hospital records. Obtain clarification orders as needed. -Transcribe orders in accordance with procedures for admission orders. -Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. -New orders require a second nurse to cosign the orders, indicating review of the orders for accuracy. -Perform a 24-hour chart check to verify all new orders have been addressed.Resident #8 was admitted to the facility in June 2018 with diagnoses including pressure ulcer of the left hip.Review of the Minimum Data Set assessment, dated 5/29/26, indicated Resident #8 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15.Review of Resident #8's Hospital Discharge summary, dated [DATE], indicated but was not limited to:- Chronic decubitus ulcers - Resident was also on Zinc 220 milligrams (mg) daily for a total of 14 days.-Zinc Sulfate 220 mg daily for 9 more days to complete a 14-day course.Review of Resident #8's current Physician's Orders indicated but was not limited to:- Zinc Sulfate 220 mg, give one tablet by mouth one time a day, dated 5/9/2026, entered by Unit Manager #3Review of Resident #8's May and June 2026 Medication Administration Record (MAR) indicated he/she received Zinc Sulfate 220 mg daily as prescribed.During an interview on 6/22/26 at 1:27 P.M., Unit Manager #3 said when a resident returns from the hospital one nurse reviews the resident's medications and a second nurse will enter them in the electronic medical record. Unit Manager #3 reviewed Resident #8's hospital Discharge summary, dated [DATE], and said she missed the part of the Zinc Sulfate order to continue it for nine additional doses and implemented the order without a stop date.Review of Resident #8's medical record and orders failed to indicate the Zinc Sulfate was discontinued or addressed with the physician.Review of the Physician Communication Book indicated but was not limited to:-Date: 6/22/26-Name: Resident #8-Reason: Hospital discharge paperwork says Zinc Sulfate for nine doses. Has been about two months. Stop or continue?Resident #8 received 45 total doses of Zinc Sulfate.During an interview on 6/23/26 at 11:29 A.M., the Assistant Director of Nursing (ADON) said Resident #8's Zinc Sulfate should have been only implemented for nine doses upon return from the hospital unless extended by the Physician and documentation of the reason, but there was not.During an interview on 6/23/26 at 2:30 P.M., Physician #1 said Resident #8's Zinc Sulfate should have been stopped after nine doses, but it was not.

Based on observation, interview, and test tray results, the facility failed to ensure staff served palatable, attractive, and flavorful food at appetizing temperatures for two out of two test trays conducted. Findings include:On 6/17/26 at 11:02 A.M., the surveyor conducted the Resident Council with 18 residents in attendance. During the meeting, the residents collectively expressed ongoing food concerns, with specific complaints including: the food is terrible, the food is cold, the meat is hard, flavor is either bland or too spicy, and the coffee has a bad taste and is often cold. Furthermore, 18 of 18 residents said the food is always cold.On 6/22/26 at 7:45 A.M., the surveyor requested a breakfast tray.On 6/22/26 at 8:32 A.M., the food truck containing Test Tray #1 left the kitchen for the [NAME] unit and arrived at 8:36 A.M. At 8:55 A.M., the last tray was delivered to a resident.On 6/22/26 at 8:55 A.M., the surveyor completed a regular texture test tray with the following results in degrees Fahrenheit (F):- Pancake: 113 F, lukewarm temperature, slightly dry, bland flavor;- Scrambled eggs: 112 F, lukewarm temperature, rubbery texture, bland flavor;- Oatmeal: 132 F, white in color, flavorful - could detect slight cinnamon flavor; and- Coffee: 157.3 F, flavorful served hot. On 6/22/26 at 12:33 P.M., the surveyor requested Test Tray #2. The food truck containing Test Tray #2 left the kitchen for the [NAME] unit and arrived at 12:48 P.M. At 1:10 P.M., the last tray was delivered to a resident.On 6/22/26 at 1:11 P.M., the surveyor completed Test Tray #2 with the following results:- Pork Cacciatore: 136.5 F, well-seasoned, tough texture;- Summer Squash: 134.4 F, bland, mushy texture;- Vegetable soup with pasta: 136.4 F, mushy, bland;- Lemon pepper fish: 126.5 F, well-seasoned, balanced flavor;- Seasoned rice: 120 F, buttery taste, slightly dry, warm; and- Mashed potato: 135.3 F, bland, thin in texture.The results of the two test trays validated the residents' expressed concerns of cold and unpalatable food.During an interview on 6/22/26 at 3:41 P.M., the Food Service Director said his expectations are to have the last tray as warm as the first tray that leaves the kitchen and should be served at appropriate temperatures.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1.Label and date food products in the main kitchen walk-in refrigerator; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). Findings include:Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Review of the facility's policy titled Dietary Department Guidelines, dated 5/2015, indicated but was not limited to the following: -All food items should be labeled and dated to allow rotation of supplies. -All items stored in the refrigerator will be covered, labeled with the contents and the date. -All potentially hazardous foods must be discarded within 3 calendar days after the date prepared. 1. On 6/16/26 at 7:55 A.M., the surveyor observed the following in the main kitchen walk-in refrigerator: -Egg whites in clear container, unlabeled and undated. -One pitcher pureed peas, bright green, fluorescent color, dated 6/11. -One package of turkey deli meat, unlabeled and undated. -One bag of grated parmesan cheese, wrapped, undated. -Two containers of Lactaid, unlabeled and undated. -One clear container of chicken salad and one container tuna salad, unlabeled and undated. -One container of dairy free cream opened, less than half full, undated; Manufacturer's instructions indicated once opened consume within 14 days. -One opened container of dairy free whole milk, undated; Manufacturer's instructions indicated once opened consume within 14 days. -One personal/individual sized container of Arizona Iced tea, undated. -One plastic container covered with clear plastic wrap with a red chunky tomato substance, unlabeled and undated. -One clear plastic container covered with a clear plastic clear lid with shredded lettuce and four pie shaped plastic containers on top of the lettuce containing sliced tomato, 1 of 4 dated 6/15/26. -One clear plastic container with sliced cucumbers, unlabeled and undated. -One clear plastic gallon bag with bunch of celery dated 6/7. -Five Styrofoam containers unlabeled and undated. -One opened container of beef base covered with beef base on the outside of the container, unlabeled and undated. -One sheet pan with three vacuum sealed pieces of meat, unlabeled and undated. -One sheet pan with seven sealed vacuum sealed bags containing bright red ground beef, one sealed vacuum sealed bag containing light reddish/grayish colored ground beef, unlabeled and undated. -One opened bag wrapped in plastic wrap containing light reddish/grayish colored ground beef, unlabeled and undated. -One box containing two bags of raw chicken defrosting, unlabeled and undated. -One plastic squeeze container with a thick red substance, labeled strawberry reduction dated 4/30. -Fan with a grayish black substance along the seams and bottom of it. During an interview on 6/22/26 at 8:52 A.M., the Food Service Director said it is the responsibility of dietary to maintain dates on food items and monitor. 2. Review of the 2022 Food Code by the U.S. FDA, revised 1/2023, indicated but was not limited to the following: - 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under 2-301.12. (B) Except when washing fruits and vegetables as specified under 3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. - 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 6/18/26 at 11:20 A.M., the surveyor made the following observations of the lunch tray line service in the main kitchen: - 11:22 A.M.: Dietary Staff #1 begins taking temperatures of food items on the service line. Dietary Staff #1 initially uses an alcohol wipe to clean off the thermometer between food items, but switches to a rag he grabbed off the table next to the service line. Dietary Staff #1 is observed to place a container of mashed potatoes back into the steamer from the service line. Dietary Staff #1 uses the rag he was using to clean the thermometer to open the door of the steamer and then returns to the service line to continue taking temperature of food items, using the same rag to wipe the thermometer down in between each food item. - 11:33 A.M.: Dietary Staff #1 touches his hat/head with his gloved hands. Dietary Staff #1 then grabs utensils hanging over the food service line and places them into food items on the service line. Dietary Staff #1 never changes his gloves or performs hand hygiene. - 11:35 A.M.: Dietary Staff #2 exits the walk-in refrigerator with prepared sandwiches and salads. Dietary Staff #2 does not change their gloves or perform hand hygiene prior to organizing items on the food service line. - 11:36 A.M.: Dietary Staff #1 grabs two scoops from the first bay of a 3-compartment sink and begins to wash the scoops. Dietary Staff #1 then brings the scoops directly to the service line and puts them in food items. Dietary Staff #1 is observed to have water dripping from his hands into the food items. Dietary Staff #1 did not dry his hands or perform additional hand hygiene prior to putting the scoops into the food items. Dietary Staff #1 is then observed to wipe his wet hands onto his pants/shift, grab a stack of plastic cups touching the inside of the plastic cups with his hands/fingers. The plastic cups were used to place gravy into for residents' meals. Dietary Staff #1 did not perform hand hygiene and was not wearing gloves. - 11:37 A.M.: Dietary Staff #2 grabs ice cream from the cooler and brings it to the service line. Dietary Staff #2 does not change his gloves or perform hand hygiene. - 11:40 A.M.: Food service begins. No dietary staff are observed to perform hand hygiene or change their gloves prior to the start of the food service line. - 11:44 A.M.: Dietary Staff #2 wipes his hand/forearm to his face. Dietary Staff #2 does not change his gloves or perform hand hygiene. Dietary Staff #2 is then observed to drop a package of crackers on the ground. Dietary Staff #2 picks up the crackers with gloved hands, places them in the trash and returns to the food service line without changing his gloves or performing hand hygiene. - 11:47 A.M.: Dietary Staff #2 scratches his face with his gloved hand, adjusts his glasses and touches the top of his hat. Dietary Staff #2 remains on the food service line and does not change his gloves or perform hand hygiene. - 11:49 A.M.: Dietary Staff #3 dropped a spatula on the ground at the stove top. Dietary Staff #3 picked up the spatula from the ground, placed it in the 3-compartment sink and returned to the stove top to plate soup into cups for the food service line. Dietary Staff #3 did not perform hand hygiene or change his gloves prior to returning to the stove top. - 11:54 A.M.: Dietary Staff #1 is observed riffling through a binder next to the food service line with his gloved hands. Dietary Staff #1 then returns to the food service line and continues serving food items without changing their gloves or performing hand hygiene. - 11:54 A.M.: Dietary Staff #2 touches the brim of his hat with his gloved hands, remains of the food service line without changing his gloves or performing hand hygiene. - 11:58 A.M.: Dietary Staff #1 is observed to grab a wrapped hamburger from the oven with his gloved hands. Dietary Staff #1 then unwraps the hamburger and places a slice of lettuce and tomato on top of the hamburger. Dietary Staff #1 returns to the food service line, plates the hamburger and continues plating other food items without changing his gloves or performing hand hygiene. - 12:03 P.M.: Dietary Staff #1 touches the brim of his hat and continues to plate food items on the food service line without changing his gloves or performing hand hygiene. - 12:07 P.M.: Dietary Staff #2 enter the walk-in refrigerator with his gloved hands and bring out food items to the food service line. Dietary Staff #2 does not change his gloves or perform hand hygiene prior to returning to the food service line. During an interview on 6/18/26 at 3:30 P.M., the Food Service Director (FSD) said he would expect staff to change gloves and perform hand hygiene when they are changing tasks, going between cooked and uncooked food items, leaving their work area, picking items off the floor or touching their face/body with gloved hands. The FSD and surveyor reviewed the observations during the lunch food service line. The FSD said the dietary staff should have performed hand hygiene and changed their gloves.

Based on observation, interview, and record review, the facility failed to maintain essential dietary equipment in safe operating condition by failing to ensure the walk-in freezer functioned to maintain foods at safe frozen temperatures. Specifically, for the main kitchen walk-in freezer, the facility failed to ensure the freezer unit maintained temperature at or below 0 degrees Fahrenheit (F). Findings include:Review of the facility's policy titled Dietary Department Guidelines, dated 5/2015, indicated but was not limited to the following:- The facility must store, prepare and distribute food under sanitary conditions. - Food: all frozen foods will be stored below 0 F. Freezer temperatures will be monitored regularly, and logs will be maintained of all temperatures.Review of the U.S. Food and Drug Administration (FDA) Food Code, dated 2022, indicated but was not limited to the following:- FDA continues to recommend that food establishments limit the cold storage of time/temperature control for safety foods, ready to-eat foods to a maximum temperature of 41 degrees F.- Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (bacterial or viral organisms capable of causing a disease or toxin formation).- Bacterial growth and/or toxin production can occur if TCS remains in the temperature Danger Zone of 41 degrees F to 135 degrees F too long.- Refrigeration- The facility's refrigerators and/or freezers must be in good working condition to keep foods at or below 41 degrees F and the freezer must keep frozen foods frozen solid.During an interview on 6/16/26 at 7:45 A.M., the Food Service Director (FSD) said the walk-in freezer was not working correctly and not holding temperature for at least 10 days prior to the survey. He said the facility continued to utilize the freezer food.On 6/16/26 at 7:46 A.M., the surveyor, with the FSD present, entered the walk-in freezer and observed the fan to have ice buildup. There were pools of water on the floor from melting ice. The surveyor felt the interior temperature of the freezer to be warmer than expected. The surveyor read the thermometer inside the walk-in freezer which registered 32 degrees F. The surveyor touched the foods inside the freezer and found them to be soft to touch and not frozen.On 6/16/26 at 8:05 A.M., the surveyor observed the following in the walk-in freezer:- One box of bread, soft not frozen- One box of chicken cutlets, soft not frozen- One box of hamburgers, soft not frozen- One bag open with meat exposed, soft not frozen- Quarter-size hotel pan with chicken and dumplings, thawed, not frozen, dated 5/2026- One box of mirepoix, defrosted- One box of sweet potato fries, defrosted, soft to touch- One box of gluten free bread, soft to touch, not frozen- One bag of French fries, soft to touch- One bag of waffle fries, soft to touch- One box of pie crusts labeled keep frozen, not frozen- One bag of sliced salami, not frozen- One box of frozen pasta sheets labeled keep frozen- One opened bag of premade baked eggs, not frozen- Two bags with cheese blintzes exposed to the elements, not frozen- One box of bratwurst keep frozen, not frozenDuring an interview on 6/16/26 at 7:45 A.M., [NAME] #1 said maintenance had made calls to have the freezer repaired but no one had been in. He said they are using the food items from the freezer but not the meat.During an interview on 6/16/26 at 8:30 A.M., the FSD said that the facility's engineer had tried to fix the walk-in freezer but there has been no improvement. The FSD said the staff are using all products including meat and breakfast items from the freezer. The FSD said they were trying to use all new frozen products from delivery right away.During an interview on 6/16/26 at 9:17 A.M., the Administrator said she was unaware of the freezer not working. She said she knew it wasn't holding temperatures but thought maintenance fixed it. She said she had reached out to vendors to assist with repairs. The Administrator said the facility had reached out to a vendor yesterday to fix the walk-in freezer. The Administrator said the maintenance department had all correspondence regarding repairs.On 6/16/26 at 9:17 A.M., the surveyor requested any correspondence between the facility and vendors regarding the walk-in freezer in the main kitchen.During an interview on 6/17/26 at 8:52 A.M., the FSD said he would get the communication between the facility and vendors regarding the walk-in freezer. The FSD said staff were using food in the freezer until yesterday even though it was not holding temperature.Review of the walk-in freezer temperature logs for June 2026 indicated but were not limited to the following:- 6/16/26: A.M. 29 P.M. 35- 6/15/26: A.M. 29 P.M. 36- 6/14/26: A.M. 29 P.M. 36- 6/13/26: A.M. 25 P.M. 35- 6/12/26: A.M. 29 P.M. 32- 6/11/26: A.M. 30 P.M. no temp- 6/10/26: A.M. 23 P.M. no temp- 6/09/26: A.M. 20 P.M. no temp- 6/08/26: A.M. 29 P.M. no temp- 6/07/26: A.M. 20 P.M. no temp- 6/06/26: A.M. 20 P.M. 28- 6/05/26: A.M. 20 P.M. no temp- 6/04/26: A.M. 23 P.M. -9- 6/03/26: A.M. 15 P.M. no temp- 6/02/26: A.M. 10 P.M. -9- 6/01/26: A.M. 22 P.M. no tempDuring an interview on 6/22/26 at 2:34 P.M., Maintenance Staff #1 said he did not check to see if temperatures were holding and he would expect the kitchen to let them know if temperatures weren't holding. Maintenance Staff #1 said he did not have any logs related to the walk-in freezer temperature and he was told about the concerns by word of mouth.During an interview on 6/22/26 at 2:36 P.M., the Administrator said that she could not locate any correspondence from the freezer company. She said she thought she had something on her phone but did not find anything. She said that she knew on the Saturday (6/13/26) there was an issue with the walk-in freezer because she was informed by maintenance of the issue. She said she was told the temperatures were holding steady.During an interview on 6/22/26 at 3:41 P.M., Maintenance Staff #2 said he was aware of the freezer not working since approximately 6/11/26. He said he had started to defrost the fan with all the ice buildup. Maintenance Staff #2 said he was not working on 6/13/26 and did not alert the administrator.During an interview on 6/23/26 at 12:35 P.M., the Administrator said her expectation was for staff to alert maintenance staff if there was a problem with equipment.Prior to survey exit, the facility did not provide the surveyor with any correspondence regarding the maintenance and/or repair of the walk-in freezer in the main kitchen.

Based on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for one Resident (#122), out of a total sample of 22 residents. Specifically, the facility failed to ensure an order for an antidepressant medication was implemented as ordered by the physician for Resident #122.Findings include:Review of Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice.Resident #122 was admitted to the facility in February 2026 with diagnoses including adjustment disorder with mixed anxiety and depressed mood.Review of the Minimum Data Set assessment, dated 5/15/26, indicated Resident #122 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15.Review of Resident #122's psychiatric evaluation and consultation, dated 5/28/26, indicated but was not limited to:-Adjustment disorder with anxiety and depression, start Mirtazapine (antidepressant medication) 7.5 milligrams (mg) at bedtime.Review of Resident #122's medical record indicated he/she was hospitalized from [DATE] to 6/13/26.Further review of the medical record failed to indicate Resident #122's Mirtazapine was implemented or addressed with the physician.During an interview on 6/22/26 at 1:15 P.M., Nurse #2 reviewed Resident #122's psychiatric evaluation and consultation, dated 5/28/26, and current physician's orders and said he/she does not have an order for Mirtazapine. Nurse #2 said after a resident is seen by the mental health provider the unit manager receives the recommendations and follows up with the physician on whether or not to implement the recommendations.During an interview on 6/22/26 at 1:23 P.M., Unit Manager #3 said the mental health provider fills out a Provider Orders and Recommendation form for any recommendations to be addressed with the physician. She said she put the Provider Orders and Recommendation form in the Doctors Communication Book. She provided the surveyor with Provider Orders and Recommendation form signed by the Physician on 5/28/26. She said Resident #122 was transferred to the hospital on 5/29/26 prior to the order for Mirtazapine being entered into Resident #122's Physician Orders. She said on 6/13/26 Resident #122 returned from the hospital and she wanted to review the order for Mirtazapine with the Physician prior to implementing the medication to verify if the Physician still wanted to implement the medication, but she had not had a chance to do so yet.Review of the Provider Orders and Recommendation form, dated 5/28/26, indicated but was not limited to:- Order/Recommendation: Start Mirtazapine 7.5 mg at night.- Diagnosis: Depression- Target Behaviors: depression - Signed by the Mental Health Provider, dated 5/28/26- Approved and signed by the Physician Further review of Resident #122's medical record, on 6/23/26, 11 days after he/she was readmitted to the facility failed to indicate Mirtazapine was implemented for Resident #122 as ordered by the Physician on 5/28/26.Review of the Physician Communication Book, on 6/23/26, indicated but was not limited to:- Provider Orders and Recommendation form, dated 5/28/26, signed by the Physician with a yellow sticky note on it stating re-start followed by a question mark.During an interview on 6/23/26 at 1:42 P.M., the Assistant Director of Nursing said the physician's order for Mirtazapine for Resident #122 should have should have been initiated when he/she returned from the hospital but was not.During an interview on 6/23/26 at 2:30 P.M., Physician #1 said he and the Mental Health Provider had discussed starting Resident #122 on Mirtazapine, on 5/28/26, to help with his/her mood and depression. He said Resident #122 should have started Mirtazapine upon readmission as he had ordered, but he/she was not.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for two Residents (#8 and #89), out of a total sample of 22 residents. Specifically, the facility failed:1. For Resident #8, to ensure staff wore appropriate personal protective equipment (PPE) for enhanced barrier precautions (EBP) when providing a bed bath; and2. For Resident #89, to ensure staff wore appropriate PPE for EBP when providing wound care.Findings include:Review of the facility's policy titled Enhanced Barrier Precautions, undated, indicated but was not limited to:-It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDROs). Novel or targeted MDROs are organisms that are resistant to all or most antibiotics tested, are uncommon in a geographic area, or special genes that allow them to spread their resistance to other germs.-Enhanced barrier precautions require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk of transmission of multi resistant organisms. High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring linen changes, toileting, device care and wound care.-Orders for enhanced barrier precautions will be obtained for residents with a novel or targeted MDRO infection/colonization when contact precautions do not apply. Enhanced barrier precautions will also be implemented for residents with wounds or indwelling medical devices, regardless of their MDRO colonization status, that reside on a unit or wing where a resident with a known infection or colonization with a novel or targeted MDRO resides.1. Resident #8 was admitted to the facility in June 2018 with diagnoses including extended spectrum beta lactamase (ESBL, bacteria resistant to many standard antibiotics, including penicillins and cephalosporins) resistance, methicillin resistant staphylococcus aureus infection (MRSA, type of staph bacteria that has developed resistance to many of the antibiotics traditionally used to treat ordinary staph infections), and multiple chronic wounds.Review of the Minimum Data Set (MDS) assessment, dated 5/29/26, indicated Resident #8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.During an interview on 6/18/26 at 2:41 P.M, Resident #8 said when the staff come to provide him/her with care or wound care they usually wear gloves and a gown.Review of Resident #8's Physician's Orders indicated but was not limited to:- Enhanced Barrier Precaution related to wounds, gastrostomy tube (medical device inserted through the abdomen directly into the stomach), history of MRSA/ history of C-diff (Clostridioides difficile, is a highly contagious bacterium that causes severe inflammation of the colon and watery diarrhea) every shift, dated 5/26/2026On 6/16/26 at 11:47 A.M, the surveyor observed that Resident #8 had an EBP sign, undated, from the Centers for Disease Control and Prevention (CDC) posted on the door to his/her room, which indicated but was not limited to the following:- Stop Enhanced Barrier Precautions- Everyone Must: - Clean their hands, including before entering and when leaving the room.- Providers and staff must also: - Wear gloves and a gown for the following High-Contact Resident Care Activities. - Dressing - Bathing/Showering - Transferring - Changing Linens - Providing Hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound Care: any skin opening requiring a dressingOn 6/17/26 at 11:09 A.M., the surveyor observed a Certified Nursing Assistant (CNA) giving Resident #8 a bed bath. The CNA donned (put on) gloves but failed to don a gown.On 6/23/26 at 1:40 P.M., the Assistant Director of Nursing (ADON) said a bed bath is considered high contact care. She said the CNA should have donned a gown prior to providing Resident #8 with a bed bath.2. Resident #89 was admitted to the facility in December 2025 with diagnoses including abscess (localized pocket of pus) of the perineum (soft tissue and skin at the bottom of the pelvis between the scrotum and the anus) and open wound of external genital organs.On 6/16/26 at 9:59 A.M., the surveyor observed that Resident #89 had an EBP sign, undated, from the CDC posted on the door to his/her room, which indicated but was not limited to the following:- Stop Enhanced Barrier Precautions- Everyone Must: - Clean their hands, including before entering and when leaving the room.- Providers and staff must also: - Wear gloves and a gown for the following High-Contact Resident Care Activities. - Dressing - Bathing/Showering - Transferring - Changing Linens - Providing Hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound Care: any skin opening requiring a dressingReview of Resident #89's Physician's Orders indicated but was not limited to:-Enhanced Barrier Precaution related to wounds and history of ESBL every shift for infection control, dated 4/23/2026.During an interview with observation, dated 6/17/26 at 2:19 P.M., the surveyor, with Nurse #1 present, observed Resident #89's open wound areas. Nurse #1 performed hand hygiene and donned gloves. Nurse #1 failed to don a gown. Nurse #1 assisted Resident #89 with bed mobility and provided wound care. Nurse #1 doffed (took off) his gloves and performed hand hygiene. Nurse #1 reviewed the EBP sign outside of Resident #89's room and said he did not don a gown prior to providing wound care and assisting Resident #89 with bed mobility but should have.During an interview on 6/17/26 at 2:37 P.M., Unit Manager #3 said Resident #89 was on EBP for his/her wounds and Nurse #1 should have donned a gown prior to providing high contact care.

Based on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of and properly contained within a receptable constructed with a tight-fitting lid. Findings include: Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA) indicated outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. Review of an e-mail from the local Fire Department, dated 2/6/25, to the Department of Public Health indicated but was not limited to the following: -Over the past year, since I have been in this position we have run into several safety concerns and issues with the facility from overflowing trash bins and trash left on the ground outside the facility, hood systems not being cleaned in the appropriate time frames, to now a possible overflowing leach field behind the building. On 5/15/25 at 9:00 A.M., the surveyor made the following observations of the outside trash receptacles located outside of the main kitchen: Inside the fenced in dumpster area: - Two dumpsters in the wooden fence area: one on the left for recyclable cardboard and one on right for general refuse, both dumpsters were overflowing. Located within the fenced area on the ground were 8-10 cardboard boxes stacked, three black trash bags between the two dumpsters, an old mattress behind the refuse dumpster, four black trash bags to the right of the refuse dumpster, and five black trash bags in front of the refuse dumpster. There was miscellaneous trash scattered around the dumpster on the ground, including blue disposable gloves, small boxes, milk crates, plastic wrap, cups and other various debris. Outside the fenced in dumpster area: -A dolly cart with two black bags of trash and two empty cardboard boxes, uncovered. -Three large plastic laundry carts, each overflowing with white clear trash bags, uncovered. -One gray laundry cart overflowing with clear and black plastic trash bags, uncovered. -One canvas, darker blue laundry cart overflowing with clear and black plastic bags, uncovered. -There were multiple clear and black plastic trash bags which had fallen off the laundry carts onto the ground. During an interview on 5/15/25 at 11:22 A.M., the facility's outside trash removal contractor said he is here to pick up some of the trash; he does not have room in his truck to remove all of it. He said this happens frequently, the trash was not picked up due to non-payment. During an interview on 5/16/25 at 12:54 P.M., Dietary Staff #1 said the trash overflows frequently because it's not picked up regularly. During an interview on 5/20/25 at 10:01 A.M., the Administrator said she was not aware the trash was not being removed or of any payment issues.

Based on observation and interview, the facility failed to ensure mechanical equipment in the main kitchen was maintained in a safe operating condition, specifically (1) the walk-in freezer, (2) the stove hood, and (3) the ice machine. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. 1. On 5/15/25 at 8:15 A.M., the surveyor observed the following in the walk-in freezer in the main kitchen: -Freezer door unable to fully seal due to ice buildup; -Only two plastic freezer strip curtains were intact, the rest were missing; -Large amount of ice build-up at the base of freezer door, extending into the left side of the freezer; -Large amount of drops of condensation frozen on the entire ceiling, the metal racks inside were covered with frozen condensation; - Ice buildup on boxes on every shelf; and -Frozen condensation observed inside boxes and inside numerous clear packaged food items, and three frozen hamburger tubes were encased in frozen condensation. During an interview on 5/21/25 at 1:59 P.M., the Director of Maintenance said when he started this week, the freezer was frozen over, and he thawed it out. He said the freezer strip curtains were broken and the door was not sealing. He said he now has a call out for service. 2. Review of the Certification of Local Fire Inspection, dated 3/18/25, indicated but was not limited to the following: -Nursing home or rest home quarterly inspection. -Not to be in compliance with local ordinances regarding the prevention and safety. The following violations were observed: -Hood cleaning done 2/21/24. 180 days. On 5/15/25 at 8:15 A.M., the surveyor observed the stove hood inspection sticker, which indicated the last inspection was 2/21/24, and the next inspection was due in 180 days. Indicating the inspection was now 269 days overdue. During an interview on 5/16/25 at 12:54 P.M., Dietary Staff #1 observed the hood sticker and said he knows the hood is overdue for cleaning and inspection. 3. Review of the Ice Cleaning and Maintenance Log, located in the maintenance office, indicated the ice machine filter was due to be changed in January 2025. The filter change was three and half months overdue. During an interview on 5/21/25 at 2:10 P.M., Maintenance Staff #1 said he cleans the ice machine, but does not change the filter. He said they have a company for that, and it was due to be changed in January 2025, and it was not. During an interview on 5/16/25 at 2:35 P.M., the Administrator said she was made aware the hood inspection was overdue. She said she was not aware of the condensation in the freezer or the overdue service for the ice machine. During an interview on 5/21/25 at 9:35 A.M., the Food Service Manager (FSM) said he was not aware of the regularly scheduled maintenance of the equipment in the kitchen. He said the maintenance department handles all the service and regular maintenance of the ice machine, the freezer, and the hood.

Based on observation and interviews, the facility failed to maintain their septic system drain field in working order and/or increase pumping of their septic tank to prevent the liquid wastewater from running into their parking lot. Findings include: Review of website www.epa.gov/septic/how-septic-systems-work, included but was not limited to the following information from the federal government: How a typical conventional septic system works: 1. All water runs out of your home from one main drainage pipe into a septic tank. 2. The septic tank is a buried, water-tight container usually made of concrete, fiberglass, or polyethylene. Its job is to hold the wastewater long enough to allow solids to settle down to the bottom forming sludge, while the oil and grease floats to the top as scum. Compartments and a T-shaped outlet prevent the sludge and scum from leaving the tank and traveling into the drainfield area. 3. The liquid wastewater (effluent) then exits the tank into the drainfield. 4. The drainfield is a shallow, covered, excavation made in unsaturated soil. Pretreated wastewater is discharged through piping onto porous surfaces that allow wastewater to filter through the soil. The soil accepts, treats, and disperses wastewater as it percolates through the soil, ultimately discharging to groundwater. If the drainfield is overloaded with too much liquid, it can flood, causing sewage to flow to the ground surface or create backups in toilets and sinks. Review of an e-mail from the local Fire Department, dated 2/6/25, to the Department of Public Health indicated, but was not limited to the following: -Over the past year, since I have been in this position we have run into several safety concerns and issues with the facility from overflowing trash bins and trash left on the ground outside the facility, hood systems not being cleaned in the appropriate time frames, to now a possible overflowing leach field behind the building. Review of the handwritten pumping log maintained in the maintenance office indicated the septic system was last pumped on 3/27/25. Review of the last invoice received from the septic system pumping company was dated 3/26/2025. On 5/20/25 at 9:15 AM., the surveyor observed the lower parking lot and observed water bubbling out from the manhole cover, creating a stream of water running into a line of parked cars. The water created a strong smell of sewage. During an interview on 5/20/25 at 9:15 A.M., Consultant #1 and Consultant #2 said they were on the premises for the first time to evaluate the septic system for the facility. Consultant #1 said they were unable to comment on the condition of the current septic system at this time, other than there is a problem. Consultant #1 said the water running from the manhole cover into the parking lot was effluent water, meaning it had gone through the septic tank and should be leaching into the ground. Consultant #1 and Consultant #2 both said more frequent pumping of the septic tank would be helpful since the water is not leaching now. During an interview on 5/20/25 at 11:25 A.M., the Maintenance Director said he just started in the building on Monday. He said the last pumping receipt he has is from March 2025. He said the two engineers that were here today are going to the Town Hall for some investigation to see what can be done to fix the problem. During an interview on 5/20/25 at 11:32 A.M., the Regional Maintenance Director said he was made aware of the problem one to two months ago and was here in the building a month ago. He said he was not aware of the problem in February 2025. He said his boss knew about it before him and was managing it with the previous Plant Manager by having it pumped out. During an interview on 5/21/25 at 11:21 A.M., the Administrator said she was not aware of when the concern with the septic system started or what the previous pumping schedule was. The Administrator said she has requested the timeline from the regional maintenance director as requested by the surveyor but has not received it. During an interview on 5/21/25 at 2:10 P.M., Maintenance Staff #1 said there has been no pumping of the septic system since March 2025. He said that this has been a problem, especially when it rains a lot, and the problem gets worse. The facility did not provide the requested timeline of when the facility was made aware of the septic system problems or any mitigation plan at the time of survey exit.

Based on interviews and observations, the facility failed to ensure it provided a clean, comfortable, and homelike environment for the residents residing on one unit ([NAME]) out of three units. Findings include: Review of the facility's policy titled Policy for Environmental Rounds, undated, indicated but was not limited to the following: -Environmental rounds will be an integral part of daily routine and will also be performed regularly throughout the entire facility. -Environmental survey worksheets will be retained for review to illustrate the improvement of quality of life within the facility and for review/comparison purposes within the facility over a period of time. Review of the most recent Resident Council Minutes, dated 4/24/25, indicated it has been noted there was a lack of maintenance in the building. On 5/15/25 at 8:40 A.M., during the initial tour of the [NAME] unit, the surveyor observed the following: -Two keypads to the unit were loose (due to missing screws) and duct tape was visibly holding it together. -room [ROOM NUMBER]'s bathroom light panel was missing in the bathroom with loose screws and light bulb exposed. -room [ROOM NUMBER] had the residents' names written on medical tape with a black marker and stuck to the room number display. -room [ROOM NUMBER] had a heating panel which was broken and had fallen off the unit. -room [ROOM NUMBER] had multiple unpainted areas on the wall. -Back hallway had wallpaper peeling off the walls approximately 15 inches. -room [ROOM NUMBER] had bathroom ceiling tiles that were cracked and stained, missing molding in the bathroom, and frayed curtains. -room [ROOM NUMBER] had water damage near the window causing paint to bubble and chip. The curtains were ripped and frayed. -room [ROOM NUMBER] was missing a room number and had the Resident's first initial and last name taped to the wall outside of their room on a label. The Resident's wheelchair had about 4 inches of yellow foam coming out of the arm rest. -room [ROOM NUMBER] had an air conditioner unit installed lined with duct tape and the inside had large patches of black stains and a filter that was dirty with dust and debris. -The [NAME] dining room had peeling wallpaper with residents sitting at the table to eat their meals. -The electrical panel was unlocked and ajar in the dining room exposing wires. -The molding in the [NAME] dining room was missing near the refrigerator exposing a brown wall. -The sink and countertop area in the [NAME] dining room had water damage which caused the appearance of rippling in the countertop and foam sealant was exposed, the underneath cabinets were zip tied together but the cabinets would not close all the way. -The door near the nurses' station leading to the outside was rotting in multiple areas, exposing the outside through holes. During an interview on 5/15/25 at 11:19 A.M., Resident #16 said nothing seems to work correctly and there are many things that are broken in their room. He/She said they have told staff about the sink being clogged for days now as well as the footboard on the bed being broken. The Resident also showed the surveyor areas of the walls that were missing molding. During an interview on 5/15/25 at 12:00 P.M., Resident #366 said his/her name was written in marker on tape on his/her door for over a week. She said the door frames were completely rotted, and the unit was in disrepair. He/She said the bed was being held together with duct tape and the ceiling tiles were stained in the halls from water damage. During an interview on 5/20/25 at 8:24 A.M., Resident #109 said his/her bathroom light panel has been broken since he/she was admitted which was at the beginning of April. He/She said staff were aware because they were in and out of the bathroom offering assistance. During a tour of the [NAME] unit on 5/20/25 at 1:34 P.M., the Director of Maintenance said he expects the unit to be in good repair and reflect a homelike environment. He stated that this is not an environment he would want to live in and agreed that these items needed to be repaired. He said currently the building is using a notebook to report maintenance needs and work orders. He said he counts on staff to bring these types of things to his attention but has found the staff only seem to report issues that affect staff such as a leak or broken call light. During an interview on 5/20/25 at 1:40 P.M., the Regional Director of Maintenance said this unit should be in better condition and he expects all the areas including dining rooms, resident rooms, and hallways to be repaired. He said he was not aware the maintenance log was currently a single bound notebook. He said he expects the maintenance log to be completed by staff with who, what, where, when, and that maintenance is indicating the progress of the work order. He said there needs to be a better system in place and staff need to know what types of maintenance issues to report. During a tour with an interview on 5/20/25 at 2:34 P.M., the Administrator said the expectation is the unit offers a safe, clean, and homelike experience for the residents and maintenance is reviewing and fixing the items necessary. She said it is her expectation all staff are reporting these concerns and the team develops a tightened process for work orders and rounding. She said staff need to know that ripped curtains and holes in walls are not acceptable.

Based on record review and interview, the facility failed to ensure a Resident with an alteration in skin integrity related to a wound, specifically a gastrocutaneous fistula (an abnormal opening between the stomach and the skin allowing gastric contents to leak onto the skin) at an old feeding tube site, received necessary treatment and services to promote healing for one Resident (#85), out of a total sample of 23 residents. Specifically, the facility failed to transcribe and implement wound care per recommendations by the stoma clinic, complete wound care as ordered, and to notify the physician when the surrounding skin at the wound site was macerated (white and soggy skin from exposure to excessive moisture from body fluids). Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Treatments, dated April 2015, indicated but was not limited to the following: -It is the responsibility of all nursing staff to constantly evaluate the health state of residents/patients as to the need for treatments, once treatments are ordered, they are to be carried out as prescribed. -All treatments must be charted as ordered on the treatment sheet by indicating an initial in the appropriate slot. -The physician should be notified if there is significant change in the area of the treatment, either positive or negative change as warranted. Review of the facility's policy titled Consultant Services, dated April 2025, indicated but was not limited to the following: -The consultant should document findings and recommendations on the form. -The charge nurse will then notify the attending physician of findings, and he/she can then order the specific treatments as outlined by the consultant. -A consultant's report or some form of documentation pertaining to the results will be retained in the clinical record. Review of the facility's policy titled Physician's Orders-Transcription, dated April 2015, indicated but was not limited to the following: -All written physician's orders or telephone physician's orders will be duly noted and accurately transcribed by licensed nursing staff. -Carefully transcribe orders as written to the Medication Administration Record (MAR) and/or the Treatment Administration Record (TAR). Resident #85 was admitted to the facility in February 2024 with diagnoses which included cerebral infarction (stroke), dysphagia (difficulty swallowing), artificial opening of digestive tract, and depression. Review of the Minimum Data Set (MDS) assessment, dated 4/18/25, indicated Resident #85 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, had an open wound and was receiving dressing changes. Review of the medical record indicated his/her Health Care Proxy (HCP) was invoked, indicating he/she was not able to make his/her own medical decisions. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Actual alteration in skin integrity related to chronic wound to stoma of gastrostomy tube (G-Tube) site. Chronic wound of abdomen status post gastrostomy. GOAL: Wound will be free of infection. INTERVENTIONS: -Follow physician orders for skin care and treatments. (Utilize Best Practice Guidelines) -Discuss non-compliance issues with resident/responsible party and educate about primary risk factors and prevention. FOCUS: Behavior Problem related to reactive Depression. Refuses treatments at times, delusional, requires two care givers due to accusations, and unaware of personal limits. GOAL: He/she will remain at reduced risk for harm to self or others with interventions in place. INTERVENTIONS: -Two care givers at all times. -Explain care to resident in advance, in terms resident understands. -Involve HCP/family as needed to discuss behaviors and reality of situations. Review of the medical record indicated Resident #85 was followed by the Hospital Stoma Clinic. Review of the Consults section of the medical record indicated but was not limited to the following: -1/9/25: Appointment at Hospital Stoma Clinic -Other Instructions: Change pouch every three days and as needed if leaking. Remove pouch, clean skin with warm water and pat dry. Apply stoma powder, brush away excess. Apply stoma barrier spray and dry thoroughly. Apply Convatec Natural SurFit urostomy pouch #401544 with Convatec 1 3/4-inch wafer #413184. Review of the Nursing Progress notes indicated but were not limited to the following: -1/13/25: Resident has new orders: Apply Convatec Natural [NAME]-Fit urostomy pouch #401544 with Convatec 1 3/4-inch Convex wafer #413184 with pouch/application changes. -1/22/25: Resident returned from gastrointestinal (GI) appointment with new order. MD/NP aware. Change stoma applies (sic) to small size. Review of the Physician's Orders including interim/telephone orders indicated but were not limited to the following: 1/13/25: -Discontinue stoma orders. -Change stoma pouch and appliance every three days and as needed of leaking. -Remove pouch, clean skin with warm water, pat dry, apply stoma powder, brush away excess. Apply stoma barrier spray and dry thoroughly with pouch/appliance changes. -Apply Convatec Natural [NAME]-Fit urostomy pouch #401544 with Convatec 1 3/4-inch Convex wafer #413184 with pouch/application changes. 1/22/25: -Apply 1% Silver Nitrate (solution to prevent or treat infection) to G-tube site with applies (sic) changes. -Change stoma applies (sic) to smaller size. The physician's order written on 1/22/25 failed to indicate the size and reference number of the appliance to be used, only indicating smaller size. Further review of the Physician's Orders including interim/telephone orders indicated: 3/1/25: -May transfer to emergency room for 10 out of 10 Abdominal Pain. Review of the Hospital After Visit Summary, dated 3/1/25, indicated but was not limited to the following: -Diagnosis: Maceration of peri wound (skin around the wound) skin; Enterocutaneous fistula (abnormal connection between the skin and gastrointestinal tract, allowing stomach or intestinal contents to leak through the skin). -Follow up Appointment on this Wednesday with Hospital Surgeon to discuss surgical correction of the area. -In the meantime, keep the area very dry. Apply stoma powder clear once daily instead of every three days. Review of the Physician's Orders including interim/telephone orders indicated but were not limited to the following: 3/1/25 -Order given to keep stoma area very dry. -Apply stoma powder every day instead of every three days. Review of the Consults section of the medical record indicated but was not limited to the following: -3/5/25: Appointment at Hospital Stoma Clinic -Change in Treatments: Use Convex Wafer with a 7/8-inch opening #413180 (was previously using 1 1/8-inch opening) -Other Instructions: -Please change pouch twice per week to prevent skin from burning. -Empty pouch when 1/3 full. -Cleanse skin with warm water and pat dry before applying pouch. Review of the Nursing Progress notes indicated but were not limited to the following: -3/1/25: Resident complained of pain and inching (sic) around stoma site. Orders given. Follow-up Appointment on 3/5/25 with general surgeon. -3/5/25: Resident returned from trauma/stoma appointment. New order received to change wafer size to 7/8-inch, left message for medical supply to order supplies. Review of the Physician's interim telephone orders failed to indicate an order for the 7/8-inch wafer was obtained and transcribed, failed to indicate to empty the pouch when 1/3 full, and failed to indicate pouch to be changed twice a week to prevent burning. Review of the Physician's Progress note, dated 4/8/25, indicated but was not limited to the following: -Fistula with leakage. -Patient experienced consistent leakage from the tube site and developed red excoriated (irritated) skin to the surrounding area with increased pain. -It was felt the erythema (redness) surrounding the tube site was most likely due to chemical irritation from stomach contents contacting his/her skin. Review of the progress notes failed to indicate the physician had declined the recommendation to change the appliance to the 7/8-inch size (the smaller size would leave less skin exposed to come in contact with the leaking fluid). Review of the ConvaTec website (https://www.convatec.com) product information page indicated but was not limited to the following: -Product Reference #413184 has a 1 3/4-inch flange with a 1 3/8-inch stoma opening. -Product Reference #413183 has a 1 3/4-inch flange with a 1 1/4-inch stoma opening. -Product Reference #413182 has a 1 3/4-inch flange with a 1 1/8-inch stoma opening. -Product Reference #413181 has a 1 3/4-inch flange with a 1-inch stoma opening. -Product Reference #413180 has a 1 3/4-inch flange with a 7/8-inch stoma opening. Features include: -Durahesive® Skin Barrier provides added protection from liquid output. Durahesive® Skin Barriers will turtleneck or gently swell up and hug the stoma, better protecting the skin around your stoma. -Remember to empty pouch when 1/3 full. Review of the active Physician's Orders indicated but were not limited to the following: -Change Appliance and Document the following: Stoma size, Stoma color, Stoma tissue, and PeriStoma, every 72 hours remove pouch, clean site with warm water, pat dry, apply stoma powder, brush away excess, apply stoma barrier spray and dry thoroughly**Apply Convatec Natural [NAME]-Fit Urostomy pouch #401544 with Convatec 1 3/4-inch Convex fit wafer #413184. (original order date 1/9/25; entered into new electronic medical record order system 2/20/25) Review of the appliance the facility was actively using for Resident #85 indicated the following: -Product Reference #413183 which has a 1 3/4-inch flange with a 1 1/4-inch stoma opening. The facility failed to ensure the physician's order accurately matched the appliance being used. Review of the MAR and TAR from January 2025 through May 2025 indicated but were not limited to the following: February 2025 -2 of 10 opportunities the appliance was not signed off as being changed. -5 of 10 opportunities the Silver Nitrate1% was not signed off as being applied. March 2025 -5 of 10 opportunities the appliance was not signed off as being changed. -3 of 10 opportunities the Silver Nitrate1% was not signed off as being applied. -7 of 31 opportunities the Stoma Powder was not signed off as being applied. The facility transitioned from paper MAR/TAR charting to electronic (eMAR/eTAR) charting on 3/26/25. -The facility failed to transcribe the Stoma Powder daily to the eMAR/eTAR to the March 2025 orders. -The updated appliance change orders now included a description of the stoma site. -3/28/25 indicated the nurse documented 9 (9=see nurse's note). The correlating nurse's note indicated the appliance was intact and failed to indicate the appliance was changed per the order. -3/31/25 indicated the appliance was changed and the appearance of the stoma was documented as M (M=macerated). Review of the progress notes failed to indicate the facility notified the physician or the Hospital Stoma Clinic that the area was macerated on 3/31/25. Additionally, the notes failed to indicate the physician was notified the above treatments were not completed as ordered. April 2025 -The facility failed to transcribe the Stoma Powder daily to the eMAR/eTAR. -The appliance was signed off as being changed as ordered. -9 of 10 times the documentation indicated the area was macerated. Review of the progress notes failed to indicate the facility notified the physician or the Hospital Stoma Clinic the area was macerated. May 2025 -The appliance was signed off as being changed as ordered. -6 of 6 times the documentation indicated the area was macerated. Review of the progress notes failed to indicate the facility notified the physician or the Hospital Stoma Clinic the area was macerated. During an interview on 5/21/25 at 10:34 A.M., Nurse #1 said she was unsure what the current treatment to the stoma site was specifically. She said Resident #85 has been going to see the surgeon as they have been trying to get the area to close, but he/she is going to need surgery to close it, which has been scheduled for the end of this month. She said after an appointment, the nurse working reviews the referral and recommendations with the attending physician and then would write the orders and schedule follow up appointments if needed. She said the supplies in his/her room do not match the order in the computer and neither match the most recent recommendations for a 7/8-inch opening. She did not know why the orders did not match as they should. During an interview on 5/21/25 at 10:42 A.M., Unit Manager (UM) #2 said the physician has been burning the area closed when he/she goes to the Surgeon's office and is going the end of the month to have the area surgically closed. She said the supplies in his/her room do not match the order and she did not know why. Additionally, she said when the Resident goes to the appointment, the specialist writes their recommendations on the referral and then we obtain the orders from the attending and notify central supply to order the new supplies. She said the orders in the system should match the appliance being used. She was unsure why the order for 7/8-inch opening appliance was never written as indicated. She said she was going to investigate it a little bit more as now she was unsure what appliance was supposed to be in use and would need to clarify the orders once she figures it out. During an interview on 5/21/25 at 2:36 P.M., the Director of Nurse (DON) said all appliance orders should have the specific size and reference number as part of the order. She said the appliance the nurses apply to the resident should match the physician's order. Additionally, she said when a resident goes out for an appointment, the specialist writes recommendations on the referral. She said the nurse then calls the attending physician to obtain new orders, transcribes those orders, and should write a progress note. She said if the attending declines a recommendation, it should be noted on the referral and in the progress notes. She said the recommendations to use a smaller size appliance made sense because the area was macerated from skin being exposed. She said she called the nurse who failed to write the order on 3/5/25, today after being notified of the discrepancy, and she said the order was never changed because the resident did not want the appliance size changed. She said that is why there is a late entry note from today, in the record indicating such. She said there should have been education provided to the Resident and the HCP regarding the rationale of why the clinic wanted to use a smaller size and there was not. Additionally, the notes do not indicate the HCP was notified about the Resident not wanting to change the appliance, and the HCP should have been notified. She said the order and appliance being used should match and they do not. Additionally, she said the TAR does not indicate the treatments were done per physician's orders, because if it was not signed it was not done. The DON said if the area has remained macerated the physician and/or stoma clinic should have been notified and a progress note written, but they did not do that either.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Maintain one of three kitchenettes in a clean and sanitary condition; and 2. Properly label and date food products in the main kitchen walk-in refrigerator. Findings include: Review of the facility's policy provided by the Administrator for food storage in the kitchen, which was untitled and not dated, indicated but was not limited to the following: -The Dietary Department will be maintained in a clean and sanitary manner to prevent foodborne illness. -All food items shall be labeled and dated to allow for rotation of supplies. -Meats will be stored on the bottom shelves of the refrigerator to prevent drippings from contaminating food on lower shelves. -All items stored in the refrigerator will be covered and labeled with contents and the date. -All potentially hazardous foods must be discarded within three calendar days after the day prepared. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. 1. 1. On 5/21/25 at 9:22 A.M., the surveyor made the following observations on the [NAME] unit nourishment kitchenette: In the refrigerator: -Clear basket of creamers which had a used disposable wipe, artificial sweetener packets, alcohol prep pad cartons, and two cartons of lactose free milk. -On the door shelf were rolled up used napkins, multiple [NAME] Peppermint Patties unlabeled, mayonnaise packets, and a carton of milk. -On the second shelf was a black insulated container on its side, unlabeled and stuck in a clear sticky dried liquid that had leaked out onto the back corner of the shelf. Upper Cabinets: -The shelves were visibly dirty with loose cup covers, random cups, and spoons. Under the sink cabinet.: -The sink drainpipe was leaking onto the cabinet floor, with a large black stain observed on the white cabinet floor, in addition, a white towel which was soiled with a black substance directly under the drainpipe. During an interview on 5/21/25 at 9:35 A.M., The Food service Manager (FSM) said after viewing the [NAME] nourishment kitchenette, said it is the responsibility of the kitchen staff to keep the refrigerator, plastic containers of condiments clean and stocked, and the cabinets clean. The FSM said it's the responsibility of maintenance to clean under the sink or fix any leaking pipes. 2. On 5/13/25 at 8:10 A.M., the surveyor made the following food storage observations in the main kitchen: Walk-in refrigerator: -Large clear plastic container of cooked macaroni, not labeled and undated. -An unidentified food wrapped in plastic wrap, dated 5/7 and unlabeled. -An unsealed package of partially cooked bacon located in a box of frozen pancakes, not labeled and undated. -Metal container of cut watermelon. not labeled and undated. -Stored on a metal pan were multiple dishes of cut cucumbers, tomatoes, and salads, undated. -One Chef salad containing eggs, turkey, ham, dated 5/8. -Bowl of fresh fruit uncovered, not labeled and undated. -Metal Container, which was covered with tinfoil, not labeled and undated. Inside the metal container was egg salad, with nine hard boiled eggs on top of the already made egg salad. -Reusable plastic bag of raw chicken meat, not labeled and undated. The bag was stored on top of a sealed cardboard box containing raw chicken. No drip pan. -Reusable plastic bag containing raw hamburger, not labeled and undated. The bag was stored on top of three additional rolls of sealed raw hamburger. No drip tray underneath the raw hamburger. -Plastic container of tuna fish, dated 5/5. -Metal container of an unidentifiable green vegetable covered with clear plastic wrap, labeled 4 puree, dated 5/10. -Large clear plastic container of chicken salad, labeled but undated. -Clear plastic container of melon, dated 4/28. - Metal container of pickles, not labeled and undated. Observation of the walk-in freezer: -Boxes were stacked in the center of the freezer on the floor. -The freezer was observed to have heavy frozen condensation on the ceiling, on all the boxes, inside the open boxes, thick ice buildup around the opening to the freezer, especially on the lower left floor by the door. -Plastic container of frozen strawberries, partially covered with tinfoil. -There were multiple boxes which were open, the internal plastic bags were open, and the food was covered with frozen condensation, including pancakes, biscuits, strawberries, pie crusts, and frozen patties. -The frozen hamburger tubes on the lower right shelf were encased in frozen condensation. During an interview on 5/13/25 at 8:30 A.M., the Food Service Manager said the food in the refrigerator should be labeled and dated. He said if the food is older than three days, it should be thrown out. In addition, he said the boxes and the bags should be sealed in the freezer to prevent the condensation on the food.

Based on observation, interviews, and test tray results, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for two of two test trays. Findings include: During initial resident screening on 4/7/24, the survey team identified the following concerns expressed by residents about food palatability: -Resident #8 said the food could be ice cold and could be improved. -Resident #88 said the food was sometimes not warm enough. -Resident #70 said the food was deplorable; the taste was not good and was usually not warm despite mentioning these concerns during previous food committee meetings. -Resident #38 said the food was always stone cold, especially the soup. The Resident said these things had previously been discussed at Resident Council. -Resident #45 said the food was terrible and cold all the time. -Resident #74 said sometimes the food temperature was not right. -Resident #53 said the food could be better, and sometimes it was cold. -Resident #1 said the food was not that great. The Resident said the food was served warm and was bland at times. -Resident #68 said the food was horrendous. The Resident said they sent the last five meals back to the kitchen. The Resident said they could not usually say anything good about the food, and they often ordered takeout from local restaurants. -Resident #43 said the food was terrible, low-grade. -Resident #47 said the food was not palatable, the flavor could use more salt and pepper. -Resident #1A said the food was not good in terms of texture, flavor, and visually. -Resident #55 said their family brought them food because they did not like the facility's food. -Resident #89 said the food was bland; temperature was warm. -Resident #20 said the mashed potatoes were watery, meat was overcooked, and hot food was served cold. The Resident said their friends bring them food. -Resident #70 said the food had bad flavor and was usually not warm. -Resident #33 said the food was terrible; that it was cold with no flavor. Review of Resident Council Meeting Minutes, dated 3/21/24, indicated several resident concerns about: -cold breakfast. -cold soups. Review of Resident Council Meeting Minutes, dated 2/22/24, indicated several resident concerns about receiving cold food, especially breakfast. During Resident Council Meeting on 4/8/24 at 3:15 P.M., several residents said they had concerns with: -cold breakfast. -cold soup. On 4/8/24 at 1:00 P.M., the surveyor requested a lunch test tray to the [NAME] Unit. The food truck left the kitchen at 1:16 P.M., and arrived on the unit at 1:17 P.M. The test tray was conducted with the Food Service Director (FSD) obtaining temperatures at 1:35 P.M. with the following results: - Mixed vegetables: 124 Fahrenheit (F), cold, extremely soft, mushy texture, little flavor. - Baked dinner roll: 127 F, cold. - Baked lasagna: 152 F, very warm. During an interview on 4/8/24 at 1:00 P.M., the FSD declined to taste the contents of the lunch test tray. The FSD said the mixed vegetables were overcooked. On 4/9/24 at 8:30 A.M., the surveyor requested a breakfast test tray to the [NAME] Unit. The surveyor observed the food temperature log for breakfast that morning was not completed. The food truck left the kitchen at 8:32 A.M. and arrived on the unit at 8:33 A.M. The test tray was conducted with the FSD obtaining temperatures at 8:47 A.M. with the following result: -Omelet 123 F, lukewarm. -Hashbrown 123 F, lukewarm. -Orange juice in cup, 56 F, lukewarm. During an interview on 4/9/24 at 8:30 A.M., the FSD declined to taste the test tray. The FSD said breakfast tended to be the meal where most residents were concerned with temperature. The FSD said it was difficult to serve breakfast trays at the desired temperatures. During an interview on 4/10/24 at 9:47 A.M., the Dietitian said test tray meal temperatures have been mixed lately, with breakfast meals more consistently difficult to hold within the desired temperature range. Specifically, the Dietitian said the milk on Tuesday's test tray warm at 60 F. Review of Room Test Tray Evaluation forms indicated acceptable temperature ranges for food and beverage: -Hot food items 135-160 F -Cold food items 40-55 F -Hot beverages 145-180 F -Cold beverages 40-55 F Review of completed Test Tray Evaluation sheets indicated, but were not limited to, the following: -4/8/24 Lunch: pulled pork sandwich entree 168 F prior to meal service, 134.2 F upon delivery; mixed vegetables 122 F upon delivery; ambrosia dessert 36 F prior to meal service, 87.6 F upon delivery; whole milk 60.6 F upon delivery. The Dietitian wrote all items were out of temperature range except for the coffee which is poured on the unit, and the vegetables were waterlogged. -3/12/24 Lunch: chicken entree 166 F prior to meal service, 128.5 F upon delivery; Spinach 167 F temperature prior to meal service, 128.3 F upon delivery. The Dietitian wrote the meal plate was lukewarm. -3/19/24 Lunch: fish entree 175 F prior to meal service, 112.3 F upon delivery; mashed potato 166 F prior to meal service, 124.7 F upon delivery; mixed vegetables 165 F prior to meal service, 106.1 F upon delivery. -3/21/24 Dinner: hot sandwich entree 160 F prior to meal service, 114.8 F upon delivery; French fries 164 F prior to meal service, 107.1 F upon delivery; coffee 142.4 F upon delivery; soup 125.1 F upon delivery; milk 58 F upon delivery. The Dietitian wrote the meal was tasty but unfortunately cold. -3/27/24 Lunch: chicken picatta entree 132.2 F upon delivery; spaghetti 122 F upon delivery; summer squash 133.3 F upon delivery; milk 60.7 F upon delivery; cottage cheese 56.2 upon delivery. -3/28/24 Breakfast: waffle 92.3 F upon delivery; sausage links 91.8 F upon delivery; oatmeal 176 F prior to meal service, 122.9 F upon delivery; milk 35 F prior to meal service, 56.5 F upon delivery. The Dietitian wrote the meal was too cold, with residents complaining the waffle was cold and hard and difficult to cut. -3/5/24 Breakfast: pancakes 119.1 F upon delivery; orange juice 35 F prior to service, 65 F upon delivery. The Dietitian wrote the pancakes were too cold, the plate was warm, not hot. The Dietitian also wrote the juice was too warm. -1/26/24 Breakfast: scrambled eggs 160 F prior to service, 106.5 F upon delivery; orange juice 35 F prior to service, 60.5 F upon delivery. The administrator wrote the eggs were too cold and the orange juice was too warm. During an interview on 4/10/24 at 12:47 P.M., the Administrator said he has experienced issues with food temperatures when he completed Room Test Tray Evaluation forms, and he was aware of residents' concerns with food temperatures.

Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen was maintained in a sanitary condition; 2. Ensure food items were properly labeled and dated in the main kitchen refrigerators; 3. Ensure food and drink items were properly stored, labeled, and dated in two of three kitchenettes; 4. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross-contamination (transfer of pathogens (biological contaminants) from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 5. Utilize proper equipment cleaning and sanitation to prevent cross-contact (the inadvertent introduction of an allergen into a product that would not intentionally contain that allergen as an ingredient) during handling of ready-to-eat food. Findings include: 1. Review of the 2022 Food Code (model for safeguarding public health and ensuring food is safe for consumption) by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. 6-501.14 (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. Review of the facility's policy titled Dietary Infection Control Policies, revised January 2011, indicated but was not limited to the following: -The facility must store, prepare, and distribute food under sanitary conditions. -The Dietary Department will be maintained in a clean and sanitary manner to prevent foodborne illness. Review of the facility's policy titled Safety and Sanitation, revised February 2005, indicated but was not limited to: -Cleaning schedule will be available for staff. -A cleaning schedule will be posted weekly, followed by staff, and monitored by the Director of Dining Services (termed Food Service Director [FSD] in this citation). Review of the main kitchen's Closing Check List indicated but was not limited to: -All food items are put away, labeled, and dated. Check walk-in for compliance. -Floor swept and mopped On 4/7/24 at 8:03 A.M., the surveyor made the following observations concerning sanitation in the main kitchen: -buildup of food crumbs and debris along the perimeter of the kitchen floor. -splashes of dried food on several large bins underneath one preparation counter. -wheeled carts holding dishwasher trays visibly dirty with crumbs and food debris. -shelving in the dry storage room had cobwebs. -shelving in the dry storage room had items, such as Styrofoam cups, condiment packets, sugar packets, whole and pieces of food packaging, bottle caps, and dust and debris on the floor around and underneath the shelving\. On 4/8/24 at 11:27 A.M., the surveyor made the following observations concerning sanitation in the main kitchen: -buildup of food crumbs and debris along the perimeter of the kitchen floor. -debris buildup on several of the stovetop burners. -buildup of dust in the top portion of floor-to-ceiling tubing located in or adjacent to one food preparation area, the steam table, and the three-bay sink. -buildup of dust on all ceiling vents in the kitchen. -pot and pan shelving in main kitchen with visible dust and rust. -shelving in the dry storage room had cobwebs. -shelving in the dry storage room had items, such as Styrofoam cups, condiment packets, sugar packets, whole and pieces of food packaging, bottle caps, and dust and debris on the floor around and underneath the shelving. During an interview on 4/8/24 at 7:51 A.M., the FSD said he expected the dry storage shelving to be free of cobwebs and the kitchen floor to be clean and free of debris and food particles. The FSD said the ceiling vents and tubing should be free of dust as it could potentially contaminate work surfaces, equipment, and food. On 4/10/24 at 2:45 P.M., the FSD provided the surveyor with records of the Closing Check List for the main kitchen. Review of Closing Check List records showed the most recent documentation was on 1/12/24, on which date staff indicated they had swept and mopped the floors. During an interview on 4/10/24 at 9:47 A.M., the FSD said it appeared that staff were sweeping the open area of the dry storage room floor but not underneath the shelving. 2. Review of the 2022 Food Code, revised January 2023, indicated but was not limited to the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in paragraphs (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of 7 days. The day of preparation shall be counted as Day One. Review of the facility's policy titled Total Quality Management Program Dining Services Indicators, reviewed March 2011, indicated but was not limited to the following: -Food is stored properly. -Food is labeled and dated in the refrigerator and freezing and storage area. -Open items are wrapped or in an approved container, dated and labeled. Review of the facility's policy titled Dietary Infection Control Policies, revised January 2011, indicated but was not limited to the following: -All items stored in the refrigerator will be covered, labeled with the contents and the date. On 4/7/24 at 8:03 A.M., the surveyor made the following food storage observations: A. Walk-in refrigerator in the main kitchen: -One opened ham luncheon meat, no label or date. -One opened bag of pre-cooked meatballs, no label or date; the packaging was not securely closed and contents were exposed to air. -One opened container of cottage cheese, no label or date. -Two plated side salads, wrapped, no label or date. -One open package of cubed potatoes, no label or date. -One open package of shredded cheese, no label or date. B. Dry storage room off the main kitchen: -Two bags of muffin mix, out of original box, no date. -One opened bag containing brown powder, no label or date. C. Outdoor walk-in freezer trailer: -One open box of omelets, no label or date. During an interview on 4/7/24 at 3:25 P.M., the Regional FSD said he expected any open boxes of product in the walk-in freezer to be labeled and dated. During an interview on 4/9/24 at 7:51 A.M., the FSD said any items removed from boxes should be labeled and dated. The FSD said the two bags of muffin mix in dry storage should be dated and the opened bag of brown powder should be labeled and dated. During an interview on 4/10/24 at 9:47 A.M., the Regional FSD said he expected any open food or drink items in the walk-in cooler to be labeled and dated with the date it was opened. 3. Review of the facility's policy titled Personal Food Policy, undated, indicated but was not limited to the following: -Families and visitors of residents are permitted to bring food into the facility for the resident use. However, nursing home residents are at risk for serious complications from foodborne illness which may occur from unsafe food handling practices. In order to ensure the safety of our residents, food may only be brought into the facility in accordance with this policy. -The staff person receiving the personal food shall label the container with the date it was brought into the facility (or the date of preparation, if known) and the name of the resident receiving it. -Dietary aides are responsible for checking nourishment refrigerators daily and discarding any unused refrigerated food after three days. -Any perishable items that are found outside of the refrigerator or unlabeled shall be discarded unless it can be verified that the food has not been out for more than two hours. Review of the facility's policy titled Dietary Infection Control Policies, revised 1/2011, indicated but was not limited to the following: -Foods brought into the facility by family members will be kept in appropriate storage, refrigerated if indicated, and discarded as appropriate. For example, prepared foods that require refrigeration should be discarded after 3 calendar days, whereas crackers stored in an airtight container may be kept longer. On 4/8/24 at 8:53 A.M., the surveyor observed in the [NAME] Unit kitchenette: -One container of iced tea, opened with no resident label or date. -One container of thickened dairy beverage, opened, with no date. The manufacturer's label indicated to use within four days of opening. On 4/8/24 at 4:52 P.M., the surveyor observed in the [NAME] Unit kitchenette: -One container of iced tea, opened with no resident label or date. -One container of thickened dairy beverage, opened, with no date. The manufacturer's label indicated to use within four days of opening. -One plastic bag with a sandwich and bag of chips, no resident label or date. On 4/10/24 at 7:42 A.M., the surveyor observed in the [NAME] Unit kitchenette: -One container of iced tea, opened with no resident label or date. -One Styrofoam cup with straw, filled with liquid, no resident label or date. During an interview on 4/10/24 at 7:42 A.M., Certified Nursing Assistant (CNA) #4 and CNA #7 said unit staff should label all food and drink with resident name and date when it was placed in the refrigerator. CNA #4 and CNA #7 said opened food or drink should be labeled and can be in the refrigerator for three days before being thrown away. CNA #7 said unit kitchen staff were responsible for monitoring dates and expiration dates of the food in kitchenettes. On 4/10/24 at 8:50 A.M., the surveyor observed the following in the [NAME] Unit kitchenette refrigerator: -One pink water bottle, with no resident label or date. -one bottle of Vitamin Water, with no resident label or date. -one container of brown soup in Tupperware container, with no resident label or date. On 4/10/24 at 9:12 A.M., the surveyor observed the following in the [NAME] Unit kitchenette refrigerator: -one container of sour cream with room number, with no date; the manufacturer's expiration date was 3/25/24. -one container of brown soup in Tupperware container, with no resident label or date. During an interview on 4/10/24 at 12:47 P.M., the surveyor observed the following in the [NAME] Unit kitchenette refrigerator: -one container of sour cream with room number, with no date; the manufacturer's expiration date was 3/25/24. -one container of brown soup in Tupperware container, with no resident label or date. During an interview on 4/10/24 at 12:47 P.M., the Regional FSD said the container of sour cream should be labeled with the resident's name and dated. The Regional FSD said the sour cream was past the expiration date. 4. Review of the 2022 Food Code, revised January 2023, indicated but was not limited to the following: 3-301.11 Preventing Contamination from Hands. (A) food employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Review of the facility's policy titled Dietary Infection Control Policies, revised January 2011, indicated but was not limited to the following: -All foods shall be prepared according to the FDA Food Code, with special attention paid to potentially hazardous foods. These include meats, poultry, stuffing, milk, dairy products, eggs, salads, cream-filled pastries, etc., and will be handled with extreme caution throughout the preparation and storage processes. -Handling of all food items during the preparation process will be minimized. This may be accomplished by using clean kitchen tools or by wearing clean gloves for each task. On 4/8/24 at 11:22 A.M., the surveyor observed Dietary Staff #1 making peanut butter and jelly sandwiches with no gloves on. On 4/8/24 at 12:26 P.M., the surveyor observed the FSD using visibly soiled oven mitts with gloved hands. The FSD returned to the tray line wearing the same gloves. The FSD was observed using the same gloves to grab handfuls of tossed salad to plate. The FSD was subsequently observed touching the tops of several resident lunch plates, buns, rolls, and tray line utensils while wearing the same gloves that handled the soiled oven mitts. During an interview on 4/10/24 at 9:47 A.M., the Regional FSD said he expected Dietary Staff to take off gloves as soon as they leave a station, and for Dietary Staff to wash hands before entering a station. The Regional Food Service director said staff should use designated utensils for plating salad. During an interview with the FSD and the Regional FSD on 4/10/24 at 9:47 A.M., the FSD said the oven mitts had not been laundered in about 4 months. The Regional FSD said oven mitts could be an infection control issue. 5. Review of the 2022 Food Code, revised January 2023, indicated but was not limited to the following: 3-304.11 Food Contact with Equipment and Utensils. Food shall only contact surfaces of: (A) Equipment and utensils that are cleaned as specified under Part 4-6 of this Code and sanitized as specified under Part 4-7 of this Code. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. 4-702.11 Before Use After Cleaning. Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning. On 4/8/24 at 12:46 P.M., the surveyor observed Dietary Staff #4 placing a peanut butter and jelly sandwich directly onto a prep table and re-using a knife to cut crust off the sandwich. Dietary Staff #4 was observed leaving the station without cleaning or sanitizing the prep table. Dietary Staff #4 left the used knife on the prep table. On 4/8/24 at 1:12 P.M., the surveyor observed the FSD placing a tuna salad sandwich on the same area of the prep table where Dietary Staff #4 prepared the peanut butter and jelly sandwich. The FSD was observed cutting the tuna salad sandwich using the same knife that cut the peanut butter and jelly sandwich. The FSD was observed leaving the station without cleaning or sanitizing the prep table. During an interview on 4/10/24 at 9:47 A.M., the Regional FSD said the prep table, where the peanut butter and jelly sandwich and the tuna salad sandwich were cut, should have been cleaned and sanitized after each use. The Regional FSD said Dietary Staff should have used a new knife to cut the tuna salad sandwich to prevent cross-contamination.

Based on observation and interview, the facility failed to ensure resident rooms were maintained in good repair to promote a homelike environment on one of three units. Specifically, the facility failed to repair areas of chipped and loose textured ceiling, also known as popcorn ceiling, in five resident rooms in one out of three units. Findings include: During an observation with interview on 4/8/24 at 9:30 A.M., the surveyor observed several patches of popcorn ceiling missing from Resident #12's room in the area above the bed. Resident #12 said a storm caused water to leak from the ceiling causing areas of the popcorn ceiling to peel away and fall from the ceiling. Resident #12 said a piece of the popcorn ceiling fell and hit them on the head with no injury occurring. Resident #12 said the edges of the area where the popcorn ceiling was missing were peeling. Resident #12 said the remainder of the popcorn ceiling should be chipped away and repaired. Resident #12 said the ceiling had been in that condition for about three months and did not know why the facility had not yet made the repairs. Resident #12 said the ceiling situation was an issue. Resident #12 said the peeling ceiling was a hazard and someone could get hurt. During an observation with interview on 4/9/24 at 1:22 P.M., the surveyor observed several sizeable patches of the popcorn ceiling missing in Resident #8's room in the area above or adjacent to the Resident's bed. Resident #8 said the popcorn ceiling had been in disrepair since at least 10/31/23. Resident #8 said the remaining area adjacent to where the popcorn ceiling was missing was separating from the ceiling and the Resident wondered if any specks were going to fall down, particularly into their food. During an observation with interview on 4/9/24 at 3:30 P.M., the surveyor observed several sizeable areas of the popcorn ceiling missing in the room where Resident #51 and Resident #56 resided. Resident #51 and Resident #56 both said the missing patches of popcorn ceiling were unsightly, making the facility look old, and they would like the ceiling to be repaired. During an observation with interview on 4/7/24 at 9:30 A.M., the surveyor observed several areas of the popcorn ceiling missing in Resident #94's room. Resident #94 said they can see the areas of missing popcorn ceiling whenever they are in their room, and they would like the ceiling to be fixed. During an observation with interview on 4/7/24 at 3:00 P.M., the surveyor observed several sizeable patches of popcorn ceiling missing in Resident #88's room. Resident #88 said they did not like the missing patches of ceiling and would like for the facility to repair those areas. During an interview on 4/9/24 at 10:24 A.M., the Maintenance Director said he was aware of the loosening of the popcorn ceiling. The Maintenance Director said the maintenance department had chipped away as much of the loose popcorn ceiling as they could and were working on getting a vendor to make the repairs. The Maintenance Director said the Administrator was also aware of the ceiling situation on the unit. During an interview on 4/10/24 at 12:47 P.M., the Administrator said he was aware of the needed repair of the popcorn ceilings in the unit and was working to get the ceiling repaired.

Based on observations, interviews, record review, and policy review, the facility failed to ensure adequate supervision and develop and implement fall interventions for one Resident (#4), out of a sample of 19 residents, resulting in a fall with major injury. Findings include: Review of the facility's policy titled Falls Management, last revised August 2018, included but was not limited to: -The facility will utilize all resident/patient related information made available upon admission and ongoing to determine resident/patient at-risk for fall status. The information includes but is not limited to the following: -Hospital admission -Discharge summary -Nursing Admission Evaluation -Fall Risk Evaluation -A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly Minimum Data Set (MDS) cycle when a significant change in status occurs, annually and following a fall. -The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score -A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall without injury Resident #4 was admitted to the facility with diagnoses including dementia and a history of falls. Review of the Minimum Data Set assessment, dated 9/1/22, indicated Resident #4 had severe cognitive impairment as evidenced by a score of 00 on the Brief Interview for Mental Status assessment, requires extensive assistance from staff for all activities of daily living (ADL) and had one fall with major injury since the prior assessment. Review of Resident #4's comprehensive care plans included but was not limited to: -Focus: Resident is at risk for fall related injury due to fall prior to admit to facility resulting in a right femur fracture, impaired mobility, weakness, osteopathic and depression (10/6/21) -Interventions: -educate/remind resident to request assistance prior to ambulation, footwear; -remind resident and reinforce safety awareness, lock brakes on bed, chair, etc. before transferring, when rising from a lying position, sit on side of bed for a few minutes before transferring/standing (10/6/21) -Goal: Resident will not sustain a fall related injury by utilizing fall precautions through next review date of 12/1/22. Review of the medical record indicated Resident #4 had an unwitnessed fall in his/her room on 3/6/22 at 11:50 P.M. Review of a 3/7/22 Nursing Progress Note indicated the Resident was found on the floor at the bedside. The Resident was unable to say what happened due to his/her cognitive status. The Resident was given a pudding and 8 ounces of milk. The care plan for falls was updated with the following intervention: -Offer snack at bedtime (3/7/22) Review of Nursing Progress Notes included, but was not limited to: -5/1/22: Patient restless at times getting up out of bed and wandering. Redirected as need as patient has no safety awareness; patient is a high risk for fall. -5/9/22: Resident getting up during the night, appears to be sleep walking, unsafe, hard to get to follow simple directions. -5/10/22: Resident restless and getting out of bed multiple times without asking for help. -5/12/22: Resident up in the middle of the night trying to get into roommate's bed. Appeared to be sleep walking. -5/13/22: Resident up during the night, pulled off brief and johnny; found standing next to his/her bed. -5/30/22: Resident out of bed at beginning of 11:00 P.M. to 7:00 A.M. shift. Continually standing up out of wheelchair. Resident would not stay in bed. -6/16/22: Resident was awake most of 11:00 P.M. to 7:00 A.M. shift strolling the hallway going into every resident room during the night; very hard to redirect. On 6/28/22, the following intervention was added to the care plan for falls: -Invite, encourage, remind, escort to activity program consistent with resident's interests to enhance physical strengthening needs (6/28/22) No new effective interventions were developed to address the Resident's lack of safety awareness and repeated behaviors of getting up at night. Review of an 8/8/22 Progress Note indicated a new order written by the Nurse Practitioner (NP) to increase Trazodone (antidepressant) from 25 milligrams (mg) to 50 mg at bedtime. Further review of Nursing Progress Notes indicated: -8/12/22: The Resident has been awake and out of his/her room numerous times so far this shift. Started a new dose of Trazodone at bedtime with poor results. Resident wakes up and walks out of his/her room. CNA and nurse assist resident when walking, however he/she continually gets up out of chair and bed. Interventions include multiple cups of fluid, snacks, redirection with poor outcome. -8/13/22: On 8/12/22 at approximately 11:45 P.M., Resident #4 had an unwitnessed fall and was found on the floor by the nurse while doing bed checks. The Nurse observed the Resident sitting on the floor in between the roommate's dresser and the bed with his/her back to the dresser. The Resident had a large contusion in the middle of his/her forehead and a small laceration on the bridge of his/her nose. 911 was called and the Resident was sent to emergency room for evaluation. Review of a 8/14/22 Hospital Discharge Summary indicated Resident #4 was evaluated after having an unwitnessed fall at the facility and found to have a 1.0 X 2.9 centimeter hematoma to the forehead and a minimally displaced left nasal bone fracture. Review of Resident #4's Physician's Orders, dated 8/15/22, indicated -to initiate continuous 1:1 monitoring until assessed and discontinued by the Physician. Review of the medical record indicated, on 9/6/22, Resident #4 was admitted to the hospital for treatment of a urinary tract infection and was readmitted on [DATE]. Review of the medical record indicated that all previous Physician's orders were continued except for the order for 1:1 monitoring. There was no documentation in the medical record to indicate the Physician assessed and discontinued the order for 1:1 monitoring. Review of the medical record indicated on 9/26/22 at 6:10 A.M., Resident #4 had an unwitnessed fall in his/her room and was found by staff face down on the floor with his/her head underneath a bureau. The Resident was sent to the hospital for evaluation. Review of the 9/26/22 Hospital documentation indicated Resident #4 was evaluated for an unwitnessed fall with head strike and was found to have impact injury in the forehead (bruising). During an interview on 9/30/22 at 9:35 A.M., Physician #1 said he did not discontinue the order for 1:1 monitoring and due to the Resident #4's high risk of falls, the 1:1 monitoring should have been resumed upon his/her return from the hospital to prevent further falls.

Based on interviews and record review, the facility failed to monitor the nutritional status of two Residents (#43 and #42), out of a total sample of 19 residents. Specifically, the facility 1. Failed to monitor the weight loss of Resident #43, resulting in a significant weight loss; and 2. Failed to implement nutritional interventions for Resident #42. Findings include: 1. Review of the facility's policy titled Weights, dated August 2015, indicated the following residents would be weighed weekly for four weeks: -residents with unanticipated weight loss of more than 5% in one month -all residents with significant weight loss are reviewed by the interdisciplinary team and interventions implemented as appropriate and are monitored weekly -a weight loss/gain of 5 pounds or more on a resident weighing over 100 pounds, requires a reweigh for verification Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease. Review of the care plans indicated Resident #43 was at risk for a nutritional decline related to Parkinson's disease with a goal, revised on 5/23/22, to have the weight stable at 165 pounds (lbs.). Review of the medical record for Resident #43 indicated the following nutritional history: -On 02/04/22, the Resident weighed 176.4 lbs. On 03/04/22, the Resident weighed 166.8 lbs. which was a -5.44 % loss in four weeks. -On 02/10/22, the Resident weighed 176.4 lbs. On 05/05/22, the Resident weighed 162.0 lbs. which was a -8.16 % loss in three months. -Nursing progress note, dated 5/25/22, indicated a recommendation from the Registered Dietitian (RD) for 8 ounces of Ensure every day - RD progress note 6/1/22 indicated Resident continued with weight loss, supplements were added, weekly weights requested, and the Resident remained at nutritional risk During an interview on 9/27/22 at 1:40 P.M., Unit Manager #2 said all weights for residents were located in the electronic medical record and there were no paper records of resident weights for the unit. Review of the electronic medical record for Resident #43 indicated the Resident was weighed weekly in the month of June 2022 and weighed monthly following that. The following weights were in the medical record as of 9/30/22: -7/5/22: 163.4 lbs. -8/5/22: 160.8 lbs. -9/2/22: 155.4 lbs. During an interview on 10/4/22 at 10:13 A.M., the RD said Resident #43 should have been weighed weekly since May 2022, so the RD was able to monitor the Resident's weight closely and add interventions before the weight loss became significant. She said Resident #43 previously had a significant weight loss and had stabilized in the month of June 2022. She reviewed the electronic medical record at this time and said she had not been aware of the weight of 155.4 lbs. on 9/2/22 (one month prior). She said the Resident should have been re-weighed and the RD should have been notified by the Unit Manager. During an interview on 10/4/22 at 11:52 A.M., the Director of Nurses said the facility was having trouble getting weekly weights on residents. She said Resident #43 should have been reweighed following a change in weight on 9/2/22. On 10/5/22 Resident #43 weighed 149.0 lbs. On 7/5/22, the Resident weighed 163.4 lbs. which was a -9.66 % loss in three months. On 4/5/22, the Resident weighed 165.8 lbs. which was a -11.28 % loss in six months. During an interview on 10/5/22 at 9:00 A.M., the RD said Resident #43 was now 149.0 lbs. and had a significant weight loss. 28450 2. Resident #42 was admitted to the facility in February 2022 with medical diagnoses including dysphagia (difficulty swallowing), gastro-esophageal reflux disease without esophagitis, and type 2 diabetes mellitus. Review of the dietary Nutritional Care Recommendation, dated 7/18/22, indicated to discontinue Glucerna and administer 4 ounces of Ensure Plus three times a day. This order requested medical review due to a weight loss of 37 lbs. Review of the Physician's Progress Notes, dated July 2022, indicated the Resident was evaluated for weight loss. The progress notes indicated Resident was referred to be seen by nursing staff on 7/20/22 for evaluation. The progress note indicated, a new order to stop Glucerna (current) and start Ensure Plus 4 ounces three times a day. Review of the Minimum Data Set (MDS) assessment, dated 8/15/22, indicated Resident #42 is moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS indicated the Resident eats independently and requires set up only. The MDS indicated the Resident's height is 60 inches and weighed 166 pounds which triggered a weight loss which was not prescribed. The weight loss was 5% or more in the last month and 10% or more in the last six months. The threshold for significant unplanned or undesired weight loss is based on the following criteria: a. 1 month - 5% weight loss is significant, greater than 5% is severe b. 3 months - 7.5% weight loss is significant, greater than 7.5% is severe c. 6 months - 10% weight loss is significant, greater than 10% is severe Review of the Physician's Orders, dated September 2022, failed to include a physician's order to discontinue Glucerna and administer Ensure Plus 4 ounces three times daily, weekly weights for four weeks, order dated 7/20/22 for weight loss monitoring. Facility failed to obtain the weekly weight as ordered. Review of the clinical record indicated Resident #42's weekly weight as ordered was not obtained as follows: 7/28/22; 8/11/22; and 8/13/22 out of the four weeks. Resident weight was obtained on 8/4/22 at 2:31 P.M., the weight value equals 166.4 lbs. on a standing scale indicating 17.2 pounds less in comparison to the last weight obtained of 183.6 lbs. obtained on 5/5/22. Further review of the clinical record indicated the facility staff did not administer the new supplement nor obtain the weekly weight for 4 weeks as ordered. In addition, the progress note did not indicate he/she refused or was unavailable to obtain weekly weights. During an interview on 10/04/22 at 01:16 P.M., Nurse #4 said Resident #42 is receiving Glucerna 237 milliliters at 2:00 P.M. daily. During an interview on 10/04/22 at 01:40 P.M., Unit Manager #1 said the Medication Administration Record indicated to administer Glucerna 237 milliliters at 2:00 P.M. daily to Resident #42. She said she administered Glucerna to the Resident when there are no nurses, and she is administering medications. The Unit Manager said the order for the weekly weight and the supplement were not documented in the record.

Based on interviews and record reviews, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the needs of two Residents (#43 and #40), in a total sample of 19 residents. Specifically, the facility failed 1. For Resident #43, to ensure weekly weights were obtained to monitor weight loss, resulting in significant weight loss; and 2. For Resident #40, to ensure wound care was provided as ordered. Findings include: 1. Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease. Review of the care plans indicated Resident #43 was at risk for a nutritional decline related to Parkinson's disease with a goal, revised on 5/23/22, to have the weight stable at 165 pounds. Review of the medical record for Resident #43 indicated the following nutritional history: -On 02/04/22, the Resident weighed 176.4 pounds (lbs.). On 03/04/22, the Resident weighed 166.8 lbs. which was a -5.44 % loss in four weeks. -On 02/10/22, the Resident weighed 176.4 lbs. On 05/05/22, the Resident weighed 162.0 pounds which was a -8.16 % loss in three months. - Registered Dietitian (RD)'s Progress Note, dated 6/1/22, indicated the Resident continued with weight loss, supplements were added, weekly weights were requested, and the Resident remained at nutritional risk. Review of the electronic medical record for Resident #43 indicated the Resident was weighed weekly in the month of June 2022 and weighed monthly following that. The following weights were in the medical record as of 9/30/22: -7/5/22: 163.4 lbs. -8/5/22: 160.8 lbs. -9/2/22: 155.4 lbs. During an interview on 10/4/22 at 10:13 A.M. the RD said Resident #43 should have been weighed weekly since May 2022, so the RD would be able to monitor his/her weight closely and add interventions before the weight loss became significant. She said the weekly weights were not obtained due to staffing. During an interview on 10/4/22 at 11:52 A.M., the Director of Nurses said the facility was having trouble getting weekly weights on residents due to staffing and Resident #43 should have been reweighed following a change in weight on 9/2/22. During an interview on 10/5/22 at 9:00 A.M., the RD said Resident #43 was now 149.0 lbs and had a significant weight loss. 2. Resident #40 was admitted to the facility in February 2022 with diabetes and a wound to the right heel and had developed multiple diabetic wounds. Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following treatment: -8/1/22 Right heel: Cleanse with normal saline wash, pat dry, then apply nickel-thick Santyl ointment to wound bed, cover with ABD pad, wrap with Kerlix, change daily. The September 2022 TAR indicated the right heel treatment was not completed on 9/2, 9/5, 9/7, 9/9, 9/13, 9/14, 9/15, 9/16, 9/17, 9/19, 9/22, and 9/23/22 (12 out of 27 days). Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following wound treatments: -7/30/22 Right shin: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily -7/30/22 Right calf: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily -6/29/22 Right lower leg: apply ace bandage daily with dressing change The September 2022 TAR indicated the right shin, calf and lower leg treatments were not completed on 9/2, 9/6, 9/7, 9/9, 9/13, 9/14, 9/15, 9/16, 9/17, 9/18, 9/19, 9/22, and 9/23/22 (13 out of 27 days) During an interview on 9/30/22 at 2:00 P.M., Unit Manager #2 said the nurses may not have had time to complete the treatments for Resident #40. She said the nurses had to prioritize how they cared for the residents on the unit, and usually there was only one nurse on the [NAME] Unit. She said there were times when she was the only nurse on the unit and responsible for being the Unit Manager, administering medications, completing treatments, doing assessments, monitoring meals, and things were getting missed. During an interview on 9/29/22 at 3:55 P.M. Nurse #3 said she was the only nurse on the [NAME] Unit today with 35 residents. She said usually the nurse will provide medications to all of the residents on the unit with the hope that the Unit Manager could do the treatments. She said any issues the unit had could be resolved with additional staffing. During an interview on 10/4/22 at 11:00 A.M. Nurse #7 said she was the only nurse on the [NAME] Unit (the Unit Manager was off) with two Certified Nursing Assistants (CNAs) and the Unit Secretary was providing one to one (1:1) services to a resident. She said as the only nurse, it was a lot of work to provide care to 35 residents. Review of the Facility assessment dated as revised on 9/19/22 indicated the average daily census on the [NAME] Unit was 35 residents. Review of the facility nursing schedule from 9/11 through 10/5/22 indicated the following days when only one nurse was working on the [NAME] Unit on the 7:00 A.M. to 3:00 P.M. shift: 9/11, 9/14, 9/16, 9/17, 9/18, 9/19, 9/23, 9/25, 9/29, 10/1, 10/2, 10/3, 10/4, 10/5/22.

Based on observation, record review, and staff interview, the facility failed to ensure that for 1 Resident (#13), of a total sample of 24, that the Resident's pain was adequately managed, and that narcotic [MEDICATION NAME] were available and administered to the Resident in accordance with the physician's orders [REDACTED].>Findings included: Resident #13 was admitted with [DIAGNOSES REDACTED]. According to the most recent MDS (Minimum Data Set), signed as being completed 2/25/16, the Resident had no cognitive deficits and scored 15/15 on the most recent BIMS (Brief Interview for Mental Status). The MDS indicated that the Resident was totally dependent for all ADL's (Activities of Daily Living) and experienced frequent pain that affected his/her daily function. The MDS also indicated that the Resident received PRN (as needed) pain medication, that according to the record was administered for bilateral lower extremity spasms and complaints of generalized pain, associated with the Resident's longstanding [MEDICAL CONDITION]. Record review on 3/15/16, revealed that the Resident had an order to receive the narcotic [MEDICATION NAME], 4 mg (milligrams) every 4 hours PRN, to treat the Resident's chronic pain. The record indicated the Resident's generalized pain and lower extremity pain/spasms, was caused by a 19-year history of [MEDICAL CONDITION]. Review of the MAR indicated [REDACTED]. The Resident was interviewed in his/her room on the Nye Unit on 3/15/16 at 11:50 A.M. The Resident was observed lying in bed with a concerned/disturbed look on his/her face. He/She told Surveyor #1 with a tearful look on his/her face that he/she had a bad night the previous night, because he/she was in a lot of pain and pain medication was not available when he/she requested it. The Resident said he/she had received a dose of [MEDICATION NAME] at around 12:00 P.M. on 3/14/16 for generalized pain. When the effects of the 12:00 P.M. dose of [MEDICATION NAME] wore off, and he/she began experiencing significant pain at around 5:00 P.M., he/she asked the nurse for another dose of [MEDICATION NAME]. The Resident said that he/she was told by the nurse on duty that the pharmacy had not delivered the [MEDICATION NAME] as of yet and there was none available. The Resident said that he/she continued to experience significant pain throughout the 3:00 P.M. to 11:00 P.M. shift. The Resident said that he/she did not receive a dose of [MEDICATION NAME] until 12:30 A.M. The Resident told the Surveyor that this was the second time since admission in November 2015 that the pain medication was not available when he/she requested it. The DON (Director of Nursing) was interviewed on 3/15/16 at 12:30 P.M. regarding the Resident's [MEDICATION NAME] not being available the evening of 3/14/16. The DON said she investigated the Resident's concern over not receiving adequate pain relief the evening of 3/14/16 due to the [MEDICATION NAME] not being available from the pharmacy. The DON said that the facility ran out of [MEDICATION NAME] on the day shift after the 12:00 P.M. dose was administered. According to the DON, the day shift nurse sent a prescription to the pharmacy at around 1:30 P.M. The DON said that the [MEDICATION NAME] was not available on the 3:00 P.M. to 11:00 P.M. shift until 10:30 P.M. The DON said that the [MEDICATION NAME] arrived at the facility at 10:30 P.M., however it was not administered to the Resident until 12:30 A.M. The DON said she understood that the Resident's pain was not adequately managed due to the [MEDICATION NAME] not being available and that administration was delayed when the medication did arrive. She could not explain the exact cause of the delay, but acknowledged that prescriptions should be sent well in advance of the last dose being available. Additionally, the DON said she could not explain why the [MEDICATION NAME] was not administered when it arrived from the pharmacy at 10:30 P.M. She said that she understood the additional concern by Surveyor #1, that the Resident's physician was not notified by the nurse, that the Resident was in pain, and that the facility had run out of the Resident's [MEDICATION NAME]. The DON acknowledged that the Resident's physician should have been notified that the [MEDICATION NAME] was not available so consideration could be made to consider ordering a one time dose of a pain medication until the [MEDICATION NAME] was became available. The DON acknowledged that nurses need to ensure that prescriptions are obtained and sent to the pharmacy in a timely manner, so that residents do not experience delays in receiving adequate pain management. She also acknowledged the importance of prompt notification of the physician when a medication is not available. The DON also said that the facility was adding [MEDICATION NAME] to their emergency narcotic kit so that it will be available in the event of future emergency situations. She said that nurses would be educated on timely submission of prescriptions so that delays in obtaining needed medications are avoided, and resident's medical conditions are not compromised by not having medications available when needed.

Based on observation, record review, and staff interview, the Facility failed to provide pharmacy services to meet the needs of 1 (Resident #13) Resident, of a total sample of 24 Residents, to ensure that narcotic analgesics were available and administered to manage the Resident's chronic pain. Findings include: Resident #13 was admitted with [DIAGNOSES REDACTED]. Record review on 3/15/16, revealed that the Resident had an order to receive the narcotic analgesic Dilaudid, 4 mg (milligrams) every 4 hours PRN, to treat the Resident's chronic pain. The record indicated the Resident's generalized pain and lower extremity pain/spasms, was caused by a 19-year history of multiple sclerosis. Review of the MAR indicated [REDACTED]. The Resident was interviewed in his/her room on the Nye Unit on 3/15/16 at 11:50 A.M. The Resident was observed lying in bed with a concerned/disturbed look on his/her face. He/She told Surveyor #1 with a tearful look on his/her face that he/she had a bad night the previous night, because he/she was in a lot of pain and pain medication was not available when he/she requested it. The Resident said he/she had received a dose of Dilaudid at around 12:00 P.M. on 3/14/16 for generalized pain. When the effects of the Dilaudid wore off, and he/she began experiencing significant pain again at around 5:00 P.M., he/she asked the nurse for another dose of Dilaudid. The Resident said that he/she was told by the nurse on duty that the pharmacy had not delivered the Dilaudid as of yet and there was none available. The Resident said that he/she continued to experience significant pain throughout the 3:00 P.M. to 11:00 P.M. shift. The Resident said that he/she did not receive a dose of Dilaudid until 12:30 A.M. The Resident told the Surveyor that this was the second time since admission in November 2015 that the Dilaudid was not available when he/she was experiencing pain and he/she requested it. The DON (Director of Nursing) was interviewed on 3/15/16 at 12:30 P.M. regarding the Resident's Dilaudid not being available the evening of 3/14/16. The DON said she investigated the Resident's concern over not receiving adequate pain relief the evening of 3/14/16 due to the Dilaudid not being available from the pharmacy. The DON said that the facility ran out of Dilaudid on the day shift after the 12:00 P.M. dose was administered. According to the DON, the day shift nurse sent a prescription to the pharmacy at around 1:30 P.M. (However, there was no documentation to indicate that the facility had asked the pharmacy to fill the prescription STAT/immediately). The DON said that the Dilaudid was not available on the 3:00 P.M. to 11:00 P.M. shift until 10:30 P.M. The DON said that the Dilaudid arrived at the facility at 10:30 P.M., however it was not administered to the Resident until 12:30 A.M. The DON said she understood that the Resident's pain was not adequately managed due to the Dilaudid not being available and that administration was delayed when the medication did arrive. She could not explain the exact cause of the delay, but acknowledged that prescriptions should be sent well in advance of the last dose being available. Additionally, the DON said she could not explain why the Dilaudid was not administered when it arrived from the pharmacy at 10:30 P.M. The DON also said that the facility was adding Dilaudid to their emergency narcotic kit so that it will be available in the event of future emergency situations. The DON said that nurses would be educated on the timely submission of prescriptions to the pharmacy so that delays in managing resident's pain and other medical conditions will be minimized.

Based on record review and staff interviews the facility failed to implement, monitor and revise appropriate care plan interventions to prevent a significant fall for 1 Resident (Resident #22), who had a recent decline in condition, from a total sample of 24 residents. Findings include: 1. Resident #22 was a closed record review and the Resident expired on [DATE] (4 days following the Resident's fall). Resident #22 was admitted to the facility in ,[DATE] with the following pertinent Diagnoses: [REDACTED]. A review of the initial Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident needed extensive assistance from two staff persons for activities of daily living, had an impaired balance and was a high risk for falls. The Quarterly MDS review of [DATE] (3 months prior to fall)indicated that the Resident required extensive assistance with 2 person physical assist for transfers and extensive assistance with one person physical assist for "locomotion off unit". The Resident utilized a wheelchair. On [DATE], review of the fall Incident/Accident Report and the facility's internal investigation submitted on [DATE] (Department of Public Health) indicated the following narrative summary: On [DATE] at approximately 7:25 P.M. a CNA was wheeling the Resident to the shower room located approximately 10 feet from the nurse's station (where the Resident usually sits per his/her routine).The CNA stated that the Resident was leaning forward in the wheelchair so the CNA put his left hand on the Resident's left shoulder to support him/her while transporting, however the CNA removed his hand from the Resident's shoulder in order to navigate the wheelchair around the corner. As the CNA approached the doorway to the shower room the Resident leaned forward, suddenly dropped his/her feet and fell forward out of the chair striking his/her head on the floor of the shower room. The CNA did not stop and reposition the Resident for safety or ask for assistance from other staff before releasing his hand from the Resident's shoulder due to slouching forward. After the fall, the CNA stayed with the Resident and called for help. Two staff nurses responded and applied pressure to the lacerations and took neurological vital signs. The Resident remained responsive and 911 was notified. The Resident was transported to the hospital by EMS while maintaining cervical immobilization. Review of the hospital emergency room report dated [DATE] indicated that the Resident had suffered an acute cervical fracture at C1-C3 and was not likely to survive more than the next 72 hours. The Resident expired on [DATE]. On [DATE], review of the closed medical record including the Fall Risk Assessment indicated that the Resident was at a high risk for falls (and had previous fall in ,[DATE]). Review of the Nursing Summary, dated [DATE] (3 weeks prior to the fall), the mobility assessment indicated the following: Section 4.) B "wheelchair with assist and Dysfunction: unsteady gait, rigidity/[DIAGNOSES REDACTED], tremors/uncoordinated movements, decreased range of motion, decreased motivation, poor conditioning and left/right hemiparesis. Review of the Resident's Care Plan for falls and activities of daily living (ADLs) with a revision in ,[DATE] and target date of [DATE], indicated the following focus areas: previous history of falls, impaired sense of balance and unsteady gait, generalized weakness, cognitive impairment, decreased endurance/strength, history of cerebral vascular accident and Parkinson's disease-decreased safety awareness. The care plan interventions for falls and ADLs indicated the following: gripper socks in bed, call light in reach, instruct to ask assistance prior to attempting to transfer or ambulate as needed, physical assist of 1 with wheelchair mobility and "assist with transport while Resident is seated in a wheelchair". On [DATE] the Nurse Practitioner requested a physical therapy evaluation due to staff concerns regarding the Resident's recent decline in function and in particular, a recent change in posture/trunk control (slouching forward) while in the wheelchair. Review of the Physical Therapist (PT) witness statement dated [DATE] indicated that the nursing staff and the Resident's Certified Nursing Assistant (CNA) reported to her that the Resident had a recent overall decline in strength, endurance/balance (including trunk control) and was now leaning forward in his/her wheelchair. Review of the CNA witness statement dated [DATE] indicated that he had requested a seatbelt for the Resident from the PT department, which was never evaluated and the CNA reported to nursing staff and PT that the new wheelchair was too small and not deep enough for the Resident. The CNA said that the Resident had lifted his/her feet up "with knees bent while transporting". (The Resident did not have leg/foot rests on the wheelchair at the time of the fall because he/she had been able to self-propel in wheelchair). Review of the Physical Therapy Evaluation and Plan of Treatment report dated [DATE] (5 days prior to the fall) indicated that the Resident was trialed in a new narrower wheelchair for appropriate seating and positioning to prevent slouching and leaning to the right (target date of [DATE]). There was no further follow-up P.T. evaluations regarding the effectiveness of the new wheelchair or documented observations of the Resident's trunk control/posture while in the newly trialed wheelchair. There was no documentation of an inter-disciplinary discussion with nursing staff about the effectiveness of the new wheelchair during the wheelchair trial period (just prior to the fall), despite staff nurse witness statements (dated [DATE], [DATE] and [DATE]) that indicate that the newly trialed wheelchair was not the right fit (too small and seat not deep enough) for the Resident's safety. Review of a "Summary of Skill" report dated [DATE] and [DATE] (3 days following initial PT evaluation) indicated that Resident was ''fitted and trialed with smaller 20 inch wheelchair (had been using a larger w/c previously) and nursing notified of wheelchair update and signed by the PT Aide". They do not indicate a re-assessment of the new wheelchair in terms of posture correction or lower extremity support, (in light of the Resident's recent decline in condition) during the wheelchair trial period. On [DATE] at 1:00 P.M. the Surveyor (with 2 other Surveyors present) interviewed the Physical Therapist (PT). The PT said that the initial referral was made following nursing staff concerns that the Resident had been leaning forward a lot in the wheelchair. She also said that the Resident could propel him/herself in the wheelchair and that there were no foot rests on the wheelchair. She said that her intervention was to switch out the larger 22 inch w/c for a smaller 20 inch w/c so that the Resident would sit more upright. The Surveyor asked what observations the PT had made during the wheelchair trial period and what was communicated with the nursing staff during the trial period. The PT said that she did not communicate with the staff during the trial period of the new wheelchair and that she and the PT aide felt it was the right fit for the Resident, despite the staff observations (in witness statements) of continued poor trunk posture. She also said that the PT Aide was the person who re-assessed the Resident during the trial period, but did not document the effectiveness of the smaller wheelchair and did not speak with direct care staff about the effectiveness of the new and smaller wheelchair. On [DATE] at 2:10 P.M., the survey team interviewed the Administrator and interim DON in the conference room. The Administrator said that following the incident on [DATE], a corporate review was conducted as part of the facility's Performance Improvement. The Administrator offered to provide the report to the survey team, which was not included in the facility's internal investigation folder. On [DATE] at 6:37 P.M., the Surveyor interviewed the Nursing Supervisor, over the telephone. The Supervisor responded to the Resident on the evening of the fall incident. She said that she felt that the seat cushion was too small for the w/c and that the seat should have been larger to accommodate the Resident who had become more fatigued, especially in the evenings. She said that the CNA had showered the Resident many times and the only thing different on this evening was the new wheelchair. She said that she did not have a discussion with the PT following the change in the Resident's wheelchair, during the wheelchair trial period from [DATE]-[DATE] ([DATE] is date of the fall). On [DATE] at 6:57 P.M., the Surveyor interviewed the staff nurse who responded to the Resident on the evening of the [DATE] incident. She said that she didn't feel that the cushion was right and that the cushion hung over the chair. She could not remember discussing her observations with the PT about the Resident's new wheelchair. She also said that the facility had implemented a new policy to include foot rests (in a kangaroo pouch attached to the wheelchair) and available to all wheelchairs for transporting residents. After Surveyor inquiry, she said that the CNA no longer worked at the facility and was let go shortly after the incident. Review of the corporate report (dated [DATE]) indicated that the facility implemented new procedures for staff education to include the following: resident positioning needs, audit of all wheelchairs seating (completed on [DATE]), leg rests during transports and proper storage of the leg rests. Policy for wheelchair transport, use of leg rests and safe patient handling was reviewed and revised which now requires the use of leg rests during any staff assisted wheelchair transport activity. Beginning [DATE], all new CNAs will have education at orientation utilizing case scenarios to facilitate critical thinking.

Based on record review and interviews, for one of three sampled residents (Resident #1), who had poor safety awareness, the Facility failed to ensure that Resident #1 received continual supervision during meals in a 1:8 setting (staff to resident ratio), per plan of care, to prevent injury. On 3/6/12 at about 5:30 P.M., Resident #1 rang the call light, as Nurse #1 entered Resident #1's room, Resident #1 stated Resident #1 was burned. Resident #1 spilled hot chocolate onto self causing redness to the left breast, left elbow, and left hand. Later, on the 11:00 P.M. - 7:00 A.M. shift, a nurse observed two blisters on Resident #1's left breast. Findings include: Resident #1's Admission record indicated that Resident #1 was admitted to the Facility in January, 2010, and medical [DIAGNOSES REDACTED]. Facility policy titled Meal Service: Resident in Room, indicated that in section 10, assistance with eating included providing supervision, limited assistance, extensive assistance, and/or total assistance as required by the resident's current level of self-performance in eating. The Alteration in Cognition plan of care, dated as initiated 11/24/11, indicated that Resident #1's short and long term memory was impaired, Resident #1 had poor decision making, and poor safety awareness, related to the medical [DIAGNOSES REDACTED]. The Assistance with the Activities of Daily Living (ADL) plan of care, dated as initiated 11/24/11, indicated that Resident #1 required assistance with ADL's because of the medical [DIAGNOSES REDACTED].#1 required supervised meals in a 1:8 setting (staff to resident ratio). The Annual Comprehensive Nutrition Assessment, dated 11/25/11, indicated Resident #1 took meals in a supervised feeding group with a 1:8 ratio. The Monthly Nursing Summary, dated 2/19/12, and completed by the licensed nurse, indicated that for eating Resident #1 required continual supervision/cues throughout the task in a feeding group 1:8 or less. The Monthly Nursing Summary indicated the functional or cognitive reason with supporting [DIAGNOSES REDACTED]. The ADL Flow record, utilized by the certified nurse aides (CNAS) for documentation of a resident's level of function, dated 2/1/12 through 2/29/12, indicated that Resident #1 required continual supervision/cueing in a 1:8 supervised group for breakfast, lunch, and supper, during the month of February, 2012. On 4/3/12 at 8:12 A.M., the Surveyor interviewed Nurse #1. Nurse #1 said that on 3/6/12, she worked on the 3:00 P.M. to 11:00 P.M. shift. Nurse #1 said as she administered medications across the hall from Resident #1's room, Resident #1's call light went on. Nurse #1 said she heard Resident #1 stating "I'm burned, I'm burned". Nurse #1 said she entered Resident #1's room and observed that Resident #1 spilt a hot beverage onto self. Nurse #1 said she immediately pulled off Resident #1's clothing protector (bib) and johnny, grabbed a towel which was on Resident #1's bed, soaked the towel in cold water, and placed the wet towel onto Resident #1's reddened areas to Resident #1's left breast, upper left quadrant, and left elbow. Nurse #1 said she instructed a CNA to get Nurse Manager #1 and the Nurse Practitioner, who were at the nurses' desk. Nurse #1 said the Nurse Practitioner was able to assess Resident #1. On 4/3/12 at 7:35 A.M., the Surveyor interviewed CNA #1. CNA #1 said that on 3/6/12, she worked on the 3:00 P.M. to 11:00 P.M. shift. CNA #1 said she brought Resident #1's supper tray into Resident #1's room, Resident #1 was in bed, and she boosted Resident #1 in the bed. CNA #1 said she set up the supper tray which included mixing the cocoa mix into the hot water which was poured at the food cart prior to bringing in Resident #1's supper tray. CNA #1 said she added some milk to the hot cocoa. CNA #1 said Resident #1 usually ate the supper meal in Resident #1's room, and usually drank hot cocoa with the supper meal. CNA #1 said once Resident #1 was set up with the supper tray, she left the room. CNA #1 said for those residents who ate in their rooms, a CNA walked up and down the hallway during the meal checking residents during the meal. CNA #1 said she went back to Resident #1 after about 5 minutes, and Nurse #1 stated Resident #1 spilled hot cocoa. CNA #1 said she observed Resident #1's left breast, and left inner arm, near the elbow, which was red. CNA #1 said Resident #1 complained of discomfort to the areas. CNA #1 said she knew the definition of continual supervision in a 1:8 group meant constant supervision and one was not to be left alone. The nurse practitioner's progress note, dated 3/6/12, indicated the nurse practitioner was called to see Resident #1 and evaluate a burn to Resident #1's left thorax and left elbow, as Resident #1 had just spilled hot coffee/cocoa on self. The nurse practitioner's progress note indicated on examination, Resident #1 presented with a light pink patch on the left thorax and breast area, and a second pink patch on Resident #1's left elbow. The nurse practitioner's progress note indicated that because of Resident #1's allergy to sulfa, Silvadene ointment could not be used in treatment, and the plan was to implement A and D ointment with intermittent cold compresses. A review of the Facility's investigation report, occurrence dated 3/6/12, indicated that on 3/6/12 into 3/7/12, on the 11:00 P.M. - 7:00 A.M. shift, the nurse noted the development of two blisters on Resident #1's left breast, one measuring 0.5 centimeter (cm) by 0.5 cm, and the second blister measuring 3 cm by 1.5 cm. The Facility's investigation report indicated that on 3/8/12, one blister area on the left breast opened, the nurse practitioner was notified,and treatment orders were implemented. On 3/29/12 at 2:35 P.M., the Surveyor interviewed CNA #3 and CNA #4. CNA #3 and CNA #4 said they were aware that continual supervision meant a resident was to eat in a supervised setting. On 3/29/12 at 10:20 A.M., the Surveyor observed Resident #1's left breast area with Nurse Manager #1. Nurse Manager #1 removed a bandage from Resident #1's left breast. The Surveyor observed a small area on the underside of Resident #1's left breast measuring approximately 1 cm by 0.5 cm, which was white/yellow in color.