Every finding on record at Countryside Health Care of Milford

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:1. Perform hand hygiene as indicated for two of four Residents (#66 and #88) observed during medication administration; and2. For Resident #83, ensure his/her oxygen (O2) concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen through a nasal cannula) was maintained in a sanitary manner. Findings include:1. Review of Centers for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, indicated but was not limited to:-Healthcare workers should clean their hands: immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. Review of the facility's policy titled Hand Hygiene, dated as revised 8/2025, indicated but was not limited to:-It is the policy of the facility that employees will perform hand hygiene in the following instances regardless of whether gloves have been worn: after contact with blood/body fluids or excretions/ mucous membranes, after gloves are removed Review of the facility's policy titled Enhanced Barrier Precautions, dated as revised 5/2025, indicated but was not limited to:-Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO) in nursing homes. Enhanced barrier precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. Review of the CDC EBP sign indicated but was not limited to: -In addition to standard precautions Staff and Providers must: -Clean hands prior to entering and when exiting the room On 1/29/26 at 8:38 A.M., the surveyor observed Nurse #1 prepare Resident #66's morning medications. Resident #66 had a CDC EBP sign posted on the doorframe of his/her room. Nurse #1 entered Resident #66's room and administered his/her medication. Nurse #1 failed to perform hand hygiene prior to entering the Resident's room. On 1/29/26 at 8:45 A.M., the surveyor observed Nurse #1 prepare Resident #88's morning medication including Systane lubricating eye gel and Tresiba (a long-acting insulin injected into the subcutaneous tissue). Resident #88 had a CDC EBP sign posted on the doorframe of his/her room. Nurse #1 entered Resident #88's room and administered his/her medication. Nurse #1 failed to perform hand hygiene prior to entering the Resident's room. Nurse #1 applied gloves and administered Resident #88's eye drops then removed the gloves and applied a second pair of gloves prior to administering the Resident's insulin. Nurse #1 failed to perform hand hygiene after removing one pair of gloves and prior to applying a second pair of gloves. During an interview on 1/29/26 at 1:18 P.M., Nurse #1 said EBP were required for residents with indwelling catheters, chronic wounds and history of certain infections. Nurse #1 said both Residents #66 and #88 required EBP due to indwelling urinary catheters. Nurse #1 said hand hygiene should be performed before entering and upon exiting the Resident's room. Nurse #1 said she tries to perform hand hygiene before walking into every resident room. Nurse #1 said gloves should be changed when soiled and she was not sure if it was required between eye drops and insulin because it was the same resident. During an interview on 1/29/26 at 1:31 P.M., Unit Manager #3 said residents with indwelling catheters, wounds, and some infections require EBP. Unit Manager #3 said hand hygiene should be performed before entering resident rooms. Unit Manager #3 said a glove change and hand hygiene was not required when going from eye drops to insulin injection if it was the same resident and she was not sure about hand hygiene between. During an interview on 1/29/26 at 2:14 P.M., the Director of Nurses (DON) said hand hygiene should be performed prior to entering a room requiring EBP and after glove removal. During an interview on 1/30/26 at 1:08 P.M., the Infection Control Nurse said hand hygiene should be performed prior to entering a resident's room when the resident requires EBP. The Infection Control Nurse said hand hygiene should be performed between glove changes only if the gloves were soiled when they were changed. 2. Review of the Invacare Platinum Series XL, 5, and 10 Oxygen Concentrators Standard with SensO2 and Homefill Manufacturer's Guidelines indicated but was not limited to:-Cleaning the Cabinet Filter:1. Remove each filter and clean at least once a week depending on environmental conditions.2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly.3. Dry the filters thoroughly before reinstallation. Review of the facility's policy Respiratory Supplies, Changing and Disinfecting, dated 3/21/23, indicated but was not limited to:-Weekly: Filters: disposable filters, replace them when they are soiled and reusable filters rinse in warm water. Resident #83 was admitted to the facility in October 2023 with diagnoses which included chronic obstructive pulmonary disease (COPD, a progressive, irreversible lung disease that makes breathing difficult by damaging airways and air sacs and/or causing chronic inflammation/mucus). Review of Resident #83's Minimum Data Set (MDS) Assessment, dated 10/28/25, indicated he/she had a diagnosis of asthma, COPD, or chronic lung disease and utilized oxygen therapy. Review of Resident #83's Physician Order Report indicated but was not limited to:-Continuous Oxygen at all times, dated 3/24/25-Date and change O2/nebulizer/humidification setups every week on Sunday, dated 3/24/25 Further review of Resident #83's Physician Order Report failed to indicate an order to change or clean the oxygen concentrator cabinet filters. On the following dates and times of survey, the surveyor observed Resident #83 in bed wearing oxygen connected to an Invacare Platinum XL Homefill II Compatible with SensO2 Oxygen Concentrator. The surveyor observed the oxygen concentrator cabinet filter to be covered with a dry, thick gray debris:-1/27/26 at 9:39 A.M.,-1/28/26 at 3:13 P.M., and-1/29/26 at 9:04 A.M. During an interview on 1/29/26 at 1:19 P.M., Nurse #2 said the oxygen tubing was changed by the night shift weekly, but she was not sure who maintained or cleaned the filters. Nurse #2 observed the filter and Nurse #2 said the filter should have been cleaned and should not have thick, gray debris on it. During an interview on 1/29/26 at 1:30 P.M., Unit Manager #3 said oxygen concentrator filters should be cleaned weekly. Unit Manager #3 observed the concentrator filter and said it should not have debris on it. During an interview on 1/29/26 at 2:13 P.M., the DON said oxygen maintenance should occur weekly. The DON said residents with oxygen had orders in place to change the tubing weekly, but the orders did not include the care and maintenance of the filters. The DON said the oxygen concentrator filters should be clean without visible debris.

Based on interview and record review, the facility failed to complete a discharge assessment to ensure timely coding and transmitting of a Minimum Data Set (MDS) assessment for one Resident (#48), out of a total sample of 20 residents.Findings include:Review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, Version 3.0, indicated assessments must be completed no later than 14 calendar days after the assessment reference date (ARD) and transmitted and encoded within 7 days of assessment completion.Review of the medical record for Resident #48 indicated he/she was discharged from the facility on 10/30/25. A discharge MDS was initiated on 1/28/26, 59 days after discharge from the facility.During an interview on 1/28/26 at 11:02 A.M., the MDS Coordinator said the discharge assessment was not completed. She said she runs a report monthly to ensure assessments are completed and transmitted timely, but this one must have been missed.

Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional standards. Specifically, the facility failed to ensure staff properly labeled and stored all medications in three of four medication carts reviewed. Findings include: Review of the facility's policy titled Medication Storage, dated as revised ,d+[DATE], indicated but was not limited to the following: -Medications are stored safely, securely and properly -Medications are kept in the packaging in which they were dispensed by the pharmacy Review of the facility's policy titled Medication Storage in the Facility, dated as revised [DATE], indicated but was not limited to the following: -When the original seal of a manufacturer's container or vial is initially broken the container or vial will be dated. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. -The nurse will check the expiration date of each medication before administering it. Review of the facility's policy titled Administration Procedures for all Medications, dated as revised [DATE], indicated but was not limited to the following: -Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container. -Once removed from the package or container, unused or partial doses should be disposed of. During an observation with interview on [DATE] at 4:09 P.M., the surveyor completed a review of the medication cart on the Memory Care Unit, rear side, with Nurse #3, and made the following observations: -In the top drawer: three small clear plastic medication cups, all uncovered and not labeled, which included the following: -One contained four loose pills, one contained applesauce with a white powdery substance on top of it, and one contained nine loose pills Nurse #3 said the two cups containing loose pills were loose pills she was picking up in the drawers of the medication cart. She said she was placing them in the medication cups for disposal, and did not know what they were. She said the white powdery substance was Pepcid (for heartburn) crushed on top of applesauce. Nurse #3 said she prepared the crushed medication for a resident, but they were in the shower, and she could not administer it. During an observation with interview on [DATE] at 1:10 P.M., the surveyor completed a review of the medication cart on the [NAME] Unit, low side, with Nurse #4, and made the following observations: -One bottle of Latanoprost 0.005% (reduces pressure in the eye) eye drops, seal broken indicating it had been opened, not labeled with an open date. -One bottle of Artificial tears eye drops (lubricant), seal broken indicating it had been opened, not labeled with an open date. Nurse #4 said the night shift (11:00 P.M.-7:00 A.M.) is responsible for maintaining the medication cart and ensuring all medications are labeled correctly. On [DATE] at 2:05 P.M., the surveyor completed a review of the medication cart on the Pichetti Unit, with Nurse #5, and made the following observations: -One bottle of Dorzolamide 0.5% (reduces pressure in the eye) eye drops, seal broken indicating it had been opened, not labeled with an open date. During an interview on [DATE] at 9:41 A.M., the Director of Nursing (DON) said medications should not be stored in the medication cart once they are prepared for administration. She said if a resident is unavailable, the nurse should destroy the medications and prepare new ones when the resident can take them. The DON said eye drops have a shortened expiration date and must be labeled with the date opened when the seal is broken, to ensure they are not used after they have expired.

Based on interview and record review, the facility failed to timely report completed investigations to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS- a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect and misappropriation) as required for two Residents (#16 and #2), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #16, to ensure a bruise of unknown origin was reported to DPH within 24 hours as required; and 2. For Resident #2, to ensure an allegation of abuse was reported to DPH within two hours as required. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation, and Mistreatment, The Elder Justice Act of 2010, dated as revised 7/2024, indicated but was not limited to: - Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteer staff, family members, friends or other individuals. - All reports of resident abuse, neglect, mental abuse, mistreatment and injuries of an unknown origin (bruises, skin tear) shall be investigated thoroughly and promptly by facility management. - When an alleged or suspected case of abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of unknown origin is reported, the Administrator or designee, will immediately notify the State Agency but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Agency and all other persons or agencies in accordance by State law through established procedures. - Reports to the State agency will be submitted electronically through the HCFRS system. 1. Resident #16 was admitted to the facility in April 2019 with diagnoses which included cerebrovascular disease. Review of the Minimum Data Set (MDS) assessment, dated 10/19/24, indicated Resident #16 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, was unable to make needs known, and required extensive assistance/dependent of staff for bed mobility, transfers and all other activities of daily living. Review of the Grievance Log, dated 1/1/24 through 11/2024, included a grievance, dated 7/31/24, filed by Resident #16's family member which indicated a bruise was observed on Resident #16's upper lip area and family alleged negligence of staff. Review of the Event Report and completed Facility Investigation, dated 7/31/24, indicated Resident #16 was assessed with a bruise to the right-side upper lip, measuring 2 centimeters (CM) W X .6 CM L. The Resident was unable to give a description of the incident. Review of the HCFRS on 11/20/24 at 11:00 A.M., failed to indicate Resident #16's bruise of unknown origin was reported to DPH as required. During an interview on 11/20/24 at 1:00 P.M., the Director of Nurses (DON) said although she completed the investigation and was unable to substantiate the allegation, she did not feel she needed to report the incident as required. 41106 2. Resident #2 was admitted to the facility in June 2020 with diagnoses which included dementia with other behavioral disturbances, mood disorder, anxiety, and psychosis. Review of the MDS assessment, dated 9/10/24, indicated Resident #2's cognitive level could not be determined by a BIMS as evidenced by a score of 99, which indicated Resident #2 did not complete the interview. During an interview on 11/13/24 at 8:44 A.M., Resident #2 said four weeks ago he/she left the room and a man with silver hair pounded his fist together three times at him/her. Resident #2 said he/she did not report the incident to staff, but the man came back the following evening. Resident #2 said after seeing the man again, he/she spoke to the Administrator about the man who pounded his fists at him/her. Resident #2 said he/she was scared of the silver haired man and if he/she sees him again he/she will call the police. Review of the HCFRS on 11/13/24 at 9:05 A.M., failed to indicate Resident #2's alleged complaint of abuse was reported to DPH as required. During an interview with the Administrator and the DON on 11/13/24 at 9:11 A.M., the Administrator said Resident #2 did report the incident to her and they investigated it and found it was not substantiated. The DON said Resident #2 has a history of accusatory behaviors and delusions. The Administrator said she did not report the incident in HCFRS.

Based on interview and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#40), out of 20 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented for the care and maintenance of an indwelling urinary catheter device (a thin, flexible tube inserted into the bladder to drain urine). Findings include: Review of the facility's policy titled Comprehensive Care Planning, dated as revised 11/23, indicated but was not limited to the following: -Development of the care plan will begin at admission, utilizing information gathered from the resident, family, admission assessments and records from the transferring facility or referral source. -The care plan will be reviewed at the IDT meeting and the amended as needed in conjunction with the nurse and Certified Nursing Assistant (CNA) who routinely cares for the resident. -The care plan will be reviewed and updated as needed, but not less than quarterly or when there is a change in condition. -The care plan will include a statement of the problem, reasonable, measurable, and time-limited goals, and specific intervention, along with the discipline responsible. Resident #40 was admitted to the facility in June 2024 with diagnoses including metabolic encephalopathy (brain disorder that occurs when there is a chemical imbalance in the blood) and was receiving Hospice care. Review of the Minimum Data Set (MDS) assessment indicated Resident #40 had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating he/she was cognitively intact. Further review of the MDS indicated Resident #40 had an indwelling urinary catheter in place. Review of Resident #40's medical record indicated he/she had an indwelling urinary catheter for neuromuscular dysfunction of the bladder (a condition that occurs when the nerves and muscles that control the bladder do not work properly). Review of Resident #40's care plan failed to indicate a care plan for his/her indwelling urinary catheter had been developed. During an interview on 11/18/24 at 3:08 P.M., Nurse #2 said Resident #40 has a catheter in place due to urinary retention. She said she provides catheter care daily, and it should be documented on the care plan. Nurse #2 reviewed Resident #40's care plan and said there is no care plan in place for the catheter as there should be. During an interview on 11/19/24 at 9:34 A.M., Unit Manager (UM) #1 said she noted there was no care plan developed for Resident #40's indwelling urinary catheter. She said the care plan should have been put into place months ago and was overlooked. During an interview on 11/20/24 at 9:28 A.M., the Director of Nursing (DON) said care plans should be developed and updated to reflect a resident's current medical status. She said there should have been a care plan for Resident #40's indwelling urinary catheter to ensure proper care and maintenance of the device.

Based on observation, interview, and document review, the facility failed to ensure professional standards of care were met for one Resident (#96), out of a total sample of 20 residents. Specifically, the facility failed to obtain a physician's order for the self-administration of medications. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling 9324 titled Accepting, Transcribing, and Implementing Prescriber Orders, dated as last revised April 11, 2018, indicated but was not limited to the following: -It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication. -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. -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. Review of the facility's policy titled Self-Administration of Medications, dated as revised 11/21, indicated but was not limited to the following: -A resident may self-administer drugs if ordered by the attending physician and if the interdisciplinary team has determined that this practice is safe. -If a resident requests to self-administer their medications, an assessment for self-administration of medications is conducted by the interdisciplinary team. -If the resident is deemed safe to self-administer, a physician's order is obtained. -At least once during each shift, the nursing staff should check for usage of the medications by the resident. Resident #96 was admitted to the facility in February 2023 with diagnoses including chronic kidney disease and type II diabetes. Review of the Minimum Data Set (MDS) assessment, dated 10/1/24, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact. During an observation with interview on 11/18/24 at 8:31 A.M., the surveyor observed Nurse #1 prepare Resident #96's 9:00 A.M. medications which included the following: -Atorvastatin (high cholesterol) 10 milligrams (mg) one tablet -Vitamin D3 (supplement) 25 micrograms (mcg) one tablet -Colace (stool softener) 100 mg one tablet -Vitamin B-12 (supplement) 500 mcg one tablet -Folic Acid (supplement) 1 mg one tablet -Lasix (diuretic) 20 mg one tablet -Lisinopril (high blood pressure) 40 mg one tablet -Metformin extended release (diabetes) 500 mg one tablet -Omeprazole (gastric reflux) 20 mg two tablets -Tolterodine extended release (overactive bladder) 4 mg capsule Nurse #1 then brought the medications in a clear, plastic medication cup, with a cup of water into Resident #96's room. The Resident was sitting in his/her bedside chair. Nurse #1 placed the medications on top of the bedside table and told Resident #96, I have your medications and exited the room. Nurse #1 told the surveyor that Resident #96 is a very private person and likes to administer his/her own medications. Review of the Medication Administration Record (MAR) for the month of November 2024 indicated Resident #96 was receiving these medications daily at 9:00A.M. Review of Resident #96's active Physician's Orders failed to include orders for self-administration of medications. Review of Resident #96's medical record indicated a Self-Administration of Medications assessment was completed on 10/16/24, indicating he/she wished to self-administer some medications, and was appropriate to do so. Further review of the assessment indicated meds left at bedside after the nurse preps them, however failed to indicate which medications were appropriate for the Resident to self-administer. Review of Resident #96's active care plan failed to indicate that a care plan had been developed for self-administation of medications. During an interview on 11/18/24 at 10:46 A.M., Resident #96 said he/she has been administering his/her own medications for a few months now. He/she said at first the nurse would bring the medications to him/her and watch him/her take them. Resident #96 said he/she did not need to be watched and requested to administer own medications. Resident #96 said the nurse does not always return to ensure all medications have been taken. During an interview on 11/18/24 at 10:49 A.M., Nurse #1 said she prepares Resident #96's medications, and leaves them at the bedside, and he/she will take them on their own. Nurse #1 and the surveyor reviewed Resident #96's medical record together, and she said there is no physician's order, for the Resident to self-administer medications, and she is not sure if one is needed. She said after she brings the medications to the Resident she follows up with them approximately 30 minutes later, to ensure the Resident has taken all of the medications. During an interview on 11/18/24 at 11:02 A.M., Unit Manager (UM) #2 said when a resident requests to self-administer medications, they complete an initial assessment to make sure they can do it safely and review it quarterly. She said they notify the physician, obtain a physician's order and update the care plan to include self-administration of medications. UM #2 said she reviewed Resident #96's medical record and noted there was no physician's order or care plan in place. During an interview on 11/18/24 at 11:53 A.M., the Director of Nursing (DON) said when a resident chooses to self-administer medications an assessment is completed and reviewed with the physician. She said residents must have a physician's order in place. The DON said once the order is obtained, it should be documented on the care plan. She said the nurse should always return to ensure all medications are taken as ordered and document their findings in the medical record.

Based on interview, observation, and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#44), out of 20 sampled residents. Specifically, the facility failed for Resident #44, to notify the physician and obtain orders for removal of the pressure dressing applied by the dialysis center to the left arm Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis), to provide monitoring of the AV site for complications or signs of infection, and to develop and implement a care plan for the care and maintenance of the AV site. Findings include: Review of the facility's policy titled Dialysis Patient - Care and Maintenance of the AV Fistula or AV graft, dated as last revised 1/2024, indicated but was not limited to the following: -Check the patient's circulation by palpating pulses distal to the vascular access; observing capillary refill in his/her fingers; and assessing him/her for numbness, tingling, altered sensation, coldness, and pallor in the affected extremity. -Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are at increased risk of infection. -After dialysis, assess the vascular access for any bleeding or hemorrhage. -Assess for blebs (ballooning or bulging) of the vascular access that may indicate an aneurysm that can rupture and burst. Review of the facility's policy titled Physician Orders, dated as last revised 3/2024, indicated but was not limited to the following: -At the time a resident is admitted , the facility must have physician orders for the resident's immediate care. The orders should include at minimum dietary, medications, and routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Resident #44 was admitted to the facility in July 2024 with diagnoses which included dependence on renal dialysis and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 10/1/24, indicated Resident #44 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment and he/she was receiving dialysis. Review of the Physician's Orders for Resident #44 indicated but were not limited to the following: -Diet: Renal; 1000 milliliter fluid restriction. -Record dialysis weights upon return on dialysis days: Call physician for gain of 2 pounds or more in 24 hours or 5 pounds in one week. -Dialysis three times a week Tuesday, Thursday, and Saturday. -Assess for bruit and thrill (swishing sound heard and vibration felt-indicates proper function) to AV fistula left upper arm every shift. -Assess for bruising, bleeding, peripheral pulses and circulation, sensation, and motion (CSM) every shift, on Eliquis (blood thinner). -No blood pressure or blood draws to left arm due to fistula. The physician's orders failed to include orders to assess the site upon return from dialysis, to monitor the site for adverse effects/complications, or instructions/orders related to the pressure dressing that is placed on the AV fistula site after dialysis. Review of the comprehensive care plan indicated but was not limited to the following: PROBLEM: Nutritional Status: Resident #44 has chronic kidney disease requiring hemodialysis. GOAL: He/she will maintain a stable weight and labs will be within parameters. APPROACH: Diet Renal, 1 liter fluid restriction, meds as ordered, labs as ordered, weights as ordered. Dialysis communication book used. Ongoing review of fluid restriction and rationale with Resident #44 and his/her family. PROBLEM: Pressure Ulcer/Injury: Resident has actual skin alterations as evidenced by open trauma wound to anterior left lower extremity, left upper extremity dialysis fistula, and at risk for new worsening skin alterations. GOAL: His/her skin alteration will remain free from signs/symptoms of infection. APPROACH: Provide treatments as ordered. The comprehensive care plan failed to include interventions to assess the site upon return from dialysis, to monitor the site for adverse effects/complications, or instructions/orders related to the pressure dressing that is placed on the AV fistula site after dialysis. During an interview on 11/13/24 at 12:37 P.M., Resident #44 said he/she goes to dialysis on Tuesday, Thursday, and Saturday and have been going for a few years. The Resident said he/she has a bag that goes with him/her with the binder the staff writes vitals and weights in. Resident #44 said they usually leave around 10:00 A.M. and return around 3:00 P.M. The Resident said when he/she returns there is a pressure dressing on the fistula, and it needs to be removed the next morning. The Resident said he/she rarely has bleeding issues but has big band-aids in case. The Resident said he/she usually can't get the tape off the dressing alone, so the staff must help remove the pressure dressing the next day. On 11/19/24, Resident #44 went out for dialysis and remained out of the building from approximately 10:00 A.M. until 3:15 P.M. Upon return, the surveyor observed that Resident #44 had a pressure dressing on their left upper extremity covering the AV fistula site. During an interview on 11/20/24 at 10:38 A.M., Unit Manager #2 said Resident #44 only had an order to check the bruit and thrill. She said she did not know anything about a dressing, when it is put on, or when it should be removed. She said she would have to call the dialysis center to see when the dressing is supposed to come off. Additionally, she said there are no other orders to monitor the site and the care plan is all about nutrition. She said they are trying to combine care plans so everything related to a concern is in one place and there should be additional information about the care of the fistula in the care plan but there is not. During an interview on 11/20/24 at 10:40 A.M., Nurse #7 said she was not sure if Resident #44 always came back with a dressing on the fistula and if there was one covering the site, she was not sure when it should come off. During an interview on 11/20/24 at 10:48 A.M., Resident #44 said the dressing comes off the next day. He/she said staff helped take it off when he/she got dressed earlier. During an interview on 11/20/24 at 12:17 P.M., the Director of Nurses (DON) said the vitals and weights go in the communication book and if dialysis has any recommendations to change medication orders etc., they will write them in there. She said her expectation is that the evening shift review the book on return and notify the physician for new orders if needed. She said they only have an order to monitor the bruit and thrill and if he/she is coming back with a dressing on the fistula then there should be an order when to remove the dressing. She said they will have to call dialysis to clarify. Additionally, she said they are combining care plans, but his/hers is mostly all nutrition related and should have a little more in it about the AV fistula.

Based on record review and interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments were completed for one Resident (#10), out of a total sample of 20 residents. Specifically, the facility failed for Resident #10, to accurately code the diagnosis of depression on 6 out of 7 MDS assessments reviewed. Findings include: Review of the facility's policy titled Resident Assessment Instrument and Care Planning, dated as last reviewed 11/2023, indicated but was not limited to the following: -It is the policy of the facility to ensure that each resident is assessed using the Resident Assessment Instrument (RAI) specified by the State in accordance with the guideline of the RAI User's Manual. -The MDS Coordinator or designee will encode and transmit [NAME]. Resident #10 was admitted to the facility in October 2023 with diagnoses which included depression. Review of the MDS assessments indicated but were not limited to the following: -MDS dated [DATE], failed to code the diagnosis of depression. -MDS dated [DATE], failed to code the diagnosis of depression. -MDS dated [DATE], failed to code the diagnosis of depression. -MDS dated [DATE], failed to code the diagnosis of depression. -MDS dated [DATE], failed to code the diagnosis of depression. -MDS dated [DATE], failed to code the diagnosis of depression. During an interview on 11/19/24 at 2:31 P.M., MDS Nurse #1 said the diagnosis of depression should have been coded on each of the MDS assessments and they would need to be modified. During an interview on 11/20/24 at 12:17 P.M., the Director of Nurses (DON) said the diagnosis of depression should have been coded on each of the MDS assessments and they would need to be modified.

Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for two Residents (#40 and #101), out of a total sample of 20 residents. Findings include: Review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, Version 3.0, indicated assessments must be completed no later than 14 calendar days after the assessment reference date (ARD) and transmitted and encoded within 7 days of assessment completion. Review of the medical record for Resident #40 indicated a discharge MDS (with return anticipated) was initiated with an ARD of 6/13/24. Further review of the medical record indicated the Resident returned to the facility and an entry MDS was initiated with an ARD of 6/14/24. The system indicated that both MDS assessments were not transmitted until 11/13/24. Review of the medical record for Resident #101 indicated a discharge MDS was initiated with an ARD of 7/9/24. The system indicated the MDS was not transmitted until 11/13/24. During an interview on 11/19/24 at 2:07 P.M., the MDS Coordinator said all three MDS assessments were completed but not transmitted timely as required.

Based on record review and interview, the facility failed to issue notices of transfer paperwork to the Resident, Resident Representative, and the Office of the Long-Term Care Ombudsman for five Residents (#19, #72, #22, #38, and #64), out of 18 sampled residents, as required. Findings include: 1. Resident #19 was admitted to the facility in March 2022 with a diagnosis of dementia (a range of conditions that affects the brain's ability to think, remember and function normally). Review of the clinical record indicated that Resident #19 was transferred to the hospital on 7/27/23. Further review of the clinical record did not indicate any evidence that the notice of transfer paperwork was provided to the Resident, Resident Representative and Long-Term Care Ombudsman, as required. 2. Resident #72 was admitted to the facility in July 2021 with a diagnosis of chronic kidney disease (CKD-a gradual loss of kidney function). Review of the clinical record indicated that Resident #72 was transferred to the hospital on 2/16/23. Further review of the clinical record did not indicate any evidence that the notice of transfer paperwork was provided to the Resident, Resident Representative, and Long-Term Care Ombudsman, as required. 37700 3. Resident #22 was admitted to the facility in September 2016 with a diagnosis of fracture of left patella (a bone located in front of the knee joint). Review of the medical record indicated the Resident was transferred to the hospital on 5/31/23. Further review of the clinical record did not indicate any evidence that the notice of transfer paperwork was provided to the Resident, Resident Representative or Long-Term Care Ombudsman, as required. 4. Resident #38 was admitted to the facility in October 2016 with a diagnosis of fracture of upper and lower ends of the right fibula (leg bone). Review of the medical record indicated the Resident was transferred to the hospital on 7/23/23. Further review of the clinical record did not indicate any evidence that the notice of transfer paperwork was provided to the Resident, Resident Representative, or Long-Term Care Ombudsman, as required. 5. Resident #64 was admitted to the facility in August 2021 with diagnoses including malignant neoplasm (cancer) of the bladder. Review of the clinical record indicated the Resident was transferred to the hospital on 8/20/23. Further review of the clinical record did not indicate any evidence that the notice of transfer paperwork was provided to the Resident, Resident Representative or Long-Term Care Ombudsman, as required. During an interview on 9/6/23 at 11:14 A.M, the Receptionist said that she is responsible for sending notice of transfer paperwork and notifying the Long-Term Care Ombudsman when a resident has an unplanned transfer from the facility. She further said that she was providing these notices for the short-term residents only and that she was not aware that the notifications were required to be sent for long-term care residents. She said she could not provide evidence of notice of transfer or notification of the Ombudsman for Residents #19, #72, #22, #38 and #64, as required.

Based on observation, policy review, and interview, the facility failed to adhere to food safety requirements to prevent the spread of food borne illnesses. Specifically, the facility failed to ensure staff performed hand hygiene after doffing (removing) and donning (putting on) disposable gloves during the lunch meal preparation. Findings include: Review of the facility policy titled, Hand Washing, dated January 2020, indicated that hands should be washed before donning disposable gloves for working with food and after gloves are removed. During an observation of the lunch meal on 9/6/23 the surveyor observed the following: -At 11:50 A.M., Dietary Staff #1 doffed his gloves while setting up lunch trays and donned a new pair of gloves without washing his hands. -At 11:50 A.M., Dietary Staff #2 exited the walk-in refrigerator with iced coffee for a resident's tray, doffed his gloves and donned new gloves without handwashing and proceeded to take a food truck out of the kitchen onto the unit. -At 11:51 A.M., Dietary Staff #3 doffed her gloves and donned new gloves without handwashing and proceeded to make beverages for the residents' lunch trays. -At 11:52 A.M., Dietary Staff #1 doffed his gloves and donned his gloves without handwashing and continued to serve food on the lunch trays. -At 12:00 P.M., Dietary Staff #3 doffed her gloves and donned new gloves without handwashing and continued to serve beverages for the residents' lunch trays. During an interview on 9/6/23 at 11:58 A.M., the Food Service Director said that the dietary staff should be washing their hands after doffing gloves and before putting on new gloves.

Based on record review, policy review, and interview, the facility failed to provide Notice of Bed Hold Policy and readmission paperwork to the Resident and/or their Representative for four Residents (#19, #72, #22, and #64), out of 18 sampled residents, as required. Findings include: Review of the facility policy titled, Bed Holds and Readmissions, reviewed November 2022, indicated that it is the policy of the facility to provide each resident with written information explaining their Bed Hold Policy for any planned transfer to a hospital, a planned therapeutic leave of absence, or an emergency transfer to a hospital. 1. Resident #19 was admitted to the facility in March 2022 with a diagnosis of dementia (a range of conditions that affects the brain's ability to think, remember and function normally). Review of the clinical record indicated that Resident #19 was transferred to the hospital and subsequently admitted on [DATE]. Further review of the clinical record did not indicate any evidence that the Bed Hold and Readmissions Policy was provided to the Resident and/or Resident Representative, as required. 2. Resident #72 was admitted to the facility in July 2021 with a diagnosis of chronic kidney disease (CKD-a gradual loss of kidney function). Review of the clinical record indicated that Resident #72 was transferred to the hospital and subsequently admitted on [DATE]. Further review of the clinical record did not indicate any evidence that the Bed Hold and Readmissions Policy was provided to the Resident and/or Resident Representative, as required. 37700 3. Resident #22 was admitted to the facility in September 2016 with a diagnosis of fracture of left patella (a bone located in front of the knee joint). Review of the medical record indicated the Resident was transferred to the hospital on 5/31/23, admitted , and returned to the facility on [DATE]. Further review of the clinical record did not indicate any evidence that the Bed Hold and Readmissions Policy was provided to the Resident and/or Resident Representative, as required. 45435 4. Resident #64 was admitted to the facility in August 2021 with diagnoses including malignant neoplasm (cancer) of the bladder. Review of the clinical record indicated the Resident was transferred to the hospital on 8/20/23. Further review of the clinical record did not indicate any evidence that the Bed-Hold and Readmission Policy was provided to the Resident and/or Resident Representative, as required. During an interview on 9/6/23 at 11:14 A.M., the Receptionist said that she is responsible for sending bed hold and readmissions paperwork when a resident is transferred from the facility. She further said that she was providing these notices for the short-term residents only and that she was not aware the Bed-Hold and Readmission Policy were required to be sent for long-term care residents. She said she could not provide any evidence of Bed-Hold and Readmission Policy notification for Residents #19, #72, #22 and #64, as required.

Based on record review and staff interview, the facility failed to ensure a resident representative did not make decisions beyond the extent allowed by the court or delegated by the resident for one Resident (#14), out of a total sample of 18 residents. Findings include: Resident #14 was admitted to the facility in [DATE] with a diagnoses of Alzheimer's disease with late onset and dementia with other behavioral disturbance. Review of a court document titled Order Appointing Special Conservator (a person who is appointed by the court to manage finances) indicated the following: -Special Conservator for a Protected Person was established [DATE]. -Conservator may exercise only the powers specified in this order. -Power of conservator includes the ability to access assets and accounts to ensure that the Respondent's assets are not wasted or dissipated and are used to and for his/her health, safety, and well-being. -Masshealth application process needs to be started .to continue receiving necessary skilled nursing care . -Special Conservator's appointment shall expire on [DATE]. Further review of the medical record indicated the following: -Health Care Proxy (HCP- a legal document that designates a resident representative to make medical decisions only), dated [DATE], was signed by the special conservator naming a resident's family member as a Health Care Agent. -Social Service note, dated [DATE], indicated that the special conservator assigned a family member as Health Care Agent. During an interview on [DATE] at 2:04 P.M., Social Worker #1 said that the Special Conservator thought he was able to assign a Health Care Proxy which would transfer decision making authority to the family member. Social Worker #1 reviewed the Special Conservator document with the surveyor and confirmed that it had both expired and did not have the power to address medical decisions for the Resident.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of endocrine (glands that secrete hormones) disorders that were managed with medication, the Facility failed to ensure he/she was free of significant medication error, when he/she was not administered prednisone (corticosteroid medication) daily per Physician orders, nursing documented the medication was unavailable and not administered, therefore Resident #1 missed three consecutive doses of his/her prednisone, Resident #1 experienced a decline in condition, was transferred to the Hospital Emergency Department for evaluation, was admitted due to adrenal insufficiency and required intravenous (IV) administration of corticosteroids. Findings include: The Facility Policy, titled Medication Errors, date reviewed 4/2023, indicated the following: -it is the Facility's policy that residents will be free of any significant medication errors -medication errors: a medication is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional -significant medication error: one which causes the resident discomfort or jeopardizes their health and safety -guidelines for determining significance's include resident condition, drug category, and frequency of error -once aware of the discrepancy, ensure the comfort and safety of the resident, check vital signs, and notify the attending physician of the discrepancy Review of WebMD, Uses, Side Effects, and More related to Prednisone (corticosteroid) indicated: -it is used to treat the immune system and decreases response to various diseases to reduce their symptoms -Take medication exactly as directed by the doctor -Do not stop taking this medication without consulting with doctor, -conditions may become worse when this drug is suddenly stopped and person may experience symptoms such as weakness, tiredness, dizziness, nausea, muscle pain and headache Review of The HealthSite.com, What Happens if I Miss a Dose of Corticosteroids, dated 4/25/2017, indicated steroids mimic the hormones produced by the adrenal gland. Steroids are usually prescribed for a short duration; however, if the duration is longer, then skipping doses will have some serious impact on the body. If you miss a dose, take it immediately and missing a couple of doses can send your body into adrenal shock. Resident #1 was admitted to the Facility in June 2023, diagnoses included Hypothyroidism (underactive thyroid), Adrenal insufficiency (adrenal glands do not produce enough of the hormone cortisol), Atrial fibrillation (irregular heartbeat), Osteoarthritis, Rheumatoid arthritis, Muscle weakness, Anxiety disorder, Depression, Dementia, Type II Diabetes Mellitus, Hypertension, and Gastro-esophageal Reflux Disease. Review of Resident #1's Physician Orders for medications, for June 2023, included the administration of the following: -prednisone tablet 2.5 milligrams (mg); administer three tablets (for a total of equal 7.5 mg) by mouth once each morning at 6:00 A.M. Review of Resident #1's Medication Administration Record (MAR), dated June 2023, indicated: - 6/23/23 at 6:00 A.M. related to the administration of his/her prednisone (documented by Nurse #2) Not Administered: Drug/Item unavailable and will notify pharmacy Review of Resident #1's Nursing Progress Note, dated 6/23/23 at 6:04 A.M., (written by Nurse #2), indicated drugs out of stock and Pharmacy notified, message left on voicemail for prednisone 2.5 mg, Resident #1 made aware medication missing. Review of Resident #1's medical record indicated there was no documentation to support that on 6/23/23, when Nurse #2 notified the pharmacy and left a voicemail to reorder Resident #1's prednisone, that she had indicated it was a stat order or that she notified Resident #1's Physician that his/her 6:00 A.M. dose of prednisone was unavailable to administer to him/her. Review of the Pharmacy Delivery Status Form (related specifically to Resident #1's medications), dated 6/23/23, indicated that on 6/23/23 the pharmacy dispensed prednisone 2.5 mg tablet in a quantity of 30 tablets for 10 days. However further review of the Pharmacy Delivery Status Form indicated the medication was not delivered to the Facility until 6/25/23 at 2:00 P.M. Review of Resident #1's MAR, dated 6/24/23, indicated: - 6/24/23 at 6:00 A.M., related to the administration of his/her prednisone (as documented by Nurse #4) indicated, Not Administered: Drug/Item unavailable. Although Resident #1 was not administered his/her medication on 6/24/23, there was no documentation to support Nurse #4 called the pharmacy to check on when the medication was due for delivery or that she notified Resident #1's Physician that his/her 6:00 A.M. dose of prednisone was unavailable to administer to him/her. Review of Resident #1's MAR, dated 6/25/23, indicated: - 6/25/23 at 6:00 A.M. related to the administration of his/her prednisone, (as documented by Nurse #2) Not Administered: Drug/Item unavailable and pharmacy notified. Review of Resident #1's Nursing Progress Note, dated 6/25/23 at 8:37 A.M., (written by Nurse #2) indicated; spoke with Pharmacy who promises to deliver the prednisone today for Resident #1 and message left for Physician/Nurse Practitioner (NP). Review of Resident #1's Nursing Progress Note, dated 6/25/23 at 7:24 P.M., indicated Resident #1 was noted to have increased weakness, lethargy and refusing fluids, and he/she was sent to the Hospital Emergency Department for evaluation per Physician order. During an interview on 7/17/23 at 2:59 P.M., the Nurse Practitioner said she saw Resident #1 on 6/23/23 (in the facility) and she was not notified by nursing that he/she had not received his/her prednisone that day because it was unavailable. The Nurse Practitioner said at one point (exact date unknown) Resident #1's prednisone was administered at 9:00 A.M. and he/she complained of dizziness due to not receiving his/her medication earlier in the morning like he/she took it when at home, and said she gave an order to change his/her prednisone medication to be administered at 6:00 A.M., in the facility. During an interview on 7/12/23 at 2:47 P.M., the Unit Manager said she was not told on 6/23/23 that Resident #1's 6:00 A.M. medication was not available and not administered to him/her. The Unit Manager said if a medication was unavailable nurses should check the Passport (facility's automated medication dispensing system) medication inventory list and if the medication was not available in Passport, then the nurse should notify the Physician, and call the pharmacy to reorder the medication stat. During an interview on 7/17/23 at 11:33 A.M., Nurse #4 said she could not remember if Resident #1's medication was unavailable on 6/24/23 to administered to him/her at 6:00 A.M. Nurse #4 said if she had not written it in a progress note, then she had not called the pharmacy to reorder Resident #1's medication stat. During an interview on 7/17/23 at 11:57 A.M., Nurse #3 said she worked the 7:00 A.M.-3:00 P.M. shift on 6/25/23 and that during change of shift report Nurse #2 mentioned that Resident #1's prednisone had not been delivered from the pharmacy. Nurse #3 said that Nurse #2 had not reported to her that she had not administered Resident #1's prednisone medication at 6:00 A.M. to him/her. During an interview on 7/12/23 at 2:25 P.M., Nurse #1 said she was not aware that Resident #1 had not received his/her prednisone for three days. Nurse #1 said that on 6/25/23 Resident #1 was lethargic, refusing fluids and not him/herself. Nurse #1 said she notified Resident #1's Physician, and he/she was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge Summary, dated 6/27/23, indicated Resident #1 was admitted with Adrenal insufficiency and he/she had not received his/her prednisone for the past four days. The Summary indicated that the Facility was called to confirm that he/she had missed doses of prednisone, and it appeared he/she had not received his/her prednisone for multiple days and suspect his/her symptoms were secondary to several missed doses of steroid leading to adrenal insufficiency which he/she had a known history and was treated with Intravenous (IV) corticosteroids. The Surveyor was unable to interview Nurse #2, as she did not respond to the voice messages left on her cell phone or the request for an interview sent via letter to her last known address. During an interview on 7/12/23 at :42 P.M., the Director of Nurses (DON) said Nurse #2 informed her on the morning of 6/26/23 that Resident #1 had been sent to the Hospital ED on 6/25/23 and the Hospital called asking how many days Resident #1 had not received his/her prednisone medication and that she told the hospital Resident #1 had not received his/her prednisone since 6/22/23. The DON said on 6/23/23 Nurse #2 called the pharmacy and left a voicemail to reorder Resident #1's prednisone and on 6/24/24 Nurse #4 documented on Resident #1's MAR that his/her prednisone was unavailable and not administered. The DON said she spoke to the Pharmacy Director, and he said the medication was not ordered as a stat order and the Pharmacy delivered Resident #1's medication within 72-hours as a normal medication order. The DON said Nurse #2 and Nurse #4 did not notify Resident #1's Physician that his/her prednisone medication was unavailable to administer on 6/23/23 and 6/24/23 and she did not know if Nurse #2 actually called and left a message for Resident #1's Physician on 6/25/23 because the Physician or the on-call Physician always calls the Facility back. The DON said she expects all nurses to follow the Facility's Policy when a medication is unavailable and said Nurse #2 and Nurse #4 had not followed the Facility Policy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of endocrine (glands that secrete hormones) disorders which were managed with medication, the Facility failed to ensure nursing notified the Physician when his/her medication prednisone was unavailable and not administered as ordered for three consecutive days and as a result he/she required admission to the hospital for treatment of adrenal insufficiency, it was also determined that Resident #1 had not been administered his/her Levothyroxine for two days, which was also not reported to the physician. Findings include: The Facility Policy, titled Change in a Resident's Condition or Status, date reviewed 12/2022, indicated the following: -the Facility shall promptly notify the resident, his or her attending Physician or Nurse Practitioner and family/Health Care Proxy of changes in the resident's condition and/or status -the Nursing Supervisor or Charge Nurse will notify the resident's attending Physician or Nurse Practitioner when: there is a need to alter the resident's treatment significantly and deemed necessary or appropriate in the best interest of the resident -The Nurse Supervisor/Charge Nurse will record in the resident's medical record any changes in the resident's medical condition or status Resident #1 was admitted to the Facility in June 2023, diagnoses included Hypothyroidism (underactive thyroid), Adrenal insufficiency (adrenal glands do not produce enough of the hormone cortisol), Atrial fibrillation (irregular heartbeat), Osteoarthritis, Rheumatoid arthritis, Muscle weakness, Anxiety disorder, Depression, Dementia, Type II Diabetes Mellitus, Hypertension, and Gastro-esophageal Reflux Disease. Review of Resident #1's Admission Physician Orders, for June 2023, indicated his/her medication orders included the administration of the following: -prednisone tablet 2.5 milligrams (mg); administer three tablets (to equal a total of 7.5 mg) by mouth each morning at 6:00 A.M. - Levothyroxine tablet 137 micrograms (mcg); administer one tablet by mouth once a day at 6:00 A.M. Review of Resident #1's Medication Administration Record (MAR), dated June 2023, indicated: - 6/23/23 at 6:00 A.M. related to the administration of his/her prednisone (documented by Nurse #2) Not Administered: Drug/Item unavailable and will notify pharmacy Review of Resident #1's Nursing Progress Note, dated 6/23/23 at 6:04 A.M., (documented by Nurse #2), indicated drugs out of stock and Pharmacy notified, message left on voicemail for, prednisone 2.5 mg and Levothyroxine 137 mcg (last available dose was given on 6/23/23 at 6:00 A.M.), Resident #1 made aware medication missing. However, further review of Resident #1's Medical Record, indicated there was no documentation to support Nurse #2 notified Resident #1's Physician on 6/23/23, that his/her 6:00 A.M. medications were unavailable, and therefore not administered. Review of Resident #1's MAR, dated 6/24/23, indicated: - 6/24/23 at 6:00 A.M., related to the administration of his/her prednisone (as documented by Nurse #4) indicated, Not Administered: Drug/Item unavailable. -6/24/23 at 6:00 A.M. related to the administration of his/her Levothyroxine (as documented by Nurse #4) Not Administered: Drug/Item unavailable Review of Resident #1's Medical Record, indicated there was no documentation to support the Nurse #4 notified his/her Physician on 6/24/23, that Resident #1's 6:00 A.M. medications were unavailable, and therefore not administered. Review of Resident #1's MAR, dated 6/25/23, indicated: - 6/25/23 at 6:00 A.M. related to the administration of his/her prednisone,( as documented by Nurse #2) Not Administered: Drug/Item unavailable and pharmacy notified. - 6/25/23 at 6:00 A.M., related to the administration of his/her Levothyroxine(as documented by Nurse #2) Not Administered: Drug/Item unavailable and pharmacy notified) Review of Resident #1's Nursing Progress Note, dated 6/25/23 at 8:37 A.M., (written by Nurse #2) indicated spoke with Pharmacy who promises to deliver the prednisone and Levothyroxine today for Resident #1 and message left for Physician/Nurse Practitioner (NP) Although Nurse #2 documented in Resident #1's progress notes on 6/25/23 that a message was left for the Physician/NP, further review of Resident #1's medical record indicated there was no documentation to support that nursing received a call back on 6/25/23 from the Physician or NP. Further review of Resident #1's Nursing Progress Notes, indicated the following: -6/25/23 at 12:40 P.M., Resident #1 reported dizziness when getting out of bed today; -6/25/23 at 7:24 P.M., Resident #1 was noted to have increased weakness, lethargy and refusing fluids, and he/she was sent to the Hospital for evaluation per Physician order; -6/25/23 at 10:58 P.M., Hospital called for update and notified (by Hospital) Resident #1 was being admitted ; -6/26/23 at 1:13 A.M., (documented by Nurse #2), received a phone call from Hospital Pharmacist regarding Resident #1's dose (prednisone) and why it was not given for two days During an interview on 7/17/23 at 2:59 P.M., the Nurse Practitioner said she saw Resident #1 on 6/23/23 (in the facility) and that she was not notified by nursing that he/she had not received his/her prednisone or Levothyroxine that day because it was unavailable. The Nurse Practitioner said at one point (exact date unknown) Resident #1's prednisone was administered at 9:00 A.M. and he/she complained of dizziness due to not receiving his/her medication earlier in the morning like he/she took it when at home, and said she gave an order to change his/her prednisone medication to be administered at 6:00 A.M. During an interview on 7/12/23 at 2:47 P.M., the Unit Manager said she was not told on 6/23/23 that Resident #1's 6:00 A.M. medications (prednisone and Levothyroxine) were not available and not administered to him/her. The Unit Manager said if a medication was unavailable nurses should check the Passport (facility's automated medication dispensing system) medication inventory list and if the medication was not available, notify the Physician, and call the pharmacy to reorder the medication for stat delivery. During an interview on 7/17/23 at 11:33 A.M., Nurse #4 (who was Resident #1's nurse on 6/24/23) said she could not remember if Resident #1's medications were unavailable on 6/24/23 to administered to him/her at 6:00 A.M. and that she knew what the process was when a medication was unavailable to administered to a resident. Nurse #4 said if she had not documented it in a progress note, said then she also had not notified Resident #1's Physician. During an interview on 7/17/23 at 11:57 A.M., Nurse #3 said she worked the 7:00 A.M.-3:00 P.M. shift on 6/25/23 and during change of shift report Nurse #2 mentioned that Resident #1's prednisone or Levothyroxine had not been delivered from the pharmacy. Nurse #3 also said that Nurse #2 did not tell her that she had not administered Resident #1's prednisone or Levothyroxine medications at 6:00 A.M. to him/her. Nurse #3 said that Nurse #2 had not told her that she had left a message for the Physician regarding the medications, and also said she had not receive a call on 6/25/23 from Resident #1's Physician or the on-call Physician. Nurse #3 said she was not aware that Resident #1 had missed doses of his/her prednisone and Levothyroxine for a few days and said she would have intervened and notified Resident #1's Physician. Review of Resident #1's Hospital Discharge Summary, dated 6/27/23, indicated Resident #1 was admitted with Adrenal insufficiency and he/she had not received his/her prednisone for the past four days. The Summary indicated that the Facility was called to confirm that he/she had missed doses of prednisone, and it appeared he/she did not receive his/her prednisone for multiple days and suspect his/her symptoms were secondary to several missed doses of steroid leading to adrenal insufficiency which he/she had a known history and was treated with Intravenous (IV) corticosteroid's. The Surveyor was unable to interview Nurse #2, as she did not respond to the voice messages left on her cell phone or the request for an interview sent via letter to her last known address. During an interview on 7/12/23 at 3:42 P.M., the Director of Nurses (DON) said Nurse #2 and Nurse #4 had not notified Resident #1's Physician that his/her prednisone and Levothyroxine medication was unavailable to administer on 6/23/23 and 6/24/23, and they had not followed the Facility's policy. The DON said she did not know if Nurse #2 actually called and left a message for Resident #1's Physician because the Physician or the on-call Physician always called the Facility back.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of endocrine (glands that secrete hormones) disorders that were managed with medications, the Facility failed to ensure that Resident #1's physician ordered medications were available for administration as ordered. When nursing noted Resident #1's prednisone and Levothyroxine medications were unavailable to be administered, when nursing contacted the pharmacy regarding delivery, they had not informed the pharmacy that they needed the medications to be delivered stat, as a result Resident #1 missed three consecutive daily doses of his/her prednisone and two doses of his/her Levothyroxine, therefore placing his/her at increased risk for experiencing signs and symptoms associated with his/her endocrine disorders. Findings include: The Pharmacy Policy, titled Provider Pharmacy Requirements, dated 2/2019, indicated the following: -that regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies. -providing routine and timely pharmacy services as contracted, and emergency pharmacy service 24 hours per day, seven days per week -emergency or stat (immediately) medications are available for administration no more than four (4) hour(s) after the order is received by the pharmacy The Pharmacy Policy, titled Medication Ordering and Receiving from Pharmacy: Emergency Pharmacy Service and Emergency Kits, dated 2/2019, indicated the following: -emergency pharmacy service is available on a 24-hour basis, emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy and the provider pharmacy supplies emergency medications including emergency drugs and automated dispensing systems (ADS) -telephone/fax numbers for emergency pharmacy service are posted at nursing stations -the dispensing pharmacy supplies emergency or stat medications according to the provider pharmacy agreement -the ordered medication is obtained either from the emergency box or ADS, from the provider pharmacy or a back-up pharmacy that is determined by the provider pharmacy -the emergency supply is maintained in a designated area(s), along with a list of supply contents and expiration date(s) Resident #1 was admitted to the Facility in June 2023, diagnoses included Hypothyroidism (underactive thyroid), Adrenal insufficiency (adrenal glands do not produce enough of the hormone cortisol), Atrial fibrillation (irregular heartbeat), Osteoarthritis, Rheumatoid arthritis, Muscle weakness, Anxiety disorder, Depression, Dementia, Type II Diabetes Mellitus, Hypertension, and Gastro-esophageal Reflux Disease. Review of Resident #1's Physician Orders for medications, for June 2023, included the administration of the following: -prednisone tablet 2.5 milligrams (mg); administer three tablets (for a total of equal 7.5 mg) by mouth once each morning at 6:00 A.M. - levothyroxine tablet 137 micrograms (mcg); administer one tablet by mouth once a day at 6:00 A.M. Review of Resident #1's Medication Administration Record (MAR), dated June 2023, indicated: - 6/23/23 at 6:00 A.M. related to the administration of his/her prednisone (documented by Nurse #2) Not Administered: Drug/Item unavailable and will notify pharmacy Review of Resident #1's Nursing Progress Note, dated 6/23/23 at 6:04 A.M., (written by Nurse #2), indicated drugs out of stock and Pharmacy notified, message left on voicemail for, prednisone 2.5 mg and levothyroxine 137 mcg, Resident #1 made aware medications missing. Review of Resident #1's medical record indicated there was no documentation to support that on 6/23/23, when Nurse #2 notified the pharmacy and left a voicemail to reorder Resident #1's prednisone and levothyroxine, that she had indicated it was a stat order. Review of the Pharmacy Delivery Status Form (related specifically to Resident #1's medications), dated 6/23/23, indicated that on 6/23/23 the pharmacy dispensed prednisone 2.5 mg tablet in a quantity of 30 tablets for 10 days and levothyroxine 137 mcg tablet in a quantity of 10 tablets for 10 days. However further review of the Pharmacy Delivery Status Form indicated the medications were not delivered to the Facility until 6/25/23 at 2:00 P.M. Review of Resident #1's MAR, dated 6/24/23, indicated: - 6/24/23 at 6:00 A.M., related to the administration of his/her prednisone (as documented by Nurse #4) indicated, Not Administered: Drug/Item unavailable. -6/24/23 at 6:00 A.M. related to the administration of his/her levothyroxine (as documented by Nurse #4) Not Administered: Drug/Item unavailable Although Resident #1 was not administered his/her medications on 6/24/23, there was no documentation to support Nurse #4 called the pharmacy to check on when the medications were due for delivery. Review of Resident #1's MAR, dated 6/25/23, indicated: - 6/25/23 at 6:00 A.M. related to the administration of his/her prednisone, (as documented by Nurse #2) Not Administered: Drug/Item unavailable and pharmacy notified. - 6/25/23 at 6:00 A.M., related to the administration of his/her levothyroxine (as documented by Nurse #2) Not Administered: Drug/Item unavailable and pharmacy notified Review of Resident #1's Nursing Progress Note, dated 6/25/23 at 8:37 A.M., (written by Nurse #2) indicated; spoke with Pharmacy who promises to deliver the prednisone and levothyroxine today for Resident #1 and message left for Physician/Nurse Practitioner (NP). Review of Resident #1's Nursing Progress Note, dated /25/23 at 7:24 P.M., indicated Resident #1 was noted to have increased weakness, lethargy and refusing fluids, and he/she was sent to the Hospital Emergency Department for evaluation per Physician order. During an interview on 7/17/23 at 2:59 P.M., the Nurse Practitioner said she saw Resident #1 on 6/23/23 (in the facility) and she was not notified by nursing that he/she had not received his/her prednisone or levothyroxine that day because it was unavailable. The Nurse Practitioner said at one point (exact date unknown) Resident #1's prednisone was administered at 9:00 A.M. and he/she complained of dizziness due to not receiving his/her medication earlier in the morning like he/she took it when at home, and said she gave an order to change his/her prednisone medication to be administered at 6:00 A.M. During an interview on 7/12/23 at 2:47 P.M., the Unit Manager said she was not told on 6/23/23 that Resident #1's 6:00 A.M. medications were not available and not administered to him/her. The Unit Manager said if a medication was unavailable nurses should check the Passport (facility's automated medication dispensing system) medication inventory list and if the medication was not available in Passport (it was later determined that Resident #1's physician's ordered doses of prednisone and Levothyroxine were not available in Passport) then the nurse should notify the Physician, and call the pharmacy to reorder the medication stat. During an interview on 7/17/23 at 11:33 A.M., Nurse #4 said she could not remember if Resident #1's medications were unavailable on 6/24/23 to administered to him/her at 6:00 A.M. Nurse #4 said if she had not written it in a progress note, then she had not called the pharmacy to reorder Resident #1's medications stat. During an interview on 7/17/23 at 11:57 A.M., Nurse #3 said she worked the 7:00 A.M.-3:00 P.M. shift on 6/25/23 and that during change of shift report Nurse #2 mentioned that Resident #1's prednisone and Levothyroxine had not been delivered from the pharmacy. Nurse #3 said that Nurse #2 had not reported to her that she had not administered Resident #1's prednisone or levothyroxine medications at 6:00 A.M. to him/her. During an interview on 7/12/23 at 2:25 P.M., Nurse #1 said she was not aware that Resident #1 had not received his/her prednisone or levothyroxine for three days. Nurse #1 said that on 6/25/23 Resident #1 was lethargic, refusing fluids and not him/herself. Nurse #1 said she notified Resident #1's Physician and he/she was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge Summary, dated 6/27/23, indicated Resident #1 was admitted with Adrenal insufficiency and he/she had not received his/her prednisone for the past four days. The Summary indicated that the Facility was called to confirm that he/she had missed doses of prednisone, and it appeared he/she had not receive his/her prednisone for multiple days and suspect his/her symptoms were secondary to several missed doses of steroid leading to adrenal insufficiency which he/she had a known history and was treated with Intravenous (IV) corticosteroids. The Surveyor was unable to interview Nurse #2, as she did not respond to the voice messages left on her cell phone or the request for an interview sent via letter to her last known address. During an interview on 7/12/23 at :42 P.M., the Director of Nurses (DON) said Nurse #2 informed her on the morning of 6/26/23 that Resident #1 had been sent to the Hospital ED on 6/25/23 and the Hospital called asking how many days Resident #1 had not received his/her prednisone medication and that she told the hospital Resident #1 had not received his/her prednisone since 6/22/23. The DON said on 6/23/23 Nurse #2 called the pharmacy and left a voicemail to reorder Resident #1's prednisone and on 6/24/24 Nurse #4 documented on Resident #1's MAR that his/her prednisone was unavailable and not administered. The DON said she spoke to the Pharmacy Director, and he said the medications (prednisone and Levothyrozine) were not ordered as a stat order and the Pharmacy delivered Resident #1's medication within 72-hours, as a normal medication order. The DON said the pharmacy has up to 72-hours from the time a medication(s) is ordered until they are delivered to the Facility and a stat medication order would have been delivered to the Facility within 4 hours. The DON said she expects all nurses to follow the Facility's Policy when a medication is unavailable and said Nurse #2 and Nurse #4 had not followed the Facility Policy.

Based on staff interviews and documentation review, the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services to ensure the functioning of the Dietary Department. Findings include: During an interview on 9/22/21 at 10:05 A.M., the Food Service Manager (FSM) said she was in charge of the facility's Dietary Department. The FSM said she had not completed a dietary manager training program. The FSM said the Registered Dietitian worked at the facility part-time. If a facility does not employ a full-time Registered Dietitian, the Certified Dietary Director credential is a requirement for the employee who serves as the Director of Food and Nutrition Services. Review of the FSM's personnel file indicated she was hired as the full-time FSM in August 2021. The personnel file also indicated that she does not have an advanced college degree. In order to be certified, an individual must take and pass the dietary manager certification exam. During an interview on 9/24/21 at 3:25 P.M., the Administrator said the FSM had not taken a food manager certification course yet, and the Dietitian works part time. He said that when she was hired, they had discussed her enrolling in a dietary manager certification course, but she has not done that yet.

Based on observations and interviews, the facility failed to ensure sufficient support staff were available to carry out food and nutrition services to provide a dignified dining experience on 3 out of 4 units in the facility. Findings include: On 9/22/21 at 8:15 A.M., the surveyor observed Resident #58 sitting upright in bed, with a white, disposable, three-compartment container with food in it placed on an overbed table in front of him/her. The Resident said that they started using to-go containers two to three weeks ago. On 9/22/21 at 8:30 A.M., the surveyor observed Resident #33 sitting in a chair at his/her bedside, with a white, disposable, three-compartment container with food in it placed on an overbed table in front of him/her. Resident #33 said that the kitchen has been serving meals in to-go containers on and off for a few weeks because there is not enough staff in the kitchen to wash the dishes. During an interview on 9/23/21 at 10:57 A.M., the Food Service Manager (FSM) said that residents' meals were served in disposable containers with plastic utensils yesterday because there was only one cook, and two dietary aides working, and there was not enough staff to wash the dishes. She said that they use disposable items when staffing is low, which is frequent lately because they lost eight dietary staff the day before she started working at the facility three weeks ago. She said that the dementia unit always uses regular colored plates, and the other three units use disposable items when dietary staffing is low. On 9/28/21 at 8:08 A.M., the surveyor observed a dietary staff member enter the resident's room, and placed the resident's breakfast tray on the overbed table. The tray contained a Styrofoam plate with piece of toast on it, covered with a clear plastic cover. The tray had plastic utensils (a plastic knife, fork and spoon). During an interview on 9/28/21 at 8:30 A.M., the FSM said disposable items were used today because there is not enough staff to wash the dishes. During an interview on 9/27/21 at 12:55 P.M., the Dietitian said there have been staffing issues.

Based on observations, staff interview, and policy review, the facility failed to ensure that staff stored, prepared, and served food under sanitary conditions in the main kitchen and in 2 out of 4 nourishment kitchens in the facility. Findings include: Review of the facility's policies titled Food Safety for Your Loved One, 2019, and Food Safety Requirements Policy, revised June 2019, indicated, but is not limited to the following: Policy: -It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought in to residents by family and other visitors. Objective: -Follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. Procedure: -Food and beverages brought in from outside sources that require refrigeration or freezing will be labeled with the resident's name and date. -Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored and the resident's name. 1. On 9/22/21 at 8:10 A.M., the surveyor observed the Smith Unit nourishment kitchen: -The top shelf in the freezer had an opened, unlabeled container of Breyers Creamsicle ice cream. The top to the ice cream carton was not secured, and its contents were exposed to the air. The shelf on which the ice cream carton was placed, had an orange colored sticky substance. The bottom shelf of the freezer had an off-white colored sticky substance on the surface. There was an opened, unlabeled carton of Breyers Mint Chocolate Chip ice cream in the freezer door. The top to the ice cream carton was not secured, and its contents were exposed to the air. -The second shelf of the refrigerator had two take out containers that contained rice and meat on skewers. The containers were labeled with residents' names, but were undated. -There were three bottles of cranberry juice, four bottles of ginger ale, and a large plastic bin containing a large supply of plastic spoons stored underneath the sink. On 9/22/21 at 12:00 P.M., the surveyor observed the Courtyard nourishment kitchen: -The freezer door contained a brown paper bag with a container of food items dated 8/19/21. The bag was not labeled with a resident's name. On 9/23/21 at 7:40 A.M., the surveyor observed the tray line in the main kitchen. Cook #1 began plating food from the steam table and passing it to two dietary aides. A pedestal fan was next to the tray line, and was blowing air in the direction of the food trays. The fan's front grill was encased in brownish gray dust, that the surveyor observed moving in the breeze of the fan. On 9/23/21 at 10:57 A.M., the surveyor observed two pedestal fans next to the tray line in the main kitchen, blowing air in the direction of food on the tray line. Both fans front grills were encased in brownish gray dust, that was moving in the breeze of the fans. During an interview of 9/23/21 at 11:00 A.M., the Food Service Mananger said the fans should not have dust on them blowing toward the food.

Based on observations and interviews, the facility failed to ensure staff provided care in a manner that maintained respect and dignity and promoted the highest quality of life. Specifically, for three Residents (#12, #33, and #58), out of a total sample of 18 residents, and on 3 out of 4 units, meals were served to residents in disposable, three-compartment containers/ styrofoam plates with plastic utensils to eat their meals. Findings include: During an interview on 9/22/21 at 8:15 A.M., the surveyor observed Resident #58 sitting upright in bed, with a white, disposable, three-compartment container with food in it placed on an overbed table in front of him/her. Resident #58 said that he/she is not happy about eating out of the container because he/she has arthritis, and it is difficult getting the food out. The surveyor observed the Resident making multiple attempts to get eggs onto the plastic fork without it slipping off. The Resident said that they started using to-go containers two to three weeks ago, and that either the dish machine must be broken, or there's not enough help in the kitchen. During an interview on 9/22/21 at 8:30 A.M., the surveyor observed Resident #33 sitting in a chair at his/her bedside, with a white, disposable, three-compartment container with food in it placed on an overbed table in front of him/her. Resident #33 pointed to the disposable container and said that he/she hates it. The Resident said that he/she has a hard time eating food from the container, and plastic utensils are not sufficient to eat soft cooked eggs. Resident #33 said that the kitchen has been serving meals in to-go containers on and off for a few weeks because there is not enough staff in the kitchen to wash the dishes. During an interview on 9/23/21 at 10:57 A.M., the Food Service Manager (FSM) said that residents' meals were served in disposable containers with plastic utensils yesterday because there was only one cook, and two dietary aides working, and there was not enough staff to wash the dishes. The FSM said they use disposable items when staffing is low, which is frequent lately because they lost eight dietary staff two weeks ago. She said that the dementia unit always uses regular colored plates, and the other three units use disposable items. The FSM said she knows Residents eating from disposable items is not dignified, and they should eat meals from regular plates with silverware, but they just don't have enough staff. During an interview with Resident #12 on 9/28/21 at 8:08 A.M., the surveyor observed a dietary staff member enter the Resident's room and place the Resident's breakfast tray on the overbed table. The tray contained a Styrofoam plate with a piece of toast on it, covered with a clear plastic cover. The tray had plastic utensils (a plastic knife, fork and spoon). The Resident said, You never know, some days regular plates and silverware, and other days it's plastic. The Resident said that he/she does not like the plastic silverware, and that it is difficult to eat with them.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), who required the use of a mechanical lift for transfers, the facility failed to ensure staff used and he/she was provided with an appropriate assistive device during transfer to prevent an incident/accident resulting in injury. On 06/13/21, staff used the wrong type of mechanical lift sling (a toileting sling, open at the bottom to allow resident to be positioned on and use toilet without soiling sling) when attempting to transfer Resident #1 out of bed to a recliner. Staff were unfamiliar with that particular sling, and the sling was not a brand or type used by the facility. Resident #1 fell through the gap (open space) created at the bottom of the toileting sling, sustained a [CONDITION(S)] and required five staples to close his/her head wound. Findings include: Review of Resident #1's clinical record indicated that he/she was admitted to the Facility in August 2019 with diagnoses which included: Alzheimer's disease and [CONDITION(S)]. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that he/she had short-term and long-term memory problems, no recall, and severely impaired daily decision making skills. The MDS also indicated that Resident #1 required the extensive assistance of two or more persons with transfers. Review of Resident #1's Activities of Daily Living (ADL) Functional/Rehabilitation Potential care plan, start date 03/01/21, indicated to assist him/her with transfer using two person assist via Hoyer (a brand of mechanical lifts, also used to describe mechanical lifts from different manufacturers) transfers. The Care Plan did not indicate the type or size of sling to be used during transfers. Review of the Facility's Internal Investigation, dated 06/13/21, indicated that during a transfer out of bed using a mechanical lift, Resident #1 slid out of the sling used and landed on the floor. The Investigation indicated that Resident #1 sustained a hematoma (a collection of blood outside of the blood vessels most commonly caused by an injury) and a laceration to the back of his/her head. The Investigation indicated that Resident #1 was sent to the hospital and received five staples to close the laceration. Review of the Progress Note, dated 06/13/21 written by Nurse #1, indicated that Resident #1 slid out of the mechanical lift pad during a transfer from his/her bed to a recliner. The Note indicated that a laceration and a hematoma were observed to the posterior (back) portion of Resident #1's head. The Note indicated that Resident #1 was transferred to the emergency room , where he/she received five staples to close the laceration. During an interview on 07/13/21 at 11:36 A.M., Certified Nurse Aide (CNA) #1 said on 06/13/21, she prepared Resident #1 for a transfer out of bed by placing him/her into a sling and attaching it to the mechanical lift. CNA #1 said she had provided care to Resident #1 prior to 06/13/21, and said that the sling she used that day was already in Resident #1's room, but said it was not like the one she normally used for Resident #1. CNA #1 said CNA #2 assisted her with Resident #1's transfer, and said CNA #2 checked the sling to ensure it was attached correctly. CNA #1 said that during the transfer, Resident #1 said whoa, or words to that effect, and then slid through the sling, buttocks first onto the floor. CNA #1 said Resident #1 slid through a gap (open area) created in the sling near his/her buttocks. CNA #1 said the mechanical lift sling used for Resident #1 on 06/13/21 did not cover his/her entire body like the one she was used to using for Resident #1. CNA #1 said she had not seen or used that type of mechanical lift sling, prior to that day, but said she used it because it was the one left in Resident #1's room. During an interview on 07/13/21 at 10:49 A.M., CNA #2 she said that on 06/13/21, she assisted CNA #1 with Resident #1's transfer out of bed. CNA #2 said that when she entered Resident #1's room, he/she was already in the mechanical lift sling and said that the sling was attached to the mechanical lift. CNA #2 said she checked to ensure the sling was connected to the mechanical lift properly before they began the transfer. CNA #2 said that as Resident #1's body was moved up and away from the bed, he/she began to slip through the sling in a V shape, buttocks first. CNA #2 said the sling crossed over itself behind Resident #1's legs, and came around Resident #1 before attaching to the mechanical lift, which left a gap near his/her buttocks. CNA #2 said she and CNA #1 were unable to prevent Resident #1 from sliding through the gap and landing on the floor. CNA #2 said Resident #1 struck his/her head, which started to bleed. CNA #1 and CNA #2 said the mechanical lift sling did not disconnect from the lift itself, but said that Resident #1 slid through the gap (open area) created in the sling near his/her buttocks. CNA #1 and CNA #2 said that they were not familiar with the mechanical lift sling they used to transfer Resident #1 on 06/13/21. During an interview on 07/13/21 at 11:53 A.M., Nurse #1 said that when she entered Resident #1's room after being notified that he/she fell , she observed Resident #1 on the floor and the mechanical lift sling still attached to the mechanical lift. Nurse #1 said the sling appeared to be attached correctly, but said the sling was different than the one Resident #1 was usually transferred with. During an interview on 07/13/21 at 9:47 A.M. and at multiple times during the survey, the Director of Nurses (DON) said that after Resident #1's fall on 06/13/21, she found two mechanical lift slings that were not the type or brand used by the Facility. The DON said the two mechanical lift slings appeared to be of the same type and brand and included the one used for Resident #1 on 06/13/21. Observations with the DON on 07/13/21 at 1:52 P.M. of the mechanical lift sling used by CNA #1 and CNA #2 on 06/13/21 indicated that: - When it was used as described by CNA #1 and CNA #2: there would be an open area approximately 18 inches wide near where a person's buttocks would be, and of a variable depth from back to front based on the pressure applied to the sling; and, - The mechanical lift sling was identified as an Invacare brand and was observed to be gray in color with a green binding, but the size of the sling was not indicated on the label. Review of Invacare's online product catalog indicated that the mechanical lift sling observed on 07/13/21 was an Invacare [MEDICATION(S)] Series Dress Toileting High Sling, Large, and that it was a toileting sling for use with specific Invacare lifts. Review of the Invacare Patient Slings Owner's Operator and Maintenance Manual, dated 10/17/18, indicated that Invacare slings were made specifically for use with Invacare lifts. The Manual indicated that for the safety of the patient, do not intermix slings and lifts of different manufacturers. The DON said that the Facility used Linak mechanical lifts, not Invacare lifts. During observation of Resident #1's transfer out of bed on 07/13/21 at 10:00 A.M., CNA #3 and CNA #4 used a Linak brand lift.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, and assessed as having a decreased range of motion in his/her right upper extremity, the Facility failed to ensure staff followed and implemented interventions from his/her comprehensive plan of care for safety when being served hot beverages. On 11/10/20, the Cook heated hot cider to approximately 201 degrees (Fahrenheit) before pouring it into insulated carafes to be served to the residents as an activity. The Activity Director served the hot cider in a Styrofoam cup without a lid to Resident #1, who spilled the hot cider onto his/her lap, which resulted second degree (affects the first and second layers of the skin, blisters may develop and pain can be severe)[MEDICAL CONDITION] both of his/her upper thighs, which he/she required wound treatments and pain management. Findings Include: The Facility's Policy, titled Comprehensive Care Planning, dated March 2020, indicated that the Facility would develop a comprehensive care plan to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The Facility's Policy, titled Prevention of Hot Liquid Spills, dated February 2017, indicated that the Facility would ensure that residents would receive adequate supervision and assistance to prevent harm as a result of hot liquid spills. The Policy indicated that hot beverages be served at 160 - 180 degrees. The Policy indicated Styrofoam cups will not be used for hot liquids. The Facility's Investigation, dated 11/12/20, indicated that on 11/10/20, the Cook prepared hot cider for the Activities Department to pass out to residents. The Investigation indicated that the Cook heated the cider to 201 degrees (Fahrenheit) before pouring it into insulated carafes. The Investigation indicated the Activity Director served the hot cider in Styrofoam cups and without lids to residents. The Investigation indicated that Resident #1, who was sitting in his/her room, spilled hot cider onto his/her lap, which resulted in second [MEDICAL CONDITION] both of his/her thighs, and required ongoing wound treatment and pain management. Resident #1 was admitted to the Facility in January 2018, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set, dated dated [DATE], indicated that he/she was severely cognitively impaired, required limited assistance by staff while eating, and had impaired range of motion in one of his/her upper extremities. Review of Resident #1's Liquid Safety Assessment and Care Plan related to Safety, dated 9/30/20, indicated that while drinking hot beverages, Resident #1 required a cup with a lid, that Styrofoam cups would not be used for hot beverages, and the temperature of hot liquids would not exceed 150 degrees. During an interview on 11/24/20, at 11: 28 A.M., the Activity Director (AD) said that on 11/10/20, the kitchen prepared hot cider to be served to residents for an activity. The AD said that along with the carafes of hot cider, the activity cart had been set up with Styrofoam cups on top of it. The AD said she thought there may have been an issue with the Facility dishwasher and thought that's why there weren't any mugs on the activity cart. The AD said she served the hot cider using the Styrofoam cups to the residents. The AD said that she served hot cider in a Styrofoam cup, without a lid to Resident #1. The AD said she placed Resident #1's hot beverage on his/her bedside table. The AD said that she made a mistake serving the hot liquids in Styrofoam cups because she knew that it was unsafe, but she said she did not inquire with the kitchen about obtaining mugs for the hot cider. During an interview on 11/24/20 at 11:08 A.M., the Certified Nurse Aide (CNA) #1 said she was standing in the hallway on Resident #1's unit at approximately 3:00 P.M., and she heard Resident #1 say, It burns, it burns! CNA #1 said she then went to Resident #1's room, saw a Styrofoam cup on the ground and saw that Resident #1's pants were wet. During an interview on 11/24/20 at 12:10 P.M., Nurse #1 said that at the end of her shift (approximately 3:00 P.M.) on 11/10/20, she saw CNA #1 helping Resident #1 who looked like he/she was in pain and went over to assist. Nurse #1 said she and CNA #1 assisted Resident #1 remove his/her pants, and assisted him/her into bed, and said she saw blistering on Resident #1's thighs. The Nurse Progress Note, dated 11/11/20, indicated that the blisters on Resident #1's inner right thigh broke and he/she reported being in a maximum amount of pain. The Nurse Practitioner (NP) Progress Note, dated 11/12/20, indicated Resident #1 was served a hot beverage with no lid on 11/10/20, which spilled onto his/her lap and caused acute second [MEDICAL CONDITION] his/her bilateral thighs. The Note indicated that on 11/11/20, Resident #1's blisters broke and he/she had increased pain; therefore, he/she was given medication (increased Tylenol and [MEDICATION NAME] 25 milligrams (mg), every six hours as needed), and his/[MEDICAL CONDITION] treated with a cold pack and [MEDICATION NAME] dressings. The Wound Care Specialist Progress Note, dated 11/17/20, indicated Resident #1 had a second [MEDICAL CONDITION] on his/her left inner and right inner thighs. The Note indicated the left thigh burn was 7.5 centimeters (cm) long by 7.0 cm wide. The Note the right thigh burn was 12.0 cm long by 12.0 cm wide. During an interview on 11/30/20 at 11:00 A.M., the Director of Nursing (DON) said the Activity Director failed to follow Resident #1's Plan of Care, which indicated he/she required a cup with a lid and hot liquids were not be provided in Styrofoam cups.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, and assessed as having decreased range of motion of his/her right upper extremity, the Facility failed ensure he/she was provided with adequate supervision and that safety interventions were implemented to prevent an incident with injury. On 11/10/20, the Cook heated the hot cider to approximately 201 degrees (Fahrenheit) before pouring it into insulated carafes to be served to the residents as an activity. The Activity Director served the hot cider in a Styrofoam cup without a lid to Resident #1, he/she spilled the hot cider onto his/her lap, and sustained second degree (affects the first and second layers of the skin, blisters may develop and pain can be severe)[MEDICAL CONDITION] both of his/her upper thighs, which required wound care treatment and pain management Findings Include: The Facility's Policy, titled Prevention of Hot Liquid Spills, dated February 2017, indicated that the Facility would ensure that residents would receive adequate supervision and assistance to prevent harm as a result of hot liquid spills. The Policy indicated that hot beverages be served at 160 - 180 degrees. The Policy indicated Styrofoam cups will not be used for hot liquids. Resident #1 was admitted to the Facility in January 2018, with [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set, dated dated [DATE], indicated that he/she was severely cognitively impaired, required limited assistance by staff while eating, and had impairment in range of motion in one of his/her upper extremities. Review of Resident #1's Liquid Safety Assessment and Care Plan Form, dated 9/30/20, indicated that while drinking hot beverages, Resident #1 required a cup with a lid, Styrofoam cups would not be used for hot beverages, and the temperature of liquids would not exceed 150 degrees. Review of Resident #1's medical record indicated he/she received Occupational Therapy (OT) from 9/30/20 to 10/13/20 due to a displaced fracture of his/her right styloid process (wrist) and muscle weakness. The Nursing Progress Note, dated 11/6/20, indicated that Resident #1 removed the cast on his/her right wrist, which was noted to be swollen, and required physical therapy to apply a splint to his/her right wrist until his/her next orthopedic appointment. The Facility's Investigation, dated 11/12/20, indicated that on 11/10/20, the Cook prepared hot cider for the Activities Department to pass out to residents. The Investigation indicated that the Cook heated the cider to 201 degrees (Fahrenheit) before pouring it into carafes. The Investigation indicated the Activity Director served the hot cider to residents in Styrofoam cups and without lids. The Investigation indicated that Resident #1, who was sitting in his/her room, spilled hot cider on to his/her lap which resulted in second [MEDICAL CONDITION] both of his/her thighs, and [MEDICAL CONDITION] wound treatment and pain management. The Nurse Progress Note, dated 11/11/20, indicated that the blisters on Resident #1's inner right thigh broke and he/she reported being in a maximum amount of pain. The Nurse Practitioner (NP) Progress Note, dated 11/12/20, indicated Resident #1 was served a hot beverage with no lid on 11/10/20, which spilled onto his/her lap and caused acute second [MEDICAL CONDITION] his/her bilateral thighs. The Note indicated that on 11/11/20, Resident #1's blisters broke and he/she had increased pain; therefore, he/she was given medication (increased Tylenol and [MEDICATION NAME] 25 milligrams (mg), every six hours as needed), and his/her burn was treated with a cold pack and with [MEDICATION NAME] dressings. The Nurse Progress Note, dated 11/13/20, indicated that Resident #1 was restless and moaning in bed and required pain medication in the morning. The Nurse Progress Note, dated 11/13/20, indicated that Resident #1 was moaning and had facial grimacing throughout the evening shift and he/she did not have pain relief from medication. The Note indicated an order for [REDACTED]. The Nurse Progress Note, dated 11/15/20, indicated that Resident #1 periodically displayed increased facial grimacing, crying, and moaning. The Note indicated new orders were obtained to increase Resident #1's [MEDICATION NAME] to 50 mg every four hours as needed. The Nurse Progress Note, dated 11/16/20, indicated that Resident #1 had been fidgeting, moaning, and was attempting to touch his/her burns. The Note indicated that Resident #1 said he/she was in pain. The Note indicated Resident #1 removed the dressings from his/her burns. The Nurse Practitioner Progress Note, dated 11/17/20, indicated Resident #1's pain had been uncontrollable lately; therefore, [MEDICATION NAME] 5 mg was ordered every four hours as needed on 11/16/20, which provided him/her with pain relief. The Wound Care Specialist Progress Note, dated 11/17/20, indicated Resident #1 had second [MEDICAL CONDITION] on his/her left inner and right inner thighs. The Note indicated the left thigh burn was 7.5 centimeters (cm) long by 7.0 cm wide. The Note the right thigh burn was 12.0 cm long by 12.0 cm wide. The Nurse Progress Note, dated 11/18/20, indicated that Resident #1 was restless, agitated, and had picked at his/her wound dressings. The Nurse Progress Note, dated 11/20/20, indicated that Resident #1 refused to allow staff to change the dressings on his/her burns. The Wound Care Specialist Progress Note, dated 11/23/20, indicated treat to Resident #1's second [MEDICAL CONDITION] ongoing. The Note indicated the left inner thigh second degree burn now measured 4.8 cm long by 3.8 cm wide. The Note indicated the second degree burn on his/her right inner thigh, now measured 10.0 cm long by 8.5 cm wide. The Note indicated the plan was to continue to treat [MEDICAL CONDITION] and cover with gauze dressing daily, and as needed. The Nurse Practitioner Progress Note, dated 11/24/20, indicated that Resident #1 had experienced [MEDICAL CONDITION] from taking [MEDICATION NAME], therefore, the medication was discontinued. The Note indicated Resident #1's pain was being managed with Tylenol, [MEDICATION NAME], and Trazadone as needed for restlessness. During an interview on 11/24/20, at 11: 28 A.M., the Activity Director (AD) said that on 11/10/20, the kitchen prepared hot cider to be served to residents for an activity. The AD said that along with the hot cider that was in insulated carafes, said the activity cart had been set up with Styrofoam cups on top of it. The AD said she thought there may have been an issue with the Facility dishwasher and thought that's why there weren't any mugs on the activity cart. The AD said she served the hot cider using the Styrofoam cups to the residents. The AD said that she served hot cider in a Styrofoam cup, without a lid on it to Resident #1. The AD said she placed Resident #1's hot beverage on his/her bedside table. The AD said Resident #1 spilled the hot cider onto his/her lap and sustained burns. The AD said that she made a mistake serving the hot liquids in Styrofoam cups because she knew that it was unsafe, but she said she did not inquire with the kitchen about obtaining mugs for the hot cider. During an interview on 11/24/20, at 11:58 A.M., the Cook said that on 11/10/20, she had prepared hot cider for a resident activity. The Cook said she heated the hot cider to 201 degrees before pouring it into the carafes on the activity cart. The Cook said she heated the cider to that temperature because she anticipated the hot cider would sit for a while before being served to the residents. During an interview on 11/24/20 at 11:08 A.M., the Certified Nurse Aide (CNA) #1 said she was standing in the hallway on Resident #1's unit at approximately 3:00 P.M., and she heard Resident #1 say, It burns, it burns! CNA #1 said she then went to Resident #1's room, saw a Styrofoam cup on the ground and saw that Resident #1's pants were wet. During an interview on 11/24/20 at 12:10 P.M., Nurse #1 said that at the end of her shift (approximately 3:00 P.M.) on 11/10/20, she saw CNA #1 helping Resident #1 who looked like he/she was in pain and went over to assist. Nurse #1 said she and CNA #1 assisted Resident #1 remove his/her pants, and assisted him/her into bed, and said she saw blistering on Resident #1's thighs. Nurse #1 said that she went to grab an ice pack and when she returned, she saw that Resident #1's blisters had opened up. During an interview on 11/30/20 at 11:00 A.M., the Director of Nursing (DON) said that the Cook heated the hot cider too high, which violated the Facility Hot Liquid Policy. The DON said the Activity Director also violated the Facility's Hot Liquid Policy by providing hot beverages in Styrofoam cups to the residents. The DON said the Activity Director also failed to follow Resident #1's Plan of Care, which indicated he/she required a cup with a lid and hot liquids not be provided in Styrofoam cups.

Based on observation, record review and interview, the facility staff failed to maintain acceptable parameters of nutritional status and weight monitoring for 2 Resident (#35 and #49,) out of 24 sampled Residents. Facility policy titled Weight Monitoring, revision date 3/19 indicated the following: - All residents/patients will be weighed weekly or as ordered. - Once weights are obtained, the weights MUST be reviewed by a licensed nurse. -The nurse will check for technical accuracy, and will request that a resident/patient be reweighed in the event of a discrepancy of more than 3 pounds up or down. 1. Resident #49 was admitted to the Facility in 7/2012 with [DIAGNOSES REDACTED]. The most recent comprehensive significant change minimum data set (MDS) with an assessment reference date of 3/28/19, indicated Resident #49 was dependent with transfers, toileting and hygiene. He/She required an extensive assist with eating and was non-ambulatory. Review of the clinical record indicated Resident #49 had a 12.3% weight loss in one month. The following weights were recorded: - 4/18/19: 90.6 pounds (lbs) - 4/23/19: 92.6 lbs - 4/30/19: 92.4 lbs - 5/15/19: 85.6 lbs - 5/21/19: 81.2 lbs Further review of the clinical record indicated there were no reweights located in the medical record following the weight loss. There was no indication in the medical record that the weight recorded on 5/15/19 or 5/21/19 were addressed by the Dietician, the nursing staff or that the Physician was notified of the change. The care plan, titled Nutritional Status, with a reviewed/revised date of 4/4/19, indicated Resident #49 was at risk for alteration in nutrition, hydration and electrolyte imbalance secondary to GI issues, constipation and decreased appetite with a goal to consume at least 75% at each meal served. Interventions included: to provide house diet as ordered, provide preferred foods, encourage intake to at least 75% at each meal served, weights as ordered, assess any weight change, assist with meals as needed and to offer supplements and magic cups to optimize intake as accepted. There was no revision or update indicated on the care plan following the recorded weight loss on 5/15/19 or 5/21/19. An interview was conducted with the Dietician on 5/24/19 at 11:22 A.M. She said she was not informed about the weight loss for Resident #49, and said she usually reviews a weight variance report weekly to identify potential weight discrepancies and this weight loss for Resident #49 was missed. She said a reweigh should have been done and the care plan should have been updated. 2. For Resident #35, to the extent possible, the Facility staff failed to address the Resident's significant weight loss, as evident by not altering or attempting to alter the plan of care for nutrition. Resident #35 was admitted to the Facility in 7/2015 with [DIAGNOSES REDACTED]. Review of the Significant change MDS, with a reference date of 9/18/18, indicated Resident #35 had severe cognitive impairment, required supervision or cueing with meals, was 65 (5' 5) inches tall, weighed 163 pounds and received a mechanically altered diet. The Resident's health care proxy was invoked. Review of the Quarterly MDS, dated [DATE], indicated the Resident's weight was 154 pounds and the MDS did not indicate a significant weight loss, although it was a total of 9 pounds in 180 days. The most recent Quarterly MDS, dated [DATE], indicated a weight of 147 pounds. The MDS indicated it was a significant weight loss and that it was not prescribed by the physician. According to the weight record the Resident's weights were as follows: 1/8/2019 - 153 pounds. 2/14/2019 - 145.2 pounds, a significant weight loss of 7.5 pounds in less than 30 days. 3/5/2019 - 150 pounds. 4/2/2019 - 143.4 pounds. 5/7/2019 - 134 pounds, a 12.42%/19.2 pounds, weight loss since 1/2019. Review of the diet orders indicated Resident #35 received a house mechanical soft diet with ground meat and nectar thick liquids. In addition, house supplements had been offered to the Resident twice a day and extra fluids. Review of the nutrition plan of care that was initiated on 10/19/16 and last reviewed on 3/21/19, indicated the Resident required a mechanically altered diet due to dysphagia and had experienced a significant weight loss over the past 6 months. The goal was for the Resident to consume at least 75% at each meal and supplement served. The interventions included diet as order, medications as ordered, supervise and assist at all meals, weights as ordered, assess any weight change, maintain aspiration precautions every shift, supplements as ordered and all hot beverages will be in a cup with a lid and not administered without supervision. On 12/18/18 and 1/3/19, the Dietician's Quarterly assessments indicated the Resident was provided supervision with meals. The assessment indicated the Resident's intake varied and was more often than not noted to 25 - 50% of each meal/supplement. The 12/18/18 assessment indicated the Resident weight loss was 8.8 pounds in 3 months and a total of 13 pounds in 6 months, with a current weight at 154.4 pounds verses stable weight range of 171 - 174 pounds. The Dietician indicated the Resident was at risk for alteration in nutrition and that during the past 6 months had been ill. The Dietician made no changes in the plan of care. On 3/21/19, the Dietician's Quarterly assessment included the same information as the 2 previous assessments, diet type, strategies for swallowing and intake varies from 50 to 100 %. The assessment indicated Resident #35 had a significant weight loss, but failed to include the total weight loss in her assessment. The plan of care was reviewed, but interventions were generic and did not indicate that alternate strategies were implemented for the Resident with dementia. Review of the Interdisciplinary notes from 2/11/19 through 5/21/19, indicated the nursing staff were documenting the Resident's weights and intake. The nursing staff often documented the Resident had a poor appetite. The nursing staff documented a weekly note and weekly Risk Meeting notes were included in the Resident's record. Although, the staff documented the Resident was at risk for weight loss and had weight loss, the plan of care was not altered. The staff indicated his/her meals and supplements were provided as ordered and the Resident was assisted with meals. The staff documentation indicated the Resident's weight loss was identified by the staff, but there was no indication the Staff addressed the ongoing weight loss in an attempt to slow down the process. During interview on 5/24/19 at 11:00 A.M., with Unit Manager #1, she said she was aware of the Resident's weight loss. She said that it was discussed weekly and that she or another staff would document in the record. Unit Manager #1 did not know what interventions were in place in attempt to slow down the weight loss. During interview on 5/24/19 at 12:30 P.M., the Dietician said she was aware of the Resident's weight loss. She said that she use to have weekly weight meetings, but now the facility holds Risk meetings. The Dietician said she does not always attend the Risk Meeting and therefore may have missed some information. The plan of care was reviewed and the Dietician said she was unaware the plan of care was not resident centered. She said she would look at the Resident weights and put in a note.

Based on record review and interview the Facility staff failed to ensure adequate supervision and assistance devices were provided to prevent accidents for one Resident (#65) in a total sample of 21 Residents, resulting in three fractured fingers. Findings include: Review of the Facility falls prevention and management policy indicated the following: -The licensed nurse will initiate or revise the care plan as necessary and review with nursing staff -The Accident/Incident Report, along with the initial investigation, updated care plan and copy of the Fall Risk Assessment are routed to the Director of Nursing (DON) within 24 hours of the occurrence -The supervisor, Unit Manager, or DON will complete the final investigation with a summary report of conclusions and recommendations for further interventions when necessary. Resident #65 was admitted to the Facility in 10/2017 with [DIAGNOSES REDACTED]. For Resident #65, a review was conducted of the Minimum Data Set (MDS) with a reference date of 10/23/17. The MDS indicated the Resident walked with limited assistance of one staff member and utilized a walker. The Resident was observed on 02/13/18 at 1:42 P.M. to be in the unit main dining/activity area, sitting in a dining room chair with an alarm underneath him/her. The Resident was observed to stand from the chair (alarm sounded) and ambulated, staff supervised. A review was conducted of a fall investigation worksheet for 11/28/17. The worksheet indicated that on 11/28/17 at 12:00 A.M., Resident #65 was found lying on the bathroom floor with an abrasion to the right side of the forehead. The worksheet indicated the Resident was attempting to go to the bathroom and did not require supervision. The recommendations/intervention section completed by the nurse indicated that the Resident had received milk of magnesia for constipation earlier on the shift and was incontinent of bowel and slipped on the loose stool, with a plan to have a commode at bedside when laxative medication was given. A review of the Fall Care Plan was conducted. The care plan was initiated on 11/1/17. There was no indication of the addition of the intervention of a commode at bedside when given a laxative. The written care plan indicated that interventions were initiated on 11/1/17 with a revision and additional interventions on 12/11/17. A review was conducted of a fall investigation for 12/09/17. The investigation indicated that on 12/9/17 at 4:12 A.M., Resident #65 was found lying on the floor in his/her room and stated he/she had come out of the bathroom. Review of the investigation indicated that an x-ray demonstrated fractures of the first, second, and third fingers on the left hand. The interventions following the fall included changing the order for milk of magnesia to be given in the morning if needed and checking on the Resident every two hours when in bed and ask to be toileted if in bed. Review of the Medication Administration Record [REDACTED].M. The investigation did not indicate that a commode had been placed at the Residents bedside as indicated from the previous fall on 11/28/17. Unit Manager #3 was interviewed on 02/20/18 at 8:25 A.M. The Unit Manager reviewed the care plan for Resident #65 with the surveyor. The Unit Manager could not indicate if any changes to the care plan were made after the fall in loose stool in the bathroom on 11/29/17. The Unit Manager said she could not recall that the nurse had recommended an intervention of placing the commode at the bedside. The Unit Manager said she had not provided information to the staff regarding the change to the Residents plan of care. The Unit Manager said that there was no documentation that the commode was used on 12/09/18.

Based on clinical record review and staff interview, the facility failed to ensure that 1 Resident (#165) was free of any significant medication errors, in a total sample of 21. Findings include: For Resident #165, the facility failed to administer medications in accordance with professional standards. Resident #165 received, Resident #166's medications along with his/her own medications, which then resulted in Resident #165 requiring a 5 day hospitalization . Standard of Practice for medication administration are as follows: -Nurses are responsible for administering medications within their scope of practice. -Nurses are knowledgeable about the effects, side effects and interactions of medications and take action as necessary. -Nurses adhere to seven rights of medication administration: 1. Right medication, 2. Right patient 3. Right dose 4. Right time 5. Right route 6. Right reason 7. Right documentation. Resident #165 was admitted to the facility in 11/2107 with [DIAGNOSES REDACTED]. Clinical record review indicated that on 12/2/17 during the morning medication pass (approximately 9:00 A.M.), Agency Nurse #1 administered Resident #165's medications as ordered. Agency Nurse #1 then proceeded to administer Resident #166's medications to Resident #165. This resulted in Resident #165 receiving the following medications: [REDACTED] (Resident #165 medications): -[MEDICATION NAME] coated aspirin 81 milligrams(mg) 1 tablet -Calcium Antacid (tums) 500 mg, 2 tablets -[MEDICATION NAME] (antidepressant) 20 mg 1 tablet -Vitamin D3 1000 international units (iu) 3 tablets -[MEDICATION NAME] ( used to reduce extra fluid in the body ([MEDICAL CONDITION]) caused by conditions such as heart failure) 20 mg, 3 tablets (Resident #166 medications): [MEDICATION NAME]-[MEDICATION NAME] (used to treat high blood pressure and chest pain) 5-20 mg 1 capsule [MEDICATION NAME] coated aspirin 81 mg 1 tablet [MEDICATION NAME] (stool softener) 100 mg 1 capsule Indapamide (Diuretic used to treat high blood pressure and fluid retention) 2.5 mg, 2 tablets [MEDICATION NAME] (iron supplement) 324 mg, 1 tablet [MEDICATION NAME], extended release, (used to treat high blood pressure) 100 mg, 1 tablet Potassium (mineral supplement) 20 meq, 2 tablets [MEDICATION NAME] ([MEDICAL CONDITION] medication and antihypertensive drug used to treat high blood pressure and enlarged prostate) 5 mg 1 capsule Agency Nurse #1 immediately realized that she had made a mistake and administered the Resident the wrong medications. Every 10 to 15 minute vital sign checks/condition monitoring was initiated. At 12:00 P.M. on 12/2/17, the Residents blood pressure was 80/48, and the measures that had been put in place to increase the blood pressure were not effective (The Resident was given extra fluids and saltines to increase the blood pressure). The Resident was then sent out to the emergency room (911 was called). Review of the discharge summary from the hospital revealed that Resident #165 was admitted to the hospital from 12/2/17 through 12/7/17 with a [DIAGNOSES REDACTED].

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1) the facility failed to ensure acceptable standards of practice were followed on 1/24/17, when an unlicensed staff member applied an instant hot pack incorrectly to Resident #1's right knee, without a physician's orders [REDACTED].#1 sustained a second degree burn (red, blistered area) to his/her right upper thigh just above knee. Findings include: 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. The Facility Policy, titled Hot Packs, dated 3/10/14, indicated to verify physician's orders [REDACTED]. Resident #1's medical history included [DIAGNOSES REDACTED], [MEDICAL CONDITION], muscle weakness, difficulty ambulating, and bilateral lower extremity (BLE) [MEDICAL CONDITION]. Resident #1's admission physician's orders [REDACTED]. Resident #1's Treatment Administration Record (TAR), dated 1/21/17 through 1/31/17, indicated apply Cryotherapy ( treatment that uses a method of localized freezing temperatures to deaden an irritated nerve) four times for 20 minutes as needed for pain and swelling. An Accident/Incident Report, dated 1/24/17, indicated while assisting Resident #1 out of bed to use the bathroom, Nurse #1 noticed a hot pack strapped to Resident #1's right knee. The Report indicated Nurse #1 removed the hot pack and observed a reddened area and small pea sized blister approximately one inch above Resident #1's right knee. The Report indicated Certified Nurse Aide (CNA) #1 applied the hot pack to Resident #1's right knee with a paper towel as a barrier, and secured it with a Velcro strap. The Report indicated the area was evaluated by the Nurse Practitioner, with an order for [REDACTED]. Review of Resident #1's medical record indicated there was no documentation to support Resident #1 had a physician's orders [REDACTED]. The Instant Hot Pack instructions, printed directly on the hot pack indicated, approximate peak temperature is 120 degrees Fahrenheit with a therapeutic time line of 30 minutes, once activated, do not apply against unprotected skin, wrap in soft cloth and apply. The Nurse's Note, dated 1/24/17, indicated upon assisting Resident #1 out of bed the nurse noticed a hot pack strapped onto Resident #1's right knee with Velcro strap and the hot pack was wrapped with two paper towels as a barrier. The Note indicated Resident #1's right knee had an reddened area the size of hot pack with a fluid filled blister the size of a pea, will pass on and continue to monitor. Resident #1's physician's orders [REDACTED]. Resident #1's TAR, dated 1/24/17, indicated apply [MEDICATION NAME] cream topically two times a day to burn on right thigh for three days or until healed. Resident #1's TAR, dated 1/27/17, indicated apply [MEDICATION NAME] cream topically to burn on right thigh two times a day for two more days. The Surveyor interviewed Nurse #1 at 7:26 A.M., on 2/28/17. Nurse #1 said she was Resident #1's primary nurse on the night shift on 1/24/17. Nurse #1 said shortly after midnight she assisted Resident #1 out of bed, observed a hot pack strapped to Resident #1's right knee, and immediately removed the hot pack to assess Resident #1's skin. Nurse #1 said Resident #1's right knee area was reddened the same size as the hot pack, there was a small single fluid filled blister the size of a pea just above Resident #1's right knee, and that Resident #1 denied discomfort. Nurse #1 said she asked Resident #1 how the hot pack got there, and said Resident #1 told her he/she asked Certified Nurse Aide (CNA) #1 to put a hot pack on his/her knee for discomfort. Nurse #1 said CNA #1 did not ask her if Resident #1 could have a hot pack. Nurse #1 said CNA #1 did not tell her she put a hot pack on Resident #1's right knee, and said she had no idea how long that hot pack had been in place. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 10:44 A.M., on 2/27/17. CNA #1 said on 1/24/17 during the 11:00 P.M., to 7:00 A.M., shift (unable to recall exact time) Resident #1 asked her for a hot pack for his/her right knee discomfort. CNA #1 said she asked a nurse (does not recall name) if Resident #1 could have an hot pack, the nurse said yes, told her where the hot packs were stored, and said the nurse told her she could apply the hot pack to Resident #1's right knee. CNA #1 said Resident #1 told her she only wanted a paper towel as a barrier, and said Resident #1 told her to use the Velcro strap to keep the hot pack in place so it would not slip off. The Surveyor interviewed the Staff Development Coordinator (SDC) at 10:32 A.M., on 2/27/17. The SDC said it was Facility practice that CNA's should not put hot packs on residents. The Surveyor interviewed the Unit Manager at 10:55 A.M., on 2/27/17. The Unit Manager said it was not acceptable practice for a nurse to direct or delegate application of a hot pack on a resident to a CNA. The Surveyor interviewed the Director of Nurse's (DON) at 8:30 A.M., on 2/27/17 and at various times through out the day. The DON said it was not within CNA #1's scope of practice to apply Resident #1's hot pack, and said applying a hot pack to a resident is considered a treatment and would be a nursing responsibility.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure on 1/24/17 an instant hot pack applied to Resident #1's right knee was done correctly and as a result Resident #1 sustained a second degree burn (red, blistered area) to his/her right upper thigh just above knee. Findings include: The Facility Policy, titled Hot Packs, dated 3/10/14, indicated to verify physician's orders [REDACTED]. Resident #1's medical history included [DIAGNOSES REDACTED], osteoarthritis, muscle weakness, difficulty ambulating, and bilateral lower extremity (BLE) edema. Resident #1's admission physician's orders [REDACTED]. Resident #1's Treatment Administration Record (TAR), dated 1/21/17 through 1/31/17, indicated apply Cryotherapy ( treatment that uses a method of localized freezing temperatures to deaden an irritated nerve) four times for 20 minutes as needed for pain and swelling. An Accident/incident Report, dated 1/24/17, indicated while assisting Resident #1 out of bed to use the bathroom, Nurse #1 noticed a hot pack strapped to Resident #1's right knee. The Report indicated Nurse #1 removed the hot pack and observed a reddened area and small pea sized blister approximately one inch above Resident #1's right knee. The Report indicated Certified Nurse Aide (CNA) #1 applied the hot pack to Resident #1's right knee with a paper towel as a barrier, and secured it with a Velcro strap. The Report indicated the area was evaluated by the Nurse Practitioner, with an order for [REDACTED]. Review of Resident #1 medical record indicated there was no documentation to indicated Resident #1 had a physician's orders [REDACTED]. The Instant Hot Pack instructions, printed directly on the hot pack indicated, approximate peak temperature is 120 degrees Fahrenheit with a therapeutic time line of 30 minutes, once activated, do not apply against unprotected skin, wrap in soft cloth and apply. The Nurse's Note, dated 1/24/17, indicated right knee noted to have reddened area the size of hot pack with fluid filled blister the size of a pea, will pass on and continue to monitor. Resident #1's physician's orders [REDACTED]. The Nurse Practitioner note, dated 1/24/17, indicated Resident #1 asked for a hot pack overnight, hot pack was strapped down to his/her right thigh so it would not shift, and upon removal redness and blistering was noted to right upper thigh. The Nurse's Note, dated 1/25/17, indicated Silvadene applied to small fluid filled blister on right upper thigh. The Surveyor interviewed Nurse #1 at 7:26 A.M., on 2/28/17. Nurse #1 said she was Resident #1's primary nurse on the night shift on 1/24/17. Nurse #1 said shortly after midnight she assisted Resident #1 out of bed, observed a hot pack strapped to Resident #1's right knee, and immediately removed the hot pack to assess Resident #1's skin. Nurse #1 said Resident #1's right knee area was reddened the same size as the hot pack, there was a small single fluid filled blister the size of a pea just above Resident #1's right knee, and that Resident #1 denied discomfort. Nurse #1 said she asked Resident #1 how the hot pack got there, and said Resident #1 told her he/she asked Certified Nurse Aide (CNA) #1 to put a hot pack on his/her knee for discomfort. Nurse #1 said CNA #1 did not ask her if Resident #1 could have a hot pack. Nurse #1 said CNA #1 did not tell her she put a hot pack on Resident #1's right knee, and said she had no idea how long that hot pack had been in place. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 10:44 A.M., on 2/27/17. CNA #1 said on 1/24/17 during the 11:00 P.M., to 7:00 A.M., shift (unable to recall exact time) Resident #1 asked her for a hot pack for his/her right knee. CNA #1 said she asked a nurse (does not recall name) if Resident #1 could have an hot pack, the nurse said yes, told her where the hot pack were stored, and said the nurse told her she could apply the hot pack to Resident #1's right knee. CNA #1 said Resident #1 told her she only wanted a paper towel as a barrier, and said Resident #1 told her to use the Velcro strap to keep the hot pack in place so it would not slip off.

Based on observation, record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1, who had a [DIAGNOSES REDACTED]. In addition, the Facility failed to ensure that the liquids served to Resident #1 were not hotter than 150 degrees Fahrenheit (F.), per Facility protocol. On 9/20/11, at 8:15 A.M., Resident #1 was served a cup of tea made with hot water from the kitchen; the temperature of the hot water used to make the tea was 176 degrees F. Certified Nurse Aide (CNA) #1 set-up Resident #1 for breakfast and did not supervise Resident # 1. Resident #1 spilled the tea on Resident #1's self, and sustained a second degree burn (a burn that damages epidermal and some dermal tissues ... the burn is painful and red; blisters form, and wounds may heal with a scar) on the left outer thigh. Findings included: The Admission Assessment, dated 9/16/11, indicated that Resident #1 was admitted to the Facility in September, 2011 and Resident #1's [DIAGNOSES REDACTED]. The Admission Assessment also indicated that Resident #1 had decreased sensation and coordination in Resident #1's upper and lower extremities due to Parkinson's disease. The CNA Care Plan, dated 9/16/11, indicated that Resident #1 independently ate breakfast, lunch, and dinner in Resident #1's room after the meal served was set up. The Nutritional Assessment, dated 9/16/11, indicated that Resident #1 experienced severe osteoarthritis and Parkinson's disease. The Nutritional Assessment indicated that Resident #1 consumed each meal independently in Resident #1's room and Resident #1 was to be assisted with set up and meat cutting. The Hospital Social Worker (SW) was interviewed at 1:55 PM on 10/6/11. The Hospital SW said Family Member #1 told the Hospital SW Family Member #1 requested that nursing staff at the Facility supervise Resident #1 while eating. The Hospital SW said Family Member #1 told the Hospital SW that the Facility did not acknowledge Family Member #1's request. The Hospital SW said Family Member #1 also requested that nursing staff not serve hot beverages to Resident #1 because Resident #1 had Parkinson ' s disease and tremors. The Hospital SW said Family Member #1 said to the Hospital SW that Resident #1 was served hot tea and Resident #1 spilled the hot tea on Resident #1's bilateral inner thighs on 9/20/11 and sustained a burn. The Hospital SW also said that on 9/21/11, Resident #1 was served a half cup of tea and Resident #1 spilled the hot tea on Resident #1's left forearm, with no apparent injury noted. Family Member #1 was interviewed at 3:00 PM on 10/6/11. Family Member #1 said on 9/19/11, at approximately 7:00 PM, Family Member # 1 noticed that Resident #1 had a change in mental status. Family Member #1 said Family Member #1 talked to the nursing staff and requested that Resident #1 receive assistance with eating especially with drinking hot liquids. Family Member #1 said on 9/20/11 after Resident #1 spilled the hot tea on Resident #1's bilateral inner thighs, Unit Manager #1 notified Family Member #1. Family Member #1 said Unit Manager #1 told Family Member #1 that Resident #1 had no apparent injury and Resident #1 was stable. Family Member #1 said Unit Manager #1 told Family Member #1 that Unit Manager #1 had requested weighted utensils for Resident #1. Family Member #1 said on 9/21/11, at approximately 9:00 AM, Unit Manager #1 notified Family Member #1 that Resident #1 was served hot tea again and Resident #1 spilled the hot tea with no apparent injury. Family Member #1 said Family Member #1 visited Resident #1 on 9/21/11 at 8:30 PM and Family Member #1 requested to see Resident #1's burned area. Family Member #1 said Family Member #1 observed a large blister on Resident #1's left outer thigh. The Director of Nurses (DON) was interviewed at 9:30 AM on 10/06/11. The DON said Resident #1 was independent for eating and required set up only. The DON said on 9/20/11, the day of the first burn incident Resident #1 was served hot tea in a cup without a lid. The DON said Resident #1 spilled the hot tea and Resident #1sustained a second degree burn on the left outer thigh. The DON said the DON interviewed nursing staff about the aforementioned incident; the DON said nursing staff told the DON that Resident # 1 did not require assistance for eating. The DON said no new interventions were implemented after Resident #1 spilled the hot tea on 9/20/11, consequently on 9/21/11 Resident #1 was served a half cup of tea with breakfast and Resident #1 spilled the hot tea on Resident #1's left forearm with no apparent injury. Unit Manager #1 was interviewed on 10/6/11 at 10:15 AM; Nursing Supervisor #1 was interviewed on 10/6/11 at 2:50 PM; the Nurse Practitioner (NP) was interviewed on 10/6/11, at 1:10 PM, and Nurse #1 was interviewed on 10/11/11, at 9:15 AM. Unit Manager #1, Nursing Supervisor #1, the NP, and Nurse #1 said Unit Manager #1, Nursing Supervisor #1, the NP, and Nurse #1 were not aware that Resident #1 had Parkinson's disease and tremors. CNA #1 was interviewed at 11:00 AM on 10/6/11. CNA #1 said CNA #1 was passing by Resident #1's room at approximately 8:15 AM on 9/20/11 when Resident #1 called CNA #1 and said to CNA #1 that Resident #1 spilled hot tea on self. CNA #1 said CNA #1 immediately removed Resident #1's clothing and applied a cold compress to Resident #1's bilateral inner thighs and called the nurse. CNA #1 said the area was pink and intact. Nurse #1 said Nurse #1 provided care to Resident #1 on 9/20/11. Nurse #1 said at approximately 8:15 AM, CNA #1 reported to Nurse #1 that Resident #1 spilled hot tea on Resident #1's bilateral inner thighs. Nurse #1 said Nurse #1 asked Unit Manager #1 to assess Resident #1. Nurse #1 said Unit Manager #1 assessed Resident #1's bilateral inner thighs. Nurse #1 said Unit Manager #1 reported to Nurse #1 that Resident #1's skin was intact. The nurse's note, dated 9/20/11 from 3:00 to 11:00 PM shift, indicated that Resident #1 was given a cup of tea and the tea spilled on Resident #1. The nurse's note indicated that Resident #1's skin on the bilateral inner thighs was slightly pink and no redness and sign of injury were noted. Unit Manager #1 said at approximately 8:15 AM on 9/20/11, Resident #1 spilled hot tea on Resident #1's bilateral inner thighs. Unit Manager #1 said the area became slightly pink, the skin was intact and the Nurse Practitioner was notified. Unit Manager #1 said a Physician order [REDACTED]. Unit Manager #1 said Resident #1's Family was also notified. The physician order, written by the Nurse Practitioner (NP) at 10:00 AM on 9/20/11, included: assess Resident #1's bilateral inner thighs every shift for forty eight hours for redness and a burn. Nursing Supervisor #1 was interviewed at 2:50 PM on 10/6/11. Nursing Supervisor #1 said, on 9/20/11 Nursing Supervisor #1 took report from the 7:00 AM to 3:00 PM shift and learned that Resident #1 spilled hot tea on Resident #1's bilateral inner thighs with no apparent injury noted. CNA #2 was interviewed at 12:55 PM on 10/6/11. CNA #2 said on 9/21/11, CNA #2 assisted CNA #1 in providing care to Resident #1 and CNA #2 noticed a blister on Resident #1's left outer thigh. CNA #2 said CNA #1 and CNA #2 reported the blister observed on Resident #1's left outer thigh immediately to Nursing Supervisor #1. On 9/21/11 from the 3:00 PM to 11:00 PM shift, Nursing Supervisor #1 said as CNA #2 was assisting Resident #1 with toileting, CNA #2 noticed Resident #1 had a blister on the left outer thigh. Nursing Supervisor #1 said Nursing Supervisor #1 assessed the blister. Nursing Supervisor #1 said Nursing Supervisor #1 measured the blister and found it to be one centimeter by one centimeter in diameter. Nursing Supervisor #1 said Nursing Supervisor #1 notified the Physician on 9/21/11 at approximately 7:30 PM and obtained an order from the Physician for silvadene to be applied to the affected area twice a day. The Physician order, written at 7:45 PM on 9/21/11, included: cleanse with normal saline, apply silvadene cream 1% to the burn area followed by Telfa dressing. The Physician order [REDACTED]. The Occupational Therapy (OT) Narrative, dated 9/21/11, indicated nursing staff reported to OT that Resident #1 spilled hot tea on self at approximately 8:15 AM on 9/20/11. The Occupational Therapy Narrative indicated OT #1 tried five different sippy cups with Resident #1 and was unsuccessful due to Resident #1's decreased strength. The Occupational Therapy Narrative described the sippy cups as followed: two cups with one handle, two with two handles and one cup with no handle. The Occupational Therapy Narrative indicated OT #1 tried straws and four different lids with Resident #1 and was unsuccessful as well. The Occupational Therapy Narrative indicated OT #1 observed Resident #1 experiencing tremor/jerky movement that affected Resident #1's right upper extremity and Resident #1 was unable to hold a cup safely. Occupational Therapist (OT) #1 was interviewed at 12:20 PM on 10/6/11. OT #1 said OT #1 was unaware that Resident #1 spilled hot tea on self and sustained a second degree burn on 9/20/11. OT #1 said that OT #1 was notified for the first time on 9/21/11 that Resident #1 had tremors and spilled hot tea on self on 9/20/11. OT #1 said Nursing Supervisor #1 had requested that OT #1 assess Resident #1's ability to hold on to a cup on 9/21/11 after Resident #1 spilled a second cup of hot tea on Resident #1's left forearm. OT #1 said OT #1 observed Resident #1 having sporadic muscle spasms while Resident #1 was picking up a cup from a table. OT #1 said OT #1 recommended that Resident #1 receive assistance with feeding and drinking hot or cold beverages. CNA #1 said Resident #1 was served a cup of hot tea with breakfast. CNA #1 said the hot water that was used to make Resident #1's tea was in the kitchen prior to being used. CNA #1 said the hot water brought from the kitchen was too hot for Resident #1 to drink. However, CNA #1 did not know about the temperature of the hot water from the kitchen. CNA #1 said CNA #1 did not take the temperature of the hot water when CNA #1 poured the hot water into Resident #1's cup. CNA #1 said Resident #1 was served the hot tea in a cup without a lid, Resident #1 spilled the hot tea and sustained a burn. Unit Manager #1 said Unit Manager #1 assessed Resident #1 after obtaining report from Supervisor #1 on 9/21/11. Unit Manager #1 said Unit Manager #1 assessed Resident #1's left outer thigh and observed a blister that measured six centimeters by three centimeters in diameter. A nurse's note addendum written at 11:00 AM on 9/22/11, described the blister on the left outer thigh of Resident #1 as intact and measuring six centimeters by three centimeter in diameter. The nurse's note addendum indicated Resident #1 did not complain of pain and Family Member #1 was notified. The 5-day scheduled Minimum Data Set assessment, completed on 9/23/11, indicated that Resident #1: had no short-term or long-term memory problems; had no cognitive impairment; was usually understood; was able to understand; required set up only with eating, and had impairment on both sides of the upper extremity (shoulder, elbow, wrist hand). Unit Manager #1 was interviewed on 10/6/11, at 10:15 AM. Unit Manager #1 said at approximately 7:45 AM on 9/21/11, Unit Manager #1 had set up Resident #1 for breakfast. Unit Manager #1 said Unit Manager #1 placed a blanket on Resident #1's lap and instructed Certified Nurse Aide #1 to periodically monitor Resident #1. Unit Manager #1 said CNA #1 reported to Unit Manager #1 that CNA #1 left Resident #1's room for a quick moment to help another Resident and in less than five minutes Resident #1 spilled the cup of hot tea on Resident #1's left forearm. Unit Manager #1 said Resident #1 did not sustain an injury. The Dietician was interviewed at 1:30 PM on 10/13/11. The Dietician said the hot water in the kitchen usually ranged between 180 and 190 degrees Fahrenheit. The Dietician said the hot water and the coffee were poured prior to starting the steam table and the hot water and the coffee were transported to the units before the trucks were transported to the residents' units. The Dietician said when the food trucks arrived on the residents' units, the temperature of the coffee and hot water served to the residents ranged between 140 degrees Fahrenheit and 150 degrees Fahrenheit, which was an appropriate range of temperature. The Food Service Supervisor (FSS) was interviewed on 10/6/11, at 11:20 AM. The FSS said the temperature of the hot water and coffee that was poured into the carafes and the coffee pot holder for the Pighetti Unit where Resident #1 resided was 185 degrees Fahrenheit. The FSS said the carafes of hot water and the coffee pot holder remained in the kitchen for approximately 15 minutes prior to bringing to Pighetti Unit to ensure the temperature of the hot water and the coffee were not too hot for the residents. The FSS said a thermometer was placed on each unit for nursing staff to take the temperature of hot beverages prior to serving hot beverages to the residents. The FSS said the FSS was unaware that Resident #1 was served a cup of tea that was too hot and sustained a second degree burn until the FSS talked to the Surveyor. On the day of the survey visit, at 11:30 AM, the Surveyor asked the FSS to place a tea bag and hot water in the same type of cup used for Resident #1 on 9/20/11. The Surveyor and the FSS obtained the temperature of the hot water, which was 178 degrees Fahrenheit. The Surveyor took the cup of hot tea to Resident #1's unit and obtained temperatures as followed: 11:35 A.M. 176 degrees Fahrenheit, tea was too hot for the Surveyor to drink 11:40 A.M. 173 degrees Fahrenheit, tea was too hot for the Surveyor to drink 11:45 A.M. 167 degrees Fahrenheit, tea was hot, but able to be sipped by Surveyor 11:50 A.M. 156 degrees Fahrenheit, tea was at an acceptable temperature, Surveyor was able to drink the tea slowly.