Every finding on record at Fairhaven Healthcare Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record that included nursing documentation related to assessments of a new area of skin alteration that had developed on his/her left thigh.Findings include:The Facility Policy, titled Nursing Documentation Policy, undated, indicated the Facility required that nursing documentation be timely, accurate, complete, factual, and reflective of the resident's condition, care provided, notifications made, and follow up completed. The Policy indicated nursing staff would document resident condition changes, assessments and observations, wound care and skin findings, and changes of condition.The Facility Policy, titled Wound Care Policy, undated, indicated that when a wound was found, nursing staff would assess and document date and time found, location of the wound, type of wound, if known, size including length, width, and depth, wound bed appearance, drainage amount, color and odor, surrounding skin condition, pain or tenderness, signs of infection, possible cause, if known, and whether the wound was present on admission or was Facility acquired, if known. Resident #1 was admitted to the Facility in January 2025, diagnoses included diabetes, dementia, and chronic kidney disease. Review of the report submitted by the Facility via the Health Care Facilities Reporting System (HCFRS) dated 04/29/26, indicated that on the morning of 04/25/26 Certified Nurse Aide #1 reported to Nurse #1 that Resident #1 had a new reddened area on his/her right (later clarified as the left) thigh. During a telephone interview on 06/15/26 at 11:27 A.M. CNA #1 said that on 04/25/26 during routine care she observed a new reddened area on Resident #1's left thigh and said she reported it to Nurse #1. CNA #1 said she was familiar with Resident #1 and had never seen that reddened area before.During a telephone interview on 06/15/26 at 1:17 P.M., Nurse #1 said that on 04/25/26 CNA #1 told her that Resident #1 had a new reddened area on his/her left thigh. Nurse #1 said she assessed the area and said that it was a large, red and blanchable (an area of skin that temporarily turns white or pale when you press your finger on it and release). Nurse #1 said she had not been previously aware of a reddened area on Resident #1's left thigh. Nurse #1 said she did not measure the area or document her assessment.During a telephone interview on 06/15/26 at 11:48 A.M., Nurse #2 said that on 04/25/26 she worked the 3:00 P.M., to 11:00 P.M., shift and said that during shift report, Nurse #1 did not tell her that Resident #1 had a new area of skin alteration on his/her left thigh. Nurse #2 said the area had been assessed by her on 04/19/26 and was included in her progress note.Review of Resident #1's medical record indicated there was a nursing note, signed by Nurse #2, dated 04/19/26, that indicated Resident #1 was assessed as having left leg swelling and redness, however the note did not indicate any measurements of the area or specific information about a reddened area on his/her left thigh.During an interview on 06/15/26 at 01:04 P.M., Nurse #3 said that on the morning of 04/26/26 a CNA told him and Nurse #4 that Resident #1 had a new reddened area that appeared to be caused by pressure on his/her left thigh. Nurse #3 said he assessed the wound, it was reddened and blanchable but said he did not document his assessment of the wound.During a telephone interview on 06/15/26 at 01:52 P.M., Nurse #4 said that on 04/26/26 at 07:00 A.M., she was giving shift report to Nurse #3 when a CNA told her and Nurse #3 that Resident #1 had a reddened area that appeared to be from pressure on his/her left thigh. Nurse #4 said she assessed the area, which was red and blanchable, but said she did not document her assessment of the wound.During a telephone interview on 06/15/26 at 11:11 A.M., Nurse #5 said that on 04/26/26 at 04:30 P.M., CNA #3 reported to her that Resident #1 had an open area on his/her left thigh. Nurse #5 said she assessed Resident #1's left thigh and there was a new open blister surrounded by reddened skin. Nurse #5 said this was the first time she was aware of there being a wound on Resident #1's left thigh.Review of the Nurse Practitioner's Progress Note, dated 04/26/26 and timed 04:28 P.M., indicated Nurse #5 notified the on-call provider that Resident #1 had a new wound on his/her left thigh. The Note indicated the wound measured 6 centimeters (cm) by 6 cm, the wound bed was pale pink, and the surrounding skin had mild erythema (redness) and was tender.Further review of Resident #1's medical record indicated there was no documentation to support any of the facility nurses that had assessed Resident #1's left thigh area had documented measurements, wound bed description, and surrounding skin description, prior to the description in the Nurse Practitioner's Progress Note dated 04/26/26.During an interview on 6/15/26 at 02:43 P.M., the Administrator said Nurse #1, Nurse #2, Nurse #3, and Nurse #4 should have documented their assessments of the reddened area on Resident #1's left thigh but had not.

Based on record reviews and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when upon admission Resident #1's medications were not reconciled and transcribed accurately, resulting in him/her receiving two doses of Rifampin (powerful antibiotic) which had been discontinued at the hospital prior to his/her discharge.Findings include:Review of the Facility Policy titled Physician's Orders and Transcription Policy, dated May 2025, indicated all physician and authorized practitioner orders shall be:- accurately transcribed and verified by a second licensed nurse prior to final entry into the electronic medical record (EMR).-orders shall be reconciled with the physician upon admission, after hospitalization and discrepancies must be clarified immediately with the prescriber.Review of the facility Policy titled, Admissions and Medication Verification Policy, dated May 2023 and as last revised January 2026 after the Incident, indicated that the Facility reconciles medications: - utilizing the official, final medical document from the discharging hospital. - the admitting nurse identifies and resolves discrepancies prior to order entry. - second verification nurse reviews the discharge summary to confirm accuracy prior to activating in EMR.Resident #1 was admitted to the Facility in December 2025, diagnoses include latent tuberculosis (mycobacterium tuberculosis bacteria in the body- dormant causing no symptoms and non-contagious), anemia, muscle wasting, diabetes mellitus and acute kidney failure.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/24/25, indicated the Hospital called the facility on 12/15/25 to notify them that Resident #1's Rifampin had been discontinued on discharge 12/04/25 and he/she should not have received the medication.The HCFRS Report further indicated the Nurse who completed Resident #1's admission to the facility as well as the second nurse verifying the orders utilized the Preliminary Hospital Discharge summary, dated [DATE], to obtain physicians order, and did not utilize the finalized Hospital Discharge summary dated [DATE], to ensure accurate reconciliation of his/her medications.Review of Resident #1's preliminary Hospital Discharge summary, dated [DATE], indicated he/she had a discharge diagnosis of Hepatotoxicity (Liver damage) secondary to Rifampin and Latent Tuberculosis and that Rifampin was stopped due to toxicity and to remain off Rifampin indefinitely. Further review of Resident #1's Medical Record indicated there was no documentation to support that the nursing staff reviewed the finalized Discharge Summary or clarified discrepancies related to orders for Rifampin with the Provider.Review of Resident #1's finalized Hospital Discharge summary, dated [DATE], indicated not to administer the following;-Rifampin 150 mg capsule-Ibuprofen 600 mg tabletReview of Resident #1's Medication Administration Record (MAR), for the month of December 2025, indicated he/she had physicians order for Rifampin 150 milligram (mg) capsule- give three capsules once daily and although it was documented as not having been administered on 12/05/25 through 12/13/25 due to not being available, it was however documented as being administered on 12/14/25 and 12/15/25. Further review of Resident #1's medical record indicated he/she required transfer to an acute care setting on 12/15/25 and his/her Hospital Discharge summary, dated [DATE], indicated Resident #1 was readmitted to the hospital due to recurrent symptoms related to liver injury.Review of Resident #1's Physician's Progress Note, dated 12/05/25, indicated to remain off Rifampin indefinitely due to hepatotoxicity.During a telephone interview on 1/15/26 at 10:11 A.M., the Physician said Resident #1 was not supposed to be given Rifampin due to hepatotoxicity and in their records the Rifampin was not an active order.During a telephone interview on 1/15/26 at 10:21 A.M., the Nurse Practitioner (NP) said when a new admission comes to the facility and it is after hours, the nurse will call the on-call provider and read off the discharge orders from the hospital and telephone orders are given. The NP said the provider reconciles the medications in their computer system with the current hospital discharge summary and said on their computer system, the Rifampin was discontinued.During a telephone interview on 01/13/26 at 2:26 P.M., the Nursing Supervisor said that she used the preliminary (preadmission) Hospital Discharge summary, dated [DATE], that was sent to the admission Coordinator and saw Rifampin as a current medication called the on-call provider, verbally reviewed and reconciled the medication list and then entered them into their EMR system. The Nursing Supervisor said she did not see the diagnoses of hepatotoxicity related to Rifampin on the discharge paperwork and did not use the finalized Hospital Discharge Paperwork sent with Resident #1 on his/her actual date of admission to reconcile his/her medications.The Nursing Supervisor said the second nurse (who was responsible for double checking the admission orders) should have verified the medication orders from the final Hospital Discharge summary dated [DATE] and did not.During an interview on 01/12/26 at 12:58 P.M., the Unit Manager said that she was unaware that Resident #1's medications were not reconciled or transcribed accurately upon admission. The Unit Manager said that medication reconciliation is very important, should always be completed by two nurses for accuracy from the Final Discharge Summary from the Hospital to ensure that no changes have occurred and, in this case, it was not done.During a telephone interview on 1/20/26 at 11:57 A.M., the admission Coordinator said she had given the Hospital Discharge summary, dated [DATE], to the Nursing Supervisor to enter Resident #1's initial information and that she also checked for an updated Discharge Summary, printed it and brought it to the Nursing Unit where Resident #1 was being admitted . During an interview on 01/12/26 at 12:35 P.M., the Assistant Director of Nurses (ADON), said the process on admission has been that the admission Coordinator will give a copy of the preliminary Discharge Summary from the Hospital so the staff can input information but the final orders and verification process have always been to use the most recent updated (finalized) Hospital Discharge Summary and in this case it was not done. The ADON said that the Facility's expectation is that once a Resident is admitted to the facility, all medications and treatments must be reconciled by two nurses from the most current (finalized) Discharge Summary provided by the Hospital, with physician's orders obtained.On 1/12/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 12/29/25, which addressed the area(s) of concern as evidenced by:A. The Facility discontinued Resident #1's order for Rifampin on 12/15/25 and listed it as an allergy on his/her Medication Administration Record.B. Resident #1 was readmitted to the facility, he/she continues to be monitored by nursing, and remains stable. C. On 12/16/25, the Facility immediately conducted training for all nursing staff involved in the admission of Resident #1 which included a review of the Policy titled, Admissions and Medication Verification Policy and the Physician's Orders and Transcription Policy.D. On 12/16/25, a checklist for audits of admission and readmission of Residents was initiated by Nursing Administration for all Unit Managers to conduct audits on all newly admitted residents and residents being readmitted .E. The Management team has instituted morning rounds to review all residents admissions/readmissions.F. The Staff Development Coordinator continues to provide ongoing education and training with all Nursing Staff on the Admission/readmission (including accurate medication reconciliation) Process.G. On 12/15/25, an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted, and concern areas were discussed.H. The Policy titled Physician's Orders and Transcription was reviewed and new processes were implemented to ensure accuracy when reconciling and transcribing Physician's orders. I. The results of the audits will be reviewed at the next monthly QAPI meeting on 1/13/26.J. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on interview and record review the facility failed to ensure that all services provided for two Residents (#8 and #69), out of a total sample of 29 residents, met professional standards of quality. Specifically:1) For Resident #8 the facility failed to follow a physician-ordered hypoglycemic protocol by failing to re-check blood sugar or notify the physician when the Resident's blood sugar was less than 60 mg/dL (milligrams per deciliter).2) For Resident #69 the facility failed to follow Physician orders for offloading the Residents' heels. Findings include: 1) According to the Merk Manual Professional Version (revised October 2023) a plasma glucose (sugar) level of less than 70 mg/dL (milligrams per deciliter), in patients treated with glucose-lowering medications such as insulin, is considered hypoglycemia and should be treated to avoid a further decrease in blood glucose and consequences of hypoglycemia. Review of the facility policy, titled Hypoglycemia – Clinical Management of dated January 2025, indicated, but was not limited to, the following: -Hypoglycemia is defined as finger stick or serum glucose less than 60 mg/dL. - If a resident has a low blood sugar (hypoglycemia): - Perform glucose by finger stick: If less than 60 mg/dL recheck finger stick. If repeat finger stick remains below 60 mg/dL, institute the following unless a physician's order dictates otherwise. - If the resident is responsive and able to swallow, give 15 grams of rapidly absorbed carbohydrates. This includes four ounces of orange or apple juice, or eight ounces of skim milk or three graham crackers. - Recheck blood sugar 15 minutes after treatment. If the resident's blood sugar remains the same, has decreased or if the resident has a change in level of consciousness, administer IM (intramuscular) or SC (subcutaneous) glucagon (a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels), as ordered by the physician. Continue to check the blood sugar every 15 minutes until greater than 70 mg/dL. - Notify physician for further directions. Review of the facility policy, titled Notification to Physician for Change of Status Policy, dated March 2024, indicated, but was not limited to, the following: - - Nursing staff must notify the attending physician (or covering provider during evenings, nights, weekends, or holidays) immediately of: o Significant changes in a resident's medical condition. - - All notifications to the physician (or covering provider) must be documented in the Electronic Medical Record (EMAR) including: o Time and date of notification o Name of the provider contacted o Summary of the residents' condition and change in status. o Provider's response, orders received, and follow-up actions. Review of the facility's quality control log for blood glucometer readings dated August and September 2025 indicated there were no significant variances and that the facility's glucometers were accurate and functioned normally. Resident #8 was admitted to the facility in March 2018 with a diagnosis of type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/10/25, indicated that Resident #8 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 12 out of 15. Review of Resident #8's care plan indicated that the Resident had a nutritional problem related to a history of type two diabetes with the following intervention: - - Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness – initiated on 09/07/2023 Review of Resident #8's physician orders indicated the following active order: - - For Blood Sugar under 60, but responsive and able to swallow administer a carbohydrate snack. Recheck blood sugar every 15 minutes until blood sugar is greater than 70 (mg/dL) - Notify MD for blood sugar less than 60. No orange juice for dialysis residents - initiated 8/13/2023. Review of Resident #8's blood sugar levels indicated the following: - - On 8/7/25 at 7:21 A.M. Nurse #1 recorded a blood sugar level of 56.0 mg/dL - - On 8/28/25 at 11:21 A.M. Nurse #1 recorded a blood sugar level of 56.0 mg/dL - - On 9/1/25 at 8:00 A.M. Nurse #3 recorded a blood sugar level of 53.0 mg/dL - - On 9/11/25 at 7:55 A.M. Nurse #3 recorded a blood sugar level of 56.0 mg/dL Review of Resident #8's progress note, dated 8/7/25 and written by Nurse #1, indicated that the Resident had a blood sugar level of 56 mg/dL and that orange juice was given. Further review of the progress note failed to indicate that the blood sugar was re-checked in 15 minutes or that the physician was notified. Review of Resident #8's progress note, dated 8/28/25 and written by Nurse #1, indicated that the Resident had a blood sugar level of 56 mg/dL and that orange juice was given. Further review of the progress note failed to indicate that the blood sugar was re-checked in 15 minutes or that the physician was notified. Review of Resident #8's progress note, dated 9/1/25 and written by Nurse #3, indicated that the Resident's blood sugar was 53 mg/DL, that orange juice was given and that blood sugar was re-checked and within normal limits. Further review of the progress note failed to indicate that the physician was notified. Review of Resident #8's medical record failed to indicate that orange juice was provided, that the blood sugar was re-checked, or that the physician was notified after Nurse #3 recorded a blood sugar reading of 56 mg/dL on 9/11/25. Review of the Medication Administration Record (MAR) failed to indicate that nurses marked the following order as completed following blood sugar readings of less than 60 mg/dL on 8/7/25, 8/28/25, 9/1/25, or 9/11/25: - For Blood Sugar under 60, but responsive and able to swallow administer a carbohydrate snack. Recheck blood sugar every 15 minutes until blood sugar is greater than 70 (mg/dL) - Notify MD for blood sugar less than 60. No orange juice for dialysis residents. During an interview on 9/25/25 at 12:18 A.M. Nurse #1 said that when a Resident has a blood sugar below 60 mg/dL that nursing should administer orange juice or crackers and should notify the physician. Nurse #1 said that he provided orange juice on 8/7/25 and 8/28/25 in response to Resident #8's low blood sugar readings but did not re-check the Resident's blood sugar; Nurse #1 did not recall if he had notified the physician of the Resident's low blood sugar readings. During an interview on 9/25/25 at 11:33 A.M. Nurse #3 said that if a Resident's blood sugar fell below 70 mg/dL that nursing should provide orange juice and re-check the blood sugar in 15-30 minutes; Nurse #3 said this would be documented. Nurse #3 said she did not notify the physician or Nurse Practitioner about Resident #8's low blood sugar readings on 9/1/25 or 9/11/25. During an interview on 9/25/25 at 11:49 A.M. Unit Manager #4 said that if a Residents blood sugar was below 60 mg/dL that she would expect the nurse to provide a carbohydrate heavy snack and orange juice, notify the provider and re-check every 15 minutes and that this would be documented in the electronic medical record. Unit manager #4 said she was not aware of Resident #8's low blood sugar levels on 8/7/25, 8/28/25, 9/1/25, or 9/11/25 and did not notify the physician or nurse practitioner but would have expected the Nurse to have done so. During an interview on 9/25/25 at 11:55 A.M. Nurse Practitioner (NP) #1 said she would expect nurses to follow the physician-ordered hypoglycemic protocol. NP #1 said she is on call and available to be notified by staff of medical changes from 7 A.M. until 5 P.M. NP #1 said she was not notified about Resident #8's blood sugar readings on 8/7/25, 8/28/25, 9/1/25, or 9/11/25. NP #1 said she would have especially expected to be notified of Resident #8's low blood sugar levels as they have been happening so often and that this was a significant issue for this Resident; NP #1 said the risk of not following the hypoglycemic protocol for a Resident with low blood sugar is that if the blood sugar was low enough and did not come back up the Resident would be at risk for coma. During interview on 9/25/25 at 2:40 P.M. and 9/26/25 at 9:29 A.M., the Physician said she would expect nurses to follow the physician-ordered hypoglycemic protocol. The physician said that NP #1 would have been the provider to be notified about the blood sugar readings on 8/7/25, 8/28/25, 9/1/25 and 9/11/25 as the Physician did not work on those days. The physician said the provider should have been called for blood sugars of less than 60 mg/dL and that this should have been documented. The Physician said if a Resident with low blood sugar did not receive the hypoglycemic protocol that the Resident could become more hypoglycemic. During an interview on 9/26/25 at 9:55 A.M. the Director of Nursing (DON) said that if a Resident had a blood sugar of less than 60 mg/dL that the nurse should provide the Resident with orange juice, notify the physician, and re-check the blood sugar level in 15 minutes. The DON said that she would expect nursing to document in the medication administration record if the hypoglycemic protocol was initiated. 2.) Resident #69 was admitted to the facility in October 2022 with diagnoses including end stage renal disease, muscle weakness and type 2 diabetes. Review of Resident #69's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 9 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The MDS further indicated the Resident was at increased risk of pressure ulcer development. On 9/24/25 at 8:53 A.M., the surveyor observed the Resident lying in his/her bed with heels directly on the mattress. On 9/25/25 at 8:30 A.M., the surveyor observed the Resident lying in his/her bed with heels directly on the mattress. During an observation and interview on 9/26/25 at 11:25 A.M., the surveyor observed the Resident lying in his/her bed with heels directly on the mattress. The Resident said he/she has not been wearing the heel boots since his/her heels wounds healed. Review of the Resident's current physician orders indicated the following: -Dated 2/24/25, Off-load heels with floating booties when in bed every shift for red boggy heels. -Dated 4/21/23, Elevate left heel off mattress with heel boot while in bed every shift for prevention wear multipodus while in bed. -Dated 9/19/25, Skin prep to left heel every shift document appearance. Review of care plan date initiated 10/25/24: Resident has potential alteration in skin integrity related to comorbidities. Intervention dated 9/16/25: Apply heel booties when in bed. During an interview on 9/26/25 at 11:31 A.M., Certified Nursing Assistant (CNA)#4 said he had provided morning care to the Resident. He said Resident #69 did not have heel booties and he did not see them in the room. During an interview on 9/26/25 at 11:32 A.M., Nurse #3 said the Resident has orders for heel booties while in bed and he/she should have them on. During an interview on 9/26/25 at 11:49 A.M., the Director of Nursing said the orders should be followed and nurses should ensure the heel booties are applied.

Based on observation, record review and interview the facility failed to provide a dignified dining experience for two Residents (#49 and #107 ) out of a total sample of 29 residents. Specifically:1. For Resident #49, the facility failed to ensure a dignified dining experience.2. For Resident #107, the facility failed to ensure a dignified dining experience and referred to the Resident as a feeder, rather than by his/her preferred name. Findings include:The facility policy titled Resident Dignity, dated June 2024, indicated:-Residents shall be treated with respect at all times. -A dignified dining experience is provided to all residents. -Staff must address residents by their preferred name and never by diagnosis, room number or care needs. 1. For Resident #49 the facility failed to ensure a dignified dining experience. Resident #49 was admitted to the facility in April 2025 and has diagnoses that include Alzheimer's disease, dementia without behavioral disturbance and osteoarthritis of the shoulders. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/25/25, indicated Resident #49 is rarely understood and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #49 requires set-up or cleaning assistance with eating. Review of the most recent Nutrition Risk Assessment, dated 8/25/25, indicated Resident #49 eats w(with) /continual supervision, assistance as he/she allows. Review of the Activities of Daily Living care plan, dated as revised 9/2/25, indicated Resident #49 had the following interventions:-Eating: Continual supervision with assistance as resident allows;-Utilize task segmentation as indicated to help improve ADL participation.-Provide the amount of staff intervention that is needed for task completion with self-performance fluctuations Review of the most recent Quarterly Functional Abilities Assessment, dated 7/10/25, indicated Resident #49 is dependent on staff for eating. On 9/24/2025 at 8:55 A.M., Resident #49 was observed seated at a table in the unit dining room, facing the wall with his/her back to the staff in the room. Resident #49 had a breakfast plate in front of him/her and was eating scrambled eggs ands toast covered with jelly with his/her hands. Resident #49 had jelly all over his/her hands and was licking his/her fingers that were covered in eggs and jelly. There were utensils present, as well as several staff present in the dining room however staff were assisting other residents and provided no cues to use utensils and offered no assistance with the meal. On 9/24/2025 sat 12:27 P.M., Resident #49 was observed seated at a table in the unit dining room with a plate of lunch directly in front of him/her. Resident #49 had utensils available however was observed to be eating salad with his/her hands. There were 6 staff present in the dining room but none were supervising Resident #49 or providing cues to use the utensils and no assistance was offered. The surveyor continued to make the following observations:-Between 12:27 P.M., and 12:31 P.M. Resident #49's hands became covered in pizza sauce and salad dressing and he/she was licking the food off of his/her hands. On 9/25/2025 at 8:19 A.M., Resident #49 was observed seated at a table in the unit dining room. Staff placed a breakfast plate in front of him/her that included scrambled eggs, toast, a cinnamon bun and oatmeal. There was a spoon placed on the plate beside the eggs. The surveyor continued to make the following observations:-At 8:36 A.M., Resident #49 stuck his/her fingers into the scrambled eggs then licked them. There were several staff present in the dining room, however no one cued Resident #49 to use his/her utensil and no assistance was offered. Throughout the observation between 8:19 A.M., and 8:36 A.M., staff did not offer assistance with feeding or cueing to use utensils when he/she ate non-finger like food with his/her hands. On 9/25/2025 at 12:09 P.M., Resident #49 was observed seated at a table in the unit dining room. Staff placed a lunch plate in front of him/her that included macaroni and cheese and a chicken thigh. After placing the lunch and a fork in front if Resident #49 the staff person walked away and Resident #49 began eating the macaroni and cheese with his/her hands. The surveyor continued to make the following observations:-At 12:10 P.M., a staff person stood beside Resident #49 setting up his/her tablemate with lunch. While doing so Resident #49 ate the macaroni and cheese with his/her hands. The staff person offered no assistance to Resident #49 and no cues to use a utensil.-At 12:14 P.M., a staff person again stood beside Resident #49 and cut up the tablemate's food. While doing so Resident #49 ate the macaroni and cheese with his/her hands. The staff person offered no assistance to Resident #49 and no cues to use a utensil.Throughout the observation between 12:09 P.M., and 12:14 P.M., staff did not offer assistance with feeding or cueing to use utensils when he/she ate non-finger like food with his/her hands. 0n 9/26/2025 at 8:24 A.M., Resident #49 was observed seated at a table in the unit dining room. Staff placed a breakfast plate in front of him/her that included toast, oatmeal and scrambled eggs. The surveyor continued to make the following observations. -Between 8:24 A.M., and 8:34 A.M., Resident #49 made no attempts to self feed. At 8:34 A.M., he/she attempted to use a spoon to eat the eggs, however as Resident #49 lifted the spoon to his/her mouth the eggs fell onto the table and Resident #49 used his/her hands to eat the eggs off of the table.-At 8:41 A.M., Resident #49 picked up a butter container and ate the butter by licking it off his/her fingers. At that time there were 8 staff present in the dining room and no cueing or assistance was provided.-At 8:43 A.M., after consuming the butter container with his/her fingers, Resident #49 picked up a jelly container and ate the jelly by licking it off his/her fingers.Throughout the observation between 8:24 A.M., and 8:43 A.M., staff did not offer assistance with feeding or cueing to use utensils when he/she ate non-finger like food with his/her hands. During an interview with the Nurse Unit Manager #3 on 9/26/2025 at 9:58 A.M., she said that it is her expectation that if a resident has variable ability to self feed and staff observe the resident struggling to eat or eat non finger foods such as eggs, or macaroni and cheese with their hands that the staff intervene and offer assistance, cue the resident to use a utensil or offer a meal that is finger food such as a sandwich. During an interview with Resident #49's Certified Nursing Assistant (CNA) #3 on 9/26/2025 at 10:17 A.M., she said that Resident #49 sometimes needs assistance with meals because he/she tires. CNA #3 said that if the staff notice Resident #49 using his/her hands while eating they try to help him/her or give him/her a spoon. CNA #3 added that Resident #49 should be receiving finger foods for meals because he/she forgets a lot and eats things with his/her hands that he/she shouldn't. During an interview with the Director of Nursing (DON) on 9/26/2025 at 1:01 P.M., she said that it is her expectation that if a resident is struggling to eat and eating non-finger food with their hands, staff should intervene as it is not a dignified dining experience. 2. For Resident #107, the facility failed to ensure a dignified dining experience and referred to the Resident as a feeder, rather than by his/her preferred name. Resident #107 was admitted to the facility in September 2024 and has diagnoses that includes Alzheimer's disease, epilepsy and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/11/25, indicated that Resident #107 rarely is understood and is assessed by staff to have severely impaired cognition. The MDS further indicates that Resident #107 has no behavior of rejecting care and is dependent on staff for eating assistance. Review of the Functional Abilities and Goals Assessment, dated 9/23/25, indicated Resident #107 is dependent on staff for eating assistance. Review of the Activities of Daily Living care plan, dated as revised 9/23/25, indicated Resident #107 requires assist of one for eating. On 9/24/2025 at 8:32 A.M., Resident #107 was observed seated in a recliner chair in the unit dining room. There was a covered breakfast plate placed directly in front of him/her. Resident #107 was observed to lean forward and attempt to take the cover off the food, however as he/she did so, a staff person walked by, said in a little while and pushed the plate of food out of reach. The surveyor continued to make the following observations: -At 8:37 A.M. a Certified Nursing Assistant (CNA) sat beside Resident #107, facing his/her tablemate and assisted the tablemate with their meal. No assistance was offered to Resident #107 and his/her plate of food remained covered and out of reach.-At 8:39 A.M., Resident #107 looked multiple times at his/her covered plate of food and then at the staff assisting the table mate. He/she remained without any assistance. On 9/24/2025 at 12:23 P.M., Resident #107 was observed seated in a recliner chair in the unit dining room. A staff person placed a covered plate of food in front of Resident #107 and walked away without offering assistance. The surveyor continued to make the following observations: -At 12:29 P.M., Resident #107 leaned forward and tried to take the cover off the plate of food but was unable to do so. He/she sat back in the chair and watched a tablemate be fed their meal. On 9/25/2025 at 8:13 A.M., Resident #107 was observed seated in a recliner chair in the unit dining room with 2 tablemates. All three residents had drinks however Resident #107s were placed out of reach. The surveyor continued to make the following observations: -At 8:17 A.M., Resident #107 watched as a CNA stood beside him/her feeding a tablemate. The staff person did not offer Resident #107 any assist with the covered beverages placed in front of him/her.-At 8:27 A.M., a CNA placed a covered plate of food in front of Resident #107 and walked away without offering assistance.-Between 8:27 A.M., and 8:32 A.M., Resident #107 watched on as the CNA assisted his/her tablemates, while he/she sat there with a covered plate of food in front of him/her. -At 8:32 A.M., a CNA sat down beside Resident #107, and using her hands tore apart piece of toast and placed it in Resident #107's oatmeal and began feeding him/her. On 9/25/2025 at 12:07 P.M., Resident #107 was observed seated in a recliner chair in the unit dining room with 3 tablemates. All 4 residents had drinks however Resident #107s chair was reclined back at a 45 degree angle and the drink was out of reach. On 9/26/25 at 8:25 A.M., Resident #107 was observed seated in a recliner chair in the unit dining room waiting for breakfast. -At 8:27 A.M., a CNA placed a covered bowl of oatmeal in front of Resident #107 and walked away.-At 8:30 A.M., a CNA sat down to assist Resident #107's tablemate with breakfast. Resident #107 say with a covered bowl of oatmeal in front of him/her watching. -At 8:31 A.M., a CNA placed plate of scrambled eggs and toast on the table in front of Resident #107 but out of reach and walked away. Resident #107 looked at the plate of food then watched on as his/her tablemate was fed. -At 8:34 A.M., a CNA placed a cover on top of Resident #107's plate of food and walked away.-At 8:39 A.M., a CNA sat down beside Resident #107, and while laughing and talking to another staff person at table, placed a spoonful of oatmeal in Resident #107's mouth. During an interview with the Nurse Unit Manager #3 on 9/26/2025 at 9:55 A.M., she said that Resident #107 is dependent on staff for all care, including feeding. Nurse Unit Manager #3 said that is is her expectation that residents that require feeding assist not have their food placed in front of them until the staff are ready to sit down and provide the assistance. Nurse Unit Manager #1 said that she prefers that resident's who require feeding assistance be seated together and be fed at the same time because the residents should not have to watch tablemates be fed while they wait for assistance. During an interview with Resident #107's CNA #2 on 9/26/2025 at 10:05 A.M., she said that Resident #107 is dependent on staff for all aspects of care, including meals. CNA #2 said that Resident #107 is a feeder we try to put all the feeders at the same table because we should not serve them until they are ready to eat. CNA #2 said that she remembers being told at one time she should not to refer to residents as feeders, but by their name. During a follow-up interview with the Nurse Unit Manager #3 on 9/26/2025 10:17 A.M., she said that staff should mot be referring to residents as feeders but by their name. Nurse Unit Manager said that she has a lot of new staff that still need education. During an interview with the Director of Nursing (DON) on 9/26/2025 at 1:01 P.M., she said that it is her expectation that staff should serve food when they are ready to provide feeding assistance and that dependent residents should not have to sit at the table watching others eat while waiting with food in front of them. As well, the DON said that staff should refer to residents by their name, not by their care need.

Based on record review and interviews, the facility failed to ensure one Resident, (#77 ) was free from unnecessary psychotropic medication, out of a total sample of 29 residents. Findings include:Review of the facility policy titled PRN use of Psychotropic Medication , dated June 2025, indicated the following:-PRN psychotropic medications may only be given if prescribed by a licensed physician or authorized prescriber and with appropriate consents signed by the appropriate person.-Each PRN order must specify indication, dosage, frequency, and duration.-The attending physician will be notified of repeated or ineffective use, and the order will be reviewed routinely or as scheduled by authorized provider. Resident #77 was admitted to the facility in July 2023 with diagnoses including alcoholic cirrhosis of the liver, psychosis, and anxiety. Review of Resident #77's most recent Minimum Data Set (MDS) assessment, dated 6/19/25, indicated the Resident scored a 5 out of a 15 on the Brief Interview for Mental Status exam, indicating that Resident #77 had severe cognitive impairment. Review of Resident #77's physician orders indicated the following order with a start date of 11/6/24.-Lorazepam (an antianxiety medication) Oral Concentrate 2mg/ml (milligrams/milliliter). Give 0.5 mg by mouth every 8 hours as needed for anxiety related to anxiety disorder.Review of Resident #77's physician orders indicated the following with a start date of 12/9/24.-Lorazepam (an antianxiety medication) Oral Concentrate 2mg/ml (milligrams/milliliter). Give 1 mg by mouth every 8 hours as needed for anxiety related to anxiety disorder. The medical record failed to indicate a 14 day stop date had been initiated for the PRN lorazepam. Review of the Medication Administration Record, dated November 2024 through September 2025, indicated the Resident received Ativan five times in November, five times in December, one time in January, one time in February, one time in March, five times in April, five times in May, four times in July, six times in August, and four times in September. Review of Resident #77's Behavioral Health Group recommendations, dated 11/5/24, indicated:-Lorazepam, liquid, (2mg/ml) give 0.5mg by mouth every 8 hours for anxiety prn for 30 days then reassess.Review of Behavioral Health Group recommendation, dated 12/3/24, indicated:-Lorazepam, 2mg/ml. Increase to 1mg/0.5ml every 8 hours for anxiety. Review of Resident #77's consultant pharmacist recommendation to prescriber, dated 7/19/25, indicated:-Resident is receiving the following PRN psychotropic medication- Ativan (Lorazepam). Please note PRN psychotropic medications are required to be re-evaluated after the initial 14 days of therapy and at the prescriber's discretion thereafter.-If therapy is to continue, beyond 14 days, please note medical justification for continued use in progress note and specify number of days the PRN order is to continue. Review of Resident #77's physician progress note, dated 7/25/25, indicated:-Patient followed by psych and recommendation to increase lorazepam to 1mg every 8 hours as need for anxiety. No concerns since that. Will continue to get as he/she needs it occasionally per staff. During an interview on 9/25/25 at 11:56 A.M., Nurse #1 said a PRN psychotropic should be ordered for one to two weeks and then reassessed by physician. During an interview on 9/25/25 at 12:01 P.M., Unit Manager #1 said a PRN psychotropic medication should be reevaluated by the physician in about one week and that should be part of the order. During an interview on 9/25/25 at 12:31 P.M., the Director of Nursing said a PRN psychotropic should have a 14 day stop date unless the physician documents a reason to extend the medication use.

Based on observation, record review and interview the facility failed to ensure one Resident (#28) out of a total sample of 29 residents was provided with the correct physician ordered adaptive equipment with meals. Specifically, Resident #28 was not provided with a double handed mug for 5 of 5 observed meals. Findings include:The facility policy titled Adaptive Equipment and Assistive Devices, dated January 2025, indicated the following:Purpose: To ensure residents have safe and appropriate access to adaptive equipment that promotes independence, mobility, and quality of life, while minimizing risks of accidents or misuse. -The facility provides and supervises the use of adaptive equipment such as mobility aids (wheelchairs, walkers, canes), bathroom safety devices (grab bars, toilet risers, commodes) and specialized dining utensils. -Equipment needs are identified through the comprehensive assessment and documented in the resident's care plan. -Consideration include strength, range of motion, balance, cognition and personal fit. Resident #28 was admitted to the facility in April 2024 and has diagnoses that include dementia without behavioral disturbance and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/11/25, indicated Resident #28 is rarely/never understood and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #28 has no behaviors and is dependent on staff for eating. Review of Resident #28's active physician's orders include the following order, with a start date of 1/30/25:-Use double-handled mug with red straw lid for all beverages, with all meals Review of Resident #28's Activities of Daily Living (ADLs) care plan, with a revision date of 9/23/25, indicated the following interventions:-EATING: requires assist from staff to dependent. Need for assist d/t (due to) cognitive loss, would not eat without staff assist, dx (diagnosis) dysphagia. Use cup with lid for all beverages, start date 11/26/24. Review of Resident #28's Nutrition care plan, dated as revised 8/22/25, indicated the following interventions-Adaptive equipment as ordered: lip plate, mug with lid & straw, start date 10/10/24. Review of Resident #28's most recent Nutritional Risk Assessment, dated 8/11/25, indicated:-Resident #28 attempts to self-feed w/supervision at times and will otherwise be assisted at meals. On 9/24/2025 at 8:31 A.M., Resident #28 was observed seated in the unit dining room waiting for breakfast. There were two mugs, with one handle each, and a straw in each, placed directly in front of him/her. The surveyor continued to make the following observation:-At 8:39 A.M., staff sat down beside Resident #28 to provide feeding assist with the meal, however they did not provide the physician ordered double-handled mug with a red straw lid. On 9/24/2025 at 12:14 P.M., Resident #28 was observed seated in the unit dining room waiting for lunch. There were two mugs, with one handle each, and a straw in each, placed directly in front of him/her. On 9/25/2025 at 8:12 A.M., Resident #28 was observed seated in the unit dining room waiting for breakfast. There were two mugs, with one handle each, and a straw in each, placed directly in front of him/her. The surveyor continued to make the following observation:-At 8:24 A.M., Resident #28 used his/her thumb to push one of the straws toward his/her mouth then without attempting to lift the mug with one handle, leaned forward and drank from the straw. -At 8:26 A.M., staff delivered breakfast to Resident #28 however did not replace the mugs present with the correct physician ordered mugs. On 9/25/2025 at 12:06 P.M., Resident #28 was observed seated in the unit dining room waiting for lunch. There were two mugs, with one handle each, and a straw in each, placed directly in front of him/her. The surveyor continued to make the following observation:- Resident #28 was observed to attempt but was unable to pick up one of the mugs, and rather he/she leaned forward to drink from the straw. On 9/26/2025 at 8:22 A.M., Resident #28 was observed seated in the unit dining room waiting for breakfast. There were two mugs, with one handle each, and a straw in each, placed directly in front of him/her. The surveyor continued to make the following observation:-At 8:27 A.M., a Certified Nursing Assistant (CNA) placed a bowl of oatmeal in front of the Resident however did not replace the mugs present with the correct physician ordered mugs. During an interview with Resident #28's CNA #1 on 9/26/2025 at 9:49 A.M., she she said that Resident #28 requires total assistance with care, including feeding. CNA #1 was not sure what type of mug Resident #28 is supposed to use with beverages. During an interview with Nurse Unit Manager #3 on 9/26/2025 9:51 A.M., she said that she was not aware that Resident #28 had a physician's order for mugs with double handles and that she would have to follow-up. During an interview with the Director of Nursing (DON) on 9/26/2025 at 1:01 P.M., she said that if their is a physician's order for Resident #28 to have double handed mugs with his/her meals, then they should be provided.

Based on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (#102), following the completion of one comprehensive assessment.Specifically, facility staff failed to review and revise the care plan when Resident #102 started hospice and a comprehensive assessment for significant change in status (SCSA) was completed. Findings include:Review of the facility policy titled, Updating Care Plans Following Significant Changes in Resident Condition, dated April 2025, indicated the following:-A significant change in condition may include, but is not limited to: -Substantial decline in physical, mental, or psychosocial status. -New physician orders impacting care.-The Interdisciplinary Team (IDT) will immediately review the residents' condition and revise the care plan to reflect updated goals, interventions, and outcomes. Updates must be completed with the regulatory timeframe (generally within 7 days of identification of change) or sooner if clinically indicated. Resident #102 was admitted to the facility in October 2024 with diagnoses that include dysphagia, protein calorie malnutrition, and gastrostomy tube (G tube). Review of Resident #102's Minimum Data Set, dated [DATE], revealed that Resident #102 had a Brief Interview for Mental Status score of 7 out of a possible 15 which indicated that he/she has severe cognitive impairment. The MDS also indicated that Resident #102 had a G tube, was NPO (nothing by mouth), and was receiving hospice services. According to census, dated 8/20/25, Resident #102 was admitted to hospice. Review of Resident #102's social service progress note, dated 8/18/25, indicated health care proxy agreed to hospice sign on. Resident be seen by hospice team to sign on. Review of Resident #102's social service progress note, dated 8/26/25, indicated that Resident was admitted to hospice. Review of Resident #102's social service progress note, dated 9/3/25, indicated significant change noted, Resident signed on with hospice. Review of Resident #102's current plan of care failed to include any care related to hospice. During an interview on 9/25/25 at 9:30 A.M., Unit Manager #1 said that care plans are updated by nursing with significant changes in status. During an interview on 9/25/25 at 12:31 P.M., the Director of Nursing said that she would expect nursing to update care plan when a resident starts on hospice.

Based on observation, record review and interview the facility failed to ensure assistance with Activities of Daily Ling (ADLs) was provided for one Resident (#49) out of a total sample of 29 residents. Specifically, for Resident #49 the facility failed to ensure assistance was provide with meals. Findings include:Review of the facility policy titled Activities of Daily Living (ADL), dated April 2024 indicated:-Residents who cannot perform ADLs independently will receive appropriate services to support nutrition, grooming, personal and oral hygiene, mobility, toileting, dining and communication. Resident #49 was admitted to the facility in April 2025 and has diagnoses that include Alzheimer's disease, dementia without behavioral disturbance and osteoarthritis of the shoulders. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/25/25, indicated Resident #49 is rarely understood and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #49 requires set-up or cleaning assistance with eating. Review of the most recent Nutrition Risk Assessment, dated 8/25/25, indicated Resident #49 eats w/continual supervision, assistance as he/she allows. Review of the Activities of Daily Living care plan, dated as revised 9/2/25, indicated Resident #49 had the following interventions:-Eating: Continual supervision with assistance as resident allows.-Utilize task segmentation as indicated to help improve ADL participation.-Provide privacy and promote dignity, converse with resident while providing care.-Provide the amount of staff intervention that is needed for task completion with self-performance fluctuations Review of the most recent Quarterly Functional Abilities Assessment, dated 7/10/25, indicated Resident #49 is dependent on staff for eating. On 9/24/2025 at 8:55 A.M., Resident #49 was observed seated at a table in the unit dining room, facing the wall with his/her back to the staff in the room. Resident #49 had a breakfast plate in front of him/her and was eating scrambled eggs ands toast covered with jelly with his/her hands. Resident #49 had jelly all over his/her hands and was licking his/her fingers that were covered in eggs and jelly. There were utensils present, as well as several staff present in the dining room however staff were assisting other residents and provided no cues to use utensils and offered no assistance with the meal. On 9/24/2025 sat 12:27 P.M., Resident #49 was observed seated at a table in the unit dining room with a plate of lunch directly in front of him/her. Resident #49 had utensils available however was observed to be eating salad with his/her hands. There were 6 staff present in the dining room but none were supervising Resident #49 or providing cues to use the utensils and no assistance was offered. The surveyor continued to make the following observations:-Between 12:27 P.M., and 12:31 P.M. Resident #49's hands became covered in pizza sauce and salad dressing and he/she was licking the food off of his/her hands. On 9/25/2025 at 8:19 A.M., Resident #49 was observed seated at a table in the unit dining room. Staff placed a breakfast plate in front of him/her that included scrambled eggs, toast, a cinnamon bun and oatmeal. There was a spoon placed on the plate beside the eggs. The surveyor continued to make the following observations:-At 8:36 A.M., Resident #49 stuck his/her fingers into the scrambled eggs then licked them. There were several staff present in the dining room, however no one cued Resident #49 to use his/her utensil and no assistance was offered. Throughout the observation between 8:19 A.M., and 8:36 A.M., staff did not offer assistance with feeding or cueing to use utensils when he/she ate non-finger like food with his/her hands. On 9/25/2025 at 12:09 P.M., Resident #49 was observed seated at a table in the unit dining room. Staff placed a lunch plate in front of him/her that included macaroni and cheese and a chicken thigh. After placing the lunch and a fork in front if Resident #49 the staff person walked away and Resident #49 began eating the macaroni and cheese with his/her hands. The surveyor continued to make the following observations:-At 12:10 P.M., a staff person stood beside Resident #49 setting up his/her tablemate with lunch. While doing so Resident #49 ate the macaroni and cheese with his/her hands. The staff person offered no assistance to Resident #49 and no cues to use a utensil.-At 12:14 P.M., a staff person again stood beside Resident #49 and cut up the tablemate's food. While doing so Resident #49 ate the macaroni and cheese with his/her hands. The staff person offered no assistance to Resident #49 and no cues to use a utensil.Throughout the observation between 12:09 P.M., and 12:14 P.M., staff did not offer assistance with feeding or cueing to use utensils when he/she ate non-finger like food with his/her hands. 0n 9/26/2025 at 8:24 A.M., Resident #49 was observed seated at a table in the unit dining room. Staff placed a breakfast plate in front of him/her that included served toast, oatmeal and scrambled eggs. The surveyor continued to make the following observations. -Between 8:24 A.M., and 8:34 A.M., Resident #49 made no attempts to self feed. At 8:34 A.M., he/she attempted to use a spoon to eat the eggs, however as Resident #49 left the spoon to his/her mouth the eggs fell onto the table and Resident #49 used his/her hands to eat the eggs off of the table.-At 8:41 A.M., Resident #49 picked up a butter container and ate the butter by licking it off his/her fingers. At that time there were 8 staff present in the dining room and no cueing or assistance was provided.-At 8:43 A.M., after consuming the butter container with his/her fingers, Resident #49 picked up a jelly container and ate the jelly by licking it off his/her fingers.Throughout the observation between 8:24 A.M., and 8:43 A.M., staff did not offer assistance with feeding or cueing to use utensils when he/she ate non-finger like food with his/her hands. During an interview with the Nurse Unit Manager #3 on 09/26/2025 at 9:58 A.M., she said that Resident #49 has variable ability to self feed, therefore staff should observe the resident with meals and offer assistance as needed. During an interview with Resident #49's Certified Nursing Assistant (CNA) #3 on 9/26/2025 at 10:17 A.M., she said that Resident #49 sometimes needs assistance with meals because he/she tires. CNA #3 said that staff monitor the Resident with meals and if the staff notice Resident #49 using his/her hands while eating they try to help him/her or give him/her a spoon. During an interview with the Director of Nursing (DON) on 9/26/2025 at 1:01 P.M., she said that it is her expectation that staff provide assistance with meals as needed. The DON said that if a resident is struggling to eat, and eating non-finger food with their hands, staff should intervene and offer assistance.

Based on observation, record reviews and interviews, the facility failed to provide treatment and services related to an indwelling urinary catheter (a thin flexible tube inserted into the bladder to drain urine outside the body), for two Residents (#3 and #92) out of a total sample of 29 residents. Specifically,1.For Resident #3, the facility failed to implement the physician's orders related to the correct indwelling catheter balloon and size.2.For Resident #92, the facility failed to implement the physician's orders related to the correct indwelling catheter balloon and size and empty the urinary drainage bag as ordered.Findings include:Review of the facility policy titled 'Urinary catheter Care' dated April 2024, indicated the following:-Empty the drainage bag at least every 8 hours and as needed.1.) Resident #3 was admitted to the facility in June 2021 with diagnoses including benign hyperplasia with lower urinary tract symptoms and neuromuscular dysfunction of bladder. Review of Resident #3's Minimum Data Set (MDS) assessment, dated 8/1/25, indicated the Resident scored an 8 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition, the MDS further indicated the Resident required indwelling catheter. On 9/25/25 at 9:10 A.M., the surveyor and Nurse #2 observed Resident #3's indwelling urinary catheter as size 16 French (fr) with a 5 milliliter (ML) balloon. Review of Resident #3's physician's order dated 6/24/23 indicated: -Insert foley catheter 16 fr with 10ml balloon every night shift starting on the 17th and ending on the 17th every month related to neuromuscular dysfunction of bladder. Review of Resident #3's care plan date initiated 9/10/25: Resident has a foley catheter because of BPH, urinary retention, bilateral hydronephrosis and acute focal pyelonephritis 14Fr 10cc. -Interventions: Change foley and bag per MD order. Review of Resident #3's Treatment Administration Record (TAR), dated 9/17/25 indicated the indwelling catheter was changed. During an interview on 9/25/25 at 12:26 P.M., Nurse #2 said nurses should follow orders with correct size of indwelling urinary catheter. During an interview on 9/25/25 at 1:35 P.M., Unit Manager #2 said when changing the foley catheter the nurses should check order to ensure they have the correct catheter size. If there is no same catheter size, they would then notify the Nurse Practitioner (NP) to have orders for a substitution catheter that they have on hand. 2.) Resident #92 was admitted to the facility in March 2023 with diagnoses including retention of urine, urinary tract infection, neuromuscular dysfunction of bladder. Review of Resident #92's Minimum Data Set (MDS) assessment, dated 8/6/25, indicated the Resident scored a 10 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. The MDS further indicated the Resident required indwelling catheter. On 9/24/25 at 2:35 P.M., the surveyor observed Resident #92's foley catheter bag with 1400 milliliters (ML) of urine. During an observation and interview on 9/24/25 at 4:56 P.M. Nurse #5 said that she worked on this unit regularly and that she was Resident #92's nurse. Nurse #5 said she had not emptied Resident #92's foley catheter bag yet this shift and observed that Resident #92's foley catheter bag currently contained 1,600 mL of urine. Nurse #5 said certified nursing assistants (CNA's) were supposed to change the Resident's foley catheter bag at the beginning and end of their shift and that if they had emptied the bag at the beginning of the shift it would not be that full. On 9/25/25 at 9:10 A.M., the surveyor and Nurse #2 observed Resident #3's indwelling urinary catheter as size 18 French with a 10 milliliter (ML) balloon. Review of Resident #3's physician's order indicated:-Empty foley bag two times a shift for prevention of irritation/urine backflow related to retention of urine. Dated 6/12/25-Foley catheter care every shift. Dated 3/12/25-Insert a foley catheter 20 French (fr) 10 milliliter (ML) balloon. -Cipro (antibiotic used for treating infections) oral tablet 500 milligram (MG) give one tablet via gastrostomy tube two times a day for UTI (urinary tract infection) for 10 days. Dated 9/15/25 Review of Resident #92's care plan date initiated 4/12/25: Resident has a foley catheter 14 fr 10 ml balloon because of urinal retention This places the resident at risk for Infection Urinary retention. -Intervention: Catheter care every shift and as needed. During an interview on 9/25/25 at 12:26 P.M., Nurse #2 said nurses should follow orders with correct size of indwelling urinary catheter and the Resident's catheter is emptied twice per shift as his/her bag fills up quickly. During an interview on 9/25/25 at 1:35 P.M., Unit Manager (UM) #2 said when changing the foley catheter the nurses should check the order to ensure they have the correct catheter size. If there is no same catheter size, they would then notify the Nurse Practitioner (NP) to have orders for a substitution catheter that they have on hand. The UM said the Resident's catheter is emptied twice a shift because he/she has a large output due to receiving fluids every 4 hours.During an interview on 9/26/25 at 11:46 A.M., the Director of Nursing said nurses should follow physician order for correct catheter size to prevent causing bladder irritation. She also said foley catheters are emptied every shift and as needed and for Resident #92's foley catheter it is emptied twice a shift as the Resident has high urine output.

Based on observations record review and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#2) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to.) out of a total sample of 29 residents. Specifically, the facility failed to ensure clamps and pressure dressings were kept with the Resident in case of emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings includeReview of the facility policy titled 'Emergency Care of Dialysis Patients' dated April 2025, indicated the following but not limited to:-Staff will monitor and respond to common dialysis emergencies, including but not limited to: -Excessive bleeding from access site. -Apply direct pressure to control bleeding at vascular access site. Resident #2 was admitted to the facility in August 2025 with diagnoses including End stage renal disease, dependent on dialysis. Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment. The MDS further indicated the Resident was dependent on dialysis. Review of Resident #2's current physician orders indicated the following:-Non serrated clamps to be kept at bedside and on person. Review of Resident #2's current plan of care related to hemodialysis indicated the following:-If bleeding occurs apply pressure dressing and call 911.-Non serrated clamp will be kept at bedside and in dialysis bag and on wheelchair to clamp chest port catheter in the event of bleeding. On 9/25/25 at 8:25 A.M., Resident #2 was observed sitting on edge of bed. The surveyor did not observe emergency clamps or pressure dressings in the Resident's room. On 9/25/25 at 10:30 A.M. Resident #2 was observed walking around his/her room. The surveyor did not observe emergency clamps or pressure dressings in the Resident's room. During an observation and interview on 9/25/25 at 10:52 A.M., the surveyor and Nurse #1 did not observe emergency clamp and pressure dressing in the Residents room. Nurse #1 said emergency clamp and pressure dressings should be in the Resident's room. During an interview on 9/25/25 at 12:01 P.M., Unit Manager #1 said emergency clamp should be in the Resident's room, next to bed. During an interview on 9/25/25 at 12:31 P.M., the Director of Nursing said residents with tunneled dialysis catheters should have emergency clamps and pressure dressing at the bedside.

Based on records reviewed and interviews the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for one Resident (#13), who was receiving antipsychotic medications, out of a total sample of 29 residents. Findings include:Review of facility policy titled Psychotropic Medication Management, dated October 2023, indicated the following, but not limited to:*Perform a baseline Abnormal Involuntary Movement Scale (AIMS) assessment upon initiation of any antipsychotic medication and every six months thereafter. Resident #13 was admitted to the facility in November 2024 with diagnoses including dementia with psychotic disturbance. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 7/31/25, indicated the Resident scored a 4 out of a possible 15 on the Brief Interview for Mental Status, indicating he/she had severe cognitive impairment. The MDS further indicated that the Resident was receiving an antipsychotic. Review of Resident #13's physician's order, dated 11/6/24, indicated:-Quetiapine fumarate ER oral tablet extended release 24-hour 300 mg(milligram). Give 600 mg by mouth at bedtime.Review of Resident #13's physician's order, dated 9/24/25, indicated:-Risperdal oral tablet 0.5mg. Give one tablet by mouth two times a day. Review of Consultant Pharmacy Recommendation dated 4/1/25 through 4/12/25, indicated:-Resident is receiving the following antipsychotic medication, Risperdal. AIMS assessment is required every 6 months.Review of Consultant Pharmacy Recommendations dated 9/9/25, indicated: Resident is receiving Seroquel XR 600 mg at bedtime and Risperdal 1mg daily. Dose evaluation is recommended periodically to help determine the lowest effective dose. If no change is indicated please note medical necessity and potential risk of side effects versus therapeutic benefit of current therapy in progress note. Review of Resident #13's medical record failed to indicate that staff completed an Abnormal Involuntary Movement Scale (AIMS) assessment as required. During an interview on 9/25/25 at 11:56 A.M., Nurse #1 said she was not aware who completed the AIMS assessment or how often it needed to be completed. During an interview on 9/25/25 at 12:01 P.M., Unit Manager #1 said that the Assistant Director of Nursing completes the AIMS assessment. During an interview on 9/25/25 at 12:31 P.M., the Director of Nursing said an AIMS should be completed upon admission and every six months for residents who receive antipsychotic medications. She said there was no system in place to complete AIMS assessments for those residents who were not being seen by psych services.

Based on observations, interviews, and record review for one Resident (#62) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of three nurses observed made two errors out of 26 opportunities resulting in a medication error rate of 7.69%. Specifically, Nurse #4 administered the incorrect type of multivitamin and the incorrect type of eye drops. Findings include:Review of the facility policy titled Medication Administration - Oral, dated June 2025, indicated:-Verify Medication order on MAR (medication administration record). Check against physician order.-Compare the medication label to the resident's/patient's MAR. Resident #62 was admitted to the facility in June 2021 with diagnoses including bilateral cataracts (cloudy areas that form on the lens of the eye) and anemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/8/25, indicated Resident #62 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/26/25 at 9:34 A.M., the surveyor observed Nurse #4 administer the following medications to Resident #62:-One multivitamin with minerals tablet.-One drop of refresh eye drops into bilateral eyes. Review of Resident #62's physician's orders, initiated 3/26/22, indicated:-Multivitamin tab, give 1 tablet orally one time a day.-Systane 0.3%-0.4% drops, instill one drop in both eyes four times a day. During a follow-up interview on 9/26/25 at 1:14 P.M., Nurse #4 said she was unaware there was another multivitamin available. Nurse #4 said she was unsure if refresh eye drops were the same as systane eye drops. During an interview on 9/26/25 at 10:10 A.M., Unit Manager #1 said the facility multivitamin with minerals should only be given if the physician ordered the multivitamin with minerals. Unit Manager #1 said the facility has a multivitamin, without minerals, available and that should be given if the order indicates to administer multivitamin. During an interview on 9/26/25 at 12:56 P.M., the Director of Nursing (DON) said multivitamin with minerals should only be given if the physician ordered the multivitamin with minerals. The DON said the facility has a multivitamin, without minerals, available and that should be given if the order indicates to administer multivitamin. The DON said refresh eye drops are a different medication than systane eye drops, and Resident #62 should have received the systane eye drops, not refresh eye drops.

Based on observations and interviews, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to ensure two bottles of lorazepam (a Schedule IV controlled substance) was maintained in a separately locked compartment. Findings include:Review of the facility policy titled Medication Storage Policy, dated March 2024, indicated:-Controlled Substances: Controlled medications are stored in a separately locked compartment within the medication cart or storage room. On 9/26/25 at 9:02 A.M., the surveyor observed an unlocked compartment in Pawtucket medication room containing two bottles of lorazepam oral concentrate 2 mg (milligrams)/ml (milliliters). There was a lock on this compartment, however it was not engaged, and the door was able to be opened without any key. During an interview on 9/26/25 at 9:03 A.M., Nurse #2 said the compartment should have been locked because it contained controlled substances. Nurse #2 said controlled substances must be locked separately from other medications. Nurse #2 said he should have locked the compartment containing lorazepam in the Pawtucket medication room but did not. During an interview on 9/26/25 at 12:56 P.M., the Director of Nursing (DON) said controlled medications, such as lorazepam) must be stored in a separately locked compartment within the medication cart or storage room. The DON said Nurse #2 should have locked the compartment containing lorazepam in the Pawtucket medication room.

Based on observation and interview the facility failed to ensure proper food handling on 1 of 4 resident units. Specifically, on the Pawtucketville unit, 2 different staff handled resident's toast with their bare hands. Findings include:The facility policy titled Food Handling and Safety, dated April 2024, indicated the following:-All staff handling food must wash hands thoroughly before and after handling food, wearing gloves when appropriate.-Staff will receive ongoing education on food safety ad infection control practices. On 9/25/2025 at 8:32 A.M., while observing breakfast on the Pawtucketville unit, the surveyor observed a Certified Nursing Assistant (CNA) sit down beside a resident in the unit dining room. The CNA then picked up the resident's toast with her bare hands, tore the piece of toast into pieces and placed it in the residents oatmeal. On 9/26/2025 at 8:40 A.M., while observing breakfast on the Pawtucketville unit, the surveyor observed a CNA sit down beside a resident in the unit dining room to assist with breakfast. The CNA picked up the resident's toast with his bare hands and moved it to a different part of the plate to cover it with jelly. During an interview with CNA #2 on 9/26/2025 at 10:05 A.M., she said that staff should always wear gloves when handling food items such as a resident's toast. During an interview with the Nurse Unit Manager #3 on 9/26/2025 at 10:17 A.M., she said that staff should not be handling resident's food with their bare hands because it is an infection control issue. The surveyor shared the observations of two different staff handling toast with their bare hands and Nurse Unit Manager #3 said that she has a lot of new staff that still need education. During an interview with the Director of Nursing (DON) on 9/26/2025 at 1:01 P.M., she said that staff should not be handling resident's food with their bare hands.

Based on observation, record review and interview, the facility failed to meet professional standards of quality for three Residents (#61, #40 and #78), out of a total of 24 residents. Specifically: 1. For Resident #61, the facility failed to apply wound care dressing per physician orders. 2. For Resident #40, the facility failed to apply hand rolls to both hands per physician orders. 3. For Resident #78, the facility failed to provide 15-minute checks and ensure a wanderguard was in place per physician orders. Findings include: 1. Resident #61 was admitted to the facility in October 2024 with diagnoses including need for assistance with personal care. Review of Resident #61's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. The MDS further indicated that the Resident is at risk of developing pressure ulcers/injuries and is dependent on staff for activity of daily living care. On 10/23/24 at 11:17 A.M., the surveyor observed Nurse #3 prepare to perform a wound dressing change for Resident #61. Nurse #3 was observed removing a soiled silicone dressing from the Resident's buttock. The silicone dressing had no date or initials. Review of Resident #61's physician's order dated 10/21/24 indicated the following: Treatment Order (cleanse with wound cleanser and apply collagen and bordered gauze) Location: (coccyx/right buttock). During an interview on 10/23/24 at 11:36 A.M., Nurse #3 said the silicone foam dressing was the incorrect treatment applied. Nurse #3 said there was no shortage of the border gauze dressing. During an interview on 10/23/24 at 12:05 P.M., the Assistant Director of Nursing (ADON) said nursing staff should follow the orders as ordered and follow facility protocols for wound care treatment. 48671 2. Resident #40 was admitted to the facility in August 2015 with diagnoses including quadriplegia, contracture right elbow, contracture left elbow, and dementia. Review of Resident #40's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, indicating he/she has moderate cognitive impairment. Further review indicated Resident #40 is dependent on staff for all functional tasks. Review of Resident #40's active physician's orders indicated the following: -Hand rolls at night daily every evening shift for Contractures. Dated: 12/08/2023 -Hand rolls off every day shift for Contractures. Dated 12/28/2023 Review of Resident #40's Occupational Therapy (OT) discharge summary dated 3/11/24, included the following information: Patient will safely wear least restrictive splining /orthotic device night hours only without complaints of discomfort in order to improve ability to participate with self-feeding. Review of the OT In-Service training dated 3/6/24 indicated the following: -Topic Splint care and universal cuff use during meals. -Resident should wear comfy palm roll splints overnight. Review of Resident #40's care plans failed to indicate the use of bilateral hand rolls. On 10/21/24, at 7:29 A.M., the surveyor observed Resident #40 laying in bed sleeping. Resident #40 was not wearing bilateral hand rolls. The hand rolls were not visible in the room. A hand written sign was observed hanging behind the Residents bed that indicated Please put hand rolls in hands at night when he/she sleeps. Thanks Rehab. On 10/22/24, at 7:21 A.M., the surveyor observed Resident #40 laying in bed sleeping. Resident #40 was not wearing bilateral hand rolls. The hand rolls were not visible in the room. A hand written sign was observed hanging behind the Residents bed that indicated Please put hand rolls in hands at night when he/she sleeps. Thanks Rehab. During an interview on 10/22/24, at 1:05 P.M., Certified Nursing Assistant (CNA) #7 said the Resident cannot move his/her fingers well and said the Resident did not have on hand rolls when she came in this morning and said she has never seen Resident #40 wearing them. During an interview on 10/22/24 at 9:04 A.M., Nurse #7 said she was unaware that Resident #40 had hand rolls and said she did not see hand rolls on the Resident. During an interview on 10/22/24 at 1:21 P.M., Unit Manager #4 said she was not aware of the Resident requiring hand rolls and said staff should be placing them on in the evening and removing them in the morning as the order is written. Unit Manager #4 said she would find hand rolls for the Resident. During an interview on 10/23/24 at 9:14 P.M., the Assistant Director of Nurses (ADON) said Resident #40 was receiving occupational therapy and should be wearing bilateral hand rolls as ordered. During an interview on 10/23/24 at 11:43 P.M., the Director of Nurses (DON) said Resident #40 should have been wearing the hand rolls and said orders should be followed. 3. Resident #78 was admitted to the facility in February 2024 with diagnoses including major depressive disorder, traumatic brain injury, acute pain due to trauma, anxiety, alcohol abuse, suicidal ideations, cognitive communication deficit, and expressive language disorder. Review of Resident #78's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, indicating he/she has moderate cognitive impairment. Review of Resident #78's active physician's orders indicated the following: -15 minute checks for safety every shift for Safety, for 14 Days. Start Date:10/15/2024. Review of the Nurse Practitioner progress note dated 10/17/24, indicated: Resident #78 had an unwitnessed fall and was found on the floor at bedside. The Resident was agitated and verbally aggressive towards staff. Resident refused assessment and was transported to the hospital after making SI/HI statement. Review of the Nursing Progress note dated 10/16/24 indicated: Safety precautions in place. Call light within reach. Recommendations: Continue to monitor with 15-minute checks for safety. Review of Resident #78's Falls care plan dated 2/27/24, indicated Resident #78 is at risk for falls due to history of fall with injury - s/p (status post) fall with comp fx (compound fracture) 3/3/24- unwitnessed fall in room, 4/15/24 - witnessed fall in parking lot. Dated as revised 5/23/24. The falls care plan failed to indicate the need for 15-minute checks. On 10/22/24 from 8:35 A.M. to 9:11 A.M., the surveyor observed Resident #78 in his/her room sitting in a wheelchair with a breakfast tray place on the overbed table. No staff were observed providing 15-minute checks to Resident #78 and no staff were visible in the hallway walking by or looking into Resident #78's room throughout the observation. At 9:12 A.M., a staff member walked into Resident #78's room to remove the breakfast tray. During an interview on 10/22/24 at 12:48 P.M., Behavioral Health Nurse Practitioner (NP) #2 said Resident #78 had a recent fall and was sent to the hospital and said he/she has a history of behaviors with recent suicide ideations. NP #2 said Resident #78 has been doing well and is currently on 15-minute checks for safety after the fall. During an interview on 10/22/24 at 1:39 P.M., Unit Manager (UM) #4 said Resident #78 is on 15 minute checks for safety for recent falls and history of behaviors. UM #4 said she expects staff to conduct 15-minute checks and to follow the physician orders. UM #4 said staff are to document safety checks in the binder and showed the surveyor the binder and said staff should not document checks that were not completed. During an interview on 10/23/24 at 9:37 A.M., The Assistant Director of Nursing said 15 minute safety checks were implemented due to a recent fall and said Resident #78 reported his/her call light in bathroom was not working. The ADON said Resident #78 has a history of behaviors and requires 15-minute checks for safety but is not an elopement risk. During an interview on 10/23/24 at 12:14 P.M., the Director of Nurses (DON) said Resident #78 is behavioral and said 15 minute checks were implemented for safety. The DON said Resident #78 could be harmful to him/herself and staff must follow physician orders.

Based on observations, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice for three Residents (#317, #77, #42) out of a total sample of 24 Residents. Specifically, the facility failed to: 1. Ensure oxygen filters were in use while Resident #317 was receiving oxygen via nasal cannula 2. Ensure oxygen filter was clean, oxygen tubing was dated and labeled and CPAP (continuous positive airway pressure) machine was clean and stored in a sanitary way. 3. Ensure oxygen filter was clean, oxygen tubing was dated and labeled, distilled water was changed and dated, and BIPAP (bilevel positive airway pressure) machine was clean and stored in a sanitary way. Findings include: Review of facility policy titled 'Oxygen Administration Nasal Cannula' dated April 2024, indicated the following but not limited: -To deliver low flow oxygen per physician's order. -Oxygen source. Review of facility policy titled 'CPAP/BiPAP Management' dated April 2024, indicated the following but not limited to: -Masks and nasal pillows wash daily with mild detergent (rinse thoroughly with warm water to remove all detergent and residue air dry. 1. Resident #317 was admitted to the facility in October 2024 with diagnoses including acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus. Review of Resident #317's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. The MDS further indicated that Resident #317 requires oxygen therapy. The surveyor made the following observations: - On 10/21/24 at 8:01 A.M. and 8:43 A.M., Resident #317 was sleeping in his/her bed receiving oxygen via nasal cannula. The oxygen machine did not have any external filters in place. - On 10/21/24 at 12:57 A.M., Resident #317 was in his/her bedroom sitting in his/her wheelchair receiving oxygen via nasal cannula. The oxygen machine did not have any external filters in place. - On 10/22/24 at 7:10 A.M.,, Resident #317 was sleeping in his/her bed receiving oxygen via nasal cannula. The oxygen machine did not have any external filters in place. Review of Resident #317's physician's order dated 10/8/24 indicated the following: Oxygen at 4-10 LPM (liters per minute) via NC (nasal cannula) continuously every shift Review of Resident #317's oxygen therapy care plan dated 10/8/24 indicated the following intervention: Oxygen Settings: O2 (oxygen) via nasal prongs @ 4-10 liters continuously. During an interview on 10/22/24 at 12:45 P.M., Unit Manager #3 and the surveyor observed Resident #317's oxygen concentrator machine. Unit Manager #3 and the surveyor observed the oxygen machine to not have any external filters on either side. The surveyor asked Unit Manager #3 if the machine was supposed to have filters on it and she was unable to answer the question and said she would go ask the Assistant Director of Nursing (ADON). During an interview on 10/22/24 at 1:03 A.M., the ADON observed the oxygen machine and said there were no external filters. The ADON said she was not sure if it should have filters since it is a high flow oxygen machine. At 1:16 P.M., the ADON said she would expect the oxygen machine to be ready for use once delivered but will need to review the oxygen machine's operator's manual. Review of the oxygen concentrator's operator's manual indicated there was a spot for cabinet filters on the sides of the machine. Further review of the manual indicated instructions for routine cleaning of the oxygen filters indicating they should be in use while the machine is operating. During an interview on 10/22/24 at 1:28 P.M., the surveyor and ADON reviewed the manual and she said filters should be in place on Resident #317's oxygen concentrator machine. On 10/23/24 at 11:14 A.M., a representative from the company that provided Resident #317's oxygen concentrator arrived at the facility with external filters. He said the machine should have filters on it. 46339 2. Resident #77 was admitted to the facility in January 2024 with diagnoses including dependence on other enabling machines and devices (CPAP). Review of Resident #77's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 10 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was moderately cognitively impaired. On 10/22/24 at 8:15 A.M., the surveyor observed the oxygen concentration in Resident #77's room with a thick layer of dust on the filter. The CPAP machine was visibly dirty and laying on the bedside table. On 10/22/24 at 11:13 A.M., the surveyor and Nurse #1 observed the oxygen concentrator with a thick dust covered filter, the tubing was undated, the CPAP mask was laying on the bedside table. Review of physician order dated 1/10/2024 indicated the following: CPAP to be worn at bedtime. Settings set between 8-20 with 2 liters per minute oxygen every evening shift for insomnia. Review of the Treatment Administration Record (TAR) for October 2024, indicated the Resident had been wearing the CPAP at night for the past 17 consecutive nights. There was no documented refusal to wear the CPAP. During an interview on 10/22/24 at 11:22 A.M., Nurse #1 said he did not know how often the oxygen filter was changed and how often the CPAP cleaning was one. During an interview on 10/22/24 at 11:24 A.M., Unit Manager #1 said the oxygen tubing and filters are changed weekly, and the CPAP mask should be cleaned daily. During an interview on 10/23/24 at 9:24 A.M., the Assistant Director of Nursing (ADON) said the oxygen tubing, filters are changed weekly on 11-7 shift and are stored in a bag with name and room number and the CPAP mask is cleaned daily and air dried. 48671 2. Resident #42 was admitted to the facility in February 2024 with diagnoses including dependence on other enabling machines and devices BIPAP, (bilevel positive airway pressure machine that delivers air through a mask on your face), chronic obstructive pulmonary disease, obstructive sleep apnea, dependency on supplemental oxygen, chronic respiratory failure with hypoxia, and morbid obesity. Review of Resident #42's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was cognitively intact. On 10/21/24 at 8:15 A.M., the surveyor observed Resident #42 sleeping in bed wearing oxygen. The oxygen tubing was dated 3/10/24. The concentrator had one 540 ml (milliliter) bottle of sterile water connected and was dated 6/7/24. There was one clear bag hanging off the side of the concentrator with a label which indicated: Date issued 9/23/24. Time: 0645. Equipment in use; BIPAP connecting tubing. The concentrator had a thick layer of dust covering the entire filter. The BIPAP machine was located on the bedside table and contained no water. The facemask was visibly dirty with discolored yellow and tan flakes and stains covering the entire facemask. On 10/22/24 at 7:56 A.M., the surveyor observed Resident #42 sleeping in bed. The oxygen tubing was dated 3/10/24. The concentrator had one 540 ml bottle of sterile water connected and was dated 6/7/24. There was one clear bag hanging off the side of the concentrator with a label which indicated: Date issued 9/23/24. Time: 0645. Equipment in use; BIPAP connecting tubing. The concentrator had a thick layer of dust covering the entire filter. The BIPAP machine was located on the bedside table and contained no water. The facemask was visibly dirty with discolored yellow and tan flakes and stains covering the entire facemask. Review of Resident #42's active physician orders indicated the following: -Oxygen as needed via nc (nasal cannula) at 2 LPM (liters per minute) as needed as needed [SIC] for keep sas [SIC] >90% Start Date: 08/29/2023. -Change O2 tubing every Sunday on the 7 am to 3 pm shift. In the morning every Sunday. Dated 6/5/22. -Change BIPAP tubing every Sunday 7 AM - 3 PM one time a day every Sun. Dated 2/12/23. -Change distilled water at bedtime every evening shift. Dated 12/28/21. -Clean filter weekly with soap and water rinse and dry on Friday. Dated 12/31/21. -Tubing wash bi-monthly with mild detergent soap and rinse with water air dry wipe BIPAP machine with damp cloth on the 1st and 15th every month for BIPAP maintenance. Dated 3/15/22. -Wash mask everyday with soap and water air dry on 7-3 shift every day shift. Dated 12/29/21. -BIPAP on at all time while resident is sleeping/taking a nap. Every shift. Dated 1/4/23. -BIPAP setting auto BIPAP 15 max IPAP 5 min EPAP bleed in 2L/min oxygen every shift. Dated 10/11/23. Review of the Treatment Administration Record (TAR) for October 2024, indicated the Resident had been wearing the BIPAP at night for the past 20 consecutive nights. There was no documented refusal to wear the BIPAP. Further review of the TAR indicated the following: -O2 tubing was documented as changed on 10/20/24 -BIPAP tubing was documented as changed on 10/20/24. -Distilled water was documented as changed 12 of the 20 documented days during the month of October. The last documented change was 10/20/24. -The filter was documented as cleaned with soap and water on 10/18/24. -The BPAP tubing was documented as changed on 10/20/24. -The mask was documented as last washed on 10/21/24. During an interview on 10/22/24 at 1:02 P.M., Certified Nursing Assistant (CNA) #7 said the Nurses clean the oxygen and BIPAP equipment and put it on the resident when he/she needs it. On 10/22/24 at 12:34 P.M., the surveyor observed the oxygen tubing changed dated 10/22/24. The concentrator had a new one 540 ml (milliliter) bottle of sterile water connected and was dated 10/22/24. There was one clear bag hanging off the front of the concentrator labeled Date 10/22/24. The concentrator still had a thick layer of dust covering the entire filter. The BIPAP machine was located on the bedside table and contained no water. The facemask was cleaned. During an interview on 10/22/24 at 1:25 P.M., Unit Manager #4 said she went into Resident #42's room while he/she was outside and changed out the respiratory and BIPAP equipment, washed the facemask and equipment and removed the old water and dated the tubing because sometimes the Resident will refuse and it is easier to change it when he/she is not in the room. UM #4 said the oxygen tubing and filters are changed every Sunday and said the BIPAP equipment needs to be cleaned daily and air dried. UM #4 said tubing needs to be dated weekly and stored in a bag with name and room number. UM #4 said physician orders must be followed and if the Resident is refusing care it needs to be documented by the nurses in the TAR and not documented as administered. During an interview on 10/23/24 at 9:24 A.M., the Assistant Director of Nursing (ADON) said the oxygen tubing and filters are changed weekly, and the BIPAP mask should be cleaned daily. During an interview on 10/23/24 at 11:47 A.M., the Director of Nursing (DON) said staff must follow physician orders for respiratory care and cleaning and said the tubing must be dated appropriately and changed according to the order. The DON said the filters and masks must be checked and cleaned weekly. The DON said Resident #42 should not have distilled water attached to the concentrator that is outdated.

Based on observation, record review and interview, the facility failed to follow infection control practices to prevent possible spread of infection by: 1. Failing to perform proper hand hygiene and failing to use Personal Protective Equipment (PPE) for an Enhanced Barrier Precaution room. 2. Failing to sanitize shared medical equipment between residents, specifically a glucometer (a machine used to test blood sugar). 3. Failing to follow infection control practices during a wound dressing change, specifically not performing hand hygiene after glove removal and storage of wound treatment supplies. Findings include: Review of the facility's policy titled Personal Protective Equipment, undated, indicated the following: - Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE). - PPE is required for transmission-based precautions is maintained outside and inside the resident's room, as needed - Training on proper donning, use of PPE is provided upon orientation and at regular intervals. 1. The surveyor observed signage indicating Enhanced Barrier Precautions hanging outside of rooms [ROOM NUMBERS] on the Belvidere Unit. The signage indicated the following: - Everyone must: clean their hands, including before entering and when leaving the room. - Providers and staff must also wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, wound care. `On 10/21/24 the surveyor made the following observations: - At 12:43 P.M., a housekeeper entered room [ROOM NUMBER], identified as occupying a resident requiring enhanced barrier precautions, without performing hand hygiene. The housekeeper then exited room [ROOM NUMBER] without performing hand hygiene. The housekeeper then proceeded to enter room [ROOM NUMBER], occupied by a resident requiring enhanced barrier precautions, without performing hand hygiene. The housekeeper changed the trash with her bare hands. Then outside of room [ROOM NUMBER] the housekeeper put gloves on both hands without performing hand hygiene, re-entered room [ROOM NUMBER] and then proceeded to exit. At 12:59 P.M., the housekeeper entered room [ROOM NUMBER] wearing the same gloves and exited the room to remove her gloves. At 1:02 P.M., she put on a new pair of gloves without performing hand hygiene and was observed changing the trash and sweeping. On 10/22/24 the surveyor made the following observations: - At 11:49 A.M., two certified nursing assistants (CNA) were observed in room [ROOM NUMBER], identified by a sign that the room was occupied by a resident requiring enhanced barrier precautions, one CNA (#2) was making the Resident's bed while the other CNA was wheeling out the Hoyer lift. The resident was observed to be sitting in his/her [NAME] chair in his/her room while the CNAs were in his/her room. The CNAs were observed wearing masks, no gloves or gowns in the room. During an interview on 10/22/24, CNA #2 said the Resident in room [ROOM NUMBER] is totally dependent on staff for all ADL care and requires two staff members for transfer. CNA #2 continued to say she was just providing ADL care to that resident and needed another CNA to help her. During an interview on 10/23/24 at 9:10 A.M., the Assistant Director of Nursing (ADON), who is also the Infection Preventionist, said she would expect staff to be following the instructions for each precaution sign outside of a resident's room. The ADON said housekeepers should be performing hand hygiene before entering rooms and when exiting rooms. The ADON further said all staff including CNAs should be following the enhanced barrier instructions for PPE while providing care to the residents. 46339 2 Review of the facility's policy, Glucose monitoring equipment, revised August 2024, included but not was limited to the following: Blood glucose monitoring equipment will be checked for accuracy, including a quality control test performance. Blood glucose monitoring equipment will be cleaned with a bleach wipe before and after use and/or as per manufacturer guidelines. On 10/23/24 at 7:45 A.M., the surveyor observed Nurse #1 gather supplies to check a resident's blood sugar. The surveyor observed Nurse #2 exit the resident's room and place the glucometer back in the basket on his medication cart that contained other blood sugar testing items. On 10/23/24 at 7:49 A.M., the surveyor observed Nurse #1 checking another resident's blood sugar without cleaning the glucometer. During an interview on 10/23/24 at 7:54 A.M., Nurse #1 said the glucometer should be sanitized after each use. During an interview on 10/23/24 at 12:13 P.M., the Assistant Director of Nursing (ADON) said glucometers should be sanitized after each use. 3. Review of the facility's policy titled, 'Prevention and management of Pressure injuries' dated July 2023 included but was not limited to the following: Infection control: -Clean technique is utilized in performing dressing changes. Sterile technique may be ordered by the physician as indicated. -Standard precautions are utilized per policy unless otherwise indicated. On 10/23/24 at 11:17 A.M., the surveyor observed Nurse #3 perform wound care on Resident #61. During the wound care treatment, the following were observed: -Nurse #3 was observed placing the dressing treatment supplies on the Resident's bed, then proceeded with removing the old, soiled dressing from Resident #61's right buttock, Nurse #3 did not perform hand hygiene after removing her gloves. -Nurse #3 applied new gloves without performing hand hygiene, applied a new dressing to the Resident's wound. Nurse #3 proceeded to remove her gloves without hand hygiene, removed a sharpie from her pocket and dated the Resident's dressing while on the Resident's body. -Nurse #3 then removed the unused portion of the dressing treatment supplies and placed them in the Resident's personal drawer which contained personal clothing in the drawer. During an interview on 10/23/24 at 11:36 A.M., Nurse #3 said she should perform hand hygiene after removing gloves, use a sterile field to place dressing treatment supplies, and to store the dressing supplies appropriately. Nurse #3 further said she should not be writing on the Resident and should have dated the dressing prior to applying to the Resident. During an interview on 10/23/24 at 12:05 P.M., the Assistant Director of Nursing (ADON) said nurses are to follow the facility wound care protocol and hand hygiene should be performed before putting on gloves, in between changes and after completing the treatment.

Based on observation, record review and interview, the facility failed to provide a dignified existence for one Resident (#317) out of a total sample of 24 Residents. Specifically, the facility failed to utilize a privacy bag while Resident #317's urinary catheter bag was visible and in use. Findings include: Review of the facility policy titled Resident Rights Policy and Procedures, revised and dated 9/18/23, indicated the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence. Resident #317 was admitted to the facility in October 2024 with diagnoses including acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus. Review of Resident #317's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. The MDS further indicated that Resident #317 is dependent on staff for toileting hygiene. The surveyor made the following observations: - On 10/21/24 at 8:01 A.M., Resident #317 was sleeping in his/her bed. A urinary catheter bag with visible yellow urine was hanging from the bed. The urinary catheter bag could be seen from the Resident's doorway in the hallway. No privacy bag was in use. - On 10/21/24 at 12:57 A.M., Resident #317 was in his/her room eating lunch while sitting in his/her wheelchair. The Resident's urinary catheter bag was clipped to the left arm rest of the wheelchair with yellow urine visible. The urinary catheter bag was visible from the Resident's doorway in the hallway. No privacy bag was in use. - On 10/22/24 at 6:47 A.M., Resident #317 was sleeping in his/her bed. A urinary catheter bag with visible yellow urine was hanging from the bed. The urinary catheter bag could be seen from the Resident's doorway in the hallway. No privacy bag was in use. - On 10/22/24 at 8:21 A.M., Resident #317 was laying in his/her bed awake, eating breakfast. A urinary catheter bag with visible yellow urine was hanging from the bed. The urinary catheter bag could be seen from the Resident's doorway in the hallway. A privacy bag was observed next to the hanging urinary catheter bag but was not in use. - On 10/22/24 at 9:47 A.M., Resident #317 was laying in his/her bed. A urinary catheter bag with visible yellow urine was hanging from the bed. The urinary catheter bag could be seen from the Resident's doorway in the hallway. A privacy bag was observed next to the hanging urinary catheter bag but was not in use. - On 10/23/24 at 6:58 A.M., Resident #317 was sleeping in his/her bed. A urinary catheter bag with visible yellow urine was hanging from the bed. The urinary catheter bag could be seen from the Resident's doorway in the hallway. No privacy bag was in use. Review of Resident #317's physician's orders dated 10/16/24 indicated the following: - Foley Catheter care every shift - Replace foley bag monthly the 16th every month - Insert foley catheter 16fr (French) with 5ml (milliliter) balloon. - Change foley catheter bag as needed During an interview on 10/23/24 at 8:56 A.M., Nurse #3 said all urinary catheter bags should have a privacy bag when in use so they cannot be seen from the hallway. Nurse #3 and the surveyor observed Resident #317's urinary catheter bag from the hallway and she said it should have a privacy bag covering it. During an interview on 10/23/24 at 9:02 A.M., the Assistant Director of Nursing said Resident #317 should have a privacy bag over his/her catheter bag when in use.

Based on observation, record review and interview, the facility failed to ensure person-centered care plans with measurable goals and individualized interventions were developed and implemented for two residents (#58 and #94), out of 24 sampled residents. Specifically: 1. For Resident #58 the facility failed to develop a plan of care related to the prevention of pressure ulcers. 2. For Resident #94, the facility failed to develop comprehensive pacemaker care plan. Findings include: 1. Resident #58 was admitted to the facility in June 2024 and has diagnoses that include adult failure to thrive, type 2 diabetes mellitus, and need for assistance with personal care. During an observation and interview on 10/21/24 at 9:41 A.M., Resident #58 was laying on his/her bed without sheets under him/her. Resident #58 said he/she was incontinent and staff stripped his/her bed. Review of the Minimum Data Set (MDS), assessment dated [DATE], indicated Resident #58 scored a 14 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having intact cognition, and requires set up/clean up assistance with toileting and is at risk of developing pressure ulcers. Review of the comprehensive MDS dated [DATE] indicated at section M that Resident #58 was at risk for developing pressure ulcers. Review of the Care Area Assessment (CAA) Pressure Ulcer/Injury indicated Resident is at risk of PI (pressure injury) r/t (related to) needing assistance with ADLs (activities of daily living) and incontinence and a pressure ulcer/injury will be addressed in a care plan. Review of the Norton Plus (an assessment that determines the level of risk for developing pressure ulcers/injuries) completed for Resident #58 indicated the following: -6/7/24 assessed score of 12 moderate risk. -6/21/24 assessed score of 11 moderate risk. -6/28/24 assessed score of 10 high risk. -7/5/24 assessed score of 11 moderate risk. Review of Resident #58's care plans failed to indicate a care plan for the risk of developing pressure ulcers/injuries was developed. During an interview on 10/23/24 at 9:16 A.M., Certified Nursing Assistant (CNA) #3 said Resident #58 requires assistance with daily care. CNA #3 said the Resident wears a brief and is incontinent of urine. During an interview on 10/23/24 at 9:41 A.M., Nurse #5 said Resident #58 is incontinent of bladder. Nurse #5 said incontinence is a risk for developing pressure ulcers and Resident #58 should have a risk for pressure injury care plan. During an interview on 10/23/24 at 9:45 A.M., Unit Manager #4 said incontinence puts a resident at risk for skin breakdown. Unit Manager #4 said Resident #58 is incontinent of bladder and should have a risk for skin breakdown care plan. 46339 2. Review of the facility policy titled Pacemaker Checks', dated April 2024, indicated the following: Identify type and identification number of pacemaker resident/patient has on admission and note same in medical record. Document in the medical record. Resident #94 was admitted to the facility in August 2023 with diagnoses that include presence of cardiac pacemaker. Review of Resident #94's most recent Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 indicating he/she had moderate impaired cognition. Review of Nursing- Admission readmission-V2 assessment dated [DATE] indicated the Resident had a pacemaker upon admission. Review of the Resident medical record failed to indicate a care plan was developed for the pacemaker. During an interview on 10/22/24 at 11:18 A.M., Unit Manager #1 said that the Resident's pacemaker was new and that a care plan should have been developed. During an Interview on 10/23/24 at 12:10 P.M., the Assistant Director of Nursing (ADON) said a care plan for pacemaker should have been developed.

Based on observations, record review, policy review and interviews, the facility failed to provide supervision with meals for one Resident, (#44) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADL) dated as revised April 2024, indicated A program of activities of daily living (ADL) is provided to residents to maintain or restore maximum functional independence. The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or other members of the interdisciplinary team. A program of assistance and instruction in ADL skill is developed and implemented based on the individual evaluation to encourage the highest level of functioning. This process is reviewed minimally quarterly. Resident #44 was admitted to the facility in March 2017 with diagnoses including dysphasia, hyperlipidemia, failure to thrive and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 9/1/2024, indicated Resident #44 did not have a Brief Interview for Mental Status (BIMS) assessment completed. Further review of the MDS indicated Resident #44 is dependent on staff for all functional tasks. On 10/21/24 at 8:45 A.M., the surveyor observed Resident #44 in bed, breakfast was set up on the overbed table, and the Resident was attempting to eat the meal. Eggs were observed on the Residents chest, overbed table and floor. The Resident was not visible from the hallway, no staff were present in the room throughout the breakfast meal. On 10/22/24 from 8:18 A.M. to 8:59 A.M., the surveyor made the following observations: Resident #44 was sitting up sleeping in bed, the breakfast tray was placed on the overbed table. The Resident was not visible from the hallway, no staff were present in the room. At 8:55 A.M., the surveyor observed a staff member walk into the Residents room and set up breakfast items on the overbed table, pour milk into the cereal bowl and exit the room. The Resident remained sitting up sleeping. The Resident was not visible from the hallway, and no staff were present in the room. At 8:58 A.M., the surveyor observed a staff member walk into Resident #44's room and remove the breakfast items from the overbed table and exit the Residents room. The Resident remained sitting up in bed sleeping. The staff member made no attempts to arouse Resident #44 throughout the observations. Review of Resident #44's nutrition care plan indicated has a potential for impaired nutrition status due to variable po (oral) intake with the following interventions: EATING: Supervision 1:8 ratio with occasional assist (assistance) of one. Resident prefers to eat meals in his/her room. Staff assist him/her to sit upright in his/her chair, and provide set-up help and cues for all meals. [NAME] mug (thermal mug) with cover at all meals. Dated 3/24/17. Allow the resident adequate time to consume meals Dated 3/28/2017. He/she may refuse meals at times. Diet liberalized to encourage eating. Staff to offer him/her extra portions of the foods he/she may enjoy. Dated: 9/09/2024 Review of Resident # 44's CNA (Certified Nursing Assistant) Resident Care Card (form indicating level of care) indicated the following: -Eating- Independent, assist into chair and set up for all meals. -Provide mug with lid for hot liquids. During an interview on 10/22/24 at 12:57 A.M., CNA #6 said Resident #44 needs help with eating because he/she needs reminders. CNA #6 said staff use the Kardex and care cards to see what level of assistance each resident requires and said she documents care in the computer. During an interview on 12/23/24 at 11:49 A.M., the Director of Nursing said she expects staff to follow the care plan and provide supervision to residents if indicated and said Resident #44 should not be eating alone.

Based on observation, record review and interview, the facility failed to ensure nutritional supplements were provided to one Resident (#15), after having sustained significant weight loss, out of a total of 25 sampled Residents. Subsequently, Resident #15 continued to lose weight. Findings include: Review of the facility's Weight/Weight Loss Policy, dated August 2023, indicated: *If a significant weight loss/gain is identified (>5% in 30 days or 10% in 6 months the IDT (interdisciplinary team), Dietitian, Physician and Family are notified. *All Residents with a significant weight loss reviewed by the IDT and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Resident #15 was admitted to the facility in October 2019 with diagnoses including vascular dementia and dysphagia. Review of the Minimum Data Set Assessment (MDS dated ) 10/25/23 indicated Resident #15 scored a 7 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she has severe cognitive impairment. The MDS also indicated that Resident #15 requires assistance with bathing, dressing and transfers. On 11/13/23 at 9:33 A.M., the surveyor observed Resident #15 seated in the hallway in his/her wheelchair. Resident #15 appeared thin and frail. Review of the Dietitian's Quarterly assessment dated [DATE] indicated recommendations for Resident #15's Ensure supplement to be increased from twice a day to three times a day. Review of Resident #15's physicians orders on 11/13/23 indicated: Ensure Clear two times a day for risk for malnutrition, initiated 4/7/23; the order failed to indicate the recommendation for Ensure Clear three times daily was implemented. Review of Resident #15's weights indicated the following: 8/15/23: 106.2 lbs (pounds) 9/12/23: 100 lbs (a loss of 5.84% of his/her total body weight) 10/17/23: 99 lbs 10/31/23: 98 lbs 11/7/23: 97 lbs (a loss of 8.66% of his/her total body weight) Review of the clinical record failed to indicate Resident #15 was assessed or identified has having continued or significant weight loss in September 2023 or October 2023. Review of the Risk Note dated 11/10/23 indicated: Will add supplements for weight loss BID (twice daily); an intervention ordered since 4/7/23. Review of the physician's orders on 11/14/23 indicated Resident #15's orders for Ensure twice daily had been ended and replaced with a new order dated 11/13/23 for Resident #15 to receive Mighty Shakes twice daily. During interviews on 11/14/23 at 7:53 A.M., and 8:36 A.M. and the Dietitian said he started working at the facility last month. The Dietitian said that Resident #15 was reviewed at risk meetings for weight loss and that Resident #15 had orders for Ensure Clear. The Dietitian said that because there was a shortage of Ensure Clear, and because Resident #15's orders were not changed for a substitute supplement, Resident #15 had not been getting his/her ordered supplements. The Dietitian said that he attributed Resident #15's weight loss to him/her not receiving supplements. The Dietitian said last Friday, (11/10/23), he recommended to change the Ensure to Mighty Shake so Resident #15 would get supplements as ordered. The Dietitian said that he was not aware of the previous dietitian's recommendations for Resident #15 to receive Ensure three times daily. The Dietitian said that he would expect recommendations made to address weight loss to be implemented. Review of Resident #15's Medication Administration Records (MAR) for September 2023, October 2023 and November 2023 all indicated he/she received Ensure Clear twice daily as ordered. Review of the Resident Council minutes dated 9/19/23 and 10/17/23 indicated participating residents had expressed concerns regarding a lack of Ensure supplements. During an interview with the Food Service Director (FSD) on 11/14/23 at 8:36 A.M., she said that for about six weeks, there had been no Ensure available at the facility. The FSD said that there were other supplements available to Residents. Review of the Supplier notice dated 9/7/23 indicated that Ensure was out of stock with no expected recovery date listed for Ensure Clear and 29 other types of Ensure. Review of an email between the Supplier and the Administrator In Training (AIT) dated 11/14/23 at 9:19 A.M., indicated that there continued to be shortages and Ensure continued to be unavailable with the exception of Ensure Plus Fiber Vanilla 8 oz. During an interview on 11/14/23 at 8:42 A.M. Nurse #2 said that he was not sure how long the facility has not had Ensure in stock. Nurse #2 said that if a Resident has orders for an item that is not available, the nurse staff should document that it is not available and alert the physician. Nurse #2 said he could not say if Resident #15 had received an alternative supplement. During an interview on 11/14/23 at 8:44 A.M. Unit Manager #1 said that she thought the facility had been without Ensure for about a month. Unit Manager #1 said staff should have provided Resident #15 with an alternative supplement and documented in the medical record. Unit Manager #1 said she could not determine if Resident #15 had received an alternative supplement. During an interview on 11/14/23 at 10:09 A.M., the Physician Assistant (PA) said that he had been aware of Resident #15's weight loss. The PA said he was not aware that the previous Dietitian had recommended Resident #15 receive supplements three times daily. The PA said that the facility had been having difficulty obtaining Resident #15's Ensure supplements. The PA said that last week he was told Resident #15 had been receiving supplements infrequently and he had told facility staff to change Resident #15's orders to an alternative supplement.

Based on record reviews and interviews for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure appropriate safety measures were implemented by staff to prevent residents from [MEDICAL CONDITION] being served and left unsupervised or unassisted by staff with hot liquids. - On 03/21/20 Resident #1, who required continual supervision with eating and drinking, was left unsupervised by staff, he/she spilled a cup of hot coffee onto himself/herself and sustained second [MEDICAL CONDITION](burn that involves the outer layer of skin and part of the inner layer) to the left upper arm and left breast. - On 03/11/20, a staff member heated water in a styrofoam cup in the unit microwave, gave the cup of hot water to Resident #2 without a lid on it and also did not check the temperature of the water before serving it to Resident #2, the hot water spilled from the cup and Resident #2 sustained second [MEDICAL CONDITION] his/her right foot. Findings include: 1. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 3/24/20, indicated that on 3/21/20 Certified Nurse Aide #1 gave Resident #1 a hot cup of coffee in a styrofoam cup, Resident #1 spilled the coffee and and sustained a reddened area to his/her left breast with a fluid filled blister noted. The Report indicated the reddened area measured 4.2 centimeters (cm) x 3.0 cm, blistered area measured 3.5 cm x 2.1 cm and Resident #1 to be treated with [MEDICATION NAME] cream twice a day to blistered areas for seven days and then be re-evaluated. Review of Resident #1's Nursing Progress Note, dated 03/21/20 at 10:22 P.M., indicated he/she spilled hot coffee onto himself/herself while in bed and sustained fluid filled blisters to the left upper arm and left breast. Review of Resident #1's Nursing Progress Note, dated 03/26/20 at 09:07 A.M., indicated the Wound Doctor noted a second degree burn measuring 4.2 cm x 1.1 cm on the left breast. Review of Resident #1's Nursing Progress Note, dated 04/02/20 at 01:59 P.M., indicated the Wound Doctor noted second [MEDICAL CONDITION] 5.5 cm by 7.4 cm by 0.1 cm on the left inner upper arm. Review of Resident #1's Admission Record indicated, [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/04/20, indicated he/she had modified independence with cognitive skills for daily decision making, required setup help with supervision when eating and drinking, and had one sided upper extremity limited in range of motion that interfered with daily functions or placed him/her at risk of injury. Review of Resident #1's Care Plan for Activities of Daily Living, indicated he/she required continual supervision, group ratio 1:8, for assistance with meals. Review of Resident #1's Certified Nurse Aide (CNA) Resident Care Plan, dated 01/28/20, indicated he/she required continual supervision (ratio of 1:8) feeding group with eating. During an interview on 07/31/20 at 01:05 P.M., CNA #1 said on 03/21/20 at approximately 08:45 A.M. she entered Resident #1's bedroom with his/her breakfast tray which contained a cup of coffee. CNA #1 said while Resident #1 was laying in bed, she raised the head of the bed to properly position him/her to eat independently. CNA #1 said she ensured covers were removed from the food and drinks, including the coffee. CNA #1 said coffee was served in the standard coffee cup. CNA #1 said brought the over the bed table in front of Resident # 1 to ensured he/she could reach the coffee and food on the breakfast tray and left the bedroom. CNA #1 said she thought Resident #1 did not require constant one to one supervision, and had intended to return every five to ten minutes to check on him/her. CNA #1 said a few minutes after leaving Resident #1's bedroom, she heard yelling, and immediately reentered Resident #1's bedroom. CNA #1 said Resident #1 had spilled his/her coffee under his/her breast. During an interview on 07/24/20 at 10:45 A.M., Nurse #1 said coffee was poured from a carafe provided by the kitchen. Nurse #1 said the nurses and CNA's do not reheat the coffee. Nurse #1 said she saw CNA #1 enter Resident #1's bedroom to give him/her a cup of coffee and leave the bedroom. Nurse #1 said approximately five to ten minutes later, she heard Resident #1 yelling from his/her bedroom. Nurse #1 said she immediately entered the bedroom and saw that Resident #1 had spilled the coffee on his/her left upper arm and breast. Nurse #1 said CNA #1 told her that she gave Resident #1 the coffee served in a foam cup with no cover, and left Resident #1 unsupervised in his/her bedroom to serve other residents their drinks. Nurse #1 said there were no covers for the styrofoam cups on the Unit that day. During an interview on 07/24/20 at 12:25 P.M., Unit Manager #1 said Resident #1 was capable of reaching for objects as he/she had adequate upper body strength. The Unit Manager said Resident #1 was capable of feeding himself/herself but required supervision at all times. During an interview on 07/24/20 at 11:40 A.M., the Director of Nurses (DON) said since all residents during the COVID 19 outbreak were required to eat in their bedrooms and supervised eating groups were not feasible, beverages were typically served first to all residents, and then the meal was delivered. The DON said CNA's were expected to keep hot liquids out of reach of residents that required continual supervision until staff were able to remain with the residents to supervise them. The DON said Resident #1's Care Plan indicated he/she required continual supervision, therefore CNA #1 would of been expected to remain with Resident #1 until he/she completed his/her coffee and meal. Review of the Hot Liquid Temperature Log Entry (obtained on Resident #1's Unit), dated 03/21/20, indicated that the coffee was 170 degrees Fahrenheit. 2. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 3/16/20, indicated that on 3/11/20, Resident #2 asked Certified Nurse Aide (CNA) #2 for a hot cup of water so he/she could make soup. CNA #2 gave Resident #2 a styrofoam cup with hot water (without a lid). Resident #2 (who was seated in a wheelchair) put the cup of hot water between his/her right thigh and the side of the wheelchair, and started to self propel back to his/her room. The Report indicated the cup of hot water tipped over and spilled onto Resident #2's right foot. Resident #2 sustained second [MEDICAL CONDITION] his/her right foot, with a reddened area measuring 7 cm x 11 cm and two fluid filled blisters. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's Admission Record indicated [DIAGNOSES REDACTED]. Review of Resident #2's Nursing Progress Note, dated 03/11/20, indicated Nurse #2 was notified at 10:30 P.M. by a CNA (name not provided) that Resident #2 sustained a burn from a cup of hot water. The Note indicated the top of Resident #2's right foot had a second degree burn with a 7 cm x 11 cm reddened area. During an interview on 07/24/20 at 12:25 P.M., Resident #2 said he/she had a staff member (identity not recalled) heat up a cup of hot water for him/her at the kitchenette on the Unit. Resident #2 said he/she intended to use the hot water to make a cup of instant soup in his/her room. Resident #2 said the CNA handed him/her a styrofoam cup with hot water, that there was no lid on it, he/she placed the styrofoam cup between his/her right leg and the side of the wheelchair and propelled the wheelchair using his/her hands to go back to his/her room. Resident #2 said the cup tipped forward splashing hot water on his/her sock covered foot and he was determined to [MEDICAL CONDITION] the area. During an interview on 07/15/20 at 04:35 P.M. and on 07/24/20 at 11:30 A.M., Certified Nurse Aide (CNA) #2 said Resident #2 approached the nurses' desk and requested warm water to make instant soup. CNA #2 said Resident #2 refused to allow staff to make the soup for him/her. CNA #2 said Nurse #1 instructed her to give hot water to Resident #2 by heating water in the microwave for one minute and 30 seconds. CNA #2 said she obtained water from the sink, heated it for the instructed length of time and handed it to Resident #2. CNA #2 said there were no covers available for the styrofoam cup, so she gave it to Resident #2 without one. CNA #2 said she had not been instructed to obtain a safe temperature reading prior to serving a hot liquid and was not aware if there was a thermometer available on the Unit. CNA #2 said sometime later that night (exact time unknown) Resident #2 told her he/she may have gotten burned, and she immediately reported it to Nurse #2. During an interview on 07/24/20 at 11:35 A.M., Nurse #2 said just before 11:00 P.M. on 03/11/20 CNA #2 told him Resident #2 spilled hot water on his/her foot. Nurse #2 said he was unaware that CNA #2 had heated water and provided it to Resident #2. Nurse #2 said Resident #2 told him he/she received the cup of hot water, brought it back to his/her room and it spilled onto his/her foot. Nurse #2 said he removed Resident #2's sock, and found second [MEDICAL CONDITION] the right foot. Nurse #2 said no thermometers for measuring the temperatures of food and liquids were on the Unit. During an interview on 07/24/20 at 11:40 A.M., the DON said all hot liquids should be served at a temperature no greater than 165 degrees Fahrenheit irregardless of whether the drink was provided by the kitchen in a carafe or heated in a microwave. The DON said thermometers were available on the Units. The DON said CNA #2 should have obtained a lid for the styrofoam cup and checked the temperature of the heated water before giving it to Resident #2. Review of the Reheating Chart, undated, indicated to microwave a one serving beverage (one cup) at medium to high microwave power for 30 to 40 seconds from room temperature, and to heat a refrigerated one serving beverage for one and a half minutes to two minutes. The Reheating Chart indicated for a serving temperature at point of service to be 165 degrees Fahrenheit.

Based on record review, interviews and observation the Facility failed to provide 1 of 24 sampled residents (Resident #20) with the necessary care and services to manage the resident's substance use disorder who then had an overdose at the facility. Findings include: Resident #20 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. On 9/19/16, Resident #20 was found unresponsive in the bathroom. The paramedics were called and the resident was treated with [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation.) The resident was then sent to the hospital. Review of the hospital records dated 9/20/16, indicate that the paramedics found the resident to have a needle in his/her arm and that the resident admitted to using heroin that evening. The resident was later returned to the nursing facility. The facility failed to provide patient specific care and services to adequately address and treat this resident's substance use disorder. On 10/11/16, review of the admission MDS, dated [DATE], indicated that the resident had an active [DIAGNOSES REDACTED]. Further review of the medical record indicated there was not a comprehensive assessment as to the resident's substance use and [MEDICATION NAME] treatment history. Review of the resident's care plans on 10/11/16, indicated that on 8/16/16 a care plan was created for signs and history of depression, anxiety, post-traumatic stress disorder, [MEDICAL CONDITION] disorder. This resident reported current multiple mood issues. The care plan has an non-specific intervention of psychiatric consult/follow up. The care plan in place dated 8/16/16, for history of intravenous (IV) drug use was not patient centered in that it read that the staff would offer non-judgmental support as needed, notify MD of suspected drug use and prohibit non-prescribed drug use; and, did not detail the frequency and specific services to be provided to support the resident in maintaining a sober lifestyle while at the facility. Further review indicated a behavioral health consultation and treatment plan in the resident's record by the psychologist. (The psychologist note had a date of service of 8/18/16, but was signed by the psychologist on 6/23/16, reflecting a previous admission of the resident at the facility.) The review indicated that the psychologist believed the resident was currently on [MEDICATION NAME] (a narcotic used to treat opioid addiction). The psychologist recommended that the resident would benefit from 1:1 counseling while at the facility but there was no further specificity as to the plan for treatment. There were no further visits with the psychologist after 8/18/16. In addition, a review of the hospital discharge summary dated, 8/8/16, indicated that the resident had been on [MEDICATION NAME] in the community prior to the resident's recent hospitalization and readmission in August, and that the patient can continue to get the [MEDICATION NAME] once the patient finishes receiving his/her current IV antibiotic therapy. On 10/11/16 review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident's initial participation in the facility's Circle of Hope Services did not begin until 9/12/16, for orientation; 9/14/16 for exercise. A Review of the MAR indicated [REDACTED]. On 9/16/16 the resident participated in energy work; and, then attended her first Smart recovery group on 9/19/16; and, on 9/19/16, Resident #20 was found unresponsive in the bathroom, having overdosed on heroin.