Every finding on record at Kennebunk Center For Health & Rehabilitation, LLC

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment for the medication storage room and the laundry room for 2 of 4 days of survey. Findings: 1.On 4/13/26 from 11:15 a.m. to 11:30 a.m., a tour of the laundry room too place with the Director of Operations and Director of housekeeping where the following was observed and confirmed: - Chipped wood on the door of the folding table, making it an uncleanable surface. -2 broken floor tiles by the door that goes from the clean side to the dirty side along with a rusted door frame and missing sheet rock. -Chipped paint on the windowsill of the dirty side making it an uncleanable surface. -Dirt and debris noted behind all 3 washers, along with broken floor tiles exposing untreated cement. -Wall by the sink on the dirty laundry side stained with an unknown substance, wall is noted to be lifting up, and the rubber floor trim is lifting up. 2.On 4/13/26 at 1:45 p.m. while observing the medication storage room a surveyor noticed the floor on the ride side of the back of room, under the counter had dust/debris and a dried, pink substance on the floor. On 4/13/26 at 1:49 p.m. in an interview with a surveyor the Director of Nursing confirmed the unclean floor and stated she would have housekeeping clean the floor. On 4/14/26 at 7:50 a.m. a surveyor observed the medication room floor again and the pink substance had been cleaned, but the floor still appeared to have dust/debris in the corner as well as other areas of the floor, and the wall between the frig and cabinet had chipped/missing paint, and stains creating an uncleanable surface. On 4/14/26 at 7:55 a.m. during an interview with a surveyor Register Nurse #1 confirmed this finding.

Based on record reviews and interviews, the facility failed to ensure that a care plan was developed in the area of dementia care for 1 of 2 residents reviewed for dementia (Resident #55), and in the area of accidents for 1 of 4 residents reviewed for falls (Resident #9).Findings: 1.Review of Resident #55's medical record stated he/she was admitted to the facility in July of 2025 with a diagnosis of dementia. The most recent care plan dated 2/9/26 lacked evidence that a comprehensive care plan was developed in the area of dementia care. On 4/15/26 at 1:29 p.m. in an interview with a surveyor, the Regional Director of Clinical Operations confirmed this finding. 2. On 10/22/25 the Division of Licensing and Certification (DLC) received a facility-reported incident that indicated that Resident #9 had sustained an unwitnessed fall on 10/21/25 and was subsequently transferred to an acute care hospital and diagnosed with multiple fractures. The facility's 5-day follow-up report, submitted to the DLC on 10/28/25 stated, .A toileting schedule has been added to care plan to attempt to decrease risk of falls while trying to get to the bathroom. A review of Resident #9's clinical record indicated that Resident #9 has diagnoses to include, but not limited to repeated falls and abnormalities of gait and mobility. Resident #9's most recent quarterly Minimum Data Set (MDS) Assessment completed 2/9/26 under Section GG indicates Resident #9 requires setup assistance for toilet transfers and toileting. A review of Resident #9's care plan revealed, Resident has a Deficit in Self Care Function.TOILETING: Independent (No help or staff oversight at any time) and lacked evidence of an intervention for a toileting schedule. Additionally, the care plan lacked evidence that goals and interventions were developed and implemented for falls. On 4/14/26 at 2:49 p.m., the surveyor discussed the above concern during an interview with the Director of Nursing (DNS). At this time, the DNS reviewed Resident #9's entire care plan and confirmed that it does not contain goals and interventions for falls. The DNS then stated that for some reason, Resident #9's fall care plan was resolved on 2/26/26.

Based on record reviews and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessment, for 7 of 21 residents whose care plans were reviewed (Resident #2, #7, #8, #23, #35, #40, & #79). Findings: 1. On 4/15/26 a review of Resident #2's medical record contained a quarterly Minimum Data Set (MDS) version 3.0 dated 1/16/26 and 10/16/25. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the Quarterly MDS assessment. 2. On 4/15/26 a review of Resident #35's medical record contained a quarterly Minimum Data Set (MDS) version 3.0 dated 3/4/26, 1/13/26, 10/2/25, and 7/3/25. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the Quarterly MDS assessment. 3. On 4/15/26 a review of Resident #79's medical record contained an annual Minimum Data Set (MDS) version 3.0 dated 2/25/26. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the Quarterly MDS assessment. On 4/15/26 at 12:20 p.m. in an interview with a surveyor, the Director of Social Services confirmed the above findings stating they are working on this. She stated they are having the care plans first then the MDS assessment and need to swap so the MDS assessment comes first. She also stated that they always ask the residents if they want anything added to the care plan and the nurses can add items anytime as they come up. 4. On 4/15/26 a review of Resident #8's medical record contained a Significant Change Minimum Data Set (MDS) version 3.0 completed 1/21/26. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the Significant Change MDS assessment. On 4/15/26 at 1:40 p.m., in an interview with the Director of Social Services, the above information was discussed and confirmed. 5. A review of Resident #7's clinical record revealed an MDS Quarterly Assessment was completed on 3/27/26. Further review of Resident #7's clinical record revealed that an IDT meeting was scheduled for 4/15/26 (19 days after assessment) and lacked evidence that an IDT meeting was held within 7 days following the assessment. 6. A review of Resident #23's clinical record revealed an MDS Quarterly Assessment was completed on 2/5/26. Further review of Resident #23's clinical record revealed that an IDT meeting was held 2/16/26 (11 days after assessment) and lacked evidence that an IDT meeting was held within 7 days following the assessment. 7. A review of Resident #40's clinical record revealed an MDS Quarterly Assessment was completed on 3/26/26. Further review of Resident #40's clinical record revealed that an IDT meeting was held 4/13/26 (17 days after assessment) and lacked evidence that an IDT meeting was held within 7 days following the assessment. On 4/15/26 at 9:44 a.m., during an interview with the Social Services Director, 2 surveyors discussed the above findings. At this time, the Social Services Director confirmed that Resident #7's IDT meeting is scheduled to be held today, and that the facility schedules IDT meetings within 2 weeks following the care plan review date and not within 7 days following the MDS assessments.

Based on policy reviews, record reviews, and interviews, the facility failed to adequately follow physician orders for blood sugar checks before meals for 2 of 3 residents reviewed and failed to adequately follow the facility's policy for administering long-acting insulin for 1 of 2 residents reviewed (Resident #15, #43 & #69). Findings:The facility's Medication Pass Policy, last revised 9/24 states, it is the policy of the facility that medications are administered safely and timely per the physician's orders, and for facilities that support a 'liberalized' med pass, the following times may also be added: - Liberalized Med Pass Morning 7 AM - 11 AM - Liberalized Med Pass Lunch/Midday 11 AM - 2 PM - Liberalized Med Pass Evening 3 PM - 7 PM - Liberalized Med Pass Bedtime/HS 7 PM - 10 PM - Liberalized Med Pass Sunrise 4 AM - 6 AMThe facility's Diabetes Management Protocol, last revised 2/25 states, Insulin: Basal Insulin (Long acting): Glargine (Lantus), Detemir (Levemir), or Degludec (Tresiba) provides 24-hour glucose control.1. On 4/14/26 at 9:11 a.m. a surveyor observed several late blood sugar orders during the medication administration observation that were highlighted in red in the electronic medical record. On 4/14/26 at 12:00 p.m., surveyor reviewed the Medication Admin Audit Report for R#43 that states they have an order for Fingerstick Blood Sugar (FSBS) before meals and at bedtime for diabetic management, notify HCP (Health Care Provider) for FSBS 70 or greater than 350 unless otherwise indicated. The record showed that on 4/14/26 R#43's blood sugar was checked at 9:29 a.m. after breakfast. 2. On 4/14/26 at 12:00 p.m. surveyor reviewed the Medication Admin Audit Report for R#69 that states they have an order for Fingerstick Blood Sugar before meals and at bedtime for diabetic management, notify HCP for FSBS 70 or greater than 350 unless otherwise indicated. The record showed that on 4/14/26 R#69's blood sugar was checked at 9:47 a.m. after breakfast. 3. On 4/14/26 at 11:54 a.m. during observation of R#5's medication administration, a surveyor observed the Medication Administration Record (MAR) which showed that the resident had not been given their Insulin. The order states, Glargine subcutaneous solution 100 unit/ml (units per milliliter), inject 15 units subcutaneously one time a day in the morning with a start date of 4/6/26. MedTech #1 stated that they do not do injections, the nurse does them.On 4/14/26 at 12:28 p.m. during an interview with a surveyor the Director of Nursing (DON) pulled the MAR up for R#15, and confirmed it had been given at 11:47 p.m. The surveyor questioned the timing of the administration of the medication and the DON stated that R15 is under the liberalized medication administration times. When the surveyor stated that it was past the liberalized time frame the DON stated, well an hour before and an hour after and all we can do is follow provider orders. On 4/14/26 at 12:30 p.m. in an interview with a surveyor, the DON confirmed the above findings.

Based on record review, interview and Payroll Based Journal Report (PBJ), the facility failed to ensure it was sufficiently staffed on weekends for 1 of 1 quarters reviewed (10/1/25 through 12/31/25).Findings: Review of Center for Medicare & Medicaid (CMS) PBJ Report revealed the facility triggered for low weekend staffing during the first quarter (10/1/24 through 12/31/24). On 4/15/25 at 12:00 p.m., during a review of first quarter weekend staffing with a surveyor, the Administrator confirmed the facility was not adequately staffed for 5 of 39 days reviewed (day shifts).

Based on observations and interviews, the facility failed to ensure expired lab supplies were removed from supply, available for use for 4 of 4 units, and the facility failed to ensure treatment carts were locked when unattended for1 of 1 carts, for 1 of 4 days of survey.Findings: 1.On [DATE] at 7:50 a.m. two surveyors identified lab supplies (blood collection tubes) that had expired: * 95 blue top blood collection tubes with expiration date [DATE] * 3 yellow top blood collection tubes with expiration date [DATE] * 29 red blood collection tubes with expiration of [DATE] On [DATE] at 7:59 a.m. the Assistant Director of Nursing confirmed the expired blood collection tubes with two surveyors and removed them from use. On [DATE] at 10:23 a.m. in an interview the Regional Director of Operations confirmed that the facility does sometimes do their own blood draws. 2. On [DATE] at 9:37 a.m. 2 surveyors observed an unlocked and unattended treatment cart located on the Windmere Unit. The third and fourth drawers on the left side of the cart contained various resident medications/treatments, including but not limited to Compound W, Nystatin, Diclofenac, Asperflex, hydrocortisone cream, ammonium lactate, as well as individually packaged SaniCloth disinfecting wipes. Throughout the observation, several staff members walked past the surveyors going through the cart. Throughout the survey, the survey team observed multiple residents foot propelling in their wheelchairs in the halls. On [DATE] at 9:40 a.m., the Administrator walked past the surveyors going through the cart. At this time, the surveyors stopped the Administrator and discussed the observation. During an interview at this time, the Administrator stated that the nurse assigned to the treatment cart is doing wound rounds on the unit and proceeded to lock the cart.

Based on observations, interviews, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner related to floors, walls, food preparation surfaces, the walk-in freezer, and the dish room for 1 of 1 initial kitchen tour. Additionally, the facility failed to ensure foods were sealed, labeled, and dated in a food preparation area, a dry storage room, a reach-in refrigerator, a walk-in refrigerator, and a walk-in freezer for 2 of 2 kitchen tours. Furthermore, the facility failed to maintain an emergency food supply for 2 of 4 days of survey (4/12/26, 4/13/26).Findings:Review of facility policy, Storage of Food & Supplies, revised 2/2022 states, .Labeling and rotating food supply .Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates .Food removed from its original container must be labeled with the common name of the food .Review of facility policy, Dishwashing- Dish machine, revised 1/2022 states, .Check that the machine is clean. Check wash arms, scrap trays, and final rinse jets . Clean dish machine throughout the day and during use as necessary to prevent recontamination of equipment and utensils .After Dishwashing is Complete .Clean dish room tables and dish machine. Use a de-[NAME] whenever necessary to remove mineral deposits caused by hard water .1. On 4/12/26 from 9:05 a.m.-9:45 a.m., a surveyor conducted an initial kitchen tour with [NAME] #1, during which the following was observed: In the main Kitchen/Food Preparation (prep) area:The wash sink's sanitizer solution hose was immersed below the water in the sink.There were cracks on the wall behind the sink, creating an uncleanable surface. A dedicated handwashing sink, with signage posted above the sink indicating the same, was located on a wall between the Dish Room and the food prep area. During an interview, [NAME] #1 stated that he sometimes uses the handwashing sink to rinse vegetables as a last resort. The surveyor observed that there was no air gap separation under the handwashing sink.Kitchen staff's personal water bottles, a can of RedBull energy drink, an ID badge, and a personal charger were stored on a food prep surface.There were crumbs and food debris on the stainless-steel countertop (food prep area) where the mixer is stored. A heavily soiled yellow radio was stored on the food prep countertop behind the mixer.A 48 ounce (oz) undated box of coarse flake kosher salt was observed on the bottom shelf of the food prep station next to the sink. The flip top was open, exposing the contents to air. When the surveyor discussed the finding, [NAME] #1 stated the salt was opened 3/17/26 but with repeated use, the marker used to date food items rubs off. A gallon container of Lea & [NAME] Worcestershire sauce was undated. A label on the side of container is dated 11/26/25. [NAME] #1 stated the label indicates the delivered date and that he opened the item the day it was delivered. An unlabeled, undated white bin with a clear lid was in the food prep area, containing what appeared to be oats.Food debris and crumbs were noted on the floor in multiple areas throughout the kitchen. Buildup was noted on floors, especially in corners and on baseboard trim throughout kitchen.The pink tray on top of the microwave was covered with crumbs and food debris and dried liquid. Additionally, a bottle of Smart Water was being stored on the pink tray. [NAME] #1 confirmed it is a staff member's water bottle. In the Dry Storage Area:1 pound (lb) box of baking soda, unlabeled, undated, and available for use. The flip top was open and exposing the contents to air.The reach-in (cook's) refrigerator contained the following available for use:- a square stainless steel container covered with foil, labeled [Cook #1's] Fat undated. [NAME] #1 stated this is bacon grease saved for him to use for food prep.- an undated 16 oz bag of whipped topping. The package indicated, Perishable .Best if used by. 14 days refrigerated. The Walk-In refrigerator contained the following available for use:- an unlabeled and undated open bag of spinach, located on the top right shelf.- 6 heads of green cabbage and1 head of purple cabbage, located on a silver tray on the right lower shelf. The tray was uncovered, unlabeled, and undated. - An unlabeled, open bag of shaved cheese, marked with an open date of 3/9/26 but no discard date, located on the top left shelf.The Walk-In freezer contained the following available for use:- an undated, open box of ground beef patties with the inner bag open and sticking out of the box, exposing the patties to air, located on the top left shelf. The surveyor noted freezer burn/discoloration on the edges of the exposed patties.- 2 unlabeled, a pork tenderloin, and a roll of ground beef (package imprint indicated 4/17/26 expiration date), located on the second left shelf. All were unlabeled and undated. - Additionally, the floor at back center of the freezer was covered in debris, trash, and residue buildup. The Dish Room contained the following:- The grate under the dish machine contained significant food debris.- The walls had multiple spackled areas that were unpainted, creating an uncleanable surface. -there were two wall- mounted oscillating fans, and the fan blades were covered in dust. One of the fans was blowing in the direction of the clean dishes. On 4/12/26 at 1:55 p.m., the surveyor conducted a repeat tour of the kitchen with the Administrator and discussed the above findings. At this time, the Administrator removed the visibly freezer-burnt beef patties from the walk-in freezer.On 4/13/26 at 12:48 p.m., the surveyor discussed the above findings with the Food Services Director (FSD). During an interview at this time, the FSD stated that foods should be labeled with the date received, the date opened, and a discard date.2. On 4/13/26 at 12:48 p.m., during a repeat kitchen tour with the FSD, the surveyor requested to see the facility's emergency food supply. During an interview at this time, the FSD stated that the emergency water supply is stored in the shed, but that when he started working for the facility four months ago, the emergency food supply was expired. The FSD then stated that he knows a delivery is coming tomorrow.On 4/14/26 at 9:37 a.m. during an interview, the interim Food Service Director stated that the facility's replacement emergency food supply is going to be delivered this afternoon and stated as far as she knows, the facility has always had an emergency food supply, but that she can't speak to what happened. At this time, the interim FSD stated that the facility does not have an emergency food supply list, but that she will create one today. On 4/14/26 at 9:38 a.m., during an interview in the presence of 2 surveyors, the Administrator stated the facility was utilizing its emergency food supply for routine meal prep because the supply was nearing expiration, but that there was a miscommunication, and the FSD was not replenishing the emergency supply as he used it. The Administrator then stated that the facility's emergency food supply will be delivered this afternoon. On 4/14/26 at 11:13 a.m., the surveyor observed that the emergency food supply had been delivered and was being stored in the back room of the kitchen's dry storage area.

Based on observations, interviews, record review, and facility policy, the facility failed to conduct regular inspection of all bed frames and mattresses as part of a regular maintenance program to ensure that the mattresses and bed frames are compatible and identify areas of possible entrapment for 4 of 4 units observed (Eagle, [NAME], Sagamore, and Windmere).Finding:Facility Policy Patient Bed Side Rails, revised 5/2/25 states, .The following areas of entrapment will be checked when the bed is in the flat position .Zone #7 between the head and foot board and the mattress end will not exceed more than 4 3/4 inches . Zones 5, 6 and 7 will be measured in accordance with the measurements for zones 1-4 until such time as new recommendations are made by the FDA [Food and Drug Administration] .All the beds in the facility will be checked annually using the Bed Assessment Tool to Prevent Entrapment, and when there is a change in side rail status. On 04/12/26 at 10:59 a.m., a surveyor observed Resident #7 asleep in his/her bed with his/her head at the foot end of the bed. During a repeat observation on 4/12/26 at 2:56 p.m., the surveyor observed a large gap between Resident #7's mattress and the footboard of the bed, creating an area of possible entrapmentOn 4/12/26 from 3:23 p.m. to 3:34 p.m., 3 surveyors observed large gaps between the mattress and the footboard on the following beds:- Windmere Unit: Rooms 100 Door (D), 106 D, 107 Window (w), 108 W, 109 W- Eagle Unit: room [ROOM NUMBER] W- Sagamore Unit: room [ROOM NUMBER]W- [NAME] Unit: Rooms 18 D, 20 DOn 4/12/26 at 3:38 p.m., during an interview with the Administrator, 3 surveyors discussed the above observations. At this time, the Administrator stated that the improperly fitting mattresses are something the facility has identified and has been auditing and actively working on replacing. The surveyors then requested evidence of the facility's audits and bed gap measurements.On 4/13/26 at 10:24 a.m. during an interview with the Regional Engineering Director and the Administrator in the presence of 4 surveyors, the Regional Engineering Director stated that the facility inspects zone 1-4 annually and provided a binder containing the facility's measurements. The Administrator was unable to provide evidence of the facility's original audit to the survey team and stated that a facility-wide audit was completed this morning. A review of the provided Bed System Measurement Device Test Results Worksheet revealed that only 10 beds were measured in 2024, only 6 beds were measured 9/25/25, and lacked evidence of annual measurements.

Based on observation and interviews, the facility failed to provide care to residents in a manner that maintains each resident's dignity by failing to serve all residents seated at the same table at the same time for 1 of 2 dining observations on 1 of 4 days of survey (4/12/26).Finding:On 4/12/26 between 12:07 p.m. and 12:18 p.m., a surveyor observed the lunch meal service in the facility's dining room. Upon surveyor entrance to the dining room at 12:07 p.m., Residents #7 and #48 were seated at a table with Resident #29. Resident #29 had received his/her meal, and Residents #7 and #48 had not yet received their meals. Staff proceeded to deliver meals to residents at other tables in the dining room. At 12:10 p.m., Resident #7 asked Certified Nursing Assistant (CNA) #1 where their meals were and told the CNA that Resident #29 was waiting to begin eating until he/she and Resident #48 received their meal. CNA #1 replied that she was waiting for the rest of the meal trays to be delivered to the dining room, and then continued delivering meals to residents at the other tables. At 12:16 p.m. Residents #7 and #48 still had not received their meal, and Resident #48 asked a staff member when they were going to receive their meals. At this time, the staff member replied, It's going to come out. They're really busy today. At 12:17 p.m., Resident #48 received his/her meal, followed by Resident #7. On 4/12/26 at 12:21 p.m. during an interview, CNA #2 stated that the facility recently started a new way of passing meals on the weekend and that there is supposed to be one meal cart specifically for residents seated in the dining room, but that some residents' meals ended up on the carts designated for delivery to the units.On 4/13/26 at 3:40 p.m. the surveyor discussed the above observation with the Administrator. During an interview at this time, the Administrator stated that until recently, all residents were eating in their rooms, except residents who require special assistance with meals, and that this is only the second day of implementing meal delivery in the dining room on the weekends.

Based on record review, interview and facility policy, the facility failed to ensure the physician was notified of a significant change and/or incident for 1 of 3 residents reviewed for hospitalizations. (Resident #91)Findings:Facility policy titled Change of Condition Notification states The facility will inform the resident, consult with the resident's healthcare provider, and if known, notify the resident's legal representative or family member when there is. A significant change in the resident's physical, mental, or psychosocial status. A decision to transfer the resident from the facility. Under the section titled Procedure it states Physician/family notification must be documented in the electronic health record.A review of Resident #91's clinical record shows a progress note dated 2/16/25 at 1:59 p.m., which stated Patient lethargic this afternoon. Patients unable to answer simple questions. Vitals signs reflect an infectious process. BP (blood pressure) 159/88, p (pulse) 108, temp 99.1, oxygen saturation 88% on RA (room air) . Is appearing to be off [his/her] baseline. Writer will contact on-call. Writer applied supplemental oxygen at 2 L/m (liters per minute) . Patient has a history of Urosepsis. Progress note dated 2/16/25 at 2:19 p.m., stated, Writer spoke with on-call [provider] orders from provider are as follows. CBC (complete blood count), CMP (comprehensive metabolic panel), procalcitonin, and UA (urine analysis) STAT (urgent). Start Augmentin 875 mg for 5 days. Start NS (normal Saline) at 75 ml/hr (milliliter/per hour) for 1 bag. Start neuro checks. Notify on call for any changes in condition. Further review of the clinical record showed a progress note dated 1/16/25 at 3:13 p.m. which stated, . resident unable to swallow antibiotic. writer unable to start IV (intravenous) due to lack of supplies. Writer entered labs into PCC (point click care) for lab draw on Monday morning due to lab drop off center being closed on Sunday. Another progress note on 2/16/25 at 4:34 p.m., stated Temp is up to 101.2, POA (power of attorney) wants patient send to hospital. Patient sent out to the ED (Emergency Department) for further evaluation via EMS (Emergency Medical Services) for AMS (Altered Mental Status), abnormal vitals, and increased weakness.A review of the resident's entire clinical record lacked evidence that the provider was notified regarding the residents further change in condition after he/she was initially seen by the provider along with the inability to obtain stat labs, lack of supplies needed to start an IV, and the resident's inability to swallow the antibiotics.On 4/14/26 at 9:05 a.m., in an interview with the Facility Administrator, it was confirmed that the physician was not notified of the residents further change in condition.

Based on record review and interview, the facility failed to issue a written transfer/discharge notice and a bed hold notice to include cost of care and a statement of the resident's appeal rights to the legal representative for 1 of 5 sampled residents reviewed for transfer to an acute care hospital (Resident #77).Finding:1. Documentation in Resident #77's clinical record indicated that he/she was transferred to an acute care hospital on 1/15/26 and on 4/12/26. Further review of Resident #77's clinical record lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative for the above dates.On 4/15/26 at 2:19 p.m. during an interview in the presence of 4 surveyors, the Business Office Manager confirmed that she does not issue a written transfer/discharge notice and bed hold notice to resident representatives.

Based on observations, record review, and interviews, the facility failed to ensure physician orders were followed for 1 of 1 resident receiving oxygen therapy (Resident #11).Finding:On 4/12/26 at 9:09 a.m. and 11:48 a.m., a surveyor observed Resident #11 asleep in bed, wearing oxygen (O2) via a nasal cannula with the oxygen concentrator flow rate set between 3.5 and 4 liters per minute.A review of Resident #11's clinical record revealed an active physician order for Oxygen at 2 liters per minute continuous via nasal cannula.every shift for shortness of breath.On 4/13/26 at 3:59 p.m., during an interview, Resident #11 stated that staff hand him/her the oxygen tubing and that he/she puts it on and takes it off, but that staff make all adjustments to the oxygen concentrator settings.On 4/14/26 at 8:45 a.m., the surveyor observed Resident #1 asleep in bed wearing oxygen with the oxygen concentrator flow rate set to 2.5 liters per minute.On 4/15/26 at 11:45 a.m., during a repeat observation, Resident #11 was lying in bed and was not wearing oxygen, and his/her oxygen concentrator was powered off. During an interview at this time, Resident #11 stated that he/she does not need to wear his/her oxygen today.On 4/15/26 at 1:55 p.m the surveyor discussed the order for continuous oxygen at 2 liters per minute and the above observations during an interview with the Director of Nursing (DNS). At this time, the DNS stated that the providers definitely do not want Resident #11's oxygen to be worn as needed, but that it is within Resident #11's rights to remove his/her oxygen and that he/she often does. The surveyor then discussed that Resident #11's clinical record, such as nursing progress notes and/or care plan, does not reflect Resident #11's frequent removal of the oxygen. On 4/15/26 at 3:49 p.m., the surveyor discussed the finding with the Administrator and the Regional Director of Operations.

Based on observation, interviews, record review, and facility policy, the facilities interdisciplinary team failed to determine if it was clinically appropriate for a resident to keep a medication at bedside and self-administer medications for 4 of 5 residents reviewed. (Resident ##2, #3, #4 and #5). Findings: 1. On 2/25/25 from approx. 8:15 through 9:02 a.m., the following was observed: Resident #2 had a medicine cup with an unknown cream on the bedside tray table. Resident #3 had a medicine cup with an unknown cream on the beside dresser. Resident #4 had pump bottle of Bio freeze and a tube of Triad Hydrophilic wound dressing paste on the bedside dresser. Resident #5 had a medicine cup with an unknown opaque color cream with a plastic cup over it on the bedside tray table. 2. Review of Resident #2's medical record lacked evidence of a provider order for any cream treatment other than house stock lotions, an order for self-administration, a self-administration evaluation and a care plan for self-administration. 3. Review of Resident #3's medical record contained a provider order, dated 8/6/24, for Biofreeze External Gel 4 % (Menthol (Topical Analgesic)). Apply to bilateral knees and shoulders topically every day and evening shift for OA (osteoarthritis), and an order dated 1/6/25 for Voltaren External Gel 1 % (Diclofenac Sodium (Topical))Apply to area of pain on feet topically two times a day for pain 2gm (grams). Further review, the record lacked evidence of a physician order for self-administration, a self-administration evaluation and a care plan for self-administration. 4. Review of Resident #4's medical record contained a provider order, dated 2/10/25, for Biofreeze Professional External Gel 5 % (Menthol (Topical Analgesic)) Apply to legs topically every shift for leg pain. Further review, the record lacked evidence of a physician order for Triad Hydrophilic wound dressing paste, an order for self-administration, a self-administration evaluation and a care plan for self-administration. 5. On 2/25/25 at approx. 9:02 a.m., Resident #5 was observed sitting on the side of the bed with the bedside tray table in front of him/her. On the table was a medicine cup with an unknown opaque color cream with a plastic cup over it and 2 medicine cups of applesauce with a spoon. At this time, in a brief interview, Resident #5 stated that the nurse was giving him/her medications, but they were too big to swallow, so she is cutting them in half. The surveyor asked what the unknown cream was for. Resident #5 stated, for arthritis pain. Surveyor asked if the nurse applies the cream, he/she stated, I do. At 9:05 a.m., the nurse entered the room with a cup of pills, upon leaving the room, the arthritis cream was left on the table. Review of Resident #5's medical record contained a provider order, dated 4/3/24, states, Voltaren External Gel 1% (Diclofenac Sodium (Topical)) Apply to bilateral hips topically every day and evening shift for Pain lower extremities, apply 4G (grams) of 1% gel to affected area (maximum 16g per joint per day). Further review of the medical record lacked evidence of a doctors order for self-administration, a self-administration evaluation and a care plan for self-administration. Review of facility policy Self-Administration, dated 10/2024 states and it request to self-administer medications, a self-administration evaluation is completed by the licensed nurse to evaluate the resident's safety and understanding of their medication/treatments. If the evaluation determines it is safe for the resident to self-administer, the licensed nurse will obtain an order from the health care provider for self-administration for the specific medication(s)/treatments. Upon obtaining the order for the medication treatment the licensed nurse will instruct the resident in the process of storing the medications safely which should include a locked box. The licensed nurse is responsible to account for every medication treatment on the EMAR and TAR . the IDT will initiate person-centered care plan for self-administration of medications/treatments. On 2/25/25 at 10:05 a.m., the surveyor and the Director of Nursing (DON) observed the above creams at bedside. The DON stated if a resident is administrating own medications, then there should be an MD order and evaluation completed.

Based on observations, interviews and record reviews, the facility failed to ensure medications including treatments were stored properly on 2 of 4 units observed (Sagamore and [NAME] units). for 1 of 1 day of survey. (2/25/25) Findings: 1. On 2/25/25 at 9:02 a.m., Resident #5 was sitting on the side of the bed with the bedside tray table in front of him/her. On the table was a medicine cup filled with an unknown opaque color cream with a plastic cup over it and 2 medicine cups of applesauce with a spoon. At this time, in a brief interview, Resident #5 stated that the nurse was giving him/her medications, but they were too big to swallow, so she is cutting them in half. The surveyor asked what the unknown cream was for. Resident #5 stated, for arthritis pain. Surveyor asked if the nurse applies the cream, he/she stated, I do. At 9:05 a.m., the nurse entered the room with a cup of pills, upon leaving the room, the arthritis cream was left on the table. 2. On 2/25/25 at 10:05 a.m., the surveyor rounded with the Director of Nursing (DON) and observed the following: Sagamore unit: > Resident #2 had a medicine cup filled with an unknown/unlabeled cream on the bedside tray table. At this time, Resident #2 stated to both the surveyor and the DON, the cream was for the itch on his/her legs, which he/she will apply independently when needed. > Resident #3 had a medicine cup with an unknown/unlabeled cream on the bedside dresser. > Resident #4's bedside dresser was littered with treatment supplies including a pump bottle of Bio freeze and a tube of Triad Hydrophilic wound dressing paste. [NAME] Unit: > Resident #5 had a medicine cup with an unknown/unlabeled opaque color cream with a plastic cup over it on the bedside tray table. 3. Review of Resident #2's medical record lacked evidence of a provider order for any cream treatment other than house stock lotions. 4. Review of Resident #3's medical record contained a provider order dated 8/6/24 for Biofreeze External Gel 4 % (Menthol (Topical Analgesic)). Apply to bilateral knees and shoulders topically every day and evening shift for OA (osteoarthritis) and an order dated 1/6/25 for Voltaren External Gel 1 % (Diclofenac Sodium (Topical))Apply to area of pain on feet topically two times a day for pain 2gm (grams). 5. Review of Resident #4's medical record contained a provider order dated 2/10/25 for Biofreeze Professional External Gel 5 % (Menthol (Topical Analgesic)) Apply to legs topically every shift for leg pain. Further review, the record lacked evidence of a physician order for Triad Hydrophilic wound dressing paste. 6. Review of Resident #5's medical record contained a provider order dated 4/3/24 for, Voltaren External Gel 1% (Diclofenac Sodium (Topical)) Apply to bilateral hips topically every day and evening shift for Pain lower extremities, apply 4G (grams) of 1% gel to affected area (maximum 16g per joint per day). At this time, the DON confirmed the unknown/unlabeled creams were stored improperly and removed the items from the above resident's rooms.

Based on observation, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of a chemical not being properly secured for 1 of 1 days of survey (2/25/25). Findings: The Safety Data Sheet for HDX Disinfectant Spray Linen Scent 19 oz noted the following: Description of first aid measures: Inhalation Remove to fresh air. Eye contact Rinse thoroughly with plenty of water for at least 15 minutes, lifting lower and upper eyelids. Consult a physician. Skin contact Wash skin with soap and water. Ingestion Rinse mouth. On 2/25/25 at 8:31 a.m., the surveyor observed Resident #1 to have a can of Great Value Disinfectant Spray Linen Scent on his/her bedside dresser. In a brief interview, Resident #1 stated he/she uses it for when it smells, and it's his/her personal can. On 2/25/25 at 10:05 a.m., the surveyor and the Director of Nursing (DON) observed Resident #1's can of Great Value Disinfectant Spray Linen Scent on the bedside dresser. At this time, the DON stated she was unaware of the disinfectant in the room and confirmed it should not be in the room or available for the resident to use.

Based on observations, record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 residents reviewed for medications (Resident #5). Finding: On 2/25/25 at approx. 9:02 a.m., Resident #5 was sitting on the side of the bed with the bedside tray table in front of him/her. On the table was a medicine cup with an unknown opaque color cream with a plastic cup over it and 2 medicine cups of applesauce with a spoon. At this time, in a brief interview, Resident #5 stated that the nurse was giving him/her medications, but they were too big to swallow, so she is cutting them in half. The surveyor asked what the unknown cream was for. Resident #5 stated, for arthritis pain. Surveyor asked if the nurse applies the cream, he/she stated, I do. At 9:05 a.m., the nurse entered the room with a cup of pills, upon leaving the room, the arthritis cream was left on the table. On 2/25/25 from 10:05 a.m., through 10:17 a.m., during a walk through with the Director of Nursing (DON), both the surveyor and DON observed the above cream in a medicine cup, at this time, the DON removed the cream. Review of Resident #5's provider order dated 4/3/24 states, Voltaren External Gel 1% (Diclofenac Sodium (Topical)) Apply to bilateral hips topically every day and evening shift for Pain lower extremities, apply 4G (grams) of 1% gel to affected area (maximum 16g per joint per day). The Treatment Administration Records (TAR) states, the Voltaren gel is being applied twice daily and was applied topically on 2/25/25 at 10:03 by the nurse with the location of where the gel was applied as not recorded. On 2/25/25 at 10:21 a.m., in an additional interview, the surveyor discussed the documentation on the TAR for Resident #5's Voltaren gel being administered at 10:03 a.m., when both the DON and surveyor began the walk through at 10:05 and viewed several concerns before observing R#5's cream at the bed side and the resident states he/she applies the gel independently to his/her neck and right groin. At this time, the DON stated, maybe the nurse went back in and applied the gel. On 2/25/25 at 11:57 a.m., in an additional interview, Resident #5 was asked if the nurse applied the arthritis cream this morning. He/she stated no, I do it myself. The surveyor asked where he/she applies the cream, he/she replied On the back of my neck and right here (rubbing his/her right groin area) stating, I have a patch on by back but it doesn't do anything for the front, I actually have 2 patches on my back. The surveyor asked if it was Voltaren, Resident stated, Yes, that is it. The surveyor then asked, how often does he/she use Voltaren. Resident stated, Only when I ask for it, I only use it if I need it. Again, the surveyor asked if nursing has applied the Voltaren, he/she stated, No, I do it myself. On 2/25/25 at approximately 1:15 p.m., the above was discussed with as discussed during exit with both the Administrator and the DON.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 4 of 4 units (Windermere, Eagle, Sagamore and Regena, and Laundry Room) for 1 of 4 days of survey. Findings: Sagamore unit: On 1/14/25 at 8:09 a.m., observation of the shared bathroom for room [ROOM NUMBER] and 4 with a black substance around the base of the toilet and the caulking strip peeled up. On 1/13/25 at 11:32 a.m., and on 1/14/25 at 8:11 a.m., observations of the shared bathroom for room [ROOM NUMBER] and 9 with a commode bucket stored on the floor, a large brown circular stain on the floor to the left of the toilet, a brownish tan substance around the base of the toilet and the caulking strip peeled up. On 1/13/25 at 10:29 a.m., observation of the shared bathroom for room [ROOM NUMBER] and 10 with a gray basin stored on floor and leaning against the wall. On 1/16/25 at 3:16 p.m., the above was discussed with the Administer. 44049 Laundry Room: On 1/15/25 at 08:50 a.m. 2 surveyors observed dust and debris on the 2 fans, a heater on the wall, and 3 air vents on the clean linen side. Above the laundry folding table there was dust and debris on the pipes. On the dirty linen side, the sink was heavily stained and soiled including the eye wash station. The window is covered in dust and cobwebs. Behind the hot water tank there were multiple areas of dust and cobwebs. The pipes throughout were covered in dust/debris. On 1/16/25 at 10:00 a.m. During a tour of the physical environment the following concerns were observed: room [ROOM NUMBER] - Bathroom - Heavy staining around and in back of the toilet room [ROOM NUMBER] - Wall fan dusty room [ROOM NUMBER] - Heating Unit stained room [ROOM NUMBER] - Entry into Bathroom, floor tile chipped Pink basin in the floor room [ROOM NUMBER] - Pink Basin on the floor 51331 On 1/13/25 at 10:59 a.m. and on 1/14/24 at 12:00 p.m., observation of a shared bathroom for room [ROOM NUMBER] with a gray basin stored on floor under the sink. On 1/13/25 at 10:30 a.m. and on 1/14/25 at 12:23 p.m., observation of the shared bathroom for room [ROOM NUMBER] with a gray basin stored on the floor to the side of the toilet. On 1/13/25 at 10:48 a.m. and on 1/14/25 at 12:00 p.m., observation of the shared bathroom for room [ROOM NUMBER] with 2 gray basins stored on floor under the sink. On 1/13/25 at 10:12 a.m. and on 1/14/25 at 12:22 p.m., observation of the shared bathroom for room [ROOM NUMBER] with a gray basin stored under the sink.

Based on observations, interviews, and record reviews the facility failed to provide Activities of Daily Living (ADL) care for 6 of 6 resident reviewed for ADL's (Resident #126, #6, #19, #64, #226 and #230). In addition, the facility failed to follow the care plan in the area of oral hygiene for 1 of 1 reviewed. (Resident #6). Findings: The facilities ADL Policy and Procedure issued 6/23 states, Purpose: To provide the level of care required by each individual resident and Procedure: Staff provide assistance to complete ADL activities per their person centered evaluation and care plan. These activities are broken down into eight areas. #1.Bathing/showering . #8 Personal hygiene and grooming. 1. On 4/10/24 the Division of Licensing and Certification received a complaint that Resident #126 did not receive appropriate care with his/her Activities of Daily Living (ADL). He/she was found wearing the hospital [NAME] a day after admission and for the 2 weeks Resident #126 was at the facility, his/her underwear were only changed twice, and he/she had the same socks on for 3 days in a row. Resident #126 was admitted on [DATE] for skilled services following a Chronic Obstructive Pulmonary Disease acute exacerbation. The care plan for ADL self-care performance deficit instructed nursing to provide bathing/showering, dressing and toilet use with extensive assist by 1 staff and bed mobility, transfers and personal hygiene/oral care with limited assistance by 1 staff. Review of Resident #126's Certified Nurses Aid (CNA) documentation for March 2024 lacked evidence of Activities of Daily Living which included bathing, dressing, oral hygiene, bladder and bowel elimination, bed mobility and transfers being provided on 3/8/24 both 3pm-11pm and 11pm-7am shifts and both 3/9/24 and 3/10/24 for the 3pm-11pm shifts. On 1/16/25 at 2:22 p.m., the above was discussed with the Director of Nursing who confirmed the lack of ADL documentation could not suggest Resident #126 received the appropriate ADL care. 2. On 1/13/25 at 10:31 a.m., observation of Resident #6, sitting upright in bed, his/her teeth were coated with a thick white/yellow debris at the gum line. In a brief interview, Resident #6 stated, staff help him/her with brushing his/her teeth. On 1/14/25 at 8:16 a.m. and at 11:56 a.m., observation of Resident #6 sitting upright in bed, his/her teeth were coated with a thick whitish/yellow/brown in color debris at the gum line. At this time, the resident was asked again if staff help him/her with brushing his/her teeth. He/she stated, yes. He/she was asked when the last time his/her teeth were brushed, the resident answered, I don't know On 1/16/25 at 8:36 a.m., observation of Resident #6 sitting up in bed, his/her hair is combed back into a ponytail, his/her teeth were thickly coated with whitish/yellow/ brown debris at the gum line. Review of Resident #6's care plan stated Resident has oral/dental health problems Poor nutrition, Poor oral hygiene dated 5/17/23. Instructs nursing to Monitor/document/report PRN any s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions and Provide mouth care as per ADL personal hygiene. Review of the Certified Nursing Aid (CNA) documentation from 1/3/25 through 1/15/25 for ORAL HYGIENE: The ability to use suitable items to clean teeth . Each day had documented oral care was completed. On 1/13/25 oral care was documented as completed with substantial /Max Assist: Helper does more than half the effort. On 1/14/25 oral care was documented as completed twice, with one Set-up or clean-up. Helper sets up or cleans up only and one with Dependent: Helper does all the effort. On 1/15/25 oral care was documented as completed with Supervision/touch assist: Helper gives verbal cues or touch assist. On 1/16/25 at 9:27 a.m., both the surveyor and the Director of Nursing (DON) observed Resident #6's teeth. The DON asked the resident if he/she would like help brushing his/her teeth, stating it looked like he/she needed his/her teeth brushed, the resident stated yes. 48648 3. On 1/13/25 at 9:20 a.m., a surveyor interviewed Resident #230 and learned that she/he was hoping to get a shower today because the CNAs couldn't do it yesterday, which is his/her regular bathing day. A review of Resident #230 Electronic Medical Record (EMR) showed their last documented shower was on 12/17/24 but no other documentation of showers, baths or refusals. On 1/13/25 at 9:30 a.m. a surveyor interviewed Resident #64 who was admitted to the facility on [DATE]. Resident #64 stated that he/she had refused most of his/her showers due to illness. A review of Resident #64's EMR showed no bathing documentation until 12/17/24, which was a refusal. A shower was documented on 12/24/24 and then no other bathing documentation. On 1/14/25 at 1:34 p.m., a surveyor interviewed Resident #226 and learned they do not get regular weekly showers or baths. A review of Resident #226's EMR showed no documentation of showers, baths or refusals since admission. On 1/14/25 at 1:45 p.m. A surveyor interviewed Resident #19 and learned they have not had a shower or a bath since admission on 12/17/24. She/he would very much like to have a shower, but the CNAs told him/her it takes too long because they have to wrap their arm and leg. A review of Resident #19's Electronic Medical Record failed to show any documentation of showers, baths or refusals. On 1/14/25 at 2:30 p.m. a surveyor met with the Director of Nursing (DON) and learned that CNAs are expected to document showers or baths in the EMR and if there is a refusal, they tell the nurse, and a progress note would document the refusal. A surveyor discussed the above findings with the DON.

Based on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care (Resident # 16 and #20). In addition, the facility failed to follow physician orders for 1 of 3 reviewed for respiratory care (Resident #16). Findings: The facilities Nebulizer Treatments Policy and Procedure revised 2/23, states, post treatment, disconnect the reservoir from the compressor and clean per manufacturer's Instructions, Place reservoir in a plastic bag Manufactures Instruction Manual for Power Neb Ultra Compressor Nebulizer, under section cleaning and maintenance states, clean after every use .disassemble mouthpiece or mask from cap .wash all items, except tubing in a hot water/dishwashing detergent solution. Rince under hot tap water for 30 seconds to remove detergent residue. Allow to air dry. Under section , Filter Change states, Filter should be changed every 6 months or sooner if filter discolors. 1. On 1/13/25 at 11:32 a.m., observation of Resident #16's nebulizer machine on the bedside dresser with mouthpiece/pipe stored on the back of the machine and the tubing dated 12/30. At this time, Resident #16, stated, he/she only needs it when he/she is congested. On 1/14/25 at 1:33 p.m., observation of Resident #16's nebulizer machine on the bedside dresser with mouthpiece/pipe stored on the back of the machine and the tubing dated 12/30. Review of Resident #16 physician orders dated 1/7/24 states, Change Nebulizer unit and tubing every night shift every Sun for Prophylaxis. Review of the Treatment Admission Records (TAR) for December 2024 states the nebulizer unit and tubing were changed on 12/29/24. The TAR for January 2025 states the nebulizer unit and tubing were changed on 1/5/25 and 1/12/25. In addition, the medical record lacked evidence of the filter being changed as per manufactures recommendations. On 1/16/25 at 12:59 p.m., during an interview with the Director of Nursing (DON), the surveyor discussed the above and asked how often the nebulizer filters are changed. The DON stated she was unsure and would get back to the surveyor. On 1/16/25 at 1:06 p.m., the DON returned and stated they do not have a record of changing nebulizer filters. 51331 2. On 11/13/25 at 11:07 a.m., on 1/14/25 at 12:10 p.m., and on 1/15/25 at 1:51 p.m., Observation of Resident #20's unbagged and unlabeled nebulizer pipe and tubing stored on their bedside table. On 1/15/25 at 1:51 p.m. the above information was confirmed with the Regional Director of Clinical Operations.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for excessively low weekend staffing during the fourth quarter of 2024 (July 1 - September 30). On 1/15/25 at 3:47 p.m., a surveyor met with the Administrator and reviewed weekend staffing for July 1, 2024, through September 30, 2024, the Administrator confirmed the facility did not have enough staff to meet resident needs on the weekends.

Based on interview and record review, the facility failed to ensure a resident environment remained free of potential risk of accident before moving a resident's bed against a wall and within reach of the floor electric heating register, resulting in an avoidable burn to the skin on 1 of 5 Residents sampled. (#1) Findings: On 10/11/19, at 9:12 a.m., the Division of License and Certification received a report indicating a resident was found with a burn on his/her medial area of the right foot and great toe area after placing the right foot inside the floors heating register on 10/9/19 at approximately 2200. A review of the nursing documentation, dated 10/9/19, at 22:05, indicated an injury on Resident #1's right medial great toe with skin pealed back approximately 6 cm long x 2.5 cm wide, white waxy appearance, from placement from right foot being lodged inside the heater register. Review of the wound practitioner progress notes, dated 10/18/19, indicated that Resident #1 suffered a second degree burn to the right medical toes, big toe. Review of the facility investigation indicated the thermostat was set at 75 degrees when Resident #1 was found with feet on and inside the heating register, indicated the nursing staff could still feel the heat when walking between the bed and the heating unit register after the bed was moved and after the temperature on the unit was decreased to 70 degrees. At the time of the onsite investigation, the facility provided a Plan of Correction Report, dated 10/10/19, and indicated Resident #1 had sustained a burn on his/her right medial foot/great toe from heating unit in the room. The plan of correction (P[NAME]) indicated bed positioning audits were done to ensure the residents beds are maintained at least 3 feet from the heating unit, Audits started 5 times a week for 1 week initially indicating further audits of 1 time a week for 1 month, then monthly times 3 months. The P[NAME] further indicated re-education to the nursing and housekeeping staff to ensure the proper bed position of at least 3 feet from the heating units. A review of the (MONTH) (House-wide) Bed Positioning Placement Audit sheet provided by the ADON indicated audits started 10/10/19 for weekly review with 6 of 28 beds moved 3 feet from the wall. A review of the Heater Audits conducted by maintenance and dated 10/10/19 through 10/28/19, indicating thermostat temperature monitoring with 1 bed repositioned 3 feet away from heating register. Staff education sign in sheets dated for (MONTH) 2019 provided for review indicated re-education of nursing staff on bed being 3 feet from heating units. Also included re-education of housekeeping staff to ensure beds 3 feet from electric wall heater, on 10/11/19 at 10:15 a.m. On 10/28/19, at 11:50 a.m., an interview with Director of Plant Operations who confirmed the heating is from an electric baseboard packaged heating system in resident rooms tied to a Honeywell thermostat which residents can turn up to 80 degrees. On 10/28/19, at 3:00 p.m., in an interview with the surveyor and Certified Nursing Assistant (CNA), he/she had indicated that on 10/09/19 the CNA had moved the bed against the wall and heating register prior to leaving for the evening shift. On 10/28/19 at 3:55 p.m., in an interview the Administrator and the Assistant Director of Nursing, the surveyor confirmed the finding the bed pushed against the heating unit resulted in a burn to the resident.

Based on record review and interview, the facility failed to provide the necessary pain management for 4 of 10 sampled residents (#1, #6, #8, #10). This failure resulted in four residents not having been assessed for pain and not receiving necessary medication timely for adequate pain control. Findings: 1. Resident #1 was admitted on [DATE] at 3:00 p.m., and had a left total hip arthroplasty. The resident had a physician's order [REDACTED]. A Physical Therapy evaluation was done on 6/18/10 and indicated Resident #1 described his/her pain as 8-10 on a scale of 1-10 ( ten being the worst). In an interview with the resident, on 11/8/10, he/she stated he/she had requested pain medication around 9:00 p.m. the evening of his/her admission. At 10:20 p.m. he/she received the pain medication. There was no documentation in the clinical record that the resident had received additional pain medication until 4 p.m. on 06/19/10, approximately 16 hours later. The resident also stated that his/her leg hurt " really bad " and that he/she had to " beg for meds. " The facility failed to provide and assess the need for pain medication following the initial pain medication administration until the next day, 06/19/10, at 4 p.m. 2. Resident #8, had a physician's orders [REDACTED]. Physicians orders dated 9/3/10, indicated the resident had pain at an "8" on a scale of 1-10 (10 being the worst). The Medication Record dated 9/10 and 10/10, documented the resident as having pain at an "8" consistently. Additionally, the resident has a physician's orders [REDACTED]. In an interview with the resident on 11/5/10 at 10:00 a.m., he/she stated the pain medication had been decreased at the facility, and staff often "forget" to administer the medication. The resident stated that he/she had to repeatedly ask, "up to 4 times" and had to "wait" at night for pain medication. 3. During initial tour on 11/3/10 at 7:30 a.m., Resident #6 was lying in bed. The resident was alert and oriented and was admitted for short term rehabilitation. In an interview with the surveyor, the resident stated that he/she requested pain medication" 2 hours ago" and "still hadn't gotten it". The surveyor inquired with the nurse at the medication cart, and she stated she "was getting there soon". 4. Resident #9, admitted [DATE], with a [DIAGNOSES REDACTED]. In an interview with the resident on 11/4/10 at 1:00 p.m., he/she stated that he/she has to "wait up to one hour for pain medication" when he/she requested it. In an interview with the nurse on 11/4/10 at 2:00 p.m., she indicated she was "not aware the resident was in pain". 5. Resident #10, admitted after having a hip replacement, had nurses notes dated 9/23/10 indicating the resident had "mucousy stools". Physicians orders dated 9/23/10 directed to obtain a specimen of stool for [MEDICAL CONDITION]. The specimen was not obtained. Nurses notes 9/30/10-10/9/10 continued to indicate "loose mucousy stools". Physicians notes dated 1/11/10 directed to add [MEDICATION NAME] to the residents medication regimen. On 10/18/10 , 25 days later, the Nurse Practitioner directed to obtain specimen for [MEDICAL CONDITION], as the first order was no followed. On 10/19/10, the laboratory report indicated the test for was positive [MEDICAL CONDITION]. Treatment was then initiated. In an interview on 11/4/10, with the Corporate Quality Control Nurse, she confirmed the test was not done as directed on 9/23/10.