Every finding on record at Life Care Center of Wilbraham

Based on observations, interviews, and records reviewed, the facility failed to provide food at safe and appetizing temperatures to residents on three ([NAME] Terrace, Hampshire Woods, Hampden Gardens) out of three total resident units, increasing the residents' risks for reduced food/fluid intake.Specifically, the facility failed to provide food at safe and appetizing temperatures for the lunch meal on the [NAME] Terrace, Hampshire Woods, and Hampden Gardens units.Findings include:On 5/21/26 at 10:37 A.M., a Resident Council interview was held with the survey team and 25 facility residents who resided on three out of three units. 19 residents reported the food to be unappetizing, 13 residents reported cold food, and 15 residents reported that proteins were hard or difficult to chew. The residents said food concerns had been brought up at other Resident Council meetings with the Dietary Department, but the issues continued. On 5/21/26 at 12:48 P.M., the surveyor observed [NAME] #4 with Test Tray #1 (regular texture diet) leave the kitchen and arrive at [NAME] Terrace unit at 12:50 P.M. The surveyor conducted a test tray with Unit Manager (UM) #1 with the following results in degrees Fahrenheit (F): >Sweet potato- 128 F, cool to taste >Ham- 130 F, cool to taste >Coffee- 132 F, warm to taste >Milk- 60 F, only slightly cool On 5/21/26 at 1:05 P.M., the surveyor observed [NAME] #5 with Test Tray #2 (regular texture diet) leave the kitchen and arrive at Hampshire Woods unit at 1:08 P.M. The surveyor conducted a test tray with Certified Nursing Assistant (CNA) #5 with the following results: >Fish filet- 81 F>Baked potato- 119 F, warm to taste >Beets- 81 F, cool to taste but flavorful >Milk- 49 F, cool to taste On 5/21/26 at 1:11 P.M., the surveyor observed [NAME] #6 with Test Tray #3 (mechanical soft texture) leave the kitchen and arrive at the Hampden Gardens unit. At 1:24 P.M., the surveyor conducted a test tray with Nurse #6 with the following results: >Mashed potatoes- 110 F, cool to taste >Mechanical soft ham- 117 F, cool to taste and not appetizing >Puree carrots- 160 F, warm but bland >Coffee- 109 F, cool to taste During an interview on 5/22/26 at 1:54 P.M., the surveyor reviewed the test tray results with the Food Service Director (FSD). The FSD said the observed temperatures of hot items on Test Tray #3 were too low, and not acceptable.

Based on observation and interview, the facility failed to ensure food for resident consumption in the main facility kitchen was stored, prepared, and/or distributed in accordance with professional standards for food service safety. Specifically, the facility failed to maintain safe temperatures of beverages being prepared for resident consumption in the main kitchen, putting the facility residents at increased risk of consuming food items that could harbor harmful bacteria. Findings include: Review of US Food and Drug Administration Food Code 2022 indicated the following: -Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 degrees Celsius to 57 degrees Celsius (41 degrees Fahrenheit to 135 degrees Fahrenheit) too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Review of facility policy titled Food Temperature Control, revised 6/28/24, indicated the following:-Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food-means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) -Cold foods are held at a minimum of 41 degrees Fahrenheit per CMS guidelines, unless state requirements are more stringent. -While PHF/TCS Foods are on the serving line, the food will be maintained at a safe temperature.-Milk, juice, and other chilled beverages should remain cold on the serving line and may be placed in a container designed for temperature control. On 5/20/26 at 7:31 A.M., the surveyor observed 33 beverages (11 milks, 2 tomato juices, 8 apple juices, 8 cranberry juices, and 4 prune juices) in hard plastic cups, covered with plastic lids, stacked on top of a shelf, located to the left of the steam table, where hot food was being held for breakfast service. All 33 beverage cups were observed with condensation dripping on the outside of the cups. During an interview at the time, Dietary Aide #1 said the dietary staff typically pulled the beverages from the refrigerator around 7:30 A.M. and began breakfast service at 7:40 A.M. During an interview on 5/20/26 at 7:39 A.M., the Food Service Director (FSD) said the beverages might not be cold enough if they are pulled out at 7:30 A.M. The FSD said the beverages were kept cold prior to being put on the shelf and would sit on the shelf for the duration of tray line, being placed on trays as they prepared each individual (resident) tray. The FSD said this process could take about an hour. The FSD said the process was that as the trays were filled, they would then be placed into the food (meal) carts and brought to the units. The FSD said this was the typical process for loading drinks onto meal trays. At the time of the interview the surveyor requested the temperature of one of the beverages to be measured. The FSD removed one cup of milk from the shelf and said the preferred temperature for service should be around 42 degrees Fahrenheit (F). The FSD placed a digital thermometer into the top of the milk, and the thermometer read 68.2 F. The FSD then told a Dietary Aide to remove all the beverages and re-pour them because the beverages were too warm to serve.

Based on interviews, and record review, the facility failed to ensure complaints and concerns reported during the Resident Council meetings in February 2026 and March 2026 were addressed timely and that a response/rationale by the facility was provided to the Resident Council to address the concerns for three ([NAME] Terrace, Hampshire Woods, Hampden Gardens) out of three resident units. Specifically, the facility failed to ensure that:-timely response/rationale was provided pertaining to Resident Council concerns in February 2026 regarding timeliness of staff responses to call bells.-timely response/rationale was provided relative to the Resident Council concerns documented in February 2026 and March 2026 regarding food temperatures and palatability. Findings include: Review of the facility policy titled Resident Council, reviewed 9/26/25, indicated the following procedure:The facility will designate an associate (e.g. Activities Director or Social Service Director) who will be responsible for assistance and liaison between the group and the facility's administration.The minutes for each month's meetings will be kept on file in the Activities Director or Social Service Director's office, as appropriate.The Activities Director or Social Service Director will facilitate follow-up on all complaints, suggestions, or ideas presented at the council meeting and will report results at the next meeting for the residents' information. This information will be included in the minutes.Each department director will be responsible for filling out a comment and concern form, prior to the next meeting to provide his or her input.Activities Director or Social Service Director will assist as needed in reviewing Ombudsman information, reviewing purpose and location of comment and concern form, and location of recent survey results. On 5/21/26 at 10:37 A.M., a Resident Council interview was held with the survey team and 25 facility residents who resided on the three resident units, [NAME] Terrace, Hampshire Woods, and Hampden Gardens. The following concerns were discussed:-12 residents reported waiting for longer than 15 minutes for call bells to be answered. This had been brought up at other council meetings, and they had not received a response.-19 residents reported the food to be unappetizing, 13 residents reported cold food, and 15 residents reported that proteins, specifically meats, were hard or difficult to chew. This had been brought up at other Resident Council meetings, and these food issues continued.-Several residents indicated that staff from the Dietary and Nursing Departments were present at past Resident Council meetings but their concerns remain unresolved. Review of the Resident Council Meeting Minutes from February 2026 through April 2026 included the following:February 25, 2026:-One Activity Assistant was present-Last month[sic]:--Nursing:>Call bell response taking too long (unresolved- they [sic] still shutting them off and leaving)-New items:>Refusal of assistance - Certified Nursing Aides (CNA's) refusing to help resident to prepare for bed properly (i.e. resident asked aide to help put their robe on and they aide refused).--Dietary:-Last Month[sic]:>Cold Coffee- coffee is cold once received by the resident and staff refusing to warm it up upon request.--New Items:>French fries/tater tots- terrible, soggy, cold, hardMarch 19, 2026-Four Staff were present including two Activity Assistants, the Director of Nursing (DON), and a staff from the Dietary Department--Nursing-Last Month[sic]:>Call bell response taking too long (remains unresolved)>Refusal of assistance.(unresolved- [DON] aware)-New Items (all items below were discussed with [DON] present)>Call bells- staff shutting call bells off and walking out, at times they say someone will be right back but that doesn't happen>Residents report when they request help from a CNA or a Nurse, they are told that they will notify their aide>Resident reports waiting on the toilet for 27 minutes for help--Dietary-Last Month:>Cold coffee.(unresolved - Food Service Director confirmed he is working on it)>French fries/tater tots.(unresolved)--New Items:>Cold food consistently ([DON] confirms staff may warm up their food)April 23, 2026-One Activity Assistant was present--Dietary:>Veg (vegetables) not cooked through--Nursing:>Not updating the whiteboards when shifts changeFurther review of the February 2026, March 2026, and April 2026 Resident Council meeting minutes failed to indicate any response by the facility to the concerns brought forward by Resident Council. On 5/21/26 at 3:22 P.M. the survey team requested evidence of the facility responses to the Resident Council meetings in February 2026, March 2026, and April 2026. During an interview on 5/22/26 at 8:12 A.M., Activities Assistant (AA) #1 said there had been some staff turnover in the department, and the current Activity Director was out on medical leave. AA #1 said she was present during the Resident Council meeting on 3/19/26 but did not take notes or participate. AA #1 said in the Resident Council meeting residents had reported waiting for call lights and/or staff turning off the call lights and not returning. AA #1 said that she facilitated the 4/23/26 meeting but did not review what had been previously discussed in the March Resident Council meeting. AA #1 said the DON was present at the 3/19/26 meeting and attended part of the 4/23/26 meeting. AA #1 said she was unable to recall what the DON discussed in the April Meeting. During an interview on 5/22/26 at 8:37 A.M., the DON said he was present for the 3/19/26 Resident Council meeting and recalled that residents reported issues with call light response times. The DON said that if residents reported any issues with staff to him, he would follow up to obtain details. The DON further said the expectation is to have call light response times around 5-7 minutes. The DON said he did not have evidence of any staff education or documentation of facility response relative to the resident concerns with staffing after the February 2026 or March 2026 Resident Council meetings. During an interview on 5/22/26 at 8:37 A.M., the Administrator said the process for Resident Council is to have the Activity Director, or Activity Designee, compile the meeting minutes and provide feedback to the appropriate department heads and they typically utilize a Resident Council Response Form or Care and Concern form to document. The Administrator further said the Activity Director or designee would expect a response from the department heads and then the issue would be discussed at the following Resident Council meeting. The Administrator said the review of any old business during Resident Council was when resolutions were presented from the facility. The Administrator said that if Resident Council concerns remain or were unresolved, they would be re-addressed. The Administrator said the Resident Council Response forms and Care and Concern process was not utilized and he did not have documentation of a facility response to the February 2026, March 2026, or April 2026 Resident Council meetings. The Administrator said the appropriate process for responding to the Resident Council concerns was not followed, and should have been.

Based on interview, observation, and record review, the facility failed to make prompt efforts to resolve grievances related to care and treatment and support the residents' right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal.Specifically, the facility failed to:-ensure that grievance forms were accessible to residents and visitors and maintain an accurate process on how to file a grievance anonymously. -make timely and prompt efforts to resolve grievances brought forward during the February 2026 Resident Council meeting.-make attempts to prevent violation of any resident rights when the residents expressed concern about staff retaliation in February 2026 and March 2026. Findings include:Review of the facility policy titled Grievance Program (Concern and Comment), reviewed 9/26/25, indicated the following:-Residents and their families have a right to file a complaint without fear of reprisal. Upon request, the facility must give a copy of the grievance policy to the resident.-Resident's rights should be protected when voicing customer complaints to maximize the quality of life for each individual and to promote customer satisfaction with facility care and services.-The Concern & Care program is utilized to address the concerns of residents, family members and visitors.Procedure:-Ensuring that residents and families receive upon admission information on the facility grievance procedure, including their right to file a complaint orally or in writing without fear of reprisal.-Any associate can assist in the completion of a Concern and Comment Form if a resident, family member, or guest expresses a concern or comment. Concern and Comment forms can be found in centralized locations throughout the facility.a. Resolve the concern, if possible. If resolution is not possible at that time, explain to the individual that another staff member will be assigned to investigate the concern and will contact them in a timely manner.b. All concerns will be reported to the Supervisor on duty who will then contact the Executive Director, Director of Nursing, and/or other personnel as needed.-Facilitate meetings and/or conversations with residents and families who have repeated concerns to better meet their needs.-Maintaining a record keeping system of all complaints reported via the Concern and Comment program or any other means of reporting that includes:a. The date the grievance was received,b. A summary statement to the resident's grievance,c. The steps taken to investigate the grievance,d. A summary of the pertinent findings of conclusions regarding the resident's concern(s),e. A statement as to whether the grievance was confirmed or not confirmed,f. Any corrective action taken or to be taken by the facility as a result of the grievance,g. The date the written decision was issued.-Following up with the resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction.-Executive Director and/or designee is responsible for.ensuring that all grievances and Concern & Comment reports have been reviewed and addressed in a timely and appropriate manner and that concerned individuals feel that some type of resolution has been communicated, achieved, and maintained. On 5/21/26 at 10:30 A.M., the surveyor was unable to locate any Care and Concern forms in the lobby or any other common areas in the facility and had to ask a Receptionist where the Care and Concern forms could be found. During an interview at the time, the Receptionist said the Care and Concern Forms were typically located in the lobby area but needed to be restocked. Further review of the lobby and facility common areas did not provide any evidence of how the Care and Concern forms could be submitted anonymously by a resident or family. Review of the Resident admission Agreement, dated 2025, provided by the facility, indicated:-Grievances: You or your representative are urged to bring any grievance/concern in the facility to the attention of the Facility Executive Director, State Licensing Agency, or Ombudsman. Upon request you may obtain a copy of the grievance policy.Further review of the Resident admission Agreement did not indicate how, or to whom, the resident could file a grievance anonymously. On 5/21/26 at 10:37 A.M., a Resident Council interview was held with the survey team and 25 facility residents who resided on three resident units, [NAME] Terrace, Hampshire Woods, and Hampden Gardens. The following concerns were discussed:-Multiple residents said they were not comfortable with voicing concerns to staff and were concerned about staff retaliation.--Residents stated the following comments:-It's rudeness-It's retribution-I have brought it up at family meetings and my daughter says 'pick your battles.'-Residents said there had not been a response from the facility Administration about staff retaliation which was discussed in both the February 2026 and March 2026 Resident Council meetings.-Residents indicated that the Director of Nursing (DON) attended past Resident Council meetings but felt the issues with staff retaliation continued and their concerns remained unresolved. Review of the Resident Council Meeting Minutes from February 2026 through April 2026 indicated:February 25, 2026:-One Activity Assistant was present-New items:>Retaliation - residents share this happens when they speak up.March 19, 2026:-Four Staff were present including two Activity Assistants and the Director of Nursing (DON).--Nursing-Last Month[sic]:>Retaliation.(unresolved- discussed with [DON])-New Items (all items below were discussed with [DON] present)>Resident report mistreatment, being threatened, given attitude, at times being yelled at.April 23, 2026:-One Activity Assistant was present, no other staff were indicated as being present--Nursing:>No evidence of review of prior concerns, or current status regarding attempts at resolution of those concerns was indicated.Further review of the February 2026, March 2026, and April 2026, Resident Council meeting minutes did not document any response by the facility to the concerns about staff retaliation brought forward by Resident Council. Review of the Care and Concerns Log provided by the facility did not indicate evidence of facility response to Resident Council concerns relative to staff retaliation or that the grievance process was initiated to address the Residents' concerns. On 5/21/26 at 3:22 P.M. the survey team requested evidence of the facility response to the Resident Council meetings in February 2026, March 2026, and April 2026. During an interview on 5/22/26 at 8:12 A.M., Activities Assistant (AA) #1 said she was present during the Resident Council meeting on 3/19/26 and recalled residents had said that staff would take it against them when they use the call bell. AA #1 said that the DON was also present at the 3/19/26 meeting and attended part of the 4/23/26 meeting. AA #1 said she was unable to recall what the DON discussed in the April Meeting. AA #1 said that she facilitated the 4/23/26 meeting but did not review what had been previously discussed in the March 2026 Resident Council meeting. During an interview on 5/22/26 at 8:37 A.M., the DON said he was present for the 3/19/26 Resident Council meeting and he recalled that residents reported concerns about staff retaliation to him, and he told the residents they did not need to fear retaliation and to approach him directly to address any issues. The DON said that he felt the staffing issues were relative to the Hampden Garden Unit, he made staffing changes to increase and hire new CNAs, but those CNAs were not retained after their orientation. The DON further reported that multiple other staff had been fired as well. The DON said that staff are provided education on the facility Code of Conduct annually and upon hire, which addresses Resident Rights to voice a grievance and protection against staff retaliation. The DON said he did not have evidence of any facility response to the February 2026 Resident Council concerns relative to staff retaliation. The DON said that he did not have evidence of any staff education or written documentation of facility response relative to concerns about staff retaliation after he was present for the March 2026 Resident Council meeting, and new grievances were reported relative to staff behavior. During an interview on 5/22/26 at 8:37 A.M., the Administrator said the process for responding to the Resident Council was to utilize a Resident Council Response Form or Care and Concern Form to document steps taken towards resolution. The Administrator said the Resident Council Response Forms and Care and Concern process was not utilized and he did not have documentation of the facility response to the February 2026, March 2026, or April 2026 Resident Council meetings. The Administrator said the appropriate process for responding to the Resident Council concerns were not followed and should have been.

Based on observations, interviews, and record reviews, the facility failed to ensure there was adequate staffing to provide nursing care and related services timely and as required to meet the needs of four residents (#32, #99, #56, and #127) out of a total sample of 24 residents. Specifically, the facility failed to:1. ensure that staff responded timely to Resident #32's call light when the Resident waited 35 minutes for staff to answer his/her call light. 2. ensure that Resident #99 was awake and assisted with the breakfast meal timely, when staff delayed providing the breakfast meal trays to the [NAME] Terrace unit residents, and Resident #99 was provided his/her breakfast meal 71 minutes after the meal truck arrived on the unit. 3. ensure the call light was answered and continence care provided timely for Resident #56, resulting in urinary incontinence for the Resident. 4. respond timely to the call light and provide personal care for Resident #127 with a diagnosis of a right femur fracture and required assistance with ADL (Activities of Daily Living) care. 5. assess and provide a resolution to concerns related to call bell response times, staff responses to requests, and long wait times for staff assistance with toileting reported by facility residents in the February 2026 and March 2026 Resident Council meetings. Findings include: Review of the Sufficient Staffing and RN Coverage Policy and Procedure, reviewed on 3/31/26, indicated: -The facility will ensure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. -the facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. 1.Resident # 32 was admitted to the facility in May 2026, with diagnoses including muscle weakness, Parkinson's Disease, right below the knee amputation and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #32: -had moderate impairment of mental status as evidenced by a score of 9 out of 15 on the Brief Interview of Mental Status (BIMS) exam. -had Range of Motion (ROM) impairment on one side lower extremity -required assistance from staff for completion of Activities of Daily Living (ADLS- grooming, bathing, transfers). -had no mood or behavior indicators On 5/21/26 at 7:50 A.M., the surveyor observed Resident # 32 put on his/her call light. The surveyor did not observe any staff member entering the Resident's room until Certified Nurse's Aide (CNA) # 1 entered the room at 8:25 A.M. (35 minutes later). During an interview on 5/21/26 at 8:25 A.M., CNA #1 said that Resident #32 was assigned to her today, but she was unaware the call light was on because she was caring for another Resident. CNA #1 said that Resident #32 wanted his/her phone which had been out of reach so it only took a few seconds to answer and that anyone could have answered the call light and handed the Resident his/her phone. During an interview 5/21/26 at 10:35 A.M., Resident #32 said that he/she was upset the call light had been on for so long this morning and since no staff member answered the call light promptly, he/she missed an important phone call from a family member. Resident #32 said staff consistently take 35-45 minutes to answer his/her call lights and call light response time had gotten worse lately. During an interview on 5/26/26 at 1:31 P.M., the Administrator said that the facility goal was that Resident's call light wait time was no more than 5-7 minutes. The Administrator said that Resident #32 should not have waited 35 minutes to have his/her call light answered by a staff member, and it was the responsibility of all staff to answer call lights not just the assigned CNA. During an interview on 5/27/26 at 8:41 A.M., the Director of Nursing (DON) said that Resident #32 should not have waited 35 minutes to have his/her call light answered and another staff member should have gone into the room to at least see what was needed. The DON said the goal was that all call lights were answered in 5-7 minutes. 2. Resident #99 was admitted to the facility in February 2026, with diagnoses including Dementia. Review of the MDS, dated [DATE], indicated Resident #99: -was severely cognitively impaired as evidenced by a BIMS score of 3 out of 15. -had no behavior indicators -required setup from staff for eating -moderate assistance from staff for completion of ADLs. On 5/26/26 at 8:46 A.M., the surveyor observed Resident #99 asleep in bed. During an interview on 5/26/26 at 8:46 A.M., with Unit Manager (UM) #1 and Nurse #2, UM #1 said that he was unsure of how many CNAs were on the floor at this time and was unsure about which CNA was assigned to Resident #99. UM #1 said the first meal truck had arrived at [NAME] Terrace Unit at 8:05 A.M. and he thought the breakfast meal trays had been passed. UM #1 said Resident #99 eats his/her breakfast meal supervised in the dining room and did not know why he/she was not out of bed 31 minutes after the breakfast tray was delivered to the unit. Nurse #2 said the first meal truck arrived on the unit at 8:05 A.M. but was unsure of how many CNAs were scheduled to be on the floor because she thought there had been a call out. Nurse #2 said she was unsure why Resident #99 was not out of bed at this time. On 5/26/26 at 8:53 A.M., the DON arrived at the [NAME] Terrace Unit and asked the UM #1 why there was no staff members assisting with breakfast service in the Unit dayroom. During an interview on 5/26/26 at 9:11 A.M., the DON said he was unaware that a CNA had called out and the Unit had 4 CNAs working which should have been sufficient. The DON said he was not aware the breakfast trays on meal truck #1 had not been passed out and further said Resident #99 should have been out of bed and in the dayroom to have his/her breakfast prior to now. On 5/26/26 at 9:16 A.M., the surveyor observed Resident #99 receive his/her breakfast tray (71 minutes after the meal was delivered to the unit) and said that his/her coffee was cold. During an interview with the Administrator and DON on 5/26/26 at 1:31 P.M., the DON said that he and the Nurses working were unaware there had been a callout and no one had adjusted the CNA assignment to ensure Resident #99 had gotten out of bed in a timely manner to eat breakfast. The DON said that a Nurse should have adjusted the CNA assignment but did not. The DON said that when the food truck arrived on the Unit at 8:05 A.M., the CNAs were responsible for passing trays and should have asked for help if it was needed. 3. Resident # 56 was admitted to the facility in May 2026 with diagnoses including presence of right artificial knee joint and aftercare following joint replacement surgery. Review of the MDS dated [DATE], indicated Resident #56: -was cognitively intact as evidenced by a BIMS score of 15 out 15. -had no mood or behavior indicators -had Range of Motion (ROM) impairment on one side of a lower extremity -required assistance from staff for transfers, for toilet transfers, and personal hygiene. During an interview on 5/20/26 at 8:53 A.M., Resident #56 said that on the previous day (5/19/26), shortly after 3:00 P.M., he/she had asked a CNA (unsure of name) for assistance to the bathroom, but the CNA left the room and never returned. Resident #56 said he/she put on the call light, but no other staff member answered for another hour and by that time he/she had already had a urinary accident and needed assistance to be changed. Resident #56 said that prior to admission to the facility, he/she was able to maintain urinary continence during the day and only had occasional accidents at night. Resident #56 said he/she was very upset about this occurrence and further said he/she just wanted to go home. 4. Resident #127 was admitted to the facility in May 2026 with diagnoses including fracture of the right femur and need for assistance with personal care. Review of the Medical Record indicated Resident #127 was cognitively intact as evidenced by a BIMS Exam score of 14 out of 15 and required assistance from staff for completion of ADLs. During an interview on 5/20/26 at 9:02 A.M., Resident #127 said the day of his/her admission he/she had pressed the call light in the evening to request assistance from staff to get on the bed pan. Resident #127 said no staff member answered the call light for over an hour and as a result he/she was incontinent with bowel and bladder. Resident #127 said he/she had to call his/her spouse who then called the facility to have a staff member answer the call light and provide incontinence care. 5. On 5/21/26 at 10:37 A.M., a Resident Council interview was held with the survey team and 25 facility residents. 12 residents reported waiting for longer than 15 minutes for call bells to be answered. The Resident Council residents said this matter was brought up at other resident council meetings, but the issues continued. Review of the February 2026 - April 2026 Resident Council Minutes indicated residents expressed concerns with call bell response times, staff responses to requests, and long wait times for assistance with toileting. Further review of the Resident Council minutes did not indicate the concerns related to staffing and call bell response times were addressed by the facility Administration. During an interview on 5/22/26 at 8:37 A.M., the Administrator said the process for responding to the Resident Council was to utilize a Resident Council Response Form or Care and Concern forms to document steps taken towards resolution. The Administrator said the Resident Council Response forms and Care and Concern process was not utilized and he did not have documentation of the facility response to the February 2026, March 2026, or April 2026 Resident Council meetings. The Administrator said the appropriate process for responding to the Resident Council concerns were not followed and should have been. During an interview on 5/26/26 at 1:31 P.M., the Administrator said that the facility goal is that Resident's call light wait time is no more than 5-7 minutes. During an interview on 5/27/26 at 8:41 A.M., the Director of Nurses (DON) said the facility goal is that all call lights get answered in 5-7 minutes.

Based on observations, interviews, and record reviews, the facility failed to ensure one Resident (#49) out of a total sample of 24 residents, was free from physical restraints. Specifically, the facility failed to ensure Resident #24 had freedom of movement when staff used a Velcro strap to secure his/her right lower extremity (RLE) to the wheelchair footrest while the RLE was fully extended in front of the Resident, when the Resident had a history of self-rising and did not have the ability to independently release the Velcro strap upon command. Findings include: Review of the Physical Restraint Use policy and procedure, reviewed 9/3/25, included: -the intent is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience, prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity, and limits physical restraint use to circumstances in which the resident has medical symptoms that may warrant the use of restraints. -the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience, and not required to treat the resident's medical symptoms. -Physical restraint- any manual method or physical or mechanical device, equipment, or material that meets all of the following criteria: >is attached or adjacent to the resident's body >cannot be removed easily by the resident (meaning it can be removed intentionally by the resident in the same manner as it was applied by the staff); and >restricts the resident's freedom of movement or normal access to his/her body. -The resident or resident representative may request the use of a physical restraint; however if there are no medical symptoms identified that require treatment, the use of a restraint is prohibited. -A physician's order is required for the use of the specific type of restraint. The order should include the specific type of restraint, the condition and/or medical symptom that warrants restraint use, where and how the restraint is to be applied and used, and the time and frequency the restraint should be released. Review of the Resident Rights policy and procedure reviewed 9/26/25, included: -The resident has the right to be free from any physical or psychoactive drugs imposed for purposes of discipline or convenience and not required to treat medical symptoms. Resident #49 was admitted to the facility in March 2026, with diagnoses including unspecified fracture of the right lower leg closed fracture [sic], and age-related osteoporosis with current pathological fracture of the left humerus. Review of the Minimum Data Set (MDS) Assessment, dated 3/23/26, indicated: -severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) exam score of 3 out of 15. -required maximum assistance from staff for completion of Activities of Daily Living (ADLs). -has impaired range of motion (ROM) to one side of lower extremities and one side of upper extremities. Review of Resident #49's Fall Care Plan, initiated 3/24/26, indicated the Resident had fractures of the left humerus (upper arm bone) and fracture of the right patella (knee) after a fall. Review of Resident #49's Medical Record failed to indicate a Physician's order for a restraint and evidence that the RLE Velcro strap was assessed as a potential restraint. On 5/20/26 at 8:34 A.M., the surveyor observed Resident #49 seated in his/her wheelchair in the dayroom with an immobilizer brace on the right leg extending from the mid-thigh to the calf. The Resident's RLE was fully extended straight in front of him/her and positioned on the wheelchair footrest. There was a Velcro strap around Resident #49's right ankle that secured the ankle to the wheelchair footrest. On 5/21/26 at 8:36 A.M., the surveyor observed Resident #49 seated in his/her wheelchair in the dayroom with an immobilizer brace in place extending from the mid-thigh to the calf. The RLE was fully extended straight in front of the Resident and positioned on the wheelchair footrest. There was a Velcro strap around Resident 49's right ankle that secured the ankle to the footrest. On 5/21/26 at 9:35 A.M., the surveyor observed Resident #49 seated in his/her wheelchair at the nurses' station with an immobilizer brace in place extending from the mid-thigh to the calf. The RLE was fully extended straight in front of the Resident and positioned on the wheelchair footrest with a Velcro strap placed around Resident #49's right ankle that secured the ankle to the footrest. On 5/21/26 at 10:49 A.M., the surveyor observed Resident #49 seated in his/her wheelchair at the nurse's station with an immobilizer brace in place extending from the mid-thigh to the calf. The RLE was fully extended straight in front of the Resident and positioned on the wheelchair footrest and a Velcro strap placed around Resident #49's right ankle that secured the ankle to the footrest. At the time of the observation, Resident #49's family member who was present with the Resident, said that he/she had a history of falls prior to admission to the facility. On 5/26/26 at 8:10 A.M. and 8:58 A.M., the surveyor observed Resident #49 seated in his/her wheelchair wearing an immobilizer brace in place extending from the mid-thigh to the calf. The RLE was fully extended straight out in front of the Resident and positioned on the wheelchair footrest with a Velcro strap secured around Resident #49's right ankle and attached to the footrest. During an interview at the time, CNA #3 said that the Resident is a fall risk and at times tries to rise out of his/her chair, so staff keep a leg strap on the RLE to keep the leg positioned correctly. During an interview at the same time, the Physical Therapist (PT) said Resident #49 used the Velcro strap for positioning of the RLE and the PT thought Resident #49 could self-remove the Velcro strap from around the ankle/footrest. The PT asked Resident #49 to reach down and remove the Velcro strap and after several verbal requests, Resident #49 was unable to follow instructions to release the Velcro strap. The PT said he was mistaken and the Resident was unable to remove the Velcro strap, limiting his/her ability to move freely. During an interview on 5/26/26 at 9:25 A.M., CNA #4 said staff place the Velcro strap lower on the leg to prevent Resident #49 from removing it. Resident #49 was observed trying to move his/her RLE but could not, became restless, and said, help I cannot even move it. During an interview on 5/26/26 at 12:44 P.M., the Rehabilitation Manager said she had reassessed the Velcro strap on 5/26/26 after it was brought to her attention and determined that the Velcro strap was restricting Resident #49's movement and should have been assessed as a potential restraint but had not been. The Rehabilitation Manager said any restraint used should be properly assessed, have a specific Physician order and education provided for the staff but this did not occur. During an interview on 5/26/26 at 1:06 P.M., the Director of Nursing (DON) said he had no awareness that staff had been using the Velcro strap to secure Resident #49's RLE to the wheelchair footrest. The DON said that since it was determined the Velcro strap was limiting Resident #49's freedom of movement, it should not have been used unless it was properly assessed as a restraint which did not occur.

Based on observations, interviews, and records reviewed, the facility failed to provide proper care and services to maintain hearing abilities for one Resident (#61), out of a total sample of 24 residents.Specifically, for Resident #61, the facility failed to:-maintain the Resident's hearing aids as recommended by the Audiologist, including changing the batteries, changing the wax guards, and cleaning the hearing aids.-schedule an audiology appointment for the Resident and have his/her hearing aids be evaluated by an Audiologist when the Resident's hearing aids were not effectively assisting the Resident to hear others when being spoken to. Findings include:Review of the facility policy titled Vision and Hearing Assistive Devices, reviewed 9/18/25, indicated but was not limited to the following:-Policy: Ensure residents receive proper treatment and assistive devices to maintain.hearing abilities.-The facility will assist as needed with making appointments and arranging transportation to obtain needed services. Review of the facility policy titled Use of Outside Consultants, reviewed 4/1/26, indicated but was not limited to the following:-Each Consultant will report to the Executive Director any recommendations in writing and in an exit interview. The Consultant will also assist in the development of action plans for implementations and expectations for continued assessment.-It is the responsibility of the Executive Director or designee to act on these written reports and to document his/her actions and outcomes based upon the consultation. Resident #61 was admitted to the facility in June 2021, with diagnoses including need for assistance with personal care. Review of Resident #61's Order Summary Report, dated 5/26/26, indicated:-May consult:.audiology.as needed. Order date 6/9/21. Review of Resident #61's clinical record failed to indicate any Physician orders relative to the maintenance (cleaning and changing batteries) of the Resident's hearing aids. Review of Resident #61's Request for Service Form, signed by the Resident on 9/27/23, indicated the Resident requested to be seen for audiology services. Review of Resident #61's Communication Care Plan, initiated 5/8/24, indicated:-The Resident has a communication problem related to hearing deficit. -Interventions: Refer to Audiology for hearing consult as ordered. Review of Resident #61's Audiology Encounter Note, exam date 5/29/24, indicated:-Reason for referral: Complaints of newly decreased hearing.-Right hearing aid: Changed battery, changed wax guard, cleaned aid, cleaned earmold; Good fit; Listening check good; Patient pleased with sound quality; Functioning well.-Left hearing aid: Changed battery, cleaned aid, cleaned earmold; Good fit; Listening check good; Patient pleased with sound quality; Functioning well. -Clinical findings: Severe sensorineural hearing loss - right ear; Moderately severe to profound sensorineural hearing loss - left ear. -New slight asymmetry.will continue to monitor.-Recommendations for Attending Provider/Nursing Staff:>Slow clear speech with visual cues>Medical consult due to negative middle ear pressure -left>Change batteries weekly>Change wax guards monthly>Clean hearing aid daily after use>Daily use of hearing aids is recommended>Please open battery door when hearing aids are not in use>Continue with current means of communication Review of the Minimum Data Set (MDS) Assessment, dated 3/16/26, indicated Resident #61:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15 points.-had difficulty hearing in some environments and was not using a hearing aid or other hearing appliance at the time of the assessment.-was dependent on staff for Activities of Daily Living (ADL's) including oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, and personal hygiene. During an interview on 5/20/26 at 8:49 A.M., Resident #61 said he/she could not hear the surveyor and asked the surveyor to speak up and come closer to his/her right ear when speaking. Resident #61 said he/she had hearing aids, however, has not had them in months [sic]. During an interview on 5/21/26 at 11:17 A.M., Nurse #4 said Resident #61 did not use his/her hearing aids and kept the hearing aids at his/her bedside. Nurse #4 said the Resident was able to apply and remove his/her hearing aids independently. Nurse #4 said Resident #61 underwent hearing tests from the contracted audiology provider all the time, and the Audiologist would check the Resident's hearing aids. The surveyor requested to view the Resident's hearing aids and went into the Resident's bedroom with Nurse #4, who located the Resident's hearing aids on the over-the-bed table. Resident #61 said the hearing aids did not work, and that he/she had not seen the Audiologist in a long time. Resident #61 was observed saying what? and huh? throughout the conversation, and Nurse #4 had to repeat herself. Nurse #4 said she would inform the Social Worker (SW) so that the Resident could be added to the list to be seen by the Audiologist during the Audiologist's next visit to the facility. During a follow-up interview on 5/21/26 at 11:28 A.M., Nurse #4 said she just changed the batteries of Resident #61's hearing aids and the hearing aids were now working better. Nurse #4 said one of the hearing aids was still not working as well as the other hearing aid. During an interview on 5/21/26 at 11:38 A.M., Social Worker #1 said the social services department was responsible for contacting the contracted audiology provider as needed. Social Worker #1 said Resident #61 chronically complained about his/her hearing aids not being comfortable, however had not heard much complaints lately. Social Worker #1 said the last time Resident #61 was seen by the Audiologist was on 5/29/24. Social Worker #1 said residents were seen annually by the Audiologist unless there were concerns. During an interview on 5/21/26 at 3:20 P.M., the Social Services Consultant said she called the contracted audiology provider and confirmed that Resident #61 had not been evaluated by the provider since 5/29/24. During a follow-up interview on 5/22/26 at 11:04 A.M., Resident #61 said I can't hear you to the surveyor and that his/her hearing aids were not working. Resident #61 said a Provider used to come into the facility every six weeks to clean his/her hearing aids. Resident #61 said it had been about four to five months since anybody had come to clean his/her hearing aids and change the batteries. Resident #61 said that nobody had been cleaning the hearing aids or changing the batteries since the Provider stopped coming. Resident #61 said his/her hearing aids had not been working for about six months. The Resident said he/she asked the facility if he/she could clean the hearing aids and change the batteries, and the Resident was told that he/she would be better off to let the Provider do it. Resident #61 said that the staff had to know his/her hearing aids were not working and that I can't hear anyone. During an interview on 5/22/26 at 1:46 P.M., Nurse #5 said that some hearing aids required the batteries to be changed. Nurse #5 said that the Nurse would know to change hearing aid batteries when there was a Physician order to change the batteries. During an interview on 5/22/26 at 2:13 P.M., Unit Manager (UM) #3 said it was the Nurse's responsibility to apply residents' hearing aids and remove them, and there should be a Physician's order indicated in the Medication Administration Record (MAR). UM #3 also said it was the Nurse's responsibility to change hearing aid batteries and to clean the hearing aids. UM #3 said the hearing aids should be inspected by the Nurse every time they were removed from the residents' ears. UM #3 said there were no residents on the unit that were responsible for applying and removing their own hearing aids. UM #3 said the recommendations made by the Audiologist during Resident #61's audiology encounter on 5/29/24 had not been implemented by the facility and should have been implemented as soon as the recommendations were received. UM #3 said the facility process was for the in-house Provider to review the recommendations, and the recommendations would be approved and entered as a Physician's order. During an interview on 5/26/26 at 1:54 P.M., the Director of Nursing (DON) said the expectation was that recommendations made by the Audiologist were implemented by the facility. The DON said the Nurse was responsible for changing the batteries of Resident #61's hearing aids and cleaning Resident #61's hearing aids.

Based on interviews, and record review, the facility failed to offer and administer the 2025/2026 COVID-19 vaccine in accordance with Centers for Disease Control and Prevention (CDC) recommendations, to one Resident (#74) of five applicable residents for vaccinations, out of a total sample of 24 residents, placing the Resident at increased risk for COVID-19 infection and COVID-19 infection complications.Specifically, the facility failed to offer and administer the 2025/2026 COVID-19 vaccine to Resident #74 in a timely manner when Resident #74 was eligible and consented to receive the vaccine. Findings include:Review of the Centers for Disease Control and Prevention (CDC) guidance titled 2025/2026 COVID-19 Vaccine Guidance, dated 11/4/25 and located at 2025-2026 COVID-19 Vaccination Guidance | Covid | CDC indicated the following:- . some people may be at increased risk for SARS-CoV-2 infection including . residents . in long-term care facilities.-vaccination is recommended based on individual-based decision-making with an emphasis that the risk-benefit of vaccination is most favorable for individuals who are at an increased risk for severe COVID-19 disease and lowest for individuals who are not at an increased risk, according to the CDC list of COVID-19 risk factors (including COPD and Diabetes). Review of the facility's COVID-19 (SARS-CoV-2) Vaccination Program Policy for Residents, revised 11/25/25, indicated:-The facility will ensure that residents are offered the COVID-19 vaccine unless immunizations are medically contraindicated, or the resident has already been immunized.-The vaccine may be offered and provided directly by the facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity.-If the vaccine is unavailable in the facility, the facility should provide information on obtaining vaccination opportunities (e.g. health department or local pharmacy) to the individual and the facility should maintain documentation showing the efforts to obtain vaccine accessibility at the facility. Resident #74 was admitted to the facility in January 2026 with diagnoses including Chronic Kidney Disease (CKD), Diabetes, and Congestive Heart Failure (CHF). Review of Resident #74's Covid-19 Immunization Screening and Consent Form, signed by the Resident on 1/24/26, indicated he/she consented to be given the Covid-19 vaccination. Review of Resident #74's medical record indicated no documented evidence that the Resident received the Covid-19 vaccination. During an interview on 5/20/26 at 4:36 P.M., the Infection Preventionist (IP) reviewed the immunizations and said Resident #74 consented to receive the Covid-19 vaccination on 1/24/26, and the vaccine had not yet been offered. The IP said the facility does keep vaccines in house typically but did not have the Covid-19 immunization in house at the time the Resident consented to receive the immunization. The IP said she tried to administer immunizations in batches, every three to six months. The IP said she ordered the Covid-19 vaccination on 4/1/26 and had not yet received the order yet. The IP further said she had not followed up on why the vaccination had not been delivered to the facility as yet but should have since the Resident consented to the Covid vaccination back in January 2026.

Based on observation and interview, the facility failed to ensure three Unit ([NAME] Terrace, Hampshire Woods, and Hampden Gardens) kitchenettes were maintained in a safe and sanitary condition, out of three unit kitchenettes observed. Findings include: Review of the facility's policy titled Cleaning Schedule, reviewed 4/30/24, indicated the following: -Equipment and Utensil Cleaning and Sanitization- A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc. -The Director of Food and Nutrition Services develops a cleaning schedule to include all equipment and areas to be cleaned. Review of the facility's Stocking List for Unit's Nourishment Room, updated 9/6/24, indicated the following: -Make sure to clean fridge, microwave, cupboards, and counters. On 3/5/25 at 5:02 P.M., the surveyor observed the following in the Hampden Garden Unit kitchenette: -Toaster was laden with crumbs -Inside the cabinet that stored snacks had dried dark brown splatter noted on the shelves and door. On 3/5/25 at 5:06 P.M., the surveyor observed the following in the [NAME] Terrace Unit kitchenette: -Toaster was laden with crumbs, and dried pieces of bread were stuck in the toaster; crumbs were black in color. During an interview on 3/5/25 at 5:13 P.M., the Food Service Director (FSD) said the [NAME] Terrace Unit toaster was laden with crumbs and this could pose a fire risk due to the large amount of crumbs left in the toaster. The FSD said he was unsure who was responsible for cleaning the toasters on a regular basis. On 3/6/25 at 7:35 A.M., the surveyor observed the following in the Hampden Garden Unit kitchenette: -Bottom of the refrigerator had a large dried brown spot and multiple dried dirty paper towels under the lower refrigerator drawer. -Inside the cabinet that stored snacks there was dried, dark brown splatter noted on the shelves and door. On 3/6/25 at 7:38 A.M., the surveyor observed the following in the [NAME] Terrace Unit kitchenette: -Refrigerator had dried yellow material on the floor. During observations of the Unit Kitchenettes on 3/11/25 from 10:23 A.M. to 10:32 A.M., with Dietary Aide #1, the surveyor observed the following: Hampshire Woods Unit kitchenette: -Thick dried brown material on the refrigerator floor. Hampden Garden Unit kitchenette: -Large dried brown spot and dirty paper towels remained on the bottom of the unit refrigerator. -Dried brown splatter was still noted inside the snack cabinets on the shelving and door. [NAME] Terrace Unit kitchenette: -Refrigerator had dried yellow material on the floor. Following the observations Dietary Aide #1 said the kitchenettes should be cleaned daily and it was the job of the afternoon dietary aides who stocked the snacks to make sure the kitchenettes were cleaned. Dietary Aide #1 said the refrigerators on all the units should have been wiped clean and the cabinets on the Hampden Gardens Unit should have been wiped down. During observations of the Unit Kitchenettes on 3/11/25 at 10:47 A.M., with the FSD, the surveyor observed the following: Hampshire Woods Unit kitchenette: -Thick dried brown material on the refrigerator floor. Hampden Garden Unit kitchenette: -Large dried brown spot and dirty paper towels remained on the bottom of the unit refrigerator. -Dried brown splatter was still noted inside the snack cabinets on the shelving and door. [NAME] Terrace Unit kitchenette: -Refrigerator had dried yellow material on the floor. Following the observation the FSD said all the Unit refrigerators should be cleaned daily by staff and this did not appear to have been happening on a daily basis. The FSD said all dried food or liquid materials should have been cleaned out of the refrigerator on all the Units and the cabinets on the Hampden Garden Unit as this could lead to foodborne illness concerns.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections on one unit ([NAME] Terrace), out of a total of three units, affecting eight Residents (#167, #99, #75, #95, #62, #72 #170, and #50), out of a total sample of 22 residents. Specifically, 1. for Resident #167, the facility failed to ensure Personal Protective Equipment (PPE: items such as gowns, gloves, etc. to prevent the spread of infection from one person to another) was donned correctly, the surface used to set up treatment supplies was cleaned and disinfected before use, and that the scissors used to cut of an old dressing were cleaned and disinfected before using them to cut new dressing materials, placing the Resident at increased risk of contamination and infection. 2. for Resident #99, the facility failed to ensure that dressing materials brought into the Resident's room were not returned to the treatment cart for storage placing the [NAME] Terrace unit at risk for cross contamination. 3. For Resident #75, the facility failed to implement Contact Precautions when the Resident had a suspected infection, and results were pending for Clostridium Difficile (C.Diff: multi-drug resistant organism [MDRO] that is infectious and causes diarrhea and colitis [inflammation of the colon]). 4. For Residents #62 and #95, the facility failed to implement Special Contact/Droplet Precautions for both Residents who were diagnosed with Influenza. 5. For Residents #72 and #170, the facility failed to implement Enhanced Barrier Precautions (EBP) as indicated for both Residents who were at high risk for contracting infections. 6. For Resident #50, the facility failed to implement Contact Plus Precautions for a Resident diagnosed with C-Diff. Findings include: Enhanced Barrier Precautions (EBP) - refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities. 1. Resident #167 was admitted to the facility in February of 2025 with diagnoses including Arthritis due to other bacteria of the left wrist and Heart Failure. On 3/7/25 at 11:28 A.M., the surveyor observed the following during wound care to Resident #167 provided by Nurse #1: -Nurse #1 performed hand hygiene at the Resident's room door and began to don a gown. While donning the gown Nurse #1 bent forward causing the lower half of the gown to touch the floor. -Nurse #1 finished donning the gown and prepared to enter the room when the surveyor intervened and made her aware of the observed gown touching the floor. -Nurse #1 removed the gown, performed hand hygiene, donned a new gown and gathered supplies to enter the Resident's room. -Nurse #1 dropped the bleach wipe on the floor and stated she would not be able to wipe the over-bed table to clean and disinfect the table. Nurse #1 then draped the table with a towel without cleaning or disinfecting the table and set up treatment supplies on the towel. -Nurse #1 used new scissors from a suture removal kit to remove the old dressing from the Resident, disposed of the old dressing and set the scissors on the draped table without cleaning or disinfecting the scissors. -Nurse #1 doffed gloves, performed hand hygiene, and donned new gloves. -Nurse #1 cleansed the wound with wound cleanser and gauze and patted the area dry. -Nurse #1 doffed the soiled gloves, performed hand hygiene, and donned new gloves. -Nurse #1 cut a piece of plain packing strip with the previously used scissors that were not cleaned or disinfected and applied the packing strip to the wound. -Nurse #1 covered the wound with gauze, wrapped it with gauze wrap, and secured it with tape. -Nurse #1 disposed of trash, doffed PPE, and performed hand hygiene before exiting the room. During an interview on 3/7/25 at 12:20 P.M., the surveyor reviewed the wound care observations with Nurse #1. Nurse #1 said she should have cleaned and disinfected the scissors between using them to cut off the old dressing and to cut the new dressing supplies because the old dressing was considered dirty, but she did not. Nurse #1 declined to answer any further questions from the surveyor. During an interview on 3/11/25 at 3:42 P.M., the surveyor reviewed the wound care observations with the Infection Preventionist (IP). The IP said there was concern with Nurse #1 entering room to perform wound care with a gown that had touched the floor as the floor was dirty and this could cause contamination of the wound. The IP further said the table and scissors should have been cleaned and disinfected as the table and the old dressing were considered contaminated, and this could contaminate the new dressing and/or wound. 2. Resident #99 was admitted to the facility in September 2024 with diagnoses including Malignant Neoplasm of the Glottis, Gastrostomy Status and Extended-Spectrum Beta Lactamase (ESBL). On 3/12/25 at 9:18 A.M., the surveyor observed the following during a Gastrostomy Tube (G-tube) site care for Resident #99 provided by Nurse #8: -Nurse #8 performed hand hygiene, donned a gown and gloves. -Nurse #8 gathered supplies off the treatment cart and entered the Resident's room. -Nurse #8 placed supplies on the counter in room, cleaned and disinfected the over-bed table and draped it with a disposable pad. -Nurse #8 gathered the supplies from the counter and set them up on the draped table. -Nurse #8 removed old dressing from G-tube site, disposed of it, doffed gloves, performed hand hygiene and donned new gloves. -Nurse #8 cleansed the G-tube site area with normal saline soaked gauze and patted the area dry. -Nurse #8 doffed gloves, performed hand hygiene and donned new gloves. -Nurse #8 applied a clean drain sponge gauze to the site, and secured it with tape. -Nurse #8 disposed of the used supplies, cleaned and disinfected the table, doffed gown and gloves, performed hand hygiene and exited the room with the opened package of gauze. -Nurse #8 brought the package of opened gauze to the treatment cart and placed it in a drawer. During an interview on 3/12/25 at 9:30 A.M., Nurse #8 said she should not have placed the opened gauze package that was used in Resident #99's room back into the treatment cart. During an interview on 3/12/25 at 9:40 A.M., the IP said that because the gauze had been set on a surface in Resident #99's room and then brought out and placed into the treatment cart, there was a risk for cross-contamination. 37400 3. Review of the facility policy titled Transmission-Based Precautions (TBP) and Isolation Procedure, revised 9/24/24, indicated the facility will implement and utilize TBP to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. The policy also included the following: -TBP must be used when a resident develops signs and symptoms of a transmissible infection . -The facility should refer to CDC- Appendix A to determine the type and duration of precautions recommended for select infections and conditions, unless the facility has been provided more stringent guidance from local and state health authorities. -The facility should also initiate TBP for a constellation of new symptoms consistent with a communicable disease. Empirically initiated TBP may be adjusted or discontinued when additional clinical information becomes available (e.g. confirmatory laboratory testing). -Contact Precautions are intended to prevent transmission of pathogens that are spread by direct (e.g. person to person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves before entering or upon entering (i.e. before making contact with the resident or the resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. Review of the Centers for Disease Control and Prevention (CDC) document titled About C. Diff, dated 12/18/24, indicated the following: -C.Diff is a germ that causes diarrhea and colitis and can be life-threatening. -C.Diff can affect anyone. -Most cases of C.Diff infection occur when you've been taking antibiotics or not long after you've finished the antibiotic course. -Symptoms of C.Diff include diarrhea, fever, stomach tenderness or pain, loss of appetite, and nausea. -People are up to 10 times more likely to get C.Diff infection while taking an antibiotic or during the three months after, with longer courses potentially doubling their risk. -Other risk factors include recent stay at a hospital or nursing home and previous infection with C.Diff . -C.Diff germs spread from person to person in poop [sic], but the bacteria are often found in the environment. -When C.Diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces . Review of the CDC document titled Appendix A: -Type and Duration of Precautions Recommended for Selected Infections and Conditions, dated 2/7/25, indicated: >Contact Precautions and handwashing with soap and water are recommended for individuals with C.Diff. Resident #75 was admitted to the facility in February 2025 with diagnoses including Dementia and Aspiration Pneumonia. Review of the Minimum Data Set (MDS) Assessment, dated 2/12/25, indicated Resident #75: -was rarely or never understood/understands -had severe cognitive impairment as evidenced by a BIMS score of 0 out of 15 -was dependent on staff with toileting -required assistance of staff with dressing and personal hygiene On 3/7/25 at 7:58 A.M., the surveyor observed Resident #75 calling out loudly from his/her room. Thesurveyor observed Resident #75 was dressed, seated in a wheelchair, and was shifting back and forth while seated saying, I can't wait please . The Resident was observed to pull at the top back of his/her pants while continuing to call out. The surveyor relayed the observation to Nurse #1 who said she would follow-up with the Resident and also let the Certified Nurses Aide (CNA) know. Review of the Provider Note, dated 3/10/25, indicated Resident #75 was examined and the following was noted: -elevated white blood cell (WBC: could indicate inflammation or symptom of infection) and abdominal pain over past two days -the Resident's abdomen had tenderness -increased restlessness and indication of abdominal pain -Start Augmentin (antibiotic) 500/125 twice daily for three days, for possibility of intra-abdominal infection Review of the March 2025 Physician's orders indicated: -Stool for C.Diff, ordered 3/10/25 at 2:30 P.M., and discontinued 3/11/25 On 3/11/25 at 8:59 A.M., the surveyor observed Resident #75 awake and lying in bed. The surveyor did not observe any signage outside of the Resident's room indicating TBP were in place. The surveyor observed an Activities Assistant going from resident room to resident room and passing water pitchers at this time. Review of Resident #75's laboratory test results, dated 3/11/25 at 10:18 A.M., indicated: -C. Diff positive, critical result -critical results were acknowledged by Nurse #2 During an interview on 3/11/25 at 10:55 A.M., CNA #2 said she was just notified that the Resident was positive for C.Diff infection, and they were in the process of moving the Resident to another room. The surveyor observed the Resident's room had no signage indicating TBP for Resident #75 was in place. During an interview on 3/11/25 at 10:56 A.M., Nurse #2 said she entered the Physician's order to test Resident #75 for C.Diff the previous day (3/10/25). Nurse #2 said they were able to obtain a stool specimen on 3/10/25. Nurse #2 said they would typically put a resident on TBP if they were symptomatic or if they had a laboratory culture pending. Nurse #2 said when the Physician's order was obtained, it was change of shift, and she reported to the 3:00 P.M. to 11:00 P.M. shift the Resident's current status. Nurse #2 said she alerted the nursing staff that the Resident was positive for C.Diff, and they were currently in the process of moving the Resident to another room. When the surveyor asked Nurse #2 how staff knew what PPE was required when providing care for the Resident, Nurse #2 said she told the nursing staff. During an interview on 3/11/25 at 11:20 A.M., the Infection Preventionist (IP) said she was unaware that Resident #75 had a C.Diff specimen ordered on 3/10/25. The IP said when the Physician gave an order to obtain a C.Diff specimen, Resident #75 should have been placed on Contact Precautions. 4. Review of the facility policy titled Transmission-based Precautions and Isolation Procedures, revised 9/24/24, included the following: -the use of Droplet Precautions applies when respiratory droplets contain pathogens which may spread to another susceptible individual. Respiratory pathogens can enter the body via the nasal mucosa, conjunctivae and less frequently the mouth. -examples of droplet-borne organisms that may cause infections include but are not limited to influenza . Review of the facility matrix, provided to the survey team shortly after entrance on 3/5/25, indicated Resident #95 and Resident #62 were on TBP, and resided in the same room. a. Resident #95 was admitted to the facility in February 2025. Review of a Nurse's Note dated 2/28/25, indicated the Resident was complaining of slight cough and not feeling well. Resident #95 was swabbed for Influenza (Flu) and was positive. Review of a Provider Note, dated 3/8/25, indicated the following: -Resident #95 was positive for flu, changed to full-strength Tamiflu (anti-viral medication) 75 milligrams (mg), twice daily for 5 days through 3/11/25 - Resident has a productive cough and fatigue, receiving updraft [sic] treatments. Review of the March 2025 Physician's orders indicated Isolation: -Contact and Droplet Precautions for Flu, every shift, initiated on 2/28/25 and discontinued on 3/10/25. b. Resident #62 was admitted to the facility in February 2025. Review of a Nurse's Note, dated 2/28/25, indicated the Resident called an ambulance at approximately 1:00 A.M. due to complaints of not being able to breathe. Review of the Resident #62's clinical record indicated: -he/she was readmitted to the facility on [DATE] -Provider note, dated 3/4/25: positive for Influenza upon re-admission from the hospital -Nursing Note, dated 3/4/25: remains on precautions and Tamiflu for Influenza . On 3/5/25 at 10:56 A.M., the surveyor observed Resident #95 and Resident #62 lying in their individual beds in the same room. Two signs were posted outside of the room which indicated the following: -Stop. Enhanced Barrier Precautions (and indicated for B on a round sticker) >everyone must: cleanse their hands before entering and leaving the room >staff and providers must also: wear gloves and a gown for high-contact resident care activities. -Stop. Special Droplet/Contact Precautions (did not indicate a letter on a round sticker) >Only essential personnel should enter this room. >everyone must: cleanse hands when entering and leaving the room >wear a mask >wear eye protection (face shield or goggles) >gown and glove at the door On 3/7/25 at 8:29 A.M. through 8:39 A.M., the surveyor observed the following: -Two signs indicating Enhanced Barrier Precautions and Special Droplet/Contact Precautions were observed outside of the room entrance. -A bin containing PPE including gowns, eye protection and masks. Gloves were observed upon entry into the Residents' room. -Activity Assistant (AA) #1 entered Resident #95 and Resident 62's room with a surgical mask and gown on. AA #1 did not have eye protection or gloves on. AA #1 was observed to remove her gown and exited the room shortly after. During an interview after AA #1 exited the room, AA #1 said she was passing beverages to the Residents in the room, and because she was not touching anything, she only had to put on a mask and a gown. The surveyor and AA #1 reviewed the signage posted outside of the room. AA #1 said the signs are new to her within the last few weeks, and that she had never had to put on eye protection before. AA #1 said she had not received any training on the signage. When the surveyor asked if she knew what the signage posted was for, AA #1 said both Residents had the Flu. The surveyor encouraged AA #1 to speak with nursing about the signage and the requirements for PPE at this time. On 3/7/25 at 1:50 P.M., the surveyor observed CNA #6 don an N95 mask (without performing hand hygiene), don a gown and gloves and entered the room to reposition Resident #62. CNA #6 did not don eye protection. CNA #6 assisted Resident #62 with repositioning, removed the N95 mask, gown and gloves and donned a surgical mask upon exiting the room. During an interview following the observation at 1:55 P.M., CNA #6 said she regularly worked on the other floors, but was assisting on this unit today. CNA #6 said the Enhanced Barrier signage was for residents who had catheters and skin issues, and the Special Droplet/Contact signage was for residents who were sick. CNA #6 said it was her understanding that the position of the sign indicated who the precautions were for. CNA #6 said the Special Droplet/Contact Precautions were placed above Resident #95's name so they were indicated for him/her, and the Enhanced Barrier Precautions would be indicated for Resident #62. CNA #6 said relative to Resident #62, she would only need to gown and glove when providing care. The surveyor and CNA #6 eviewed the Special Droplet/Contact Precaution signage posted outside of the room, and after reviewing the sign, CNA #6 said she would need to put on a gown, gloves mask and eye protection prior to entering the Residents' room. CNA #6 said she did not put on eye protection when she repositioned Resident #62 and she should have. CNA #6 looked in the PPE bin located outside of the Residents' room and said there was no eye protection in the bin and said that she would need to get some more. 5. Review of the facility policy titled Enhanced Barrier Precautions, revised 6/30/24, indicated the facility should use EBP as an additional Multi-drug Resistant Organism (MDRO) mitigation strategy for residents that meet the following criteria, during high contact care activities. The policy also included the following: -EBP are indicated for residents with any of the following: >infection or colonization with a CDC-targeted MDRO . Review of the facility procedure titled Hand Hygiene, reviewed 8/18/24, indicated the following: -hand hygiene is a general term to refer to handwashing, antiseptic handwashing, antiseptic hand rubbing, and surgical hand asepsis -the hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient -hand hygiene is the single most important procedure to prevent infection -to protect patients from health care-associated infection, hand hygiene must be performed routinely and thoroughly -an alcohol-based hand rub is appropriate for decontaminating the hands: >before direct patient contact, putting on gloves . >after removing gloves >after contact with a patient or with bodily fluids, excretions, mucous membranes, non-intact skin, or wound dressings (if hands are not visibly soiled) >after contact with inanimate objects in the patient's environment a. Resident #72 was admitted to the facility in December 2024 with diagnoses including neuromuscular dysfunction of the bladder and Extended Spectrum Beta Lactamase (ESBL). Review of the CDC document, dated 4/11/2024, indicated the following: -Enterobacterales are a group of bacteria that cause infections in healthcare settings and communities. -Some species are also a normal part of the human gut. -Some Enterobacterales produce enzymes called extended-spectrum beta-lactamases (ESBLs). -Extended-spectrum beta-lactamases (ESBLs) break down certain antibiotics, making some infections caused by ESBL-producing Enterobacterales difficult to treat. -ESBL-producing Enterobacterales can spread from person to person through dirty hands and surfaces. Review of Resident #72's March 2025 Physician's orders indicated the following: -Enhanced Barrier Precautions (EBP) every shift related to history of ESBL in urine, initiated 3/5/25 b. Resident #170 was admitted to the facility in February 2025 with diagnoses including left hip fracture and need for assistance with personal care. On 3/7/25 from 9:31 A.M. through 9:45 A.M., the surveyor observed the following: -EBP signage was posted outside of the Resident's room, and a PPE bin containing gowns outside of the door entry -9:31 A.M., Resident #72 initiated the call light -9:36 A.M., CNA #1 entered the Resident's room with a surgical mask and gloves in place, but did not don a gown. -CNA #1 assisted Resident #72 to the bathroom located inside of the room, then went to the Resident's closet, retrieved some pants, returned to the bathroom and then instructed the Resident to ring when he/she was done. -CNA #1 exited Resident #72's room with a glove on her left hand (did not remove the glove or conduct hand hygiene after exiting the room) and entered Resident #170's room with the same gloved hand. -CNA #1 exited Resident #170's room shortly after with the gloved left hand (did not remove the glove nor perform hand hygiene) and entered the clean linen room. -CNA #1 exited the clean linen room shortly after holding a towel in the gloved left hand and re-entered Resident #170's room. -CNA #1 exited Resident #170's room a second time with the gloved left hand (did not remove the glove nor perform hand hygiene), re-entered the clean linen room and exited short after holding a hospital gown and a brief in the left gloved hand and returned to Resident #170's room. -9:45 A.M., CNA #1 drew the privacy curtain around Resident #170 and at this time, the surveyor intervened prior to care being provided to Resident #170 as CNA #1 continued to have the gloved left hand that was contaminated. During an interview at the time, CNA #1 said she had a bad habit of forgetting to remove her gloves. CNA #1 said she should have removed gloves and performed hand hygiene after caring for Resident #72, but she did not. CNA #1 said there would be a risk for cross contamination by not removing her glove and performing hand hygiene. On 3/7/25 at 10:25 A.M., the surveyor and CNA #1 reviewed the EBP signage outside of Resident #72's room. CNA #1 said the EBP signage indicated the precautions were for Resident #72, but she was not sure why. During an interview on 3/11/25 at 11:20 A.M., the surveyor relayed observations of the precaution signage and infection control concerns relative to Resident's #95, #62, #72 and #170 with the IP. The IP said Resident's #95 and #62 had Influenza, and the expectation was for all staff to defer to the Special Droplet/Contact sign which indicated to put on a gown, gloves, mask and eye protection prior to entering the room. The IP said she understood that there may be confusion from staff on what to do when multiple signs were posted outside of the Residents' room. Relative to the observation with CNA #1, the IP said the facility would need to do more education on the precaution signage and infection control practices. 42690 5. Resident #50 was admitted to the facility in February 2025. Review of Resident #50's March 2025 Order Summary Report indicated the following: -Vancomycin HCI (antibiotic). Give 125 milligrams (mg) by mouth four times a day for C-DIFF until 3/17/25, beginning on 3/8/25. On 3/11/25 at 8:48 A.M., the surveyor observed the following: -CNA #2 entered Resident #50's room, carrying a breakfast tray and wore a surgical mask. -A Contact Plus sign was located on the outside of the door and indicated that staff and providers must: ---Clean hands before entering the resident's room ---Wear gown and gloves, change between residents ---Wash hands with soap and water before exiting. ---Hand sanitizer alone is not sufficient when exiting a resident's room. -CNA #2 performed hand hygiene using the hand sanitizer located on the wall, prior to exiting the Resident's room. -CNA #2 exited the Resident's room and immediately entered the next room over, which had an EBP sign located on the outside of the door. During an interview immediately following the observations, CNA #2 said she entered Resident #50's room to bring in a breakfast tray and did not have any contact with the Resident in the room therefore did not need to wear all the PPE indicated on the sign posted at the door. CNA #2 said that when she exited the room, she used the hand sanitizer, and did not wash her hands with soap and water before leaving Resident #50's room or before entering the room next door, which had EBP's in place. CNA #2 said that per the sign she should have washed her hands with soap and water before exiting Resident #50's room. During an interview on 3/11/25 at 9:04 A.M., the IP said it was her expectation that when a Contact Plus sign was located outside of a resident's room, that staff were donning all the required PPE noted on the sign prior to entering the room, doffing the PPE and washing their hands with soap and water before exiting the room. The IP said the Contact Plus sign indicated someone in the room was on precautions due to either C.Diff, a gastrointestinal (GI) symptoms or norovirus.

Based on observation, interview, and record review, the facility failed to ensure two Residents (#1 and #75), out of a total sample of 22 residents, were able to exercise their right to make decisions regarding their medical care when their Health Care Proxy (HCP: a document that gives someone the power to make healthcare decisions for a person who was unable to) was not invoked, and the facility had the HCP's sign advanced directives forms and consent forms. Specifically: 1. For Resident #1, the facility failed to ensure a Medical Order for Life-Sustaining Treatment (MOLST: a medical form that outlines the wishes of a person with a usually serious, progressive health condition regarding life-sustaining measures and end-of-life care (such as life support, palliative care, or Cardiopulmonary Resuscitation [CPR]), and that must be signed by an authorized health care professional (Physician, Nurse Practitioner, or Physician Assistant) form was not signed by the HCP, when the HCP was not invoked for the Resident. 2. For Resident #75, the facility failed to ensure that a MOLST form, consent for psychotropic medications and vaccination for the Respiratory Syncytial Virus (RSV: respiratory virus that infects the nose, throat, and lungs), was not signed by the HCP, when the Resident's HCP was not yet invoked. Findings include: 1. Resident #1 was admitted to the facility in February 2025 with diagnoses including Cerebrovascular accident (stroke) with aphasia (conditions that cause problems with communication) and Diabetes. Review of the Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1: -preferred language was English and Resident did not need interpreter services -was able to understand and understood others -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 Review of the Resident's clinical record indicated the following: -Nurse's Note, dated [DATE]: Resident's HCP will be in on [DATE] to sign paperwork as the Resident was Russian/Ukrainian speaking deeming it difficult to communicate. -Nurse's Notes, dated [DATE]: Resident was able to communicate his/her needs/wants, did understand and speak some English. -MOLST form, signed by the Resident's HCP on [DATE] -Social Service Note, dated [DATE]: the Resident was his/her own decision maker. Further review of the clinical record failed to indicate that Resident #1's HCP was invoked by the Physician. On [DATE] at 11:37 A.M., the surveyor observed Resident #1 dressed and seated in a wheelchair. During an interview at the time, the Resident said his/her primary language was Russian, but he/she was able to communicate in English and had no difficulty communicating with facility staff. During a follow-up interview on [DATE] at 1:31 P.M., Resident #1 said his/her HCP visited him/her and theResident was not sure if the HCP signed paperwork on his/her behalf. The Resident further said that he/she could not recall filling out paperwork about his/her wishes for life-sustaining treatment. During an interview on [DATE] at 11:40 A.M., the Assistant Director of Nurses (ADON) said nursing reviews the MOLST forms with residents. The surveyor reviewed Resident #1's MOLST form which was signed by the HCP on [DATE], and the ADON said if the Resident deferred to a HCP to sign the MOLST form, there should be a note in the chart to indicate this. During a follow-up interview on [DATE] at 3:23 P.M., the ADON said the HCP signed the Resident's MOLST form due to a language barrier as indicated in the Nursing Note dated [DATE]. The surveyor and the ADON reviewed the Resident's clinical record which indicated the Resident's HCP was not invoked and the Resident was able to make his/her own decisions. When the surveyor asked if information was provided to the Resident in his/her primary language if communication was determined to be difficult, the ADON said good point. 2. Resident #75 was admitted to the facility in February 2025 with diagnoses including Cognitive Communication Deficit and Dementia. Review of the MDS Assessment, dated [DATE] indicated Resident #75: -preferred language was English and he/she did not need interpreter services -was rarely understood or understands -was severely cognitively impaired as evidenced by a BIMS score of 0 out of 15 Review of the Resident's clinical record indicated the following: -Nursing Admission Note, dated [DATE]: Resident was alert but did not speak English, Portuguese speaking only -MOLST form, signed by the Resident's HCP on [DATE] -Vaccination consent for RSV, signed by the HCP on [DATE] -Psychotropic medication consent for Zyprexa (antipsychotic medication) signed by the HCP on [DATE], and another on [DATE] -Psychotropic medication consent for Trazodone (antidepressant medication), signed by the HCP on [DATE] -Psychotropic medication consent for Cymbalta (antidepressant medication), signed by the HCP on [DATE] -HCP invocation form, signed by the Provider on [DATE] -Physician's order to invoke Resident #75's HCP on [DATE] Review of the Resident's Communication Care Plan, initiated on [DATE], indicated Resident #75 had a communication problem related to severe cognitive impairment due to Dementia and Cognitive Communication Deficit. Further review of the Communication Care Plan interventions failed to indicate documented evidence that the HCP was invoked due to language barriers and difficulty communicating with the Resident. On [DATE] at 11:26 A.M., the surveyor observed the following: -Certified Nurses Aide (CNA) #3 was assisting Resident #75, who was seated in a wheelchair, into another room across the hallway where he/she was previously located. Resident #75 was heard continuously state No .No . when the CNA attempted to have him/her enter the room. -CNA #3 was observed to communicate with Resident #75 in English and then CNA #3 said out loud I don't understand you . On [DATE] at 9:56 A.M., the surveyor and Nurse #2 reviewed Resident #75's clinical record. Nurse #2 said the Nurses on the floor obtain the consents for the psychotropic medications and also review the MOLST form. Nurse #2 said Resident #75 was Portuguese speaking and had cognition issues. Nurse #2 said there should be a Physician's order to invoke a Resident's HCP if this was indicated and that the Resident's HCP was invoked on [DATE]. The surveyor and Nurse #2 reviewed the Resident's paperwork including the MOLST form and consents for vaccines and psychotropic medications which were signed prior to the HCP invocation, and Nurse #2 said the Nurses would notify the Provider about invoking the HCP. Nurse #2 further said sometimes Residents defer to their family to sign paperwork, and if this was the case, there should be a documentation indicating this. During an interview on [DATE] at 11:49 A.M., the ADON said she would look into why the Resident's paperwork was signed by the HCP prior to invocation and said sometimes a Resident may defer to their HCP for signing paperwork, but if this was the case, there should be notation in the clinical record. During a follow-up interview on [DATE] at 3:23 P.M., the ADON said she reviewed Resident #75's clinical record and there was notation in a Nurse's Admission Note that the staff deferred to the Resident's HCP due to a language barrier. The ADON said she was not sure if the clinical information relative to completing the MOLST form or consent forms were provided to the Resident in his/her native language prior to the HCP being invoked on [DATE]. During an interview on [DATE] at 11:50 A.M., the Director of Nursing (DON) said he was made aware of the concerns relative to Resident #1 and Resident #75's paperwork which were signed by their HCP prior to or without HCP invocation.

Based on observation, record review, and interview, the facility failed to ensure reasonable accommodations of resident's needs and preference were provided for five Residents (#98, #75, #101, #169 and #72) out of a total sample of 22 residents and on one Unit ([NAME] Terrace Unit) of three units observed. Specifically, the facility failed to: 1. answer call lights timely for Resident #98 and Resident #75 during the early morning times during shift change. 2. respond to resident call lights timely: a. on the [NAME] Terrace Unit. b. for Resident #101, resulting in the Resident being incontinent due to long wait times. 3. answer the Resident's call light timely for Resident #169, when he/she required staff assistance with mobility/transfers. 4. have staff respond timely to the call light for Resident #72, who required assistance to the bathroom and return to further assist the Resident after bathroom use as indicated. Findings include: Review of the facility policy titled Resident Call System, revised 9/12/22, indicated the nurses' station in the facility will be equipped to receive resident calls with a communication system through audible or visual signals from resident rooms, toilets, and bathing facilities. The policy also included the following: -Facility associates should always be aware of the call lights -Associates should answer call lights whether they are assigned to provide care to that resident Review of the Resident Council Meeting Meetings, dated 1/30/25, indicated the following: -Nursing: ----Old Minutes: Call bells are not being answered in a timely manner. ----New Business: Residents were reminded that the call bells are to be answered within five minutes. Staff reminded that any staff member can answer a call bell. 1. During a Resident Council meeting held on 3/6/25 from 11:00 A.M. to 11:30 A.M., the following was said relative to call bell wait times: -Resident #98 said that he/she has had to wait 15 to 30 minutes for someone to answer his/her call light. Resident #98 said he/she had to wait so long that he/she had an accident before he/she was able to get to the bathroom. Resident #98 said that long wait times occur most often on the early morning shift. Resident #98 further said his/her anxiety increased when he/she had to wait so long to use the bathroom. -Resident #75 said he/she recently had to wait 30 minutes to go to the bathroom. Resident #75 said this happened most often during the early morning, often when the staff changed shifts from the overnight shift (11:00 P.M. to 7:00 A.M.) to the daytime shift (7:00 A.M. to 3:00 P.M.). 2a. On 3/11/25 from 8:13 A.M. until 8:21 A.M., the surveyor observed the following on the [NAME] Terrace Unit: -8:13 A.M.: room [ROOM NUMBER] call light was turned on. -Certified Nurses Aide (CNA) #2 was passing breakfast trays -Nurse #2 was passing medications -CNA #2 and Nurse #2 remained in the hallway for the duration of this observation, walking by room [ROOM NUMBER] multiple times without responding to the lit-up call bell light. -8:21 A.M. (eight minutes later), Nurse #2 the entered room [ROOM NUMBER] and the call bell was turned off. 37400 2b. During the initial pool process on the [NAME] Terrace Unit on 3/5/25 and 3/6/25, the following concerns were expressed by residents: -One Resident, who requested to remain anonymous, said he/she was not given timely care or response to needs when he/she had them, that he/she did not ring the call light often, but did utilize it recently and it took an hour for a facility staff person to respond when he/she had to use the bathroom. The Resident said he/she also rang the call light for his/her roommate on the 3:00 P.M. to 11:00 P.M. shift on 3/4/25, and it took a staff person an hour and half to respond. -Resident #101 said he/she had episodes of incontinence which were new since admission to the facility because he/she had to wait for staff to assist him/her with toileting. Resident #101 said he/she had never been incontinent at home, and that it sometimes took a while for his/her call light to be answered. Resident #101 said that he/she had been given an incontinence brief, and that facility staff said if he/she needed to go an incontinence brief was in place, but the Resident said he/she prided him/herself on never being incontinent at home. -Resident #72 said he/she had to wait 30 minutes to an hour for assistance from staff on the 7:00 A.M. to 3:00 P.M. shift. The Resident said the staff are wonderful but that he/she needed assistance from staff when using the bathroom and because he/she had to wait, it has affected his/her ability to remain continent. 3. Resident #169 was admitted to the facility in March 2025 with diagnoses including history of falls, pubic fracture (one of the two bones forming the pelvis), muscle weakness and difficulty ambulating. Review of Resident 169's active Care Plans included the following: -Risk for falls, initiated 3/4/25 and included the following intervention (also initiated 3/4/25): assist with activities of daily living (ADLs) as needed -ADL assistance and Therapy Services were needed to maintain or attain the highest level of function ., initiated 3/4/25 and included the following interventions (also initiated 3/4/25 and revised 3/7/25): Assist of two staff with mobility/transfers with rolling walker and ADLs/toileting assist of two staff. On 3/6/25 at 2:13 P.M., the surveyor observed the following: -Resident #169's call light was lit and audible from the nursing station -Two Nurses were observed seated at the nursing station -2:20 P.M., Resident #169's call light remained lit. The surveyor observed Resident #169 in his/her room seated in a wheelchair positioned next to the bed. During an interview at the time, Resident #169 said he/she rang the call light to ask for assistance from staff to go back to bed. -2:27 P.M., the Resident's call light remained lit and was audible from the nursing station. During an interview at this time, Resident #169 said no staff had checked in with him/her yet since he/she originally initiated the call light. -2:30 P.M., the Resident's call light remained on, and staff were observed in the hallway. -2:32 P.M. (19 minutes later), a nurse was observed entering the Resident's room. 4. Resident #72 was admitted to the facility in December 2024 with diagnoses including muscle weakness and need for assistance with personal care. Review of the Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #72: -had clear speech, was understood and understands others -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -had bilateral range of motion impairments Review of the Resident's active Care Plans, included the following: -Risk for falls related to history of falls, muscle weakness, impaired balance ., initiated 12/15/24, included the following intervention: assist with ADLs as needed, (also initiated 12/15/24) -ADL Assistance and Therapy Services needed to maintain or attain the highest level of function, initiated on 12/15/24, included the following interventions: assist with mobility and ADLs as needed (initiated 12/15/24), ambulate to/from bathroom with four wheeled walker and one assist during the day shift and assist with wheelchair and one assist for toileting during the night shift (initiated 3/6/25) On 3/7/25 at 9:31 A.M., the surveyor observed the following: -Resident #72's call light was lit and was audible at the nursing station -One facility staff member and two Certified Nurse Aides (CNAs), including CNA #1, were observed at the nursing station conversing and and a Nurse was observed at a medication cart at the end of the hallway where the Resident's room was located. -9:33 A.M., a staff person was observed walking down the hallway and stopped at the Resident's room. Resident #72 told the staff person that he/she needed staff immediately because he/she needed to use the bathroom. The staff person was observed to inform CNA #1 who was standing near the nursing station that Resident #72 needed assistance. CNA #1 was observed to remain standing near the nursing station with the second CNA after this interaction. -9:35 A.M., the Administrator was observed to walk down the hallway and stopped at Resident #72's room and entered. -9:36 A.M., the Administrator approached CNA #1 (who remained standing with the other CNA near the nursing station), and CNA #1 said I know, they told me . and then went to Resident #72's room. CNA #1 was observed to assist Resident #72 to the bathroom, went to the Resident's closet, retrieved a pair of dark colored pants and returned to the bathroom. CNA #1 said to Resident #72 to ring when he/she was done and exited the room. -9:47 A.M., Resident #72's call light was lit, blinking red and was audible from the nursing station. A Nurse was observed at the medication cart in the hallway and other facility staff including Housekeeping and Rehabilitation staff were observed walking up/down hallway. -9:49 A.M. both call lights (white and red blinking) were observed on in Resident #72's room. -9:50 A.M. facility staff were observed seated at the nursing station where the call light was audible. -From 9:52 A.M. to 9:56 A.M., Resident #72 was heard yelling out for help numerous times, stating he/she was in the bathroom and needed help. The Resident's roommate (who had also engaged the call light) was heard telling him/her Nobody is coming . -9:56 A.M., (nine minutes after being assisted to the bathroom), Resident #72 continued to yell he/she needed help, and a CNA was observed to enter the room at this time stating she was coming. During an interview on 3/12/25 at 10:32 A.M., the Infection Preventionist (IP), who was assisting with staffing on the [NAME] Terrace Unit, said every staff person should be responding to resident call lights, including CNAs, Nursing, and Therapy. The IP said the resident call bells should be answered within four minutes, and that even if the staff who respond to the call light cannot assist, they were expected to answer the call light, speak with the resident and alert the staff who could assist with the resident's needs. The IP further said the resident call lights were audible at the nursing station, and that all staff who hear/see the call lights should respond.

Based on interview, and record review, the facility failed to ensure one Resident (#62) of four applicable residents reviewed, out of a total sample of 22 residents, had the opportunity to formulate advanced directives and/or ensure that their wishes relative to advances directives were implemented. Specifically, for Resident #62, the facility failed to ensure that the Nurse Practitioner (NP) signed all required areas of the Medical Order for Life Sustaining Treatment (MOLST) form. Findings include: Review of the facility policy titled Advanced Directives and Advance Care Planning, reviewed 9/26/24, indicated the following: -Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advanced directive. Resident #62 was admitted to the facility in February 2025 with diagnoses including Acute Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disorder (COPD). Review of Resident #62's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act Form indicated the Resident's Health Care Proxy was invoked on 2/19/25. Review of Resident #62's MOLST form indicated the following: -The front page of the form was signed and completed by the Resident's Health Care Proxy and Nurse Practitioner (NP). -The back page of the form was completed, indicating no artificial nutrition and signed by the Resident's Health Care Proxy on 2/23/25. -The Nurse Practitioner (NP) failed to sign the back side of the MOLST form. During an interview on 3/12/25 at 8:10 A.M., the surveyor and the Assistant Director of Nursing (ADON) reviewed the current MOLST form. The ADON said the back side of the form was invalid because it was not signed by the Provider (Nurse Practitioner).

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice relative to a Peripherally Inserted Central Catheter (PICC: central venous access catheter inserted through a vein and can provide intravenous [IV] access for the administration of medications, parenteral nutrition or other solutions) for one Resident (#110), of one applicable resident who was receiving IV antibiotics, out of a total sample of 22 residents. Specifically, for Resident #110, the facility failed to ensure: -accurate measurement and documentation of the external catheter length (measured from the catheter exit site to the 0 mark or, if no 0 mark is present, to the suture flange. Each line is measured as 1 centimeter/cm) and arm circumference. -identify a change in the external catheter length placing the Resident at risk for potential catheter related complications. Findings include: Review of the facility policy/procedure titled PICC Dressing Change, revised 8/19/24, indicated the following: -A transparent semipermeable dressing over a PICC requires changing at least every seven [7] days . -PICC line dressing changes require sterile technique to reduce the risk of vascular catheter-associated infection . -Use a sterile disposable tape measure or the incremental markings on the catheter to measure the external length of the catheter from the hub (end of the catheter tubing) to skin entry. -Compare the measurement to the external length documented at the time of PICC insertion to make sure the catheter hasn't migrated (moved out of place) . -Measure upper-arm circumference when clinically indicated to assess the presence of edema and deep vein thrombosis. Take the measurement ten [10] cm above the antecubital fossa (inner elbow) and compare the measurement to the baseline -If you withdraw the catheter a significant amount inadvertently during a dressing change, measure the catheter from the exit site to the hub and reapply a sterile dressing. Never advance the catheter back inside the insertion site because the contact with the skin may introduce microorganisms to the catheter. Notify the practitioner, and prepare for a chest X-ray or other diagnostic test to determine the position of the PICC tip (inside the body) Resident #110 was admitted to the facility in February 2025 with diagnoses including Metabolic Enchalopathy, Sepsis, Methicillin Susceptible Staphylococcus Aureus (MSSA) infection and Aspiration Pneumonia. Review of the Hospital Vascular Access Insertion Procedure Note, dated 2/13/25, indicated the following: -PICC line was placed into the Resident's upper right extremity for medication that required vascular access -the total catheter length was 41 cm -the tip location of the PICC line was placed in the superior vena cava -the external catheter length was two [2] cm out. -the arm circumference was 36 cm Review of the Hospital Discharge Summary, dated 2/25/25, indicated the following relative to Resident #110: -admitted to the hospital for severe acidosis (high levels of acid in the blood) and Diabetic Ketoacidosis (DKA: serious and can be life-threatening, develops when the body does not produce enough insulin), complicated by respiratory failure, Influenza Type A, Respiratory Syncytial Virus (RSV), severe sepsis, and MSSA secondary to aspiration pneumonia. -Discharge medications included: Cefazolin (antibiotic) two [2] gram (gm) IV push every eight [8] hours. Review of the IV Infusion Note, dated 2/25/25, indicated: -IV Infusion Provider was contacted by the facility due to the staff being unable to flush the Resident's PICC line. -The needle-less catheter was exchanged -the PICC was able to be flushed -the PICC was secured at the 2 cm (external catheter length) mark and was ready for use. Review of the February 2025 and March 2025 Physician's orders included the following: -Cefazolin Sodium Solution Reconstituted 1 gm, use 1 gram intravenously every 8 hours for infection, bacteremia, initiated 2/25/25 and discontinued 2/26/25 -Cefazolin Sodium Injection Solution Reconstituted 2 gm, use 2 grams intravenously every 8 hours for infection, bacteremia, initiated 2/26/25 and discontinued on 3/10/25 -Change PICC line transparent dressing, as needed for concern of line movement or infection. -Measure upper arm circumference (10 cm above antecubital. -Measure external catheter length. If length has changed since last measurement; if concern of line movement, infection, hold antibiotic and notify Medical Doctor (MD), initiated 2/25/25 -PICC Gauge: 4 French (Fr: unit of measure): Total Length: 41 cm # Lumens 1 Type of infusion: intermittent, for Bacteremia, initiated 2/25/25 -Observe PICC line insertion site, every shift for s/s (signs/symptoms) of infection. Notify MD, accordingly, initiated 2/2/25 -Change PICC line dressing on admission one time only for one day. Measure upper arm circumference (10 cm above antecubital). Measure external catheter length, initiated 2/25/25 Review of the Infection Care Plan, initiated 2/25/25, indicated the Resident was on IV antibiotics via PICC line in his/her right upper arm for MSSA Bacteremia. The care plan included the following interventions: -Medications as ordered, initiated 2/25/25 -Care of PICC line as ordered. Report any abnormalities to Nurse Practitioner (NP)/MD (initiated 3/7/25) Review of the February 2025 and March 2025 Medication Administration Records (MARs) indicated Resident #110 received the IV antibiotic medication as ordered by the Physician. Review of the Minimum Data Set (MDS) Assessment, dated 3/1/25, indicated Resident #110: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 of 15 -received antibiotics during the reference period. Review of the February 2025 Treatment Administration Record (TAR) indicated the following was documented on 2/25/25 for Resident #110: -arm circumference was measured at 36 cm -external catheter length was measured at 41 cm Review of the March 2025 TAR indicated the following documented on 3/4/25 for Resident #110: -arm circumference was measured at 12 -external catheter length was measured at 4 On 3/6/25 at 7:31 A.M., the surveyor observed Resident #110 lying upright in bed and dressed in a hospital gown. An IV pole was observed on the side of the Resident's bed and had an empty bag labeled Cefazolin 2 gm per 100 milliliters (ml) dated 3/6/25 at 6:00 A.M., and was being infused. During an interview at the time, the Resident said he/she was septic, recently had the flu and pneumonia, and had a PICC placed. The Resident showed the surveyor his/her upper inner elbow where a transparent dressing was observed dated 3/4/25. On 3/7/25 at 9:24 A.M., the surveyor observed Resident #110 awake and lying upright in bed. An IV pole was observed on the side of the bed, and an empty bag labeled Cefazolin 2 gm per 100 milliliters (ml) dated 3/7/25 at 6:00 A.M. was hung on the IV pole and was not infusing. During an interview at the time, the Resident said he/she received the IV antibiotic that morning and had no issues or side effects from the infusion. The surveyor observed the Resident's transparent dressing on his/her right upper inner arm was dated 3/4/25. On 3/7/25 at 3:51 P.M., the surveyor observed Resident #110 dressed and ambulating with Rehabilitation Staff in the hallway heading towards his/her room. The Resident was dressed in a short-sleeved shirt, and the PICC tubing was observed hanging from his/her right arm. During an interview on 3/7/25 at 4:21 P.M., Nurse #1, who had cared for Resident #110, said the arm circumference and external catheter length were measured weekly during the Resident's scheduled dressing change. Nurse #1 said the staff would measure 10 cm from the antecubital site (inner elbow) in order to obtain a measurement for the Resident's arm circumference. Nurse #1 further said that the external catheter would be measured from the insertion site to the end of the exposed tubing. Nurse #1 said it was important to obtain accurate measurements to ensure the PICC had not migrated because it would be a major issue since it should be positioned in the superior vena cava. Nurse #1 said the measurements obtained should be compared to what the measurements were when the PICC was initially placed to ensure the PICC was in the correct location. On 3/7/25 at 4:32 P.M., the surveyor and the Assistant Director of Nurses (ADON), who was overseeing the Unit reviewed the documented measurements for the Resident's arm circumference and external catheter length obtained on 2/25/25 and on 3/4/25. The ADON said there was a discrepancy with the measurements and that she would have to re-measure the Resident's arm circumference and external catheter length immediately. The surveyor accompanied the ADON into Resident #110's room and the ADON obtained the following measurements with the surveyor present: -arm circumference: 35.5 cm -external catheter length: 12 cm (difference of 10 cm since insertion) During an interview following the observation, the ADON said she could not speak to the measurements that were obtained on 2/25/25 and 3/4/25 and documented in the Resident's record. During an interview on 3/7/25 at 4:48 P.M., the surveyor and the Infection Preventionist (IP) reviewed the Resident's hospital paperwork and IV Infusion paperwork, both dated 2/25/25. The IP said the Resident's PICC total catheter length was 41 cm, the external catheter length was 2 cm, and the arm circumference was 36 cm prior to admission. The IP said she also went to observe Resident #110's PICC after the ADON and the surveyor, did not obtain measurements, but said the external catheter length was definitely not 2 cm. The IP said if the external catheter length changed by 1 cm, the Nurse should not have used the PICC and should have contacted the Provider for additional orders on how to proceed.

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards of practice related to skin care for two Residents (#22 and #62), out of a total sample of 22 residents. Specifically, the facility failed to ensure: -a new skin alteration was identified by facility staff and an investigation completed to determine the cause of the skin alteration for one Resident (#22). -weekly skin checks were completed for one Resident (#62) as indicated per their comprehensive care plan. Findings include: Review of the facility policy titled Area of Focus: Basic Skin Management, revised 11/21/24, indicated the following: -All residents have a head-to-toe skin inspection upon admission/readmission, then completed weekly, and as needed by nursing . -It is the responsibility of the Certified Nurses Aides (CNAs) and therapy department to notify nursing if a change of the resident's skin is identified . -If any new skin alteration/wound is identified, it is the responsibility of the nurse to perform and document an assessment/observation, obtain treatment orders, and notify medical doctor (MD) and responsible party. {sic} 1. Resident #22 was admitted to the facility in February 2022 with diagnoses including Vascular Dementia with behavioral disturbance. Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/25/24 indicated Resident #22 had a Brief Interview of Mental Status (BIMS)) score of seven out of 15 indicating he/she was severely cognitively impaired. On 3/5/25 at 11:05 A.M., the surveyor observed Resident #22 seated in his/her room in his/her wheelchair. Resident #22 was observed to have bilateral scabbed areas on either side of his/her philtrum (middle space underneath the nose on the upper lip. When the surveyor asked about the scabbed areas on his/her upper lip the Resident said he/she was unsure where they came from. Review of Resident #22's Weekly Skin Assessments from 1/4/25 through 3/6/25 failed to indicate documentation pertaining to how Resident #22 acquired the injuries on his/her bilateral upper lip or when the injuries occurred. On 3/10/25 at 8:29 A.M., the surveyor observed Resident #22 seated in the hallway in his/her wheelchair. The Resident was observed to still have the bilateral scabbed areas on the upper lip. During an interview on 3/10/25 at 9:26 A.M., Certified Nurses Aide (CNA) #5 said she regularly took care of Resident #22. CNA #5 said she was unsure what the bilateral scabbed areas on Resident #22's upper lip was from or when they first appeared. During a follow-up interview on 3/10/25 at 9:32 A.M., CNA #5 said she spoke with Resident #22 and Resident #22 told her he/she thought the scabbed areas were from being shaved. During an interview on 3/10/25 at 12:55 P.M., Nurse #5 said she thought the bilateral scabbed areas on Resident #22's upper lip were from being shaved. Nurse #5 said there should be documentation in the Resident's medical record indicating what the scabs were from, how the injuries occurred, and when the injuries occurred. Nurse #5 further said this information should be documented on the weekly skin report until the areas were resolved. Review of the Nursing Progress Notes from 1/30/25 through 3/11/25 failed to indicate documentation as to how Resident #22 acquired the injuries on his/her bilateral upper lip or when the injuries occurred. During an interview on 3/11/25 at 10:05 A.M., Unit Manager (UM) #1 said she was unaware of the bilateral scabbed areas on Resident #22's upper lip until it was brought to the Nurse's attention by the surveyor on 3/10/25. UM #1 said she had reviewed the Resident's medical record and could find no documentation to indicate how the injuries occurred or when the injuries occurred to the Resident's bilateral upper lip. UM #1 further said as soon as any staff members had noticed the injuries it should have been reported immediately so staff could check the Resident's skin for additional injuries and to investigate how the injuries occurred, and this was never done. UM #1 said Resident #22 was not usually one of the Resident's who had his/her face shaved so she would need to look further into the situation to see if she could figure out how the injuries occurred as there was no documentation to support how or when the incident occurred. UM #1 said skin injuries for Resident #22 were especially a concern because he/she was on an anticoagulant (medication that thins the blood) and having injuries to his/her skin put the Resident at risk for increased bleeding. 37400 2. Resident #62 was admitted to the facility in February 2025 with diagnoses including Congestive Heart Failure (CHF), cellulitis and open wound of left lower leg, muscle weakness, and protein-calorie malnutrition. Review of the MDS Assessment, dated 2/17/25, indicated Resident #62: -had moderate cognitive impairment as evidenced by a BIMS score of 8 out of 15 -was at risk for pressure ulcers, and had no pressure ulcers at the time of admission -had two or more venous or arterial ulcers Review of the Potential/Actual Impairment to Skin Integrity Care Plan, initiated 2/12/25, indicated the Resident had impaired strength/range of motion, impaired functional mobility, impaired balance, fragile skin, cellulitis, edema, and vascular wound on his/her left lower extremity and included the following intervention: -weekly skin checks, initiated 2/12/25 Review of the Resident's clinical record included a Weekly Skin Assessment completed on 3/10/25. Further review of the clinical record failed to indicate documented evidence that the Weekly Skin Assessments were completed as required during the weeks of 2/16/25 and 2/23/25. On 3/12/25 at 10:30 A.M., the surveyor requested evidence of the Resident's weekly skin assessment since admission from the Assistant Director of Nurses (ADON), who was overseeing the Unit. During an interview on 3/12/25 at 11:30 A.M., the Director of Nursing (DON) said there were no weekly skin assessments completed as scheduled on 2/18/25 and 2/25/25 for Resident #62. The DON said the weekly skin assessments should have been completed, they were scheduled in the electronic medical record to be completed weekly. The DON further said the facility utilized a paper tool in addition to ensure the completion of weekly skin assessments.

Based on observation, interview, and record review, the facility failed to ensure that necessary respiratory care and services in accordance with professional standards of practice were in place for one Resident (#4) out of a total sample of 22 residents. Specifically, for Resident #4, the facility failed to ensure Physician's orders were in place for the daily use of Continuous Positive Airway Pressure (CPAP) machine and oxygen therapy. Findings include: Review of the facility policy titled BiPAP/CPAP Administration Policy, revised 9/3/24, indicated the following: -When CPAP or BiPAP is ordered, the following must be included in the written order: a. Mode (i.e. CPAP, BiPAP, CPAP Auto set etc.). b. Pressure setting c. Size and type of mask (i.e. small, nasal, or full-face mask.) d. Liters of Oxygen (if ordered.) e. Frequency of use (example-at night when sleeping and with naps as tolerated.) Resident #4 was admitted to the facility in October 2020 with diagnoses including Complex Sleep Apnea. Review of the most recent comprehensive Minimum Data Set (MDS) Assessment, dated 8/21/24, indicated Resident #4 scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS) indicating that he/she was cognitively intact. On 3/5/25 at 10:23 A.M., the surveyor observed Resident #4 sitting in his/her room. The surveyor also observed a CPAP machine and oxygen concentrator in the Resident's room. During an interview at the time, Resident #4 said he/she utilized the CPAP every night with oxygen added to the machine. Resident #4 said the nursing staff at the facility set the CPAP up for him/her and he/she was unsure of the exact settings that were being used. Review of Resident #4's March 2025 Physician's orders failed to indicate orders for the required CPAP pressure settings and the oxygen flow rate (LPM-liters per minute) to be added when the CPAP machine was in use. Further review of March 2025 Physician's orders indicated: -CPAP .on while sleeping/napping and off while awake, start date 4/26/24. Review of the March 2025 Treatment Administration Record (TAR) indicated the Resident utilized his/her CPAP daily from 3/1/25 through 3/9/25. Review of Resident #4's Altered Respiratory Status Care Plan dated 10/27/20, indicated the following: -Oxygen with CPAP .Pressure setting 4/0 with 1.5% humidity, Medium size with nasal pillows, liter of oxygen 2 lp/m .{sic} During an interview on 3/11/25 at 6:55 A.M., Nurse #3 said Resident #4 utilized his/her CPAP with oxygen every night. Nurse #3 said when a Resident has CPAP with oxygen there should be Physician's orders in place that included the settings for the CPAP and the oxygen liter flow rate. Nurse #3 reviewed Resident #4's Physician's orders and said Resident #4 had no orders in place for the use of the CPAP machine with oxygen. During an interview on 3/11/25 at 7:39 A.M., Unit Manager (UM) #1 said Resident #4 had no orders in place for CPAP settings or an oxygen flow rate. UM #1 said there was documentation in the care plan that included the correct CPAP setting and oxygen flow rate but there also needed to be a Physician's order in place for the administration of any treatment such as CPAP and oxygen use.

Based on record review, and interview, the facility failed to ensure that professional standards of care and treatment for hemodialysis (treatment that cleans the blood by removing waste and excess fluids when a person's kidneys no longer functioned properly) were implemented for one Resident (#15), of one applicable resident, out of a total sample of 22 residents. Specifically, for Resident #15, the facility failed to ensure a Physician's order was in place for fluid restriction and documentation was maintained for the amount of fluid intake the Resident consumed during a 24-hour period when the Resident was receiving hemodialysis services. Findings include: Review of the facility policy titled Hemodialysis Offsite Policy, reviewed 9/6/24, indicated the following: -The facility and dialysis facility dieticians should coordinate the nutritional care including monitoring, documenting and deciding how and when to address weight changes in nutrition issues. a. This included identifying weight fluctuations due to fluid depletion between dialysis sessions, possible fluid volume deletion in the immediate post-dialysis period or associated with anorexia which may be due to renal failure. b. Observe fluid restriction as ordered by the physician. Review of the facility policy Monitoring Intake and Output, reviewed 9/10/24, indicated the following: -The facility will ensure the nursing staff monitors and documents intake and output consistent with Practitioner orders and professional standards. Resident #15 was admitted to the facility in May 2020 with diagnoses including End Stage Renal Disease (ESRD) and received dialysis services three days weekly. Review of Resident #15's March 2025 Physician's orders failed to indicate documentation that the resident was on fluid restriction. Review of Resident #15's Alteration in Nutrition and Hydration due to ESRD on Hemodialysis Care Plan, revised 6/2/21, indicated the following: -Encourage good fluid intake up to 1200 cubic centimeter (cc- unit of measure) per day. Further review of the Resident's medical record failed to indicate evidence that the nursing staff maintained documentation of how much fluid intake Resident #15 had daily. During an interview on 3/10/25 at 1:47 P.M., Nurse #6 said when a resident is on a fluid restriction there should be a Physician's order in place for the amount of fluid the resident is not to exceed each day. Nurse #6 said documentation is done in the intake and output (I&O) book. The surveyor and Nurse #6 reviewed the I&O book and failed to find documentation to show Resident #15's fluid intake was being monitored and recorded daily. Nurse #6 said she could not be sure exactly how much fluid intake Resident #15 was getting each day as there was no documentation. During an interview on 3/10/25 at 2:12 P.M., Unit Manager (UM) #1 said Resident #15 should have had a Physician's order in place for his/her fluid restriction and nursing staff should be documenting daily, exactly how much fluid intake Resident #15 was getting, and this was not being done. UM #1 said she could not be sure exactly how much fluid Resident #15 took in each day as there was no documentation. During an interview post survey on 3/17/25 at 9:26 A.M., the Dialysis UM, from the dialysis facility that provided treatment to Resident #15 said the nursing facility should be able to provide the Dialysis Dietician or Dialysis Nursing Staff information regarding daily fluid intake if it was requested. The Dialysis UM said fluid intake information could be utilized if the Resident was experiencing unexpected changes in his/her weight that needed to be addressed.

Based on interview, and record review, the facility failed to implement recommendations made by the Behavioral Health Care Team for one Resident (#51), out of a total sample of 22 residents. Specifically, for Resident #51, the facility failed to ensure a recommended lipid panel (blood test that measures the levels of various fats in the blood stream) and Hemoglobin A1C (HbgA1c-test used to identify Diabetes [disease that affects how the body uses blood sugar]) labs were drawn as recommended by the Behavioral Health Physician Assistant (PA) for monitoring after the Resident was started on antipsychotic medication. Findings include: Review of the National Alliance on Mental Illness (NAMI) website article (https://www.nami.org/general/why-screening-for-diabetes-is-important-especially-if-you-take-psychiatric-medications/), titled Why Screening for Diabetes is Important (Especially if You Take Psychiatric Medications), dated 3/25/14, indicated: -the American Diabetes Association suggests screening regularly for Diabetes for those who use medications to treat mental health conditions as medications used to treat mental health conditions pose an additional risk for the increase in Diabetes. Resident #51 was admitted to the facility in December 2023 with diagnoses including generalized anxiety disorder, psychotic disorder, Depression, adjustment disorder with depressed mood, Major Depressive Disorder recurrent severe with psychotic symptoms, and Dementia with psychosis. Review of the Physician Assistant's Behavioral Health Group Note, dated 6/25/24, indicated that Resident #51 was started on an antipsychotic medication due to psychosis, and a lipid panel and HbgA1c lab work should be drawn after three months of antipsychotic medication use. Review of the June 2024 Physician's orders indicated the following orders: -Zyprexa (antipsychotic medication) 2.5 milligrams (mg) .one time a day, start date 6/19/24 and end date 6/24/24. -Risperidone (antipsychotic medication) 0.5 mg .at bedtime, start date 6/26/24 and end date 7/3/24. Review of the July 2024 Physician's orders indicated the following orders: -Risperidone 0.25 mg .in the morning, start date 7/3/24 and end date 7/8/24. -Risperidone 0.5 mg .in the afternoon, start date 7/3/24 and end date 7/8/24. -Risperdal (Brand name for Risperidone) 0.5 mg .two times a day, start date 7/8/24 and end date 7/10/24. -Risperdal 0.5 mg .in the morning, start date 7/10/24 and end date 9/2/24. -Risperdal 1 mg .at bedtime, start date 7/10/24 and end date 9/2/24. Review of the September 2024 Physician's orders indicated the following orders: -Risperdal 0.5 mg .in the morning, start date 9/3/24 and end date 3/4/25. Review of Resident #51's June 2024, July 2024, August 2024, and September 2024, Medication Administration Records (MARs) indicated the Resident was administered antipsychotic medications as ordered. Review of Resident #51's medical record failed to indicate any evidence that the recommended lipid panel or HbgA1c lab had been drawn since the Behavioral Health PA's recommendation was made on 6/25/24. During an interview on 3/11/25 at 2:15 P.M., Nurse #7 said the Behavioral Health Team notes and recommendations were faxed directly to the Resident's Primary Care Provider (PCP). Nurse #7 said the PCP reads the recommendations and then returns a copy of the notes to the facility that is signed, showing that it has been reviewed. During an interview on 3/11/25 at 2:38 P.M., Unit Manager (UM) #2 said the Behavioral Health Team notes and recommendations were faxed directly to the Resident's Primary Care Provider (PCP). UM #2 said the PCP reads the recommendations and then returns a copy of the notes to the facility that is signed, showing it was reviewed and if the PCP want any recommendations implemented, the PCP would write a telephone order or verbally tell the nursing staff at the facility. UM #2 said she was unable to find any documentation that orders were put into place for the Behavioral Health Teams' recommendation for a lipid panel and a HbgA1c test. UM #2 said she was unsure why it was not ordered by the PCP after reviewing the Behavioral Health Teams' notes. UM #2 further said no one at the facility typically reads the Behavioral Health Teams' notes to ensure that recommendations were not missed.

Based on interview, and record review, the facility failed to limit the timeframe for a PRN (as needed) psychotropic medication to 14 days for one Resident (#40), out of a total sample of 22 total residents. Specifically, for Resident #40, the facility failed to ensure the PRN use of Trazodone (antidepressant medication) was limited to 14 days. Findings include: Review of the facility policy titled Psychotropic drug use, long term care {sic}, reviewed 5/20/24, indicated the following: -As-needed orders for psychotropic drugs should be limited to 14 days, at which time the prescribing practitioner should then review the order . Resident #40 was admitted to the facility in February 2025 with diagnoses including Depression and Adjustment Disorder with Anxiety. Review of Resident #40's March 2025 Physician's orders indicated the following order: -Trazodone .Give 25 milligrams (mg) every 24 hours as needed .start date 2/23/25 and no end date. Review of Resident #40's March 2025 Medication Administration Record (MAR) indicated that the Resident was administered the PRN Trazodone on 3/2/25 and 3/10/25. During an interview on 3/11/25 at 9:02 A.M., Nurse #9 said PRN psychotropic medications need to be reviewed and a new order put into place by the Physician after 14 days of use. Nurse #9 said PRN psychotropic medications should have a stop day of Day 14, it would fall off the orders and could not be given after Day 14 without Physician review. During an interview on 3/11/25 at 9:50 A.M., Unit Manager (UM) #1 said Resident #40's PRN order for Trazodone exceeded the 14-day limit, should have had a stop date of 3/9/25, and been reviewed by the Physician at that time for continued use and it was not.

Based on observation, and interview, the facility failed to ensure that medications were stored in a secure manner for one medication cart (Hampden Garden Long Hall Cart) out of three medication carts observed, out of a total of six medication carts. Specifically, the facility failed to ensure that an injectible Insulin Lispro Pen was securely stored when the medication cart was left unattended in the hallway, and accessible to Unit residents. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, revised 8/1/24, indicated the following: -Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 3/7/25 at 4:00 P.M., the surveyor observed the Hampden Garden Long Hall Cart was unattended with an Insulin Lispro Pen on top of the medication cart. The surveyor observed a resident wheeling past the cart with the unattended medication and into his/her room. The surveyor observed that the medication cart with the Insulin Lispro Pen remained unattended until 4:19 P.M., when Nurse # 4 returned to the medication cart. During an interview on 3/7/25 at 4:19 P.M., Nurse #4 said the Nurse who was assigned to the Hampden Garden Long Hall medication cart, where the Insulin Lispro Pen remained on top of the cart had left the floor and was on a on break. Nurse #4 further said that the Insulin Lispro Pen should not be left unattended due to the risk that a resident could take it. Nurse #4 removed the pen to store in her medication cart until the assigned Nurse returned to the Unit. During an interview on 3/12/25 at 9:35 A.M., the surveyor reviewed the observations of the unattended Insulin Lispro Pen on top of the medication cart with the Assistant Director of Nursing (ADON). The ADON said that no medications should be left on top of the medication cart unsupervised.

Based on records reviewed and interviews, for one of five sampled residents (Resident #4), the facility failed to ensure that the resident did not sustain physical and verbal abuse. On 08/02/17, Nurse #1 and Nurse #2 observed Certified Nurse Aide (CNA) #1 yell at and grab the arm of Resident #4 in response to his/her requests to use the bathroom. Findings include: Resident #4 was admitted to the Facility in September 2015 with [DIAGNOSES REDACTED]. The Fall Management Care Plan, dated 09/12/16, indicated that Resident #4 had short-term memory loss and frequently used the bathroom. The Mood Care Plan, updated 07/11/17, indicated that Resident #4 had significant anxiety related to his/her toileting needs. The Care Plan indicated that Resident #4 requested to use the toilet frequently throughout the day, and would attempt to toilet himself/herself if staff were not available. The Surveyor interviewed the Social Worker at 3:04 P.M. on 09/27/17. The Social Worker said that on 08/02/17, CNA #1 seemed really stressed out, agitated, and overwhelmed. The Social Worker said CNA #1 told her that she (CNA #1) was really tired and overworked. The Surveyor interviewed Nurse #1 at 1:56 P.M. on 09/27/17. Nurse #1 said Resident #4 had high levels of anxiety around using the bathroom, and all staff were responsible for taking him/her when he/she wanted. Nurse #1 said that on 08/02/17, she heard Resident #4 screaming and saw CNA #1 pull Resident #4 backward in his/her wheelchair. Nurse #1 said Resident #4 attempted to use his/her feet to propel the wheelchair and rock his/her body back and forth in what appeared to be an attempt to move the wheelchair forward away from CNA #1. Nurse #1 said Resident #4 yelled about needing to use the bathroom and for CNA #1 to leave him/her alone. Nurse #1 said she heard CNA #1 tell Resident in a loud and angry tone of voice that he/she had to wait to use the bathroom. Nurse #1 said she then saw CNA #1 grab Resident #4's arm near the elbow, by what she recalled at the time of the incident as the left arm. Nurse #1 said she intervened and separated CNA #1 and Resident #4, and Resident #4 said she hurt me, she hurt my arm, or words to that effect. Nurse #1 said she assessed Resident #4's arm and did not observe any redness, bruising or scratches. Nurse #1 said Resident #4 was upset and agitated after the encounter with CNA #1, but calmed down with reassurance. The Surveyor interviewed Nurse #2 at 2:43 P.M. on 09/27/17. Nurse #2 said Resident #4 urinated a lot, and staff took turns assisting him/her. Nurse #2 said that on 08/02/17 when CNA #1 arrived to work, CNA #1 said she wasn't going to deal with Resident #4 today, that she didn't have the patience for him/her today, or words to that effect. Nurse #2 said Resident #4 was on CNA #1's assignment, and CNA #1 looked angry about it. Nurse #2 said later that shift, she observed CNA #1 dragging Resident #4 backwards out of his/her room in a wheelchair, saying I just took you, I'm not taking you again, or words to that effect. Nurse #2 said CNA #1 appeared angry and agitated, and her tone of voice was angry. Nurse #2 said she saw CNA #1 grab Resident #4 by what she recalled at the time of the incident as the left arm. Nurse #2 said she heard Resident #4 yell, get off of me, get your hands off of me, or words to that effect, and observed Nurse #1 intervene. Nurse #2 said she assessed Resident #4's arm throughout the shift, and did not observe any signs of physical injury. Nurse #2 said Resident #4 complained of pain in the arm and was medicated with relief. The Surveyor interviewed the Director of Nurses (DON) at 4:41 P.M. on 09/27/17. The DON said that on the night of the incident, Resident #4 said he/she was trying to go to the bathroom and someone was trying to hold him/her back from going into the bathroom. The DON said there were so signs of physical injury at the time, and Resident #4 did not appear unusually agitated, angry, or distressed. Nurse #1 said an X-ray of Resident #4's arm was taken the following day due to ongoing complaints of pain in the arm by Resident #4. The Radiology Report, dated 08/03/17, indicated that an X-ray of Resident #4's left upper arm was negative for fracture. There was no documentation at the time of survey that on 08/02/17, Facility staff intervened when CNA #1 was observed to be stressed out, agitated and overwhelmed, when CNA #1 reported being tired and overworked, or when CNA #1 said she did not have the patience to deal with Resident #4. Because staff failed to intervene, Nurse #1 and Nurse #2 observed CNA #1 yell at and grab the arm of Resident #4 in response to his/her requests to use the bathroom.

Based on observations, record reviews, and staff interviews, the facility failed to follow the plan of care for 4 of 24 sampled residents (#3, #10, #13 and #16) as well as 1 of 3 Non-Sampled Residents (NS #1). Findings include: 1. For Resident #3, the facility failed to follow the care plan to monitored and supervised the resident when wandering, to provide diversional evening activities, effective alarms and/or assistance when self transferring and ambulating to prevent falls during evening hours. Resident #3 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment of 11/10/14 indicated the resident had minimal difficulty hearing, usually understood others, was severely impaired cognitively with a Brief Interview for Mental Status (BIMS) score of 7/15, was inattentive and had disorganized thinking, required extensive assistance of two for transfers, toilet use, hygiene and bathing, extensive assistance of one for ambulation and dressing, required limited assistance of one for eating due to significant weight loss, was not steady without staff assistance when moving from a seated to standing position, walking, turning around, on/off the toilet, and surface to surface transfers, was only able to steady self with staff assistance, and had impairment on one side of an upper extremity, was usually incontinent of bladder, had fallen with a fracture prior to admission, and was inaccurately coded as having no falls since admission. The care plan was rewritten 11/17/14 to have no injury due to falls related to the resident's risks of deconditioning, weakness, incontinence, palsy, pain and unsteady gait. The interventions included: -Staff assistance of 2 with gait belt for transfers and ambulation, -Do not leave unattended in bathroom or shower room, -and Bed/Chair Alarms check every shift. Review of the Nurse Progress Notes and the Accident/Incident Report and Investigation Form for Falls of 11/22/14 at 7:30 P.M. indicated the resident had a witnessed fall at the Nurse's Station, when the resident stood up from the wheel chair and fell . No injury was indicated, and there was no indication staff provided assistance when the resident attempted to self transfer. The resident was then placed with a CNA (Certified Nursing Assistant) to be monitored while the CNA charted. Review of the Nurse Progress Notes and the Accident/Incident Report and Investigation Form for Falls of 11/22/14 at 8:15 P.M. indicated the resident was at the Nurse's Station being monitored by a CNA doing charting. The resident wandered down the hall, attempted to self transfer to the bathroom, and was found on the floor by staff. While the investigation indicated that alarms were functioning, there was no documented evidence that staff heard the alarms prior to the resident's fall. The investigation indicated that the 2nd fall of 11/22/14 "may have been prevented" because there was no monitoring of the resident's wandering whereabouts by the assigned CNA, as planned. The resident's care plan was updated 11/22/14 to include 1:1 supervision as needed. Review of the Nurse Progress Notes and the Accident/Incident Report and Investigation Form for Falls of 11/27/14 at 6:15 P.M. indicated the resident was left alone in the day room, but monitored by staff from the Nurse's Station. The resident stood up and fell to the floor, hitting the head on the TV stand. The resident had a laceration on the back of his/her head. The resident was sent to the local hospital and received 2 staples. Staff had not provided the resident with 1:1 supervision to prevent this fourth fall during evening care. The care plan was updated to included not leaving the resident unattended in the day room, and offering evening activities after supper. Review of the Nurse Progress Notes and the Accident/Incident Report and Investigation Form for Falls of 12/1/14 at 7:00 P.M. indicated the resident was observed by a visitor to be on the bathroom floor. No injury was noted. Facility documentation indicated that the resident's alarms were not checked and functioning on 12/1/14 evening shift, as planned, and there was no documented evidence that staff heard any alarms prior to the resident's bedroom fall. The resident also was not placed in after supper activities as planned for supervision to prevent another evening shift fall. The care plan was updated 12/2/14 to include an alarmed self releasing seat belt in the w/c. Review of the Nurse Progress Notes and the Accident/Incident Report and Investigation Form for Falls of 12/11/14 at 8:00 P.M. indicated the resident had a witnessed fall at the Nurse's Station, when the resident stood up from the wheel chair and fell , after using the telephone. No injury was observed. The investigation indicated the alarmed seat belt did not sound, and the involved CNA who was to provide resident supervision, had not done so. This was the resident's sixth fall, between 11/8 and 12/11/14. All of the falls occurred between the 2 hour span between 6:15 P.M. to 8:15 P.M. Observation of the resident on 12/30/14 at 11:50 A.M. indicated the resident asleep and seated in a wheel chair outside the unit's dining room with an alarmed seat belt attached. At 1:30 P.M., the resident was observed in a low bed with mats on both sides of the bed, and a bed alarm activated. At 4:15 A.M., the resident was being ambulated with one person assistance and gait belt, followed by staff and a wheelchair in the corridor. During interview on 12/31/14 at 2:30 P.M., the Director of Nursing (DON) and Unit Manager (UM) #1 said the facility had not followed the care plan to provide effective supervision for the resident when the resident attempted unsafe transfers and ambulation for toileting needs. Both said that the facility had failed to provide 1:1 supervision and supervised activities in the evening for the resident during the most at-risk time period for the resident's falls between 6:15 P.M. and 8:15 P.M. Both said that this period was when staff were engaged in evening care and distracted from preventing repeated resident falls. 2. For Resident #13, the facility failed to document the resident's intake and output. Resident #13 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the I/O Record indicated: - 10/4/14, intake 820 cubic centimeters (CC), output 240 cc., - 10/5/14, intake 120 cc, output 100 cc, and - 10/6/14 - 10/8/14 there was no record of the resident's intake or output. Review of the physician's orders [REDACTED]. Review of the I/O Record indicated: - 11/11/14, intake 720 cc, output 1350 cc. - 11/12/14 - 11/15/14, there was no record of the resident's intake or output, - 11/15/14, intake 1080 cc, output 900 cc, - 11/16/14 - 11/19/14 there was no record of the resident's intake or output, - 11/20/14, intake 600 cc, output 300 cc, - 11/21/14 - 11/24/14, there was no record of the resident's intake or output, - 11/25/14, intake 1100 cc, output 700 cc, - 11/26/14 - 11/28/14, there was no record of the resident's intake or output, - 11/29/14, intake 200 cc, output 600 cc, - 11/30/14, intake 420 cc, output 1610 cc, - 12/1/14 and 12/2/14, there was no record of the resident's intake or output, - 12/3/14, intake 990 cc, output 350 cc, - 12/4/14, intake 450 cc, output 1520 cc, - 12/5/14, intake 600 cc, output 1400 cc, and - 12/6/14 - 12/11/14, there was no record of the resident's intake or output. During interview on 12/31/14 at 2:15 P.M., UM #1 said the I/O monitoring was not done as ordered by the physician on 11/11/14. Please refer to F 327. 3. For Resident #10, the facility failed to follow a physician's orders [REDACTED]. Resident #10 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively impaired and required assistance for bed mobility, transfers and ambulation. Review of the care plan for pressure ulcers, dated 4/28/14, indicated an intervention for the use of a bed cradle. Review of the 12/2014 physician's orders [REDACTED]. On 12/30/14 at 11:15 A.M. the resident was observed in bed with his/her feet covered in blankets and no bed cradle at the end of the bed. On 12/30/14 at 2:00 P.M. the surveyor, accompanied by Certified Nurse's Assistant (CNA) #1, observed Resident #10 in bed. CNA #1 said she had taken care of Resident #10 that morning and was unaware the resident used a bed cradle. She said the resident had no bed cradle at the end of the bed. On 12/30/14 at 2:15 P.M. during an interview with CNA #2, she said she regularly worked on the unit where Resident #10 resided and had never seen a bed cradle used. During an interview on 12/30/14 at 2:20 P.M., UM #1 said no bed cradle had been in use that day, but she said the resident used a bed cradle previously. Please refer to F 514. 4. For Resident #16, the facility failed to follow a physician's orders [REDACTED]. Resident #16 was admitted to the facility in 9/2014 with [DIAGNOSES REDACTED]. Review of the Initial MDS, dated [DATE], indicated the resident was cognitively impaired and required assistance for transfers and ambulation. Review of the 12/2014 physician's orders [REDACTED]. to 3:00 P.M. shift. Review of the 12/2014 Treatment Administration Record (TAR) indicated that weights were not obtained for 9 of 31 days of the month. During an interview on 1/2/15 at 10:00 A.M., UM #1 said the TAR did not support that the resident was weighed daily, and could not say whether or not the resident had been weighed. 6. For NS #1, the facility failed to administer the correct dose of a medication. NS #1 was admitted to the facility 12/2014 with [DIAGNOSES REDACTED]. During an observation of Nurse #2 administering medication to NS #1, Nurse #2 administered Cranberry Tabs, 450 milligrams (mg.), two tablets by mouth. Review of a physician's orders [REDACTED]. Review of the 12/2014 Medication Administration Record [REDACTED]. During an interview on 12/31/14 at 9:00 A.M., Nurse #2 said the physician's orders [REDACTED]. daily, which meant the resident should have received one Cranberry tablet, not two. Nurse #2 said the resident received the incorrect dose of Cranberry. During an interview on 12/31/14 at 9:15 A.M., the Assistant Director of Nurses, after she reviewed the physician's orders [REDACTED]. The resident received the incorrect dose of Cranberry for 25 days. Please refer to F 514.