Every finding on record at Lowell Healthcare

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag for 1 of 2 residents reviewed for dignity. (Resident 8)Finding includes:On 2/9/26 at 3:10 p.m. Resident 8 was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway.On 2/10/26 at 10:24 a.m. Resident 8 was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway.On 2/11/26 at 11:07 a.m. Resident 8 was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway.Record review for Resident 8 was completed on 2/11/26 at 11:26 a.m. Diagnoses included, but were not limited to, hypertension, osteoarthritis, and obstructive uropathy.The Quarterly Minimum Data Set (MDS) assessment, dated 1/20/26, indicated the resident was cognitively impaired and had an indwelling urinary catheter.A Care Plan, updated 1/28/26, indicated the resident required an indwelling urinary catheter related to obstructive uropathy. An intervention indicated to store the collection bag inside of a protective dignity pouch.During an interview on 2/11/26 at 11:17 a.m., the Director of Nursing was made aware the urinary catheter bag was visible from the hallway. She indicated the facility had dignity covers the staff were to use.3.1-3(a)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a physician's order to self-administer medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 60)Finding includes:On 2/11/26 at 9:12 a.m., LPN 1 was observed preparing Resident 60's medications, which included Miralax (polyethylene glycol, a laxative medication) 17 grams. She dissolved the medication in a cup of water and entered the resident's room to administer the medications. The resident took his pills and drank a few sips of the Miralax then set the cup on his bedside table. LPN 1 indicated she would come back later and assist him with finishing the Miralax. She completed administering the resident's other medications, exited the room, and returned to the Nurse's Station. She left the Miralax in the resident's room and had not stayed with the resident to ensure the medication was taken. Record review for Resident 60 was completed on 2/11/26 at 12:08 p.m. Diagnoses included, but were not limited to, hypertension, general anxiety disorder, and major depressive disorder.The Quarterly Minimum Data Set (MDS) assessment, dated 2/1/26, indicated the resident was cognitively impaired.There was a lack of any Physician's Orders for self-administration of medications or any assessment for self-administration of medications.During an interview on 2/11/26 at 11:17 a.m., the Director of Nursing was made aware LPN 1 had left the medication in the resident's room. No further information was provided.A facility policy, titled Self-Administration of Medications, indicated, .If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the self-administration of medication assessment observation. A physician order will be obtained specifying the resident's ability to self-administer medications and if necessary, listing which medications will be included in the self-administration plan .3.1-11(a)

Based on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance to dependent residents related to removing facial hair for female residents for 1 of 2 residents reviewed for ADL care. (Resident 45)Finding includes: On 2/9/26 at 11:29 a.m., Resident 45 was observed sitting in her wheelchair watching television. The resident had facial hair observed on her chin. On 2/11/26 at 9:43 a.m. and 11:42 a.m., Resident 45 was observed with facial hair on her chin. Resident 45's record was reviewed on 2/12/26 at 3:18 p.m. Diagnoses included, but were not limited to, Alzheimer's disease. A Care Plan, dated 9/7/16, indicated the resident required assistance with activities of daily living. Interventions included, but were not limited to, assist with bathing as needed, assist with showers twice weekly in the morning and partial bath in between per resident's preference. The Quarterly Minimum Data Set (MDS) assessment, dated 10/17/25, indicated the resident was severely cognitively impaired and required partial/moderate assistance with personal hygiene and substantial/maximal assistance with bathing. The Shower Sheets were reviewed for the last 60 days and indicated the resident had been assisted with shaving last on 2/3/26. She had received a bed bath or shower on 2/5/26 and 2/10/26 and there were no refusals for shaving documented. During an interview on 2/13/26 at 11:47 a.m., the Assistant Director of Nursing indicated the resident frequently refused assistance with shaving, but it had not been cared planned. During an interview on 2/13/26 at 3:25 p.m., the Administrator indicated the staff were supposed to document refusals on the shower sheets, however that was not completed. A facility policy titled, AM Care, indicated, .Procedure Steps .8. Shave resident, if needed or requested .16. Document the procedure. 3.1-38(a)(3)(D)

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration and humidity bottles that were outdated for 3 of 3 residents reviewed for respiratory care. (Residents 72, 15, and 10)Findings include: 1. On 2/9/26 at 11:41 a.m., Resident 72 was observed in bed with oxygen on via a nasal cannula. The resident indicated she administered the oxygen when she felt she needed it. The oxygen concentrator was set to 1.5 liters per minute and had a humidity bottle attached that was dated 1/19/26. On 2/11/26 at 9:25 a.m., Resident 72 was observed asleep in bed. She was wearing a nasal cannula attached to the oxygen concentrator set to 1.5 liters per minute. The humidity bottle was dated 1/19/26. Resident 72's record was reviewed on 2/12/26 at 3:36 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease A Physician's Order, dated 8/21/24, indicated change oxygen tubing and humidity once a day on Sunday. The Quarterly Minimum Data Set (MDS) assessment, dated 11/11/25, indicated the resident was cognitively intact. A Physician's Order, dated 12/9/21, indicated oxygen at 2 liters per nasal cannula, resident to apply when feeling short of breath. During an interview on 2/13/26 at 11:47 a.m., the Assistant Director of Nursing (ADON) indicated she had no further information to provide. 2. On 2/10/26 at 10:34 a.m., Resident 15 was observed sitting on her bed. She had a nasal cannula sitting on the floor connected to an oxygen concentrator. On 2/11/26 at 9:41 a.m., Resident 15 was sitting on the side of the bed. She had a nasal cannula on connected to a portable concentrator set to 3 liters per minute. On 2/13/26 at 10:55 a.m., Resident 15 was observed sitting up in her bed. She had a nasal cannula on connected to an oxygen concentrator set to 1.5 liters per minute. Resident 15's record was reviewed on 2/11/26 at 11:43 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and respiratory failure. A Care Plan, dated 8/21/20, indicated the resident was at risk for impaired gas exchange related to chronic obstructive pulmonary disease. Interventions included, but were not limited to, oxygen as ordered/needed. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 1/15/26, indicated the resident was moderately impaired for daily decision making and required oxygen therapy. A Physician's Order, dated 2/4/26, indicated oxygen at a 2 liters per minute per nasal cannula every shift. During an interview on 2/13/26 at 11:47 a.m., the Assistant Director of Nursing (ADON) indicated she had no further information to provide. 3. On 2/9/26 at 10:59 a.m., Resident 10 was observed in bed. He was wearing a nasal cannula connected to an oxygen concentrator with a flow rate of 1.5 liters per minute. On 2/11/26 at 9:39 a.m., 2/12/26 at 11:08 a.m., and 2/13/26 at 10:28 a.m., Resident 10 was observed in bed with no oxygen on. Resident 10's record was reviewed on 2/12/26 at 2:59 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and asthma. A Physician's Order, dated 11/24/25, indicated oxygen at 2 liters per nasal cannula every shift. The Quarterly Minimum Data Set (MDS) assessment, dated 12/11/25, indicated the resident was severely cognitively impaired and required oxygen therapy. During an interview on 2/13/26 at 11:47 a.m., the Assistant Director of Nursing (ADON) indicated she had no further information to provide. A facility policy titled, Oxygen Concentrator, indicated, .Procedure 1. Verify and understand the physician's order. 2. Know the flow rate and duration of use .9. Adjust the flow meter control knob to the flow setting prescribed by the physician .Daily Maintenance 1. Check the water level in the humidity bottle. Change the bottle as needed or every 7 days . 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were maintained, related to staff touching pills during medication administration for 1 of 5 residents observed during medication administration. (Resident 60) Finding includes:On 2/11/26 at 9:12 a.m., LPN 1 was observed preparing Resident 60's medications, which included 10 pills. She popped each pill out of the medication cards one at a time, into her hand, and then put them in a medication cup. She then administered the medications to the resident.During an interview on 2/11/26 at 11:17 a.m., the Director of Nursing was made aware LPN 1 had touched the medications with her hands.A facility policy, titled Medication Administration (Medication Pass Procedure), indicated, .5. Medications are opened without contaminating.3.1-18(b)

Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching food with dirty gloves. This had the potential to affect 76 residents who received food from the kitchen. (Main Kitchen) Findings include: 1. During a follow-up tour of the kitchen on 12/11/24 at 12:00 p.m., [NAME] 1 was observed donning gloves. He picked up a box of cellophane wrap and moved it, then picked up a cardboard box containing frozen sausage patties. He opened the box of the frozen sausage patties with the same gloved hands, opened the plastic bag inside, scooped out handfuls of the sausage patties with the same gloved hands, and placed the patties on a baking sheet. He did not perform hand hygiene or change his gloves during the preparation of the food. 2. On 12/11/24 at 12:03 p.m., the Dietary Food Manager (DFM) was observed preparing food for lunch. She had placed a baking sheet that was covered by a single layer of cellophane wrap on the food preparation counter. She manipulated the cellophane wrap to try and cover the baking sheet containing bread and then moved a box of cellophane wrap. She donned clean gloves, removed a new sheet of cellophane wrap from the box, and placed it on the countertop. She removed the old cellophane wrap from the baking sheet, picked up pieces of bread with the same gloved hands, and proceeded to prepare the food. She then covered the baking sheet with the new cellophane wrap and removed her gloves. The DFM did not change her gloves or perform hand hygiene. At the time, the DFM indicated she would dispose of the food that was touched with the gloves. A policy titled, Use of Gloves, indicated .Procedure 1. Clean gloves will be worn when handling any food directly. 2. Gloves are not a substitute for handwashing. Hands will be washed before putting on gloves and upon removal .4. Gloves are just like hands; they get soiled. Anytime a contaminated surface is touched, gloves must be changed and hands washed. 5. Gloves should only be utilized for one task. Gloves should be changed between tasks or if a single task lasts longer than 4 hours. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were maintained, related to staff touching pills during medication administration for 3 of 6 residents observed during medication administration. (Residents 71, 10, and 9) The facility also failed to ensure reuseable equipment was disinfected after use on residents for 2 of 6 residents observed during medication administration. (Residents 10 and 47) Findings include: 1. On 12/11/24 at 9:06 a.m., QMA 1 was observed preparing Resident 71's medications. She popped each pill out of the medication cards one at a time, into her hand, and then put them in a medication cup. She then administered the medications to the resident and continued to the next resident. At 9:17 a.m., QMA 1 was observed preparing Resident 10's medications. She popped multiple pills out of the medication cards one at a time, into her hand, and then put them in a medication cup. She then administered the medications to the resident and continued to the next resident. At 9:33 a.m., QMA 1 was observed preparing Resident 9's medications. She popped multiple pills out of the medication cards one at a time, into her hand, and then put them in a medication cup. She then administered the medications to the resident and continued to the next resident. During an interview on 12/11/24 at 11:32 a.m., the Director of Nursing was made aware QMA 1 had touched the medications with her hands. A Medication Administration policy was requested. A facility policy, titled Medication Administration (Medication Pass Procedure), indicated, .5. Medications are opened without contaminating. 2. On 12/11/24 at 9:17 a.m., QMA 1 was observed preparing Resident 10's medications. She obtained the blood pressure machine rolling cart from the Nurse's Station and entered the resident's room. QMA 1 applied the blood pressure cuff to the resident's left arm and turned on the machine. When the blood pressure was completed, QMA 1 removed the blood pressure cuff, rolled it up and returned it to the cart. The resident's blood pressure reading was low, so she informed RN 1. RN 1 then re-applied the blood pressure cuff to the resident's left arm and turned on the machine. When the blood pressure was completed, RN 1 removed the blood pressure cuff, rolled it up and returned it to the cart. Neither QMA 1 nor RN 1 had cleaned or disinfected the blood pressure cuff before or after use. 3. On 12/11/24 at 10:04 a.m., QMA 1 was observed preparing Resident 47's medications. She obtained the blood pressure machine rolling cart from the hallway and entered the resident's room. QMA 1 applied the blood pressure cuff to the resident's left arm and turned on the machine. When the blood pressure was completed, QMA 1 removed the blood pressure cuff, rolled it up and returned it to the cart. QMA 1 had not cleaned or disinfected the blood pressure cuff before or after use. During an interview on 12/11/24 at 11:32 a.m., the Director of Nursing was made aware QMA 1 and RN 1 had not cleaned the blood pressure cuff before or after use. A reuseable equipment cleaning policy was requested. A facility policy, titled Equipment Cleaning, indicated, .Electrical equipment .4. Select appropriate germicidal/disinfectant spray or aerosol to cover all surfaces. 5. Follow label recommendations for sit time prior to wiping off sprayed surfaces . 3.1-18(b)

Based on observation, record review and interview, the facility failed to ensure a resident with edema received the necessary care and treatment related to Medigrips (elastic type stocking) not in place as ordered for 1 of 2 residents reviewed for edema. (Resident 12) Finding includes: On 12/8/24 at 1:18 p.m., Resident 12 was observed seated in her wheelchair. Her legs were discolored a light purple and swollen, there were no Medigrips on her legs. On 12/10/24 at 1:22 p.m., the resident was observed in bed. Her legs were discolored, swollen and there were no Medigrips in place. On 12/11/24 at 9:38 a.m., the resident was observed with RN 1 seated in her wheelchair. There were no Medigrips in place. The RN indicated she was unsure who was responsible for putting them on or removing them. The RN later indicated the Medigrip order had been discontinued. The resident's record was reviewed on 12/10/24 at 10:54 a.m. Diagnoses included, but were not limited to, venous insufficiency, hypertensive heart disease with heart failure and dementia. The Quarterly Minimum Data Set assessment, dated 10/3/24, indicated the resident had significant cognitive impairment and required substantial assistance with bed mobility, transfers and toileting. A Physician's Order, dated 11/22/23, indicated to apply Eucerin cream generously to BKE (below knee extremities), then apply Medigrip size G cut to at least 55 centimeters daily. The November and December 2024 Medication Administration Record indicated the Eucerin and Medigrips were signed out daily as completed. There was no indication the order had been discontinued. During an interview on 12/11/24 at 9:53 a.m., the Director of Nursing (DON) indicated she thought the order had been discontinued due to the resident refusing them. She was made aware the order was still in place and being signed out as completed, no refusals were documented. The DON indicated they would correct the order. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary treatment for a pressure ulcer related to the incorrect treatment provided during wound care for 1 of 3 residents reviewed for pressure ulcers. (Resident 73) Finding includes: On 12/11/24 at 9:15 a.m., Resident 73's wound care was observed with the Wound Nurse. The resident had a stage 4 pressure ulcer to her sacral area. The nurse positioned the resident on her left side and removed the old dressing. She cleansed the wound bed with Anasept (a wound cleanser) and gauze. She then applied a sheet of collagen to the wound bed and a piece of Maxorb (absorbent material used for wounds). The wound nurse then used an absorbent island border dressing to cover the wound. The resident's record was reviewed on 12/9/24 at 12:55 p.m. Diagnoses included, but were not limited to, multiple sclerosis, diabetes mellitus and stage 4 pressure ulcer. The Quarterly Minimum Data Set assessment, dated 11/22/24, indicated the resident was cognitively intact and required moderate assistance for bed mobility and was dependent on staff for transfers. A Physician's Order, dated 11/26/24, indicated to cleanse the wound with Anasept, apply collagen, then apply Maxorb AG cut to fit, apply Sureprep to surrounding skin then cover with super absorbent dressing. During an interview on 12/11/24 at 9:35 a.m. with the Wound Nurse, she indicated she had forgotten to apply the Sureprep to the skin as ordered. 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to ensure a medication was kept in a locked medication cart at all times for 1 of 6 residents observed during medication administration. (Resident 10) Finding includes: On 12/11/24 at 9:17 a.m., QMA 1 was observed preparing medications for Resident 10. She indicated she could not find the resident's Miralax (a laxative medication) so she could not administer it. She notified RN 1 that she could not find the medication. RN 1 indicated she would look in the medication room to see if it was with the overflow medications. QMA 1 finished preparing the resident's other medications and gave them to the resident. On 12/11/24 at 9:33 a.m., QMA 1 began preparing Resident 9's medications. RN 1 approached the medication cart and indicated she was able to get Resident 10's Miralax from the Pyxis (a medication dispensing machine). She handed the Miralax medication to QMA 1. QMA 1 wrote Resident 10's name on the medication and set it on top of the medication cart. She then continued to prepare Resident 9's medications, entered Resident 9's room and administered his medications. QMA 1 had not put Resident 10's Miralax in the medication cart and it remained on top of the medication cart, out of her sight, while she was administering Resident 9's medications. On 12/11/24 at 10:01 a.m., QMA 1 exited Resident 9's room and returned to the medication cart. She took Resident 10's Miralax from the top of the medication cart and administered it to Resident 10. During an interview on 12/11/24 at 11:32 a.m., the Director of Nursing was made aware the QMA had not stored the medication properly. A Medication Storage policy was requested. A facility policy, titled Medication Storage and Expiration Policy, indicated, .3. Medications including treatment items should be stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . 3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of monitoring and assessments of a skin discoloration for 1 of 2 residents reviewed for non-pressure skin conditions. (Resident 47) Finding includes: On 1/23/24 at 11:28 a.m., Resident 47 was observed with a reddened area noted on her nose. The resident indicated it was from her BiPAP (bilevel positive airway pressure) mask that she wore at night. On 1/24/24 at 9:19 a.m., Resident 47 was observed sitting in a chair. She had a reddened area noted on the bridge of her nose. On 1/25/24 at 2:28 p.m., Resident 47 was observed sitting up in a chair. She had a reddened area with a small scab present, along with an indentation on the bridge of her nose. Resident 47's record was reviewed on 1/24/24 at 9:00 a.m. Diagnoses included, but were not limited to, chronic respiratory failure, obstructive sleep apnea, and chronic obstructive pulmonary disease. The State Optional Minimum Data Set (MDS) assessment, dated 11/9/23, indicated the resident was cognitively intact for daily decision making and was a 1 person assist for ADLs (activities of daily living). A current Care Plan, indicated the resident was at risk for decreased skin integrity, pressure ulcers, and skin tears, with a risk factor including, but not limited to, using BiPAP. The January 2024 Physician's Order Summary indicated, BiPAP at night with fraction of inspired oxygen (FiO2) 32%, inspiratory pressure 14, expiratory pressure 7, and oxygen at 3 liters. Change the mask & tubing as needed. There was no documentation in the clinical record related to the reddened scabbed area on Resident 47's nose. During an interview on 1/25/24 at 2:32 p.m., the Director of Nursing indicated she was not aware the resident had any marks on her nose. They will re-evaluate the mask fit and contact respiratory services if needed. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 5 residents observed during medication pass. Two errors were observed during 30 opportunities for errors during medication administration. This resulted in a medication error rate of 6.67%. (Resident 282) Finding includes: On 1/24/24 at 11:11 a.m., RN 1 was observed preparing Resident 282's medications to be administered via a gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition to the stomach). The nurse crushed 2 different medications, which included 1 Nephro Vite (vitamin) tablet and 1 Carafate (anti-ulcer medication) tablet. She poured the crushed medications together into a plastic cup and added an unmeasured amount of water. The RN indicated she added approximately 30 ml (milliliters of water to the medications). She then proceeded to check for placement of the g-tube by auscultation. She flushed the g-tube with 30 ml of water and then administered the cup with the 2 medications into the tube. The nurse then administered another 30 ml of water into the tube. She indicated she always administered the crushed medications all at once through the tube. A Nursing Skills Competency for Enteral Tube-Medication Administration, dated 1/2010 and updated 5/2023, given by the Director of Nursing (DON) indicated, .2. Dissolve each crushed medication in at least 10 cc-30 cc of water .12. Flush tubing with at least 15 cc of water between each medication . During an interview on 1/24/24 at 11:55 a.m., the DON indicated they did not have a policy that would indicate medications could not be crushed and administered via g-tube at the same time. She would expect nursing to use nursing judgment, and if there were only 2 medications, she would administer them together. The State Operations Manual (SOM) Appendix PP, revised 2/3/2023 indicated, .The standard of practice is that crushed medications should not be combined and given all at once via feeding tube. Crushing and combining medications may result in physical and chemical incompatibilities leading to an altered therapeutic response, or cause feeding tube occlusions when the crushed medications are combined and administered via feeding tube. Flushing the feeding tube between each medication is also standard of practice . 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure ADL (activities of daily living) care was provided related to not assisting a dependent resident with shaving for 1 of 3 residents reviewed for ADL care. (Resident 56) Finding includes: On 2/7/23 at 11:22 a.m. and 2/8/23 at 8:51 a.m., Resident 56 was observed in his bed, he was unshaven. On 2/9/23 at 1:20 p.m., the resident was in bed and unshaven. At that time, he indicated he preferred to be clean shaved. The resident's record was reviewed on 2/9/23 at 9:24 a.m. Diagnoses included, but were not limited to, cerebral infarction and dementia. The Quarterly Minimum Data Set assessment, dated 11/23/22, indicated he had moderate cognitive impairment and required extensive assistance of one for personal hygiene. The shower book indicated the resident received showers twice weekly on Wednesday and Saturdays. Shower sheets for the past 30 days indicated the resident had only been shaved on 1/10/23 and 1/25/23. There were no refusals noted. Interview with CNA 3 on 2/9/23 at 11:45 a.m., indicated they would give him a shower twice weekly and he needed assistance with shaving. She was unsure when the resident had been shaved last. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure tubi grips (elastic compression bandage) were in use as ordered for 1 of 1 residents reviewed for edema. (Resident 225) Finding includes: On 2/7/23 at 9:55 a.m., Resident 225 was observed seated in her wheelchair in her room. She had white crew socks and shoes in place to both feet. Her ankles appeared to be slightly swollen. On 2/8/23 at 2:18 p.m., Resident 225 was observed seated in her wheelchair in the first floor lounge area watching television. She had white crew socks and shoes in place to both feet. Her ankles appeared to be slightly swollen. On 2/9/23 at 2:05 p.m., Resident 225 was observed seated in her wheelchair in the first floor lounge area. She had white crew socks and shoes in place to both feet. Staff then escorted resident out of the lounge area to an activity. The resident's record was reviewed on 2/10/23 at 10:10 a.m. Diagnoses included, but were not limited to, hypertension, dementia, and pulmonary hypertension. The Admission Minimum Data Set (MDS) assessment, dated 11/28/22, indicated the resident was cognitively impaired. She required extensive one person assistance for bed mobility and extensive two person assistance for transfers. A Physician's Order, dated 1/25/23, indicated tubi grips to bilateral lower extremities for edema, may remove for hygiene and to be removed before bed. The Treatment Administration Record (TAR), dated 2/2023, indicated the tubi grips were signed off as in place on the day shift (7 a.m. through 3 p.m.) on 2/7/23, 2/8/23, and 2/9/23. Interview with the Director of Nursing (DON) on 2/9/23 at 2:30 p.m., indicated the resident was wearing regular socks and the tubi grips were not in place. She was going to ask the Nurse Practitioner if they could discontinue them since the resident's edema had decreased. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident with a urinary catheter, who was awaiting results of a urine Culture and Sensitivity (C&S) for a possible Urinary Tract Infection (UTI), received the proper care and services related to improper catheter positioning for 1 of 2 residents reviewed for catheters. (Resident 14) Finding includes: On 2/7/23 at 12:54 p.m., Resident 14 was observed sitting in a wheelchair in her room. The resident's catheter bag was hanging from underneath the wheelchair, out of the dignity bag and resting directly on the floor. On 2/8/23 at 9:13 a.m., Resident 14 was observed sitting in a wheelchair in her room. The resident's catheter bag was hanging from underneath the wheelchair. The bag was touching up against the legs of the wheelchair and the inner tire. The dignity bag was on the floor underneath the wheelchair. Record review for Resident 14 was completed on 2/8/23 at 9:06 a.m. Diagnoses included, but were not limited to, neurogenic bladder, and dementia. The Significant Change Minimum Data Set (MDS) assessment, dated 12/25/22, indicated the resident was cognitively intact. The resident required an extensive 1 person assist for toilet use and had an indwelling Foley catheter. A Care Plan, dated 10/21/22 and revised 1/4/23, indicated the resident required an indwelling supra-pubic urinary catheter due to: neuromuscular dysfunction of the bladder. Interventions included to not allow tubing or any part of the drainage system to touch the floor and to store the collection bag inside a protective dignity pouch. A Progress Note, dated 2/5/23 at 2:15 p.m., indicated urine was collected from the catheter collection bag to be picked up by the laboratory. The urine was dark amber, slight foul odor and sediment were noted. A Progress Note, dated 2/10/23 at 6:27 a.m., indicated the urine C&S test remained pending at the laboratory at that time. Interview with LPN 1 on 2/8/23 at 9:16 a.m., indicated the resident had a urinalysis completed. The results were received but they still had not received the C&S results. The resident's catheter bag should always be covered and not on the floor or touching any part of the wheelchair while being uncovered. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 2 of 3 residents reviewed for nutrition. (Residents 18 and 36) Findings include: 1. The record for Resident 18 was reviewed on 2/9/23 at 10:34 a.m. Diagnoses included, but were not limited to, hypertension, dementia, and cerebral infarction. The resident was hospitalized on [DATE] and returned to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment, dated 1/7/23, indicated the resident was cognitively impaired and required an extensive assistance of one with eating. The resident weighed 230 pounds on 1/4/23 and 209 pounds on 2/6/23. A Progress Note, dated 2/8/23, indicated the resident had a 9.1% weight loss in 90 days and a 10.7% weight loss in 180 days. The Meal Consumption Log for February 2023 lacked documentation of the following meals: - Breakfast on 2/1/23, 2/6/23, and 2/8/23 - Lunch on 2/1/23, 2/6/23, and 2/8/23 The Meal Consumption Log for January 2023 lacked documentation of the following meals: - Breakfast on 1/20/23 - Lunch on 1/3/23, 1/6/23, 1/8/23, 1/13/23, 1/15/23, 1/20/23, and 1/30/23 - Dinner on 1/2/23, 1/4/23, 1/5/23, and 1/6/23 Interview with the Director of Nursing (DON) on 2/8/23 at 10:41 a.m., indicated the food consumption logs were incomplete and they had been having trouble with their electronic charting going in and out. She was unable to provide any further documentation. 2. The record for Resident 36 was reviewed on 2/8/23 at 2:27 p.m. Diagnoses included, but were not limited to, dementia, hypertension, and adult failure to thrive. The Significant Change Minimum Data Set (MDS) assessment, dated 1/11/23, indicated the resident was cognitively impaired and had weight loss. The resident weighed 130 pounds on 8/6/22 and 117 pounds on 2/6/23. A Progress Note, dated 2/8/23, indicated the resident had a 10% weight loss in 180 days. The Meal Consumption Log for February 2023 lacked documentation of the following meals: - Breakfast on 2/4/23 - Lunch on 2/7/23, and 2/4/23 - Dinner on 2/6/23 The Meal Consumption Log for January 2023 lacked documentation of the following meals: - Lunch on 1/6/23, 1/7/23, 1/27/23, and 1/31/23 - Dinner on 1/3/23, 1/4/23, 1/15/23, 1/16/23, 1/21/23, 1/27/23, 1/28/23, and 1/29/23 Interview with the Director of Nursing (DON) on 2/8/23 at 10:41 a.m., indicated the food consumption logs were incomplete and they had been having trouble with their electronic charting going in and out. She was unable to provide any further documentation. 3.1-46(a)(1) 3.1-46(a)(2)

Based on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to Pharmacy recommendations lacking follow up for 1 of 5 residents reviewed for unnecessary medications. (Resident 61) Finding includes: The record for Resident 61 was reviewed on 2/10/23 at 11:31 a.m. The resident diagnoses included, but were not limited to, Alzheimer's dementia and a history of falls. The current Physician's Order Summary indicated the resident took meclizine (a medication used to treat dizziness and nausea) 12.5 milligrams (mg) in the morning and 25 mg in the evening. A Pharmacy Review, dated 1/11/23, recommended decreasing the meclizine to 12.5 mg twice daily due to a recent fall. The Pharmacy review had been signed by the Nurse Practitioner, but it was left blank as to whether to accept or decline the recommendation. Interview with the Director of Nursing on 2/10/23 at 1:46 p.m., indicated she had contacted the Nurse Practitioner and they were going to accept the recommendation to decrease the meclizine. She was unsure why it had not been completed before. 3.1-48(a)(5)

Based on record review and interview, the facility failed to develop a comprehensive care plan for a resident with identified dental concerns for 1 of 1 residents reviewed for dental. (Resident 37) Finding includes: During an interview with the resident on 10/24/21 at 10:30 a.m., she indicated she had bad teeth, that included a chipped or cracked tooth, a painful area on her right side and a cavity. She indicated someone had looked at her teeth a couple months ago, but nothing had been done yet. Resident 37's record was reviewed on 10/25/21 at 3:00 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment, dated 7/29/21, indicated the resident was cognitively intact, and required extensive two person assist for transfers using a mechanical lift. The oral/ dental section indicated there were no problems. A dental assessment, dated 7/22/21, completed by a contracted dental hygienist, indicated the resident was very concerned about an area on her lower right side. The note indicated, .It appears that food, plaque is being packed in the cusp tip of number 27 and is causing a suspicious lesion. Number 10 has a suspicious lesion that can be seen from the lingual surface . The assessment also indicated the resident had gingivitis and suspected area of broken teeth. The record lacked an oral/dental care plan Interview with Social Service Director on 10/26/21 at 10:00 a.m., indicated she was aware the resident needed to see a dentist but was having difficulty making arrangements due to family and transportation issues. During a follow up interview at 11:55 a.m., she indicated there should have been a dental care plan. 3.1-35(a)

Based on observation, record review and interview, the facility failed to monitor and treat skin conditions for 1 of 6 residents reviewed for non-pressure related skin issues. (Resident C) Finding includes: On 10/27/21 at 2:45 p.m., Resident C was observed in bed. She was positioned to her right side by a family member and a CNA. There were diffuse, scattered red spots over both buttocks, scratch marks on the abdomen and thighs, and an open abrasion, approximately 1 cm x 1 cm on her outer left thigh. The resident indicated her skin itched and she frequently scratched at it. The CNA indicated she had applied A & D ointment to buttocks prior to the observation. The resident's record was reviewed on 10/27/21 at 8:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set assessment, dated 7/21/21, indicated the resident needed extensive assistance of two for bed mobility and transfers. A CNA Shower and Skin sheet, dated 3/9/21, indicated, .redness under side skin fold, breasts and groin. Redness and open area to bottom and back/ scabs from scratching The shower sheet had been signed off by RN 3. The Nursing Progress Note, completed that day by RN 3, indicated the resident was on isolation and had no symptoms related to COVID-19. The note did not indicate any skin concerns had been identified. There was not a wound note or new order related to the observed skin issues. Weekly skin assessments were completed on 3/4/21, 3/11/21 and 3/18/21, which indicated there were no skin issues. On 3/18/21, the resident was admitted to the hospital for unrelated concerns. She returned to the facility on [DATE]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly skin assessment, dated 10/4/21, indicated [NAME] for itching, no skin issues. A weekly skin assessment, dated 10/11/21, indicated old superficial scratches to buttocks. The weekly skin assessment, dated 10/18/21, indicated no skin issues. A Nursing Note, dated 10/27/21, indicated the resident had returned and family voiced concerns about skin. The Nursing Note indicated, .resident has several abrasions on left lower buttock and right hip. Abrasions consistent with scratching .res also has multiple scarred areas and red blanching dots on buttocks Interview with the resident's family member, on 10/27/21 at 2:25 p.m., indicated he had been notified of the skin issues by the hospital staff on the day she was admitted to the hospital, 3/18/21. It had been an ongoing issue since. The resident had recently been home for a five day visit and had returned to the facility on [DATE]. He indicated when she was home, the skin issues were still present. He had spoken to the Director of Nursing (DON) by phone on 10/26/21. Interview with the DON on 10/27/21 at 3:10 p.m., indicated she had spoke to the family member the previous day and he voiced concerns about the resident's skin. She indicated she had not been aware of it, but had notified the physician. The physician was to come see the resident that day. She indicated there were no nursing notes or new orders when the skin issues were first identified on 3/9/21. This Federal deficiency relates to Complaint IN 636. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident received proper respiratory care and treatment related to incorrect oxygen flow rate for 1 of 4 residents reviewed for respiratory care. (Resident 37) Finding includes: On 10/25/211 at 1:33 p.m., Resident 37 was observed in bed with her oxygen on. The flow rate was set at 3 liters. On 10/25/211 at 3:05 p.m., she was observed in bed with her oxygen on. The flow rate was set at 3 liters. On 10/26/21 at 9:29 a.m., she was observed in bed with her oxygen on. The flow rate was still on 3 liters. Resident 37's record was reviewed on 10/25/21 at 3:00 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set assessment, dated 7/29/21, indicated the resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on 10/26/21 at 10:10 a.m., indicated nurses would turn her oxygen up at times if her oxygen saturation was low. She indicated there was not an order with parameters in place, but she would contact the provider to clarify. 3.1-47(a)(6)