Every finding on record at Oceanside Rehabilitation and Nursing Center

Based on observation and interview, the facility failed to properly follow food storage and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically:1. The facility failed to properly store food items in the kitchen and kitchenette to prevent the risk of foodborne illness.2. The failed to properly follow food handling and hand hygiene practices on the tray line to prevent the risk of foodborne illness in accordance with professional standards for food service safety.Findings include:Review of the facility policy titled Food Storage, undated, indicated the following:- Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing.- Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour. All containers must be legibly and accurately labeled.- Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded.Review of the untitled and undated policy provided to the surveyor when asked for a food handling policy indicated the following:- It is the policy of the Dietary Department to use single use gloves to protect both patrons and employees from contagious and food borne illness.- Employees will:- wash their hands thoroughly before and after or changing gloves- Change disposable gloves between tasks and not wear them continuously- Change gloves if moving from task to another- Change gloves and wash hands after touching their hair and/or face1. The surveyor made the following observations during the initial walk-through of the kitchen on 5/17/26 at 6:59 A.M.:In the Reach-In Refrigerators:- a container labeled Parmesan Cheese dated 4/22- numerous packages of deli meats open to the air, not covered, not labeled and/or dated- an opened container of chicken concentrate paste not labeled or dated- a container containing an unidentifiable yellow liquid with no label or date- a container resembling red sauce with no label or date- three jugs of opened salad dressing not labeled or dated.- two jugs of a yellow drink not labeled or dated- three trays of pre-poured juice with no label or date of when they were poured- one tray container five dessert cups with no label or dateIn the Reach-In Freezers:- an open bag containing breaded chicken patties open to air, not labeled or dated- an item wrapped tightly in aluminum foil with no label or date- two bags of sausage patties open to air, not covered, labeled or dated- a bag of an unidentifiable meat product that was clumped together, not covered and open to air with significant freezer burn. There was no label or date- a bag of hashbrown patties open to air, not covered, labeled or dated.- another bag of frozen food not covered, labeled or datedIn the Dry Storage Room:- an opened bag of hamburger buns not covered, labeled or dated- an opened bag of dry ziti pasta not covered, labeled or dated- a large plastic storage bin containing flour that was covered with plastic wrap container large opening and holes. The plastic cover was not on the bin leaving the flour open to air, there was no date or label.In the Kitchenette near the [NAME] Unit Nursing Station the surveyor observed a Tupperware container with a Resident's name and room number that was dated 4/15/26. The Resident that was named on the container was discharged from the facility in the middle of April 2026.During an interview on 5/18/26 at 12:57 P.M., the Foodservice Director (FSD) said all prepared food items stored in the refrigerators and freezers should have labels of what they are and with a use-by date. The FSD then said all food items should be discarded three days after prepared because the elderly population is more at risk of foodborne illness.During a follow-up interview with the FSD and the Corporate Dietary Manager on 5/18/26 at 1:02 P.M., they both said the unlabeled and undated food should have been labeled and should be thrown away if there is no label. They continued to say any food past the labeled date should be discarded and all stored food should be properly covered.During an interview on 5/18/26 at 1:25 P.M., the Regional Nurse said she would expect all food to be discarded if out of date or not labeled.2. The surveyor observed the lunch service tray line on 5/18/26 at 11:47 A.M. and made the following observations:- The Food Service Director (FSD) was serving food on the tray line while wearing disposable gloves. At 11:51 A.M., he touched the plated food with his gloved hands. At 12:00 P.M., the FSD left the tray line area to get more coleslaw from the reach-in refrigerator. While walking there the FSD was observed rubbing his nose with the same gloved hands and then directly touched the handle of the refrigerator. The FSD then returned to tray line without washing his hands or changing his gloves. From 12:01 P.M. to 12:02 P.M., the FSD touched multiple food items directly on the Resident's plates with the contaminated gloves.- At 12:03 P.M., while wearing the same contaminated gloves, the FSD then went to the three-bay sink and proceeded to clean dirty dishes. His left hand was directly touching dirty pans while his right hand was controlling the sprayer. The FSD then proceeded to remove a blender from the three-bay sink area and brought it to a counter away from the tray line service. The FSD then used tongs to put chicken tenders in the blender, the FSD then proceeded to put his contaminated hands with the same pair of gloves on into the blender where the chicken tenders were in.- At 12:05 P.M., the FSD returned to the tray line wearing the same contaminated gloves where he was observed to directly touch seven portions of cooked food on the Resident's plates. At 12:07 P.M., the FSD left the tray line to get more coleslaw from the reach-in refrigerator and directly touched the handle of the refrigerator. The FSD then returned to tray line and proceeded to prepare meals with the same contaminated gloves.During an interview on 5/18/26 at 1:09 P.M., the FSD and the Corporate Dietary Manager said the FSD should have washed his hands and changed his gloves between tasks and when leaving the tray line area.During an interview on 5/18/26 at 1:25 P.M., the Regional Nurse said she would expect proper hand hygiene when working with Resident food on the tray line.

Based on interviews and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on the Seaside Unit, [NAME] Unit, and for Residents eating in the dining room.Findings include:During initial resident screening and interviews numerous residents of the facility expressed concern to the surveyors regarding the quality and the temperature of the food, especially lunch and dinner meals.During the Resident Group Interview on 5/18/26 at 11:00 A.M., multiple Residents said the breakfast meal is much better than lunch and dinner.On 5/18/26, the surveyors conducted two test trays for the lunch meal in the facility. The Results were as followed:On the Seaside Unit, the meal delivery truck arrived on the unit 11:54 A.M., and at 12:04 P.M., the last resident meal tray was passed, and the surveyor took the test tray. The following was recorded:- The chicken tenders were 126.3 degrees Fahrenheit (F), lukewarm and had a soggy and rubbery texture.- The French fries were 105.4 degrees F, warm, not hot and had a soggy, rubbery texture with no flavor.- The coleslaw had a temperature of 54.5 degrees F.- The cup of milk was 51.6 degrees F, warm and not cold.- The juice was 54.4 degrees F, warm, not cold.- The fruit cocktail was 45.4 degrees F and chilled.On the Seaside Dining Room meal cart, the meal delivery cart left the kitchen at 12:02 P.M., the last resident meal tray was passed at 12:18 P.M., and surveyor received the test tray at 12:19 P.M. The following was recorded:- The chicken tenders were 120 degrees F, lukewarm, not hot and very soggy and floppy.- The French fires were 111 degrees F, lukewarm and not hot, they were soggy and congealed together and not flavorful.- There was no coleslaw on the test tray.- The milk was 51 degrees F warm and not cold.- The fruit cocktail was 48 degrees F and chilled.The surveyors conducted the following interviews from Residents on the Seaside Unit regarding their lunch meal on 5/18/26:- At 12:25 P.M., a resident said the meal was lukewarm and soggy.- At 12:29 P.M., a resident said the meal was soggy and he/she did not like it.- At 12:30 P.M., a resident said the meal was not warm and he/she does not know how the food was cooked and did not bother eating the French fries.- At 12:31 P.M., a resident said the meal was terrible and it was soggy, not hot and the food here usually is not hot. - At 12:34 P.M., a resident said the meal was not good and was not hot.The surveyors conducted the following interviews from Residents on the [NAME] Unit regarding their lunch meal on 5/18/26 at approximately 12:35 P.M.:- A resident said the French fries would be better if they were hot and he/she could not eat them.- A resident said the French fries were underdone and soggy and could not eat them.- A resident said the French fries were weak and flimsy and could not eat them, and the chicken tenders were just okay.- A resident said the chicken tenders were soggy and cold.During an interview on 5/18/26 at 1:09 P.M., the Foodservice Director and the Corporate Dietary Manager said Residents should be receiving food that is palatable and at an appropriate temperature.During an interview on 5/18/26 at 1:25 P.M., the Regional Nurse said she would expect residents to have palatable meals at an appropriate temperature

Based on observation, record review and interview, the facility failed to follow the facility menus for three of the four observed meals on two of two units.Findings include:Review of the facility policy titled Menus, undated, indicated the following:- Menu planning is the responsibility of the Dietary Manager. Menus are implemented by the Dietary Manager in conjunction with the Dietitian.- When changes in the menus are needed, changes must provide equal nutritive value. Menu changes are made in the menu system in Dietary before the meal is served. Menu changes are reviewed and approved in advance by the Dietitian.Review of the facility food menus provided to the surveyors upon entrance to the facility indicated the following for the current Week 1 menus:- Sunday Breakfast: Orange Juice, Egg Burrito, Cereal of choice, Banana, Coffee/Tea, milk- Sunday Lunch: Turkey Sandwich, Ham and Bean soup, Carrot/Raisin Salad, Beverage of choice- Monday Breakfast: Orange Juice, Sausage Patty, Cereal of Choice, French Toast, Milk, Coffee/Tea, Margarine, Syrup- Monday Lunch: Chicken Tenders, French Fries, creamy coleslaw, Fruit cocktail, Beverage of Choice.On 5/17/26 at 11:42 A.M., the surveyor observed the following menus on the wall of the Seaside Unit, which did not match the menus provided upon entrance:- Sunday Breakfast Menu: Pancakes, bacon, cream of wheat- Sunday Lunch Menu: Roasted turkey, sweet potato, mixed vegetables, apple pie.During observations of breakfast service on 5/17/26, Residents received pancakes, bacon and hot cereal.During observations of lunch service on 5/17/26, Residents received roast turkey, sweet potato and mixed vegetables.During observations of breakfast service on 5/18/26, Residents received scrambled eggs and sausage.For three of the four meals observed during the survey period, Residents did not receive the meals as outlined on the facility menus provided to the surveyors.During a telephone interview on 5/18/26 at 10:28 A.M., the Registered Dietitian (RD) said the menus used in the facility are designed by Corporate and follow a four-week rotation. The RD said she is often told about the menus not being followed and she thinks it might be due to the food ordering process. The RD then said she was not notified of the menu changes for 5/17/26 and 5/18/26.During an interview on 5/18/26 at 1:09 P.M., the Foodservice Director (FSD) said he did not work on Sunday, 5/17/26 and was not aware the menus were not followed. The FSD then said egg burritos were not served because the scheduled cook is not fast enough to make them, so they make pancakes instead. The FSD then said the facility did not have any deli turkey or bread to make French Toast, so the menus were not followed. The FSD said he did not tell the RD. The Regional Dietary Manager reviewed the menus with the surveyor and said the menus provided upon entrance were current and he said they should be followed as written. The Regional Dietary manager said if the menus are not followed, someone needs to be notified.During an interview on 5/18/26 at 1:25 P.M., the Regional Nurse said she would expect the facility menus to be followed.

Based on interview and record review, the facility failed to ensure ongoing therapy services were provided for one Resident (#38) out of a total of 17 sampled Residents. Findings include: Resident #38 was admitted to the facility in July 2025 with diagnoses including major depressive disorder, cognitive communication deficit, and bipolar disorder. Review of the Minimum Data Set Assessment (MDS) indicated Resident #38 is moderately cognitively impaired as evidenced by a score of 11 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #38 scored 11 on the patient health questionnaire (PHQ-9) indicating moderate depression. During an interview on 5/17/26 at 8:11 AM., Resident #38 appeared depressed with a flat affect. Resident #38 said he/she was doing the best he/she could. Review of Resident #38's care plans indicated:Focus: Resident has a mood behavior r/t (related to) bipolar disorder, major depressive disorder, 8/6/25Goal: Resident will have improved mood Interventions: Behavioral health consults as needed, (psych-geriatric team, psychiatrist etc). Review of the clinical record indicated Resident #38 had been seen by behavioral health services for individual therapy monthly, until 2/3/26. Review of the Psychiatric Therapy Note dated 2/3/26 indicated:Goal: Support Resident #38's continued emotional stability and effective management of obsessive behaviors while monitoring for changes in mood, behavior and cognition.Response: Resident appeared calm and engaged throughout session.Plan: Continue to monitor for changes in mood, behavior and cognition. Provide ongoing support and reinforce behavioral interventions to promote continued stability and overall well-being. There was no evidence in the clinical record indicating that ongoing therapeutic services were continued or provided to Resident #38 after 2/3/26; despite behavioral health services note indicating Resident #38 was benefitting from therapeutic interventions and a plan to continue to monitor for changes and continued support. During an interview on 5/18/26 at 11:57 A.M., Resident #38 said that he/she would be interested in having continued therapy services. Resident #38 said, I think it'd be good for me to have someone to talk to. I would be interested in speaking with someone. During an interview on 5/18/26 at 12:20 P.M., the Social Worker said she had just started working in the building recently but was made aware that there had been no outside therapy services as the agency was having issues with staffing. The Social Worker said that telehealth visits were available to residents with an urgent need, but she was not aware that Resident #38 was interested in continued therapy services or that he/she had not been seen since February 2026. During an interview on 5/18/26 at 12:56 P.M., the Director of Nursing said that there had been staffing changes and that new staff is starting with behavioral health services. The Director of Nursing said that telehealth services were available for residents, but she was not aware that Resident #38 had not been seen since February 2026 for therapy services or he/she was interested in continued therapy services.

Based on observation, record review and interview, the facility failed to ensure a wound treatment was completed as ordered for one Resident (#4), out of a total of 17 sampled Residents. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.Review of the Wound Care policy, dated October 2010 indicated: Verify that there is a physician's order for the procedure.Resident #4 was admitted to the facility in April 2026 with diagnoses including fracture of the right lower leg and strain of right quadriceps muscle, fascia (a layer of connective tissue below the skin) and tendon.Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #4 is moderately cognitively impaired as evidenced by a score of nine out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS further indicated Resident #4 had no open pressure areas. Review of the clinical record indicated Resident #4 is his/her own person and his/her healthcare proxy is not activated.During an interview on 5/17/26 at 8:32 A.M., Resident #4 said that he/she has a wound on his/her knee. Resident #4 said that he/she is worried about the wound and the treatments are done on Monday, Wednesday and Friday. Resident #4 said that the treatment was not completed this past Friday (5/15/26) and he/she asked the nurse yesterday (5/16/26) to change the dressing because it smelled.Review of the physician orders indicated: Treatment to Left knee blistered area: Wash with wound wash, apply Xeroform gauze to area, cover with ABD pads, (abdominal pads) and secure in place with brace every Monday, Wednesday, Friday & PRN (as needed) until healed, initiated 4/17/26.Review of the nurse progress note dated 5/16/26 indicated: L (left) leg wound changed today with good effect.During an interview on 5/17/2026 at 10:06 A.M., Nurse #2 said that she worked on 5/16/26 and performed a dressing change for Resident #4 because the dressing had gotten wet from a shower the day before (5/15/26). Nurse #2 said there was some scant bleeding and odor because the dressing was wet. Nurse #2 said she could not recall if she changed the dressing because Resident #4 had told her that it was not done on 5/15/26 as ordered.Review of the May 2026 Treatment Administration Record (TAR) indicated that Nurse #1 completed the wound dressing on 5/15/26 as ordered, contradicting Resident #4's statement.During an interview on 5/17/26 at 10:08 A.M., Nurse #1 said that she did not change Resident #4's dressing on Friday 5/15/26 because he/she had a shower. Nurse #1 did not respond when the surveyor inquired why the treatment was signed off as completed on the TAR. Nurse #1 said that she did the treatment on Thursday, (5/14/26). because Resident #4 had been working with rehab.On 5/18/26 at 10:37 A.M., the surveyor observed Nurse #1 perform the wound dressing change on Resident #4's knee. Resident #4 told Nurse #1 that the dressing was not changed on Friday. Nurse #1 said that she did not do the wound dressing on Friday but thought she did on Thursday. Resident #4 said that the wound dressing was changed on Wednesday and Saturday.During an interview on 5/18/26 at 11:56 A.M., the Director of Nursing said that nursing should complete treatments as ordered. The Director of Nursing said that Nurse #1 should have documented she completed a dressing change on Thursday 5/14/26 and not indicated she had done a dressing change on 5/15/26.

Based on observations and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on two of two units. Findings include: Review of the facility policy titled, Food Serving Temperatures, not dated, indicated that foods will be maintained at proper holding temperatures to ensure food safety. The temperature of potentially hazardous cold foods will not be greater than 45 F (degrees Fahrenheit) when served to the resident. Review of the facility policy titled, Food Presentation, not dated, indicated that foods will be served at proper temperatures. Hot foods hot and cold foods cold. During the initial tour of the facility on 6/8/25 the surveyors met with residents. Thirteen residents voiced dissatisfaction with the temperature and/or taste of the food served at the facility. During the resident group meeting on 6/8/25 at 1:30 P.M. the surveyor met with Residents and the following complaints were made by four residents: - The foods that were cold were not always served cold. - The foods that were hot were not always served hot. - Menus were not always followed. - They should be served condiments like cranberry sauce with hot turkey sandwiches or sour cream with a baked potato. Review of the sign titled, Monday Lunch Menu, indicated the following: - Ziti Baked - Tossed Salad with Dressing - Garlic Bread - Gelatin On 6/9/25 at 12:47 P.M., the surveyor completed a test tray on the [NAME] Unit to determine palatability and temperature of the food served, the results were as follows: - Pasta in tomato sauce- 142 degrees Fahrenheit and hot, bland taste - Mixed green salad- 98 degrees Fahrenheit, warm to taste and the cucumber was bitter, served on the same plate as the pasta. - Garlic toast- hard and unable to chew. - Milk- 65 degrees Fahrenheit, warm to taste. - Fruit cup- 72 degrees Fahrenheit and warm to taste. - Coffee- 140 degrees Fahrenheit and hot. On 6/9/25 at 12:24 P.M., the food truck arrived at the Seaside Unit at 12:29 P.M. and the surveyor completed a test tray to determine palatability and temperature of the food served, the results were as follows: - Pasta in a tomato sauce- 138 degrees Fahrenheit, bland taste. - Mixed green salad- 98 degrees Fahrenheit, warm to taste, wilted, and the cucumber was bitter, and served on the same plate as the pasta in tomato sauce. - One piece of garlic toast, too hard to chew, crouton texture. - One piece of white toast, too hard to chew, crouton texture. - Cranberry juice 58 degrees Fahrenheit, lukewarm taste. - Canned fruit 60 degrees Fahrenheit, lukewarm taste. During an interview on 6/9/25 at 12:38 P.M., several staff members at the Seaside Unit said that the kitchen usually serves cold salad on the plate with the hot pasta. The staff said that this meal usually has meat mixed in the pasta. On 6/9/25 between 12:39 P.M. through 12:49 P.M., the surveyor interviewed six Residents who were eating their lunch, and the Residents told the surveyor the following: - I didn't like the vegetables (salad), they were too bitter and warm - Usually, I love pasta, but this pasta has no flavor and no meat, we shouldn't have a cold salad on a plate with hot pasta, it makes the salad warm, the cucumbers are bitter when warm and the cucumber skin is bitter warmed up - I didn't like the warm salad - Lunch was lousy, got a bunch of salad that was warm, the ziti with the sauce was plain - I got one piece of garlic bread, and I got one piece of dry white bread, it was hard as rock and difficult to chew - I couldn't eat the salad, it was warm During an interview on 6/9/25 at 1:25 P.M., the Administrator said that the salad should be served in a separate bowl/container to prevent the temperature from going above 42 degrees. The administrator also said that the milk and fruit cup should be kept at no more than 42 degrees. During an interview on 6/9/25 at 1:25 P.M., the Corporate Nursing Director said that the salad should be served in a separate bowl/container, not on a hot plate, to prevent the salad from becoming too hot. During an interview on 6/9/25 at 1:27 P.M., the Food Service Director (FSD) said that there was no meat to add to the pasta today. The FSD said she did not thaw out meat to use with the meal, so she just served the pasta as it is without a meat substitution. During an interview on 6/10/25 at 9:34 A.M., the Dietitian said the cold salad should have been served separately in a bowl and not on a plate containing hot foods. During a follow up interview on 6/10/25 at 8:27 A.M., the Administrator said temperature safety and palatability is important for the residents and for the kitchen to serve food at the correct temperatures. The Administrator said the salad should have been stored separately to keep it at the correct temperature and the cook should have followed the recipe for the baked ziti.

Based on observation, record review, and interview, the facility failed to serve what was listed on the menu or provide a substitution for two lunch meals. Specifically, on 6/8/25 the facility failed to serve sour cream with the baked potato during the lunch meal and on 6/9/25 the facility failed to add meat to the baked ziti according to the facility's recipe during the lunch meal. Findings include: Review of the policy titled, Food Presentation, undated, indicated the following: - Foods are prepared according to standard recipes. During the resident group meeting on 6/8/25 at 1:30 P.M. the surveyor met with Residents and the following complaints were made by four residents: - Menus were not always followed. - Should have condiments like sour cream with a baked potato. On 6/8/25 at 12:10 P.M., the surveyor observed lunch being delivered to residents' rooms. The main lunch meal consisted of a slice of pork, brussels sprouts, a baked potato, margarine, and watermelon. Review of the recipe for lunch, 6/8/25, indicated the baked potato was to be served with sour cream. During an observation of lunch on 6/8/25 12:13 P.M., two residents reported wanting sour cream with their baked potatoes and did not receive it. On 6/9/25 at 11:45 A.M., the Food Service Director (FSD)/cook was observed plating baked ziti with plain tomato sauce (without meat), a tossed salad, garlic toast, and a fruit cup. Review of the recipe for lunch, 6/9/25, indicated the baked ziti was to be served with meat sauce, breadsticks, and gelatin. On 6/9/25 at 12:39 P.M. through 12:49 P.M., the surveyor interviewed two Residents who were eating their lunch, and the Residents told the surveyor the following: - Usually I love pasta, but this pasta has no flavor and no meat. - Lunch was lousy, the ziti with the sauce was plain. During an interview on 6/9/25 at 2:57 P.M., the Food Service Director said she was not in the facility on Sunday, but the menu should have been followed, and sour cream should have been provided to the residents with the baked potato. The Food Service director said there was no meat sauce served with the baked ziti today because the meat was not thawed out in time and she did not have a substitute protein to provide to the residents for lunch. During an interview on 6/10/25 at 8:28 A.M., the Administrator said that food should be prepared according to the recipe, and she was unaware the kitchen did not have beef for the pasta for lunch on 6/9/25 until after lunch had concluded. The Administrator said that the FSD should have notified her so they could have come up with an alternate protein or they could have gone to the store to get some beef for the lunch meal. During an interview on 6/10/25 at 9:38 A.M., the Dietitian said following the menu is extremely important, the beef is an important part of the recipe because it adds a combination of protein, fat, and iron to the Residents diet. The Dietitian said she was not aware of the change to the meal prior to lunch being prepared and served and said there should have been a substitute for the lack of beef. The Dietitian also said that sour cream should have been served with the baked potato for Sunday lunch.

Based on record review, observation and interviews, the facility failed to ensure one Resident (#36) out of a total sample of 18 residents did not self-administer medication without an assessment or physician's order. Findings include: Review of the facility policy titled Self-Administration of Medications dated as revised February 2021 indicated that as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Further review indicated that if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Resident #36 was admitted to the facility with diagnoses including asthma, amputation of toe multiple sites and depression. Review of the Minimum Data Set assessment, dated 5/5/25, indicated that Resident #36 is cognitively intact as evidence by a score of 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #36 requires set up assistance to substantial assistance for activities of daily living. On 6/8/25 at 7:55 A.M. and 1:41 P.M., the surveyor observed a Primatene mist inhaler (used for asthma), a bottle of calcium carbonate tablets (an antacid) and a tube of triamcinolone cream (a topical steroid) on the over the bed table, in full view. During an interview on 6/8/25 at 7:55 A.M., Resident #36 said nursing was not aware of the inhaler but that he/she has had the inhaler, and the antacid and the cream on the over the bed table for a while now. Review of the Resident's active care plan failed to indicate a plan of care for the self-administration of medications. Review of the physician's orders dated June 2025 failed to indicate an order for the self-administration of medication. Further review failed to indicate either an order for the inhaler or the calcium carbonate. Review of the medical record failed to indicate that Resident #36 has been assessed for the ability to self-administer medications. During an interview on 6/8/25 at 1:48 P.M., Resident #36 said that he/she had had two meals delivered to him/her by staff so far today and had just had staff provide morning care. Resident #36 said the medications were visible at all times to staff and no one said anything about them. During an interview on 6/8/25 at 1:48 P.M., Nurse #1 said that Resident #36 should not have medications at the bedside. Nurse #1 said residents should be assessed for the ability to self-administer medications before the medications can be left with the resident. During an interview on 6/9/25 at 8:10 A.M., the Director of Nursing (DON) said that residents are to be assessed for self-administration of medication prior to having medications left at bedside. The DON then said that Resident #36 was not assessed for the ability to self-administer medications. During an interview on 6/9/25 at 12:20 P.M., Certified Nurse's Aide #5 said that he is Resident 36's regular CNA, but he didn't notice any medications on the Resident's over the bed table. CNA #5 then said that Resident #36 should not have medications at bedside, and he would have removed them if he had noticed them.

Based on observation, record review and interview, the facility failed to consistently accommodate resident food allergies for one Resident (#26) out of a total sample of 18 residents. Specifically, for Resident #26 a. the facility failed to ensure the kitchen did not serve the Resident eggs which were listed as an allergy on his/her diet ticket, and eggs are served/offered 17 times during a 28 day menu cycle and b. the facility failed to consistently document food allergies in the medical record and on the diet ticket, including an allergy to peaches on his/her diet ticket which is offered as a dessert five times during a 28 day menu cycle. Findings include: Review of the facility policy titled, Food Allergies, undated, indicated during hours of food service operation, the kitchen will make reasonable accommodations for patients with life threatening allergies and all other food allergies. 1. Obtain copy of diet prescription order form with specific food allergies from nursing services. 2. Dietary services will list food allergies on tray card. 3. Dietary services will make modifications, under the directions of the Food and Nutrition Services Director and/or Dietitian, to meals and snacks. Resident #26 was admitted to the facility in June 2023 with diagnoses including diabetes, hypertension, and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/15/25, indicated that Resident #26 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS indicated Resident #26 required setup or clean-up assistance with eating. Review of Resident #26's plan of care related to eating, dated as 6/20/23, indicated the following: - EATING: Resident is independent after set up. a. On 6/8/25 at 8:21 A.M., the surveyor observed Resident #26's breakfast tray. There was a hard-boiled egg cut in half on his/her plate. Resident #26's food ticket indicated the following: Allergy - Eggs. Resident #26 said that he/she is allergic to eggs, and he/she experiences belly upset and diarrhea, Resident #26 said he/she would not eat the eggs on his/her plate. Review of Resident #26's diet ticket indicated the following allergies: - Eggs, fish, nuts, pork, shellfish, raisin, pork, peanut butter, **see report**. The medical record failed to include documentation to support Resident #26 has an allergy to eggs. b. Review of Resident #26's current allergies listed in the electronic health record included the following allergies and allergic response: - Peach / severity: unknown - Peanut butter / severity: unknown - Pork / severity: unknown - Raisin / severity: unknown Review of Resident #26's physician's order, dated 6/17/23, indicated: - Regular diet, Regular texture, thin consistency, allergic to nuts, peanut butter flavor, peanut oil, pork/porcine products, shellfish. Further review of the physician's order failed to indicate an allergy to eggs or peaches. Review of Resident #26's most recent assessment titled, Nutritional Risk Evaluation Quarterly - V2, dated 11/20/24, indicated: B. Relevant Medical History 3. Food Allergies: RAISIN, PORK, PEANUT BUTTER, PEACH, SHRIMP 4. Nutrition Plan: Provide preferred foods. Further review of the nutrition assessment failed to indicate an allergy to eggs. Review of the facility's four-week menu plan, dated 2025, indicated that the kitchen serves peaches as dessert on five occasions during the 28-day menu cycle and the kitchen serves eggs 17 times during the 28-day menu cycle. During a follow-up interview on 6/10/25 at 3:33 P.M., Resident #26's said he/she is allergic to peaches and that peaches cause stomach upset. During an interview on 6/9/25 at 10:43 A.M., Certified Nursing Assistant (CNA) #1 said that Resident #26 does not like eggs and that nurses will always check the trays to ensure the trays are correct before the CNAs can deliver the trays to residents. During an interview on 6/9/25 at 2:44 P.M., the MDS nurse said that nursing routinely checks the diet ticket for diet textures and allergies before staff pass out the trays. During an interview on 6/9/25 at 2:26 P.M., the Director of Nursing (DON) said allergies should be followed by the kitchen and checked by nursing prior to delivering the tray to the resident. The DON referenced the diet ticket and the Resident's allergies listed in the electronic health record and the DON said that there were discrepancies, and the allergies would need to be reviewed by the Dietitian. During an interview on 6/9/25 at 2:30 P.M., the Food Service Director said the allergies should be checked by the kitchen staff and then again by nursing staff to ensure that Resident's do not receive foods they are allergic to, the FSD said that Resident #26's dining ticket doesn't list peaches on the diet ticket, and she wasn't aware of Resident #26's allergy to peaches. The FSD said the **see report** on the diet ticket does not have a report but it is an error on the diet ticket. During an interview on 6/10/25 at 9:42 A.M., the Dietitian said that there are a lot of eyes on trays before they get to the resident, and staff need to check allergies prior to providing trays. The Dietitian said she would review the inconsistencies during her next visit, and she said she does not refer to diet ticket allergies to those listed in the electronic health record during her assessments, but she should. During an interview on 6/10/25 at 8:33 A.M., the Administrator said the kitchen is responsible for checking allergies first and then when the food truck arrives at the unit the nurse who is checking the truck should check prior to delivering tray to the resident.

Based on observations, record review, and interviews, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#27) out of sample of 18 residents. Specifically, for Resident #27, the facility failed to change oxygen tubing as indicated in the physician's orders and the facility failed to ensure staff consistently stored oxygen tubing in a sanitary manner when not in use. Findings include: Review of the facility policy titled, Oxygen Administration, dated as revised October 2010, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #27 was admitted to the facility in April 2024 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and dyspnea (difficulty breathing). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/28/25, indicated that Resident #27 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #27 required oxygen therapy. On 6/8/25 at 7:23 A.M., the surveyor observed Resident #27 receiving oxygen from a nasal canula from an oxygen concentrator. The oxygen tubing was undated. There was a bag attached to the concentrator dated 5/23/25. There was a portable oxygen concentrator resting on top of a pile of books, on top of a plastic storage unit, this oxygen tubing was undated, and the tubing was resting on books and a container of bird seed (not stored in a sanitary manner). Resident #27 said that nursing staff are supposed to change his/her oxygen tubing weekly and they (nursing staff) have not changed his/her oxygen tubing in a few weeks, and this is not that first time that they haven't changed his/her tubing weekly. On 6/8/25 at 12:22 P.M. and on 6/9/25 at 8:15 A.M., the surveyor observed Resident #27 receiving oxygen via a nasal canula from a concentrator and tubing was undated, the bag on the concentrator was dated 5/23/25. Resident #27's portable oxygen concentrator oxygen tubing was resting on top of a pile of books, on top of a plastic storage unit, this oxygen tubing was undated, and the tubing was resting on books and a container of bird seed. On 6/9/25 at 10:33 A.M., the surveyor observed Resident #27's receiving oxygen and the tubing was dated as 6/4/25, the bag on the oxygen concentrator was dated 5/23/25. The oxygen tubing for the portable oxygen concentrator was unlabeled and not stored in a bag and the tubing was resting on top of a pile of books on a plastic storage unit. Resident #27 said that staff did not change his/her oxygen tubing today nor did they change the tubing on 6/4/25 and said the tubing has not been changed in a few weeks. On 6/9/25 at 2:27 P.M., the surveyor along with the Director of Nursing (DON) observed Resident #27's portable oxygen tubing stored on top of a pile of books on a plastic storage unit, the tubing was undated, and the tubing was not stored in a plastic bag and the nasal cannula was up against the wall. Review of Resident #27's grievance form, dated 4/11/25, indicated: Section 1 - Nature of the Concern: that the facility had received a fax from the Nurse Practitioner who did a visit with the Resident and that Resident stated the oxygen tubing was not changed. Section 2 - Department Head Review: Physician order to change oxygen tubing weekly on Wednesday when regular staff is working. Review of Resident #27's physician's order, dated 4/1/24, indicated: - Oxygen (O2) via nasal cannula (NC) continuously at 2 liters per minute (LPM) to maintain saturation (SAT) at or above 94%, every shift. Review of Resident #27's physician's order, dated 5/13/25, indicated: - Change oxygen (O2) tubing weekly, every night shift on every Wednesday for infection control, label with date and initial, provide respiratory bag for storage when not in use. Review of Resident #27's Treatment Administration Record (TAR), dated 5/28/25 and 6/4/25, indicated nursing implemented the physician's order indicating Nurse #3 changed, labelled, and dated the oxygen tubing and provided a respiratory bag, as ordered by the physician. During an interview on 6/9/25 at 3:41 P.M., Certified Nursing Assistant #4 said she used Resident #27's portable oxygen concentrator during the Resident's shower on 6/8/25. During an interview on 6/9/25 at 3:35 P.M., Nurse #2 said that oxygen tubing should be changed weekly on the night shift, the oxygen tubing should be dated, and the tubing should be stored in a bag when not in use. During an interview on 6/9/25 at 2:27 P.M. the DON said she was aware of Resident #27's oxygen tubing concerns, and she had filed a grievance in the past for staff not changing Resident #27's oxygen tubing. The DON said that on 6/9/25 she noticed that Resident #27's oxygen tubing was not labelled with the date and the DON said that she looked at the TAR and she put a piece of tape on the oxygen tubing with the date the tubing was last supposed to be changed (6/4/25) and she dated the tubing that Resident #27 was currently using. The DON said that nursing should implement the physician's order and change the tubing and date the tubing in accordance with the physician's order. The DON said that oxygen tubing should be stored in a sanitary manner when not in use. On 6/9/25, 6/10/25, and 6/11/25, the surveyor attempted to interview Nurse #3 but she was unable to be reached.

Based on observations, interviews and policy review, the facility failed to properly store food items to prevent the risk of foodborne illness and in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled Preventing Foodborne Illness - Food Handling, revised [DATE], indicated the following: - Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimalized. - Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees F (Fahrenheit). The surveyor made the following observations during the initial kitchen walkthrough on [DATE] at 7:15 A.M.: In the reach-in refrigerator: - A hanging thermometer displaying a temperature of 50 degrees Fahrenheit. Resident food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. - A container containing what resembled red sauce with no identification label and a dated label of ,d+[DATE] - A container containing what resembled cooked chicken with no identification label and a dated label of ,d+[DATE] - A container with no identification label containing pinto beans covered in a thick, white, milky substance with a dated label of ,d+[DATE] - A container with no identification label containing what resembled chocolate pudding with a faded dated label of ,d+[DATE]. On the substance was an area of a white, fuzzy substance and a black fuzzy substance resembling mold. - Two gallons of milk with an expiration date of [DATE]. In the dry storage room: - A box of potatoes containing potatoes with dark, soft spots as well as potatoes with green spores sticking out of them. - Three piles of boxes containing food product directly on the floor. During the revisit to the kitchen on [DATE] at 7:45 A.M., the surveyor made the following observations: - In the reach in refrigerator, a hanging thermometer displayed the temperature of 58 degrees Fahrenheit. The surveyor put a second thermometer in the refrigerator. Resident food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. During an observation on [DATE] at 9:31 A.M., the surveyor observed both hanging thermometers displaying the temperature of 60 degrees Fahrenheit. Resident food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. During an interview on [DATE] at 7:25 A.M., the Foodservice Director (FSD) said his expectations are that all food should either be used or thrown out within three days of the date on the product. He continued to say the date written on the products represents the expiration date of the product. The FSD continued to say they do not write what the product is because the labels are too small, and he wants to update the system at some point. The FSD continued to say the expired food products should have been thrown away. During an interview on [DATE] at 9:31 A.M., the FSD said the reach in refrigerator has been running warm for two days. When asked why the food was not put in a different refrigerator once the warm temperature was identified, the FSD said the food should have been moved to a different refrigerator. The FSD said the ideal temperature range for the refrigerator is between ,d+[DATE] degrees Fahrenheit. During an interview on [DATE] at 10:19 A.M., the Director of Nursing and Regional Nurse said any expired food should have been thrown away and all food should have been moved out of the warm refrigerator when it was identified as not maintaining proper temperature. During an interview on [DATE] at 10:42 A.M., the FSD was unable to provide temperatures of the food in the reach in refrigerator showing they were within a safe temperature range.

Based on observations, interview and policy review, the facility failed to ensure that equipment in the kitchen was functioning properly. Specifically, the facility failed to ensure that a reach-in refrigerator was operating at the proper temperature while resident food was being stored inside of it. Findings include: Review of the facility policy titled Preventing Foodborne Illness - Food Handling, dated and revised [DATE], indicated the following: - Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees F (Fahrenheit). The surveyor made the following observations during the initial kitchen walkthrough on [DATE] at 7:15 A.M.: In the reach-in refrigerator: - A hanging thermometer displaying a temperature of 50 degrees Fahrenheit. Resident food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. During the revisit to the kitchen on [DATE] at 7:45 A.M., the surveyor made the following observations: - In the reach in refrigerator, a hanging thermometer displayed the temperature of 58 degrees Fahrenheit. The surveyor put a second thermometer in the refrigerator. Resident food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. During an observation on [DATE] at 9:31 A.M., the surveyor observed both hanging thermometers in the reach-in refrigerator both displaying the temperature of 60 degrees Fahrenheit. Food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. During an interview on [DATE] at 9:31 A.M., the Food Service Director (FSD) said the reach in refrigerator has been running warm for two days. When asked why the food was not put in a different refrigerator once the warm temperature was identified, the FSD said the food should have been moved to a different refrigerator but was not. The FSD said the ideal temperature range for the refrigerator is between ,d+[DATE] degrees Fahrenheit. During an interview on [DATE] at 10:19 A.M., the Director of Nursing and Regional Nurse said any expired food should have been thrown away and all food should have been moved out of the warm refrigerator when it was identified as not maintaining proper temperature. During an interview on [DATE] at 10:42 A.M., the FSD was unable to provide temperatures of the food in the reach in refrigerator showing they were within a safe temperature range.

Based on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled: The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility policy titled, Antibiotic Stewardship, dates as revised December 2016, indicated the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. -The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. - Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and overall community. - When antibiotics are prescribed over the phone, the primary care practitioner should access the resident within 72 hours of the telephone order. During an interview on 7/17/24 at 2:05 P.M., the surveyor asked the Assistant Director of Nurses (ADON) who is also the infection preventionist in the building, to provide her with the facility's line listing and antibiotic usage audit tool. The ADON said she has line listings that she reviews at the end of the month, and she will review the clinical dashboard for new antibiotics, but the facility does not meet regularly to discuss tracking or trending of infections because the building has not implemented an antibiotic stewardship program. The ADON said infections are only discussed at QAPI quarterly if there is an outbreak. The ADON said she did not have quarterly reports from the lab on antibiotic use in the facility because they have been unable to gather consistent data monthly and are looking for new processes on tracking and getting reports. During an interview on 7/17/24 at 2:28 P.M. the Director of Nurses (DON) said she is new to the facility and is in the process of implementing the Antibiotic Stewardship Program and that the steps are in place for tracking line listings, but the facility needs to gather and track the program better. The DON said she was not aware of the infection control rates currently in the facility and was unable to provide the surveyor with any documentation related to the antibiotic stewardship program.

Based on observations, policy review and interviews the facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene, dated as revised August 2019, indicated This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or , alternatively , soap (antimicrobial or non-antimicrobial)and water for the following situations: b. Before and after direct contact with residents c. Before preparing or handling medications i. After contact with residents' skin k. After handling used dressings, contaminated equipment, etc. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident m. After removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routing hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Procedure: Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. On 7/17/24 at 8:15 A.M., the surveyor observed Nurse #3 don (apply) gloves without performing hand hygiene prior, and then administer eyedrop medication to a Resident. Nurse #3 was then observed to remove her gloves, touching the contaminated glove with her bare hand, and without performing hand hygiene after discarding the contaminated gloves. Nurse #3 then touched the Residents bed linens, returned to the medication cart located in the hallway and placed the eyedrop medication into the medication cart. Nurse #3 did not perform hand hygiene at any time during this observation. On 7/17/24 at 8:22 A.M., Nurse #3 was observed to enter a resident room and administered medications in applesauce with a spoon then exited the resident room without performing hand hygiene. Nurse #3 did not don gloves or perform hand hygiene during the observation. On 7/17/24 at 9:31 A.M., Nurse #3 was observed to don another pair of gloves and administer an insulin injection with out performing hand hygiene. Nurse #3 then touched the Residents clothing covering up the injection area and carried the insulin pen into the hallway with her gloves on. Nurse #3 placed the insulin pen on top of the medication cart and removed her gloves touching the contaminated glove with her bare hand, and without performing hand hygiene after discarding the contaminated gloves. Nurse #3 did not perform hand hygiene at any time during this observation. During an interview on 7/17/24 at 9:41 A.M., Nurse #3 said she should not touch the contaminated glove with her bare hand and said the expectation is that she would use hand sanitizer or soap and water before and after glove use and when entering and after exiting a resident room. During an interview on 7/17/24 at 2:09 P.M., the Assistant Director of Nursing (ADON) said the expectation for staff is to perform hang hygiene before entering a resident's room and prior to leaving the resident's room. The ADON said staff should not touch the outside contaminated glove and should remove the gloves correctly and perform hand hygiene after glove removal. During an interview on 7/17/24 at 2:27 P.M., the Director of Nursing said she expects staff to follow infection control guidelines, perform proper glove removal and perform hand hygiene before and after glove use. The DON said staff should not be wearing gloves in the hall or placing contaminated items on top of the medication cart.

Based on observations, record reviews and interviews, the facility failed to ensure accurate medical records for one Resident (#32) out of a total sample of 18 residents. Specifically, for Resident #32, the facility failed to accurately document the level of supervision received during meals. Findings Included: Resident #32 was admitted to the facility in February 2024 with diagnoses including dysarthria (poor articulation of words) following other cerebral vascular disease and dysphagia (difficulty swallowing). Review of Resident #32's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. Further review of the MDS indicated Resident #32 is on a mechanically altered diet, require change in texture of food or liquids (e.g., pureed food, thickened liquids). On 7/16/24 at 8:25 A.M.,12:19 P.M. and 12:32 P.M., and 7/17/24 at 8:25 A.M. and 8:33 A.M., Resident #32 was observed eating in his/her room. There were no staff present to provide one-to-one assistance, or to offer small bites/sips to ensure the resident eats and drinks slowly. Review of Resident #32's physician order dated 2/17/24 indicated the following: - Aspiration Precautions, Resident must be sitting upright at 90 degrees for all meals and stay in the upright position for 30 minutes after waiting ,1;1 assist with all meals, offer small bites/sips and ensure that the resident eats/drinks slowly every shift. Review of Resident #32's Treatment Administration Record (TAR) for June and July 2024 indicated staff had signed off that he/she received one to one supervision during his/her meals. During an interview on 7/17/24 at 8:44 A.M., the Assistant Director of Nursing said Resident #32's physician order should be followed and documented on the TAR correctly. During an interview on 7/17/24 at 10:39 A.M., the Director of Nursing said the nurses should be following physician's orders and should not document in the TAR if the one-to-one supervision is not being provided to Resident #32.

Based on observation, record review and interview the facility failed to ensure the air mattress was set at the appropriate setting for one Resident (#44) with a stage 4 pressure ulcer out of a total sample of 18 residents. Findings include: The facility policy titled Prevention of Pressure Injuries, revised April 2020, indicated the following: -1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Set according to manufacturer guidance. Review of the manufacturers guidance for the air mattress that Resident #44 utilizes indicated: -Determine the patient's weight and set the control to that weight setting on the control unit. Resident #44 was admitted to the facility in February 2024 with diagnoses that included stage 4 pressure ulcer of sacral region and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) , dated 5/2/24, indicated that on the Brief Interview for Mental Status, Resident #44 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #44 had no behavior of rejecting care. Review of the current Activities of Daily Living (ADL) care plan indicated the following interventions: - BED MOBILITY: Resident #44 requires 2 staff participation to reposition and turn in bed. - BED MOBILITY: Resident #44 is totally dependent on staff for repositioning and turning in bed. Review of the current Stage 4 pressure ulcer care plan indicated the following interventions: - Air mattress for pressure relief check function q (each) shift. - Pressure reduction mattress to prevent skin breakdown as ordered. Review of the clinical record indicated the following assessments: - A Weekly Skin Review assessment, dated 7/11/24, indicated Resident #44 continued to have a pressure ulcer on his/her coccyx. - A Weekly Wound assessment, dated 7/11/24, indicated Resident #44 had an unstageable pressure area on his/her coccyx. Interventions included pressure redistribution mattress. - A Quarterly Nursing Evaluation with [NAME], dated 5/14/24, indicated on the Norton Plus Scale for Predicting Pressure Ulcers Resident #44 scored a 10, indicating Resident #44 was high risk. The assessment further indicated Resident #44 required total assist with transfers and mobility. Review of the current weight report, dated 7/1/24, indicated Resident #44 weighs 164.0 pounds (lbs). On 7/16/24 at 7:28 A.M., Resident #44 was observed in bed asleep and the air mattress was set at 280 lbs. On 7/17/24 at 7:58 A.M., Resident #44 was observed in bed asleep and the air mattress was set at 300 lbs. During an interview with Resident #44's Certified Nursing Assistant (CNA) #1 on 7/17/24 at 9:16 A.M., he said that the air mattress setting are set by the company that provides the air mattress. CNA #1 said that the air mattress should be set to a resident's weight and that he never changes the settings for Resident #44's air mattresses. As well, CNA #1 said that Resident #44 requires one to two person assistance with bed mobility and could not change the setting him/herself. During an interview with Resident #44's Nurse (#2) on 7/17/24 on 9:28 A.M., she said that the air mattress's are set to a resident's weight and that the risk if a bed is too firm (greater than the resident's actual weight by approximately 150 lbs.) for a Resident with a stage 4 pressure ulcer on the coccyx would be that it could potentially effect the ability to heal the wound. During an interview with the Director of Nursing on 7/17/24 at 1:37 P.M., she said air mattress's should be set per resident comfort. The DON said that she would provide the manufacturer's guidelines as per the facility policy they defer to the guidelines for settings. During a follow-up interview with the DON on 7/17/24 at 2:04 P.M., the DON provided the surveyor with the manufacturer's guidance for Resident #44's air mattress and it was reviewed together. The DON said that if the facility was not going to follow the facility's policy regarding air mattresses for a Resident who has a stage 4 pressure ulcer, then the facility should have taken the next step and discussed this with the Resident's responsible party.

Based on observations, record reviews and interviews, the facility failed to ensure that one Resident (#13) received treatment and care in accordance with professional standards of practice out of a total sample of 18 residents. Specifically, for Resident #13 the facility failed to: 1a. Change the Residents' PICC (A peripherally inserted central catheter (PICC), is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) line dressing when the insertion site was unable to be visualized, 1b. Measure the PICC line on admission and with the dressing change on 7/10/24 as ordered, 2. Transcribe a new treatment order from the hospital discharge paperwork. Findings Include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, dated 3/22, indicated The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Change the dressing if it becomes damp, loosened or visibly soiled. Resident #13 was readmitted to the facility in July 2024 with diagnoses that included osteomyelitis of the right big toe, type 2 diabetes, and cellulitis. Review of Resident #13's Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. 1a. On 7/16/24 at 8:23 A.M. and 7/17/24 at 8:36 A.M., the surveyor observed Resident #13's PICC line in his/her right arm dated 7/10/24, the insertion site was unable to be seen due to the site being covered in blood. Review of Resident #13's physician order, dated 7/9/24, indicated IV-PICC - change transparent dressing on admission, then weekly and PRN thereafter. During an interview on 7/17/24 at 8:42 A.M., Nurse #1 said a PICC line dressing should be changed as needed if the insertion site is not able to be visualized. During an interview on 7/17/24 at 8:44 A.M., the Director of Nurses (DON) said the expectation is nursing would change the PICC line dressing if the insertion site is not able to be seen. 1b. On 7/16/24 at 8:23 A.M. and 7/17/24 at 8:36 A.M., the surveyor observed Resident #13's PICC line in his/her right arm dated 7/10/24. Review of Resident #13's physician order, dated 7/9/24, indicated IV-PICC - Measure catheter length on admission and with each dressing change thereafter. Review of Resident #13's medical record did not indicate that nursing measured his/her PICC line on admission 7/7/24 or on 7/10/24 with the PICC line dressing change. During an interview on 7/17/24 at 8:42 A.M., Nurse #1 said when a resident is admitted with a PICC line nursing should change the PICC line dressing and obtain baseline measurements of the PICC line. Nurse #1 said she changed Resident #13's PICC line dressing on 7/10/24 and if she measured the PICC line it would be in a nursing progress note. Review of Resident #13's nursing progress notes from 7/7/24 to 7/16/24 did not indicate PICC line measurements were obtained. During an interview on 7/17/24 at 8:44 A.M., the Director of Nurses (DON) said the expectation is that nursing follow physician orders. The DON said the admitting nurse should have measured the PICC line upon admission and with each dressing change as ordered. 2. Review of Resident #13's hospital discharge summary, dated 7/7/24, indicated Wash wounds to bilateral feet with warm soapy water. Pat Dry. Apply Aqauacel AG Advantage (primary dressings for infected or at-risk wounds) to the wound beds. Cover with bordered foam. Change daily. Review of Resident #13's physician order, dated 6/13/24, indicated Treatment to callous plantar aspect Right great toe: Wash area with wound cleanser, pat dry, apply small amount bacitracin (medication is used to prevent minor skin infections caused by small cuts, scrapes, or burns) and cover with DPD (dry protective dressing) daily. During an interview on 7/17/24 at 8:42 A.M., Nurse #1 said the admitting nurse goes over all discharge instructions on the day of admission which was 7/7/24 with either the NP or MD and said the treatment orders for Resident #13's right foot should have been ordered but were not. Nurse #1 said Resident #13 has wounds on both of his/her feet that receive a treatment of bacitracin and a DPD daily. Nurse #1 said the Resident was sent out to the hospital from this facility due to his/her wounds. During an interview on 7/17/24 at 8:44 A.M., the Director of Nurses (DON) and Regional Nurse #1 said the expectation when a resident returns from the hospital is that the admitting nurse would relay all discharge instructions to the provider and the nurse would then write the new physician orders on the day of admission. The Director of Nurses (DON) and Regional Nurse #1 said the hospital wound treatment for Resident #13 should have been ordered the day of admission but was not.

Based on observation, record review and interview the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for two dependent Residents (#44 and #32) out of a total sample of 18 residents. Specifically: 1. For Resident #44, the facility failed to ensure assistance was provided with bed mobility and eating as indicated in the plan of care. 2. For Resident #32, the facility failed to ensure supervision with meals was provided as indicated in the plan of care. Findings include: The facility policy titled Activities of Daily Living (ADL), Supporting, revised March 2018, indicated the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. dining (meals ad snacks). 1. Resident #44 was admitted to the facility in February 2024 with diagnoses that included stage 4 pressure ulcer of sacral region and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that on the Brief Interview for Mental Status exam, Resident #44 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #44 had no behavior of rejecting care. Review of the current Activities of Daily Living (ADL) care plan indicated the following interventions: -Eating: Resident #44 requires cueing & occasionally assistance to eat. Review of the Kardex (resident specific care instructions for the caregivers to follow) indicated: -Eating: Resident #44 requires cueing & occasionally assistance to eat. Review of the clinical record failed to indicate Resident #44 refused care. Review of the most recent Speech Therapy discharge summary, dated 4/5/24, indicated the following: -Min risk of choking with mechanical soft. Pt (patient) is responding better to family cueing him/her to swallow before taking another bite of food. Family and caregivers are sitting pt upright and cutting (sic) food to small bite size pieces. -Functional Skills/Outcomes: swallowing abilities=min/close supervision. On 7/16/24 at 8:00 A.M., the surveyor observed a staff person deliver breakfast to Resident #44 who was in his/her room in bed. The staff person set up the breakfast on a tray table directly in front of Resident #44 then exited the room leaving Resident #44 without cueing or assistance. The surveyor continued to observe Resident #44 who was slumped sideways in bed, with the head of the bed at a 45 degree angle. Resident #44 was struggling to self feed, kept dropping the food, and appeared to have a difficult time reaching the food due to the position that he/she was in in the bed. On 7/17/24 at 8:00 A.M., the surveyor observed a staff person deliver breakfast to Resident #44 who was in his/her room in bed asleep. The staff person set up the tray, woke Resident #44 up and exited the room to continue passing trays to other residents. Resident #44 was left alone in the room without cueing or supervision. The surveyor continued to make the following observations. -At 8:05 A.M., Resident #44 was in bed, with the head of the bed at a 45 degree angle, attempting to self feed. He/she appeared to be having difficulty reaching the items on the tray due to the position of the head of the bed and was using one hand to spin the tray around to reach items on the the far side of the tray. -At 8:07 A.M., Resident #44 picked up an unpeeled banana that was on his/her tray, looked at it for a period and then placed it back down. -At 8:10 A.M., Resident #44 remained alone without cueing or assistance, there was milk and juice spilled all over his/her tray, as well as multiple pieces of egg dropped on the tray and in his/her lap. During an interview with Resident #44's Certified Nursing Assistant (CNA) #1 on 7/17/24 at 9:16 A.M., he said that Resident #44 requires one person assistance for bed mobility when he is taking care of the Resident and 2 person assistance when the girls are providing care. CNA #1 said that Resident feeds self breakfast in his/her room and does okay aside from sometimes shaking and spilling drinks. He said that Resident #44's mother is present to assist as needed with lunch and dinner every day. CNA #1 said that he does not know what cueing with meals means and does not know what the Kardex is. During an interview with Resident #44's Nurse (#2) on 7/17/24 on 9:28 A.M., she said that cueing and assistance means the staff must stay with the resident for the meal and provide cues and as needed assistance depending on how the Resident is doing that day. During an interview with the Director of Nursing on 7/17/24 at 1:37 P.M., she said that if a resident requires cues and supervision with meals then staff should pop in and out and check on them. 45343 2. Resident #32 was admitted to the facility in February 2024 with diagnoses that included dysarthria (poor articulation of words) following other cerebral vascular disease and dysphagia (difficulty swallowing). Review of Resident #32's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. Further review of the MDS indicated Resident #32 is on a mechanically altered diet, require change in texture of food or liquids (e.g., pureed food, thickened liquids). On 7/16/24 at 8:25 A.M.,12:19 P.M. and 12:32 P.M., and 7/17/24 at 8:25 A.M. and 8:33 A.M., Resident #32 was observed eating in his/her room. There were no staff present to provide one-to-one assistance or supervision. Review of Resident #32's physician order dated 2/17/24 indicated the following: - Aspiration Precautions, Resident must be sitting upright at 90 degrees for all meals and stay in the upright position for 30 minutes after waiting ,1;1 assist with all meals, offer small bites/sips and ensure that the resident eats/drinks slowly. every shift. During a record review on 7/17/24 at 6:47 A.M., Resident #32's care plan last updated on 4/26/24 indicated the following: - Eating: Resident requires cueing and supervision assistance to eat. Review of Resident #32's Kardex (a form indicating level of assistance a resident requires) indicated the following: - Eating: Resident requires cueing and distant supervision to eat. During an interview on 7/17/24 at 8:44 A.M., the Assistant Director of Nursing said Resident #32's physician order should be followed, and the resident should be supervised during all meals. During an interview on 7/17/24 at 10:39 A.M., the Director of Nursing said Resident #32 should be supervised by staff during meals per the physician's order.

Based on observation, record review, and interview, the facility failed to follow professional standards of nursing practice for one Resident (#10) out of a total sample of 18 residents. Specifically, the facility failed to obtain a physician order for an air mattress prior to the resident using one. Findings include: Resident #10 was admitted to the facility in June 2023 with diagnoses including unspecified dementia, moderate protein-calorie malnutrition and polyosteoarthritis. Review of Resident #10's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 indicated severe cognitive impairment. Further review of Resident #10's MDS indicated that he/she requires assistance with all activities of daily living. The surveyor made the following observations: - On 7/16/24 at 7:34 A.M. and 11:58 A.M., Resident #10 was observed laying in his/her bed which was an air mattress set to 80 pounds. - On 7/17/24 at 9:24 A.M. and 10:01 A.M., Resident #10 was observed laying in his/her bed which was an air mattress set to 80 pounds. Review of Resident #10's physician's order dated 7/5/23, indicated that the Resident was currently receiving hospice services. Review of Resident #10's active physician's orders care plans or kardex (nursing care card) failed to indicate the Resident is using an air mattress. Review of Resident #10's skin integrity risk care related to fragile skin dated 6/20/23 indicated the following interventions: - Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Review of Resident #10's hospice care plan dated initiated 7/5/23 and revised 6/21/24 indicated the following interventions: - Keep comfortable, observe for facial grimacing, restlessness, moaning. Review of Resident #10's document titled Norton Scale for Predicting Risk of Pressure Ulcer, dated 7/13/23 indicated that the Resident scored a 10 which indicated he/she is at a high risk for developing pressure ulcers. Review of Resident #10's hospice visitation binder failed to indicate the use of an air mattress. During an interview on 7/17/24 at 10:03 A.M., Nurse #3 said when hospice services make recommendations for orders or interventions, they will write them down and then the facility Nurse Practitioner will review them, write the physician order and then they get implemented at the facility. Nurse #3 and the surveyor reviewed Resident #10's physician's orders and hospice binder and did not identify any mention of using an air mattress. During an interview on 7/17/24 at 10:19 A.M., the Director of Nursing (DON) said hospice services will recommend orders or interventions and then the facility Nurse Practitioner will approve them and implement them at the facility. The DON said Resident #10 should have a physician's order for an air mattress since he/she has been using one.

Based on record review, interview and policy review, the facility failed to develop an individualized, comprehensive care plan for one Resident (#43) out of a total sample of 18 residents. Specifically, the facility failed to develop a comprehensive care plan for Resident #43 related to Type 2 Diabetes Mellitus . Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, indicted the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment and no more than 21 days after admission. - The comprehensive, person-centered care plan includes: measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, includes the resident's stated goals upon admission and desired outcomes. Resident #43 was admitted to the facility in December 2023 with diagnoses including Type 2 Diabetes Mellitus, muscle wasting and atrophy, and anxiety disorder. Review of Resident #43's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 5 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated that the resident has Type 2 Diabetes (T2DM). Review of Resident #43's physician's orders indicated the following: - Dated 7/10/23: Novolog Injection Solution 100 UNIT/ML (milliliters) (Insulin Aspart) - Inject as per sliding scale: if 0 - 299 = 0 no coverage; 300 - 500 = 6 units 6 units; 501+ = 10 units Call MD, subcutaneously three times a day related to Type 2 Diabetes Mellitus. - Dated 7/3/24: HGB A1C (a blood test to show what your average blood sugar level over time) now and every 3 months for Diabetes. Review of Resident #43's active care plans failed to indicate an individualized, person-centered care plan for T2DM. During an interview on 7/17/24 at 10:03 A.M., Nurse #3 said any resident with a diagnosis of T2DM should have a care plan for it. Nurse #3 and the surveyor looked through Resident #43's active care plans together and did not identify a T2DM care plan. During an interview on 7/17/24 at 10:19 A.M., the Director of Nursing said Resident #43 should have a person-centered care plan related to T2DM as he/she has T2DM with fluctuating blood sugars.

Based on record review, interviews, and observation for one of three sampled residents (Resident #1), the Facility failed to ensure the fall prevention plan of care was implemented. On 10/5/12, Resident #1, who was previously observed in bed, was found on the floor next to his/her bed and it was determined he/she had a fractured tooth and nose. The sensor pad alarm was not in place, and the bed was not in the low position per the plan of care, prior to or at the time of, Resident #1's fall. In addition, Resident #2, Resident #3, and Resident #4's plans of care included the use of a "low bed," but the beds were not observed to be positioned in the lowest position during survey, (such that they were lowered to the floor slightly above the positioned that did allowed the bed to move). The findings include: The Facility's accidents and supervision policy, dated 4/28/06, indicated the Facility communicated interventions to relevant staff, assigning responsibility to appropriately trained individual (s), implementing and documenting interventions. The policy indicated the Facility monitors for effectiveness and modification of approaches when necessary. The policy indicated for residents who were identified to be at risk for falls, the Facility was to assess the need for assistive devices, and care plan and implement preventative measures. The [DIAGNOSES REDACTED]. Resident #1's behavior plan of care, re-evaluated 9/12/12, indicated staff were to reapproach Resident #1 at a later time when agitated. The care plan was updated 3/6/12, and indicated when agitated the staff were to make sure Resident #1's surroundings were safe and were to walk away. Resident #1's Profile Card (was without a date) and did not include information that Resident #1 to use two alarms the bed, the type of alarm to be used, or that Resident #1 was to use a low bed. The bed safety evaluation, was without a date, and indicated Resident #1 used a low bed, pressure sensitive alarm, and frequent monitoring by staff. 1. The Facility reportable, dated 10/5/12, indicated at 10:00 P.M. on 10/5/12, Resident #1 rolled out of bed onto the floor. The report indicated Resident #1 broke his/her front tooth (fractured tooth) and was transferred to the emergency department for an evaluation The incident report indicted the fall was unwitnessed, Resident #1 was previously in bed, and Resident #1's activity at the time of the fall was not known. The incident report indicated Resident #1 had interventions in place at the time of the fall which included sensor alarm and low bed. The report indicated Resident #1 used a clip alarm, which was in place but did not sound and used a sensor alarm which the CNA was unable to place under Resident #1 due to Resident #1's agitation. The Surveyor interviewed Certified Nursing Assistant (CNA) #5 at 11:16 A.M. on 12/26/12. CNA #5 said she was assigned to care for Resident #1 on 10/5/12. CNA #5 said she knew Resident #1 and had cared for him/her prior to 10/5/12. CNA #5 said she thought Resident #1 used two different types of alarms and she thought they were both in place when she last saw Resident #1 at approximately 6:20 P.M. CNA #5 was not consistent regarding the position of Resident #1's bed when she last saw Resident #1. CNA #5 said the bed may have been all the way down to the floor, but recalled Resident #1's bed was not supposed to be lowered all the way as low as it safely could be, because Resident #1 liked to sit on the side of the bed and eat with an over the bed table. CNA #5 said that she recalled the Nurse being with Resident #1 at one point attempting to give Resident #1 medications, and did not observe Resident #1 agitated. The Surveyor interviewed CNA #6 at 4:58 P.M. on 12/26/12. CNA #6 said she was assigned to care for Resident #1 during the evening on 10/5/12. CNA #6 said she provided care to Resident #1 at 8:00 P.M., and at that time Resident #1 was in bed. CNA #6 said Resident #1 was at risk for falls, and care plan interventions included the use of two alarms, a clip alarm and a sensor alarm. CNA #6 said she was able to apply the clip alarm, but Resident #1 was too agitated and would not allow her to apply the sensor alarm. CNA #6 said she did not obtain another staff member's assistance to attempt to apply the sensor alarm and did not reproach or observe Resident #1 after 8:00 P.M. to apply th device. CNA #6 was inconsistent regarding whether she informed Nurse #1 and initially said she did tell Nurse #1, but later in the interview said it was possible she did not and should have. CNA #6 said she relied on the nurse to tell her residents who needed a bed lowered to the floor or mats on the floor, but said Resident #1's bed was not lowered to the floor when she left him/her at 8:00 P.M. The Surveyor interviewed Nurse #1 at 9:50 A.M. on 12/27/12. Nurse #1 said Resident #1 was at risk for falls and the care plan interventions included for Resident #1 to use two alarms; a sensor alarm and a clip alarm at all times. Nurse #1 said she was not certain whether Resident #1's care plan interventions included the use of a bed positioned low to the floor. Nurse #1 said that during rounds at approximately 10:00 P.M., CNA #6 informed her that Resident #1 was on the floor next to his/her bed. Nurse #1 said no alarm sounded prior to the CNA informing her, and upon arrival to Resident #1's room, she observed Resident #1 on the floor bleeding from the mouth. Nurse #1 said the clip alarm was attached to Resident #1 but it did not sound because it had not separated from the alarm box. Nurse #1 said Resident #1 had a broken tooth and was unable to provide her with any information regarding the fall due to cognitive impairment. Nurse #1 said she typically administered Resident #1 his/her medications at 7:00 P.M. every evening. Nurse #1 said normally Resident #1 remained out of bed later in the evening, but Resident #1 was in bed most of the shift on 10/5/12 because Resident #1 had a cough. Nurse #1 said she would have observed Resident #1 at different times during the shift prior to the fall, when she administered Resident #1 or his/her roommate medications. Nurse #1 recalled that Resident #1's head of the bed was raised to between 30 and 45 degrees, but the bed was not in the low position at any time she observed Resident #1. Nurse #1 said the bed was in a regular position such that a person would sit on the edge of the bed and place their feet onto the floor. Nurse #1 said she did not see a sensor alarm on Resident #1's bed when he/she was found on the floor, but did not discuss this with the assigned CNA. Nurse #1 said she was more intent on arranging for Resident #1 to be evaluated at the Hospital and did not have time to ask CNA #6 questions regarding the sensor alarm. Nurse #1 said she learned the following day that Resident #1 did not have the sensor alarm in place because Resident #1 was agitated with CNA #6 when CNA #6 attempted to apply the device. Nurse #1 said CNA #6 did not inform her the alarm was not in place or that Resident #1 was agitated, and she did not know whether any staff member reappoached Resident #1 to attempt to apply the sensor alarm prior to Resident #1 being found on the floor. The emergency department record, dated 10/5/12, indicated Resident #1 was noted to have an avulsion of one of his/her incisors, bleeding from the gum, and tenderness over the bridge of the nose. The radiology report, dated 10/5/12, indicated Resident #1 had a minimally depressed fracture of the nasal bones. The Surveyor interviewed the Clinical Manager at 8:45 A.M. on 12/27/12. The Clinical Manager said she spoke with direct care staff after it was determined Resident #1 sustained a fractured tooth and nose as a result of a fall. The Clinical Manager said she learned Resident #1 did not have a sensor alarm on because Resident #1 was agitated during care. The Clinical Manager said she did not ask the CNA whether, she had reapproached Resident #1 to attempt to apply the sensor alarm. The Clinical Manager said based on interviews with the direct care staff, CNA #6 never informed Nurse #1 that the sensor alarm was not in place. The Clinical Manager said she reeducated CNA #6 regarding this expectation. The Surveyor interviewed Nurse #2 at 9:10 A.M. on 12/26/12. Nurse #2 and Clinical Manager said residents who were assessed as being at risk for falls had the term, "low bed/platform bed" checked off on the care plan as a fall prevention intervention. When asked to define a low bed, Nurse #2 and Clinical Manager said all the beds had the capability to be lowered to inches above the floor, but the term low bed to them, meant the bed was positioned in a manner which allowed the resident to sit on the side of the bed and place his/her feet flat on the floor. Nurse #2 and Clinical Manager said they did not know which residents were supposed to have their beds low enough to the floor that it prevented the bed from moving but was much lower than a standard bed height. The Surveyor interviewed the Director of Nurses (DON) at 8:10 A.M. and Staff Development Coordinator (SDC) at approximately 8:56 A.M. on 12/26/12. The Surveyor interviewed the Administrator at 10:30 A.M. on 12/26/12. The Administrator, DON, and SDC said the definition of a low bed was a bed that was to be lower down close to the floor just above the point the bed was able to move. The DON and SDC said they were not aware of a list of residents being maintained whose bed was to be low down close to the floor. The Surveyor interviewed CNA #2 at 9:20 A.M. on 12/26/12. CNA #2 said she worked at the Facility for years. When asked she knew what heights residents' beds were supposed to be positioned in, told the Surveyor she did not believe any list existed, but said the height was based on the staff member's knowledge of the specific residents. The Surveyor asked CNA #2 what she thought the position was for residents whose plans of care called for a, "low bed" and CNA #2 responded that when a resident used a low bed, the bed was to be lowered all the way down to the floor. The Surveyor interviewed CNA #3 at 9:50 A.M. on 12/26/12. The Surveyor interviewed CNA #4 at 10:20 A.M. on 12/26/12. The Surveyor interviewed CNA #5 at 11:16 A.M. on 12/26/12. CNA #2, CNA #3, CNA #4, and CNA #5 said the Facility maintained a list of residents who used alarms, but there was no list for residents who plans of care included the use of mats or a low bed. CNA #3, CNA #4, and CNA #5 were asked by the Surveyor what the phrase, "the resident's care plan included the use of low bed," what does this mean? CNA #3 reponded with two different responses, the first was that the bed was to positioned in a manner that allowed the resident to stand and a subsequent response was for the bed to be lowered to the floor slightly above the point that the bed would move. CNA #4 and CNA #5 said the bed was to be low enough to prevent it from moving. CNA #4 said she knew those residents whose bed was to be in a low position because those residents also used mats and she based the position of the bed on whether or not she observed a mat in the resident's room. CNA #5 said typically she relied on the nurse to tell her whether a resident's bed was to be lowered to the floor. CNA #5 said for her most of the residents were considered to be at risk for falls and therefore she as a matter of practice lowered all residents' beds to the lowest position which could be made without allowing the bed the move.

Based on record review and interviews, for one of three residents (Resident #1) who were at risk for accidents and injuries, the Facility failed to monitor the resident environment for possible accident hazards when Resident #1 purchased a hot water dispenser to make hot tea without staff assistance and on 2/17/11, Resident #1 heated water for tea, poured the hot water into a ceramic mug and spilled the hot water in lap resulting in second degrees burns on both thighs The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 1/4/11, indicated Resident #1 was understood and understood others, repeated three words back without cueing, was oriented to day, month and year. The MDS indicated Resident #1 had no indicators for psychosis or behaviors and required a mechanical lift for transfers. The MDS indicated Resident #1 was totally dependent for dressing and toilet use and was independent with eating and drinking with set-up by staff. Review of Resident #1's Assignment Card (not dated) indicated Resident #1 eats in Resident #1's room (private room), is incontinent of urine, uses a bedpan for bowel movements, requires extensive assistance for grooming, is active, uses an electric wheelchair and travels outside and Certified Nursing Assistant (CNA) to fill ceramic mug for tea. Review of Resident #1's Care Plan Conference Summary, dated 3/7/11, indicated Resident #1 was stable with recent accident with hot water and there was a plan in place for prevention. Review of the Activities of Daily Living section of Resident #1's care plan indicated interventions included use of ceramic mug with lid and Resident #1 working with OT (Occupational Therapy) (undated). Director of Nurses (DON) and Clinical Supervisor (Supervisor) were interviewed on 3/10/11 at 9 AM. Both the DON and Supervisor said they did not know Resident #1 had a hot water dispenser in the room until the accident occurred, which resulted in second degree burns on Resident #1's thighs. The DON said Resident #1 purchased the dispenser online and it was delivered to Resident #1's room without the knowledge of the staff. The DON said after the accident, a plan was implemented to provide an insulated cup with a lid and hot water from the kitchen, which was 180 degrees when drawn from the kitchen urn, 160 degrees when it left the kitchen and about 150 degrees when it reached Resident #1. The DON said Resident #1 did not find the tea hot enough with that plan. The DON said the Facility allowed Resident # 1 to return to use of the hot water dispenser in the room, with a CNA transferring the hot water from the dispenser into a new ceramic mug with a plastic lid and a straw. The DON said the temperature of the hot water from the dispenser had not been assessed, maintenance had not checked the hot water dispenser for electrical safety and no staff inservice education had been done since the accident. The DON said the Facility did not have any manufacturer's information about the hot water dispenser, a policy about hot beverages or electrical safety, and the DON was not aware if the Facility provided residents at the time of admission with written notification about bringing personal electrical equipment into the Facility. (All of these written materials were located or obtained on 3/10/11.) Review of the Facility investigative file, dated 2/18/11, for the occurrence of 2/17/11 indicated the file consisted of the completed Department of Public Health incident report form. On 3/10/11 at 9:00 AM, the Surveyor asked the DON if there were any written statements from the staff regarding the investigation and the DON said Nurse #1 wrote a nursing note in Resident 1's medical record. Resident #1 was interviewed on 3/10/11 at 10 AM. Resident #1 said Resident #1 purchased the hot water dispenser downtown last summer (2010) to use at the Facility with the permission of Administrator. Resident #1 said Resident #1 talked with Social Worker about getting a hot water dispenser. Social Worker told Resident #1 that Resident #1 would have to get permission before acquiring the hot water dispenser. Resident #1 said Resident #1 said at the time of the incident of 2/17/11, Resident #1 was making tea with the hot water dispenser without staff assistance. Resident #1 said the burns occurred when Resident #1 was taking the ceramic mug (this ceramic mug was without a lid and purchased by Resident #1) from the table, the table was wet and the mug tipped, spilling hot water on Resident #1's thighs. Resident #1 said it hurt a lot when the hot water hit Resident #1's thighs. Resident #1 said the burns were no longer painful, except occasionally during dressing changes. Review of Nurse #1's nurse's note for Resident #1, dated 2/17/11 at 8 AM, indicated the following that Nurse #1 was in the room next to Resident #1's room and Nurse #1 heard Resident #1 calling Nurse #1's name and saying Resident #1 spilled hot tea on Resident #1. The note indicated when Nurse #1 entered the room, the front of Resident #1's pants were wet to the knees with water from the coffee cup. The note indicated Nurse #1 directed Resident #1 to position the electric wheelchair in the bathroom, and drenched Resident #1 in copious amounts of cold water, soaking the clothing and chair cushion. The note indicated Resident #1 was transferred to bed via Hoyer lift, medicated for pain and Resident #1's family and physician were notified. The note indicated the left thigh area near the groin had two raised, intact blisters with surrounding red base; the left inner mid thigh had a flat pink area (Drawing of area in record.) and no blisters noted; the right inner thigh (groin) had two raised, intact blisters; and the posterior right thigh had two raised, intact blisters with surrounding pink, flat intact area noted. The note indicated Resident #1 told Nurse #1 that Resident #1 had been thinking about buying a cup with a lid online and Nurse #1 told Resident #1 the Facility could provide a cup with a lid. Review of the Weekly Non-Pressure Skin Condition Report, dated 3/4/11, indicated the burn of the left, mid inner thigh measured 1.8 centimeters (cm) by 1.2 cm; the right groin burn measured 0.5 cm by 1.2 cm and the right; and the mid inner thigh burn measured 9.2 cm by 1.2 cm. Nurse #1 was interviewed on 3/10/11 at 11 AM. Nurse #1 said Nurse #1 was unaware Resident #1 had a hot water dispenser in the room. Nurse #1 said Nurse #1 was next door to Resident #1's room when the accident occurred and Resident #1 called out for help to Nurse #1. Nurse #1 said after treating the burned areas with cold water, transferring Resident #1 to bed, medicating Resident #1 for pain and notifying the family and physician, Nurse #1 applied cold compresses to the burned areas for three to four hours. Nurse #1 said Resident #1 refused to go to the emergency department. Nurse #1 said Resident #1 was scared and horrified when the incident happened. Nurse #1 said the entire left thigh was bright red, the inner aspect of the right thigh was worse than the inner aspect of the left thigh and the posterior right thigh was burned but not the posterior left thigh. Nurse #1 said Resident #1 was wearing an incontinence brief which protected the perineum and stomach from the hot water. Nurse #1 said blistering occurred in about thirty minutes and the blisters began to open after about two days. Nurse #1 said prior to the burns, Resident #1 received six Percocet daily for chronic abdominal pain, and that regime managed Resident #1's burn pain without additional doses. The Occupational Therapy (OT) Evaluation, dated 2/28/11, indicated Resident #1 participated in occupational therapy four times a week, beginning on 2/26/11 and continuing through 4/4/11. The Weekly OT Progress Note, dated 3/8/10 for the week of 2/28/11 to 3/7/11, indicated Resident #1 participated in OT four times this week with the focus on identifying a new adaptive mug for safely drinking hot liquids, passive range of motion exercises for the upper extremities and safety in self-feeding, with good progress noted in all areas. The Administrator was interviewed on 3/10/11 at 12 PM. The Administrator denied that the Administrator gave Resident #1 permission to use a hot water dispenser in Resident #1's room to make tea. The Administrator said he Administrator knew nothing about the dispenser prior to the incident of 2/17/11. Social Worker was interviewed on 3/10/11 at 12:30 PM. Social Worker said Resident #1 spoke with Social Worker last summer about buying a hot water dispenser to make tea in the room. Social Worker said Social Worker told Resident #1 that Resident #1 would have to get permission to use a hot water dispenser at the Facility. Social Worker said Social Worker did not know that Resident #1 was using a dispenser in the room until the burn occurred. Social Worker told Surveyor the Facility Hospitality Guide, which is given to residents at admission, contains information about resident use of electrical equipment in the Facility. Review of the Facility Hospitality Guide, dated 10/2008 and signed by Administrator, indicated that any electrical product must be checked and approved for use by a staff member. Appliances with heating coils are not permitted in the Facility. The Maintenance Manager was interviewed on 3/10/11 at 9:30 AM and 1:50 PM. The Maintenance Manager did not know Resident # 1 had the dispenser in the room prior to the incident and The Maintenance Manager had not checked it for electrical safety. The Maintenance Manager said the manufacturer's information for the hot water dispenser was obtained online and the dispenser was checked on 3/10/11 (the day of survey). The Maintenance Manager said the admission packet does contain information about the use of personal electrical equipment at the Facility. The Maintenance Manager said The Maintenance Manager checks every room at admission and annually for personal electrical equipment and tags and dates it.