Every finding on record at Our Ladys Haven of Fairhaven Inc

Based on interview and document review, the facility failed to ensure residents had access to grievance forms to formulate grievances anonymously and implement their grievance process to ensure grievances were addressed, responded to promptly, residents were provided a resolution to their grievance, and the information was documented on the grievance forms in use by the facility. Specifically, the facility failed to:a. Ensure residents were able to formulate grievances anonymously and had grievance forms easily accessible to them to complete a grievance without having to rely on the staff to provide them with the form; andb. Ensure the facility provided follow up and resolution to a grievance of an excessively loud television verbally reported by two separate Residents (#20 and #73) from the AB unit out of a sample of 18 residents and three resident units. Findings include: Review of the facility's policy titled Resident/Staff/Family member Grievances, last reviewed: 4/2025, indicated but was not limited to the following: The purpose of the policy is to resolve grievances in a timely manner. A grievance will be responded to within 72 hours and resolved. - any resident/staff/family member who has a complaint or suggestion shall report to the charge nurse or social worker on the unit involved, or complete a grievance form- the charge nurse or social worker will respond appropriately and complete the grievance form if one has not already been completed - grievance reports will be submitted to the Administrator/Department head as soon as possible- grievances are resolved utilizing a team approach and the aggrieved will be kept apprised of ongoing progress towards resolution- grievances, actions taken and results are to be documented on the grievance report a. During an interview on 9/25/25 at 10:06 A.M., the Administrator said that she was the grievance official for the facility. During a group meeting on 9/26/25 at 10:37 A.M., five out of eight residents in attendance said they do not know where the grievance forms are located in order for them to file a grievance independently and they have never been offered a grievance form when voicing concerns to a staff member. During a tour of the AB and 2 Medical unit on 9/26/25 at 11:37 A.M., the surveyor did not observe or locate any grievance forms or grievance information to be available for the residents/resident's responsible parties on the unit. During an interview on 9/26/25 at 11:39 A.M., Certified Nurse Aide (CNA) #5 said she has no idea where the grievance forms are located and she hasn't seen any, so if a resident were to ask, she would have to alert a nurse. During an interview on 9/26/25 at 11:41 A.M., CNA #6 said she believes the grievance forms are kept in a file or cabinet behind the nurses' stations and the residents would have to request one if they needed one. During an interview on 9/26/25 at 11:58 A.M., Nurse #3 said that grievance forms are not available for residents to access on the units, instead they are stored in a file cabinet behind the nurses' station. During a tour of the 1st floor nursing unit on 9/26/25 at 12:24 P.M., the surveyor did not observe or locate any grievance forms or grievance information to be available for the residents/resident's responsible parties on the unit. During an interview on 9/26/25 at 12:26 P.M., CNA #1 said grievance forms are kept with the nurses at the desk behind the nurses' station. During an interview on 9/26/25 at 12:27 P.M., Unit Manager #2 said grievance forms are kept at the nurses' stations behind the desk, and the residents or families would have to request a form or request staff complete a form for them; they are not available without asking. During an interview on 9/26/25 at 12:48 P.M., the Social Worker said grievance forms are available in the lobby and on each unit behind the nurses' stations. She said the forms are not accessible to the residents on the nursing units and they couldn't complete one anonymously. She said the residents do have the right to complete a grievance anonymously and they should have access to the forms without having to ask a staff member, but they currently do not unless they are capable of making their way to the lobby independently. During an interview on 9/26/25 at 2:25 P.M., the Administrator said the residents are encouraged to report concerns or complaints to the staff who should then be filling out a grievance form for the residents. She said she is unsure how a resident would be able to formulate a grievance anonymously if they cannot independently make their way to the lobby since the grievance forms on the nursing units are kept behind the nurses' stations. b. During a group meeting on 9/26/25 at 10:37 A.M., Resident #20 and Resident #73 said they have voiced concerns and complaints numerous times about another resident on the unit with an excessively loud television in the evening and night and have received no response or resolution to their ongoing concerns. Resident #20 said they were told they have rights, and you don't have a right to complain about that. Resident #73 said they act as if we don't have the right to be able to sleep through the night or enjoy a little peace without disruption. Both Residents #20 and #73 agreed they were speaking about the same resident and Resident #31 said they are also bothered by the excessively loud television but has not complained about it because they feel no one cares to help. Review of the facility's Grievance Book January 2025 to present failed to indicate a grievance had been formulated regarding Resident #20 and Resident #73's concern. During an interview on 9/26/25 at 12:48 P.M., the Social Worker said she was aware of the complaints of a loud television at night by Resident #20 and Resident #73 and it has been an ongoing issue that she has not been able to resolve. She said both Residents have complained about a TV belonging to another resident on the unit that they say is excessively loud in the evening and night. She said she did not complete a grievance form for this issue and has just been trying to keep the peace and make all the residents happy. She said residents have the right to verbally provide a concern or a complaint and that should be addressed through the grievance process, but she did not do that in these instances. She said she has received other concerns or complaints in which she'll ask the resident if they would like her to do a grievance and they will say that they don't want a big deal made out of it, they just want it resolved, but on reflection she can see how all concerns and complaints should be managed through the grievance process as indicated by the regulation and facility policy. During an interview on 9/26/25 at 2:35 P.M., the Administrator said when staff are told a complaint or concern, they should be filling out a grievance form and following the process. She said the Social Worker should have completed a grievance for the two Residents complaining about excessive noise, and she was not aware of that situation. She said it is clear the grievance process is not being followed as intended and she wants to make sure the residents in the facility feel heard and aware the facility is taking their concerns seriously so they must come up with a better way to implement the grievance process.

Based on observations and interviews, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to:1. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another);2. Ensure that dietary staff maintained and performed appropriate hand hygiene practices while preparing and serving meals for residents in the facility's main kitchen; 3. Reheat food according to safety standards to prevent food borne illness; 4. Ensure dietary staff wear hair coverings in the kitchen during food service; and5. Ensure thickened beverage items and/or food items were properly dated and stored in three of three kitchenette refrigerators.1. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: 3-302 Preventing food and ingredient contamination; (A) FOOD shall be protected from cross contamination by: (3) Cleaning equipment and utensils as specified under 4-602.11(A) and sanitizing as specified under S 4-703.11; 4-602.11 Equipment Food-Contact Surfaces and Utensils; (A) Equipment food-contact surfaces and utensils shall be cleaned: (3) Between uses with raw fruits and vegetables and with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD; (5) At any time during the operation when contamination may have occurred.During an observation with interview on 9/29/25 at 11:29 A.M., the surveyor observed [NAME] #1 begin taking food temperatures with a thermometer. She inserted the thermometer into a food item. She then took the thermometer out and immediately used it to temp the next food item. The thermometer became submerged in a food item and [NAME] #1 rinsed the thermometer with running sink water and then inserted the thermometer into the remaining food items. She did not wipe or sanitize the probe between food items. [NAME] #1 said this was her process for taking food temperatures prior to food service and at the conclusion of food service. During an interview on 9/29/25 at 12:22 P.M., the Food Service Director (FSD) said [NAME] #1 should have cleaned the thermometer after temping each food item to prevent cross contamination and maintain food safety. 2. During observation of the lunch meal distribution tray line on 9/29/25 starting at 11:29 A.M., the surveyor observed [NAME] #1 utilize her gloved hands to plate sliced meat on individual plates multiple times. She left the tray line and with the same gloved hands, spun a utensil hanger turnstile to retrieve a pair of tongs. She returned to the tray line and resumed plating food with her contaminated gloves. [NAME] #1 then left the tray line, retrieved a pre-made omelet, touched the microwave oven door handle to open it, placed the omelet inside the oven, closed the door and pressed the buttons to start the oven. 30 seconds later, she removed the omelet from the microwave oven and immediately returned to the tray line and resumed plating food with her contaminated gloves.During an interview on 9/29/25 at 12:22 P.M., the FSD said [NAME] #1 should have changed her gloves and performed hand hygiene after touching other items in the kitchen and before resuming food service to maintain sanitation. 3. Review of the facility's policy titled Microwave Reheating of Resident Food, undated, indicated but was not limited to:-All cooked foods being reheated in the microwave are heated to the proper temperature according to Safe Food Handling Guidelines.Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: 3-403.11). (1) Except as specified under subsections (2), (3), and (5) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding must be reheated so that all parts of the FOOD reach a temperature of at least 165 F (74 C) for fifteen seconds. (2) Except as specified under subsection (3) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding must be reheated so that all parts of the FOOD reach a temperature of at least 165 F (74 C) and the FOOD is rotated or stirred, covered, and allowed to stand covered for two minutes after reheating.On 9/29/25 at 11:50 A.M., the surveyor observed [NAME] #1 retrieve a pre-made omelet, place it in the microwave oven, and start it. The microwave oven sounded after 30 seconds and she removed the omelet from the oven and immediately returned to the tray line and put the omelet on a plate and placed it on a tray. [NAME] #1 did not measure the temperature of the omelet to ensure it had been reheated to a safe temperature prior to serving.During an interview on 9/29/25 at 11:51 A.M., [NAME] #1 said she made the omelet earlier that day and reheated it in the microwave oven for 30 seconds. She said she then put it on a plate and placed it on the tray. She did not measure the temperature of the omelet.During an interview on 9/29/25 at 12:22 P.M., the FSD said [NAME] #1 should have followed food reheating safety protocols and should have temped the omelet after it was reheated in the microwave. 4. Review of the facility's policy titled Hair Restraints, last reviewed October 2024, indicated but was not limited to the following:-All staff in a food preparation/serving areas or dish room are required to wear a hair restraint that effectively prevents hair from contacting exposed food.-All employees who have facial hair are required to wear a disposable beard protector.Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from FDA Food Code 2022 Chapter 2.During an observation of the facility's kitchen on 9/29/25 from 11:55 A.M. to 12:20 P.M., the surveyor observed one of one dietary staff with a full beard, covering his cheeks and neck in the main kitchen during meal service without wearing a beard covering.During an interview on 9/29/25 at 12:22 P.M., the FSD said Dietary Staff #1 delivers food trucks to the unit and also does dishwashing and is in and out of the main kitchen frequently during tray line service and is supposed to wear a beard covering but is not. 5. Review of the facility's policy titled Storage of Leftover Foods, last reviewed April 2025, indicated but was not limited to the following:-The facility prepares, holds and store foods in accordance with Food Code Standards, observing state and federal regulations.-Stored leftovers must be clearly labeled and dated, including resident name and room number, in food safe containers with secure cover/wrap.Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:3-501.17 Ready to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date of day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3-29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by-date based on FOOD safety.-On 9/30/25 at 9:05 A.M., the surveyor and FSD observed the first-floor unit. The FSD said the kitchen staff monitors the kitchenettes' cleanliness and police food dating. He said any resident specific food items should be labeled with the resident's name and have a date when it was brought in. The FSD said any opened items should be labeled and dated with the date it was opened. The FSD and surveyor observed the following in the first-floor unit refrigerator:-One opened single serve container of Boost Breeze, undated;-One opened container of thickened orange juice with an illegible opened date observed as a colored splotch with no decipherable lines or numbers.The FSD said the Boost Breeze and thickened orange juice should be labeled and dated with the date they were opened. Any items with no label/date should be discarded.-On 9/30/25 at 9:20 A.M., the FSD and surveyor observed the kitchenette on the second-floor medical unit. The FSD said he had already checked the unit kitchenettes earlier that morning to be sure everything was as it should be. He said he checks kitchenettes twice per week and demonstrated to the surveyor his process of checking unit refrigerators which involved ensuring the refrigerator was clean and food items had the appropriate labels and dates. The surveyor observed the FSD check the dates on a sample of items in the refrigerator and failed to check any thickened liquids or the Lactaid milk container. The FSD closed the refrigerator door and confirmed that all items inside were labeled and dated appropriately and safe for consumption.During the same observation, the FSD and surveyor reviewed the refrigerator a second time and observed the following:-five opened containers of thickened liquids, undated, with specific manufacturer instructions on each label indicating the number of days it was acceptable to use the product after opening/when the product should be discarded after opening;-one opened carton of Lactaid milk, undated, with manufacturer instructions indicating to discard 14 days after opening.The FSD said those items should be discarded because they are not labeled with the date they were opened.On 9/30/25 at 9:20 A.M., the FSD and surveyor observed the unit freezer and found a storebought coffee with a straw in the freezer with no name or date. The FSD said it should be labeled and dated.On 9/30/25 at 9:30 A.M., the FSD and surveyor reviewed the kitchenette on the second-floor A&B unit. The FSD demonstrated his process for checking refrigerated items which was to ensure the refrigerator was clean and food items had the appropriate labels and dates. The surveyor observed the FSD check the dates on a sample of items in the refrigerator. The FSD and surveyor observed a wrapped food item in a plastic container that had a resident's name but no date. The FSD said there should be a date on it and placed it back in the refrigerator. The FSD checked a sample of items in the refrigerator and confirmed all items in the refrigerator were appropriate and safe for consumption.During the same observation, the FSD and surveyor reviewed the refrigerator a second time and observed the following:-two opened containers of Lactaid milk, undated, with manufacturer instructions indicating to discard 14 days after opening;-one opened glass jar of prunes with a residents name but no date;-one opened bottle of Gatorade with no name or date.The FSD said the Lactaid should be dated when it was opened. He said the Gatorade should be labeled with a resident's name and dated when opened. He said he was unsure of when the prunes were opened but would ask the charge nurse. He placed the prunes back into the refrigerator.On 9/30/25 at 9:40 A.M., the unit nurses said they were unsure of when the jar of prunes were opened.During an interview on 9/30/25 at 11:57 A.M., the Administrator said all items in the unit kitchenettes should be labeled and dated appropriately and any opened item should have the date it was opened so staff knows when to discard it.

Based on observations, record review, and interviews, the facility failed to follow infection control and prevention practices. Specifically, the facility failed to:1. Ensure staff removed personal protective equipment (PPE) appropriately when exiting the room of Resident #54, who was on transmission-based precautions (TBP);2. Implement remediation measures in response to positive Legionella (a type of bacteria that can grow in water systems and can cause Legionnaires' disease, a serious lung infection); and3. Ensure staff wore appropriate PPE in accordance with the TBP/ isolation precaution signs posted outside of Resident #74's room.Findings include:Review of the facility's policy titled Coronavirus Guidelines, updated 5/2023, indicated, but was not limited to, the following:-Use of PPE:*Ensure that healthcare personnel are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient/resident, including attention to correct use of PPE.*Monitor staff adherence to hand hygiene and correct PPE use-Positive Resident:*Isolation sign should be placed outside door*Full PPE including N95 masks Review of the Centers for Disease Control and Prevention (CDC)'s Infection Control Guidance: SARS-CoV-2, dated 6/24/24, indicated, but was not limited to, the following:-If they [face masks] are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. Review of the Massachusetts Department of Public Health Isolation Droplet/Contact Precautions sign, updated 1/4/22, indicated in addition to standard precautions, staff and providers must: clean hands when entering and exiting, change gown between each resident, and wear an N95 respirator, eye protection, and gloves. 1. Review of the facility's Resident COVID/Flu/RSV Testing Log indicated Resident #54 tested positive for COVID-19 on 9/23/25. On 9/25/25 at 11:07 A.M., the surveyor observed a red Isolation Droplet/Contact Precautions sign hanging outside of Resident #54's room with a PPE supply container below. The surveyor observed Housekeeper #1 enter the Resident's room wearing an N95 mask, gloves, and gown. Housekeeper #1 did not don eye protection before entering the room. Housekeeper #1 exited the room on 9/25/25 at 11:10 A.M., removed her gown and gloves and sanitized her hands. Housekeeper #1 did not remove her N95 mask. During an interview on 9/25/25 at 11:12 A.M., Housekeeper #1 said staff should wear an N95 mask, gown, and gloves when entering the room of a resident on isolation precautions for COVID-19. When asked if staff should wear eye protection when entering the room of a resident on isolation precautions for COVID-19, Housekeeper #1 said staff may need to wear eye protection if performing care. During an interview on 9/30/25 at 2:19 P.M., the Infection Prevention Nurse said that when a staff member enters the room of a resident on isolation precautions for COVID-19, he/she should wear full PPE, including an N95 mask, gown, gloves, and eye protection regardless of whether or not they are providing direct care. The Infection Prevention Nurse said that upon exiting the room, the staff member should remove the N95 mask, sanitize their hands, and don a new N95 mask. The Infection Prevention Nurse said it was difficult for staff to comply with this on units with residents with active COVID-19 infection because the facility staff were to utilize N95 masks at all times while on the unit for source control and they did not always remember that they needed to change the N95 mask after exiting the room of a resident on isolation precautions. 2. Review of the facility's Legionella Management Plan, dated 11/9/17, indicated, but was not limited to, the following:-Legionella Management Plan Program Team members include: the facility's Administrator, the facility's Director of Facility Operations, Plumber, Consultant Account Manager and District Manager, and the facility's Infection Control Nurse.-This plan focuses on controlling the specific hazardous bacterium, Legionella Pneumophilia, which may develop and proliferate in potable water systems – to include both cold water and hot water distribution systems.-The mist from devices connected to water distribution systems contains water droplets. If the Legionella Pneumophilia bacteria is present in the water droplets, people exposed to the mist can become sick from Legionnaire's Disease by inhaling that mist. -Hot water temperature is monitored daily by the maintenance department. In-room hot water temperature should be between 108 degrees Fahrenheit (F) and 110 degrees F. If below 108 degrees F, the temperature should be increased and if above 110 degrees F, the temperature should be decreased.-Strategies employed under this plan to control the hazard include –1. Testing and monitoring of systems, including water samples2. Chemical treatment of the potable water system if needed (secondary building disinfection)3. Cleaning and disinfection4. Implementing shut-down and start-up procedures5. Maintenance steps to address low-flow and stagnant zones6. Contingency plans to be undertaken in response to actionable test results. -Testing shall be carried out on a semiannual basis.-These additional requirements are to be addressed as part of this plan and recorded in the Water Management Plan log book:*Note any out-of-compliance item*A relevant corrective action taken*Develop and document specific procedures for implementing water system disinfection in the event that future Legionella is found. -External Microbiology Monitoring – This shall consist of bacteria and Legionella Pneumophilia sampling as necessary. Samples are collected and tested through a qualified laboratory. This work is carried out semi-annually, at the time of the CWT (Certified Water Technologist) water system inspection visit. Laboratory reports are emailed to program team members. One sample will be as close to the main entering the facility [sic], one sample will be directly from the hot water tank, the others will be distill sites throughout the building.-Disinfection and Response Procedures for Potable Water Systems – Legionella testing will be used to drive any remediation actions. Results are reported promptly to Program Team members, and authorization for work to be carried out occurs through the Director of Facility Development and Planning. -If the percentage of positive Legionella test sites is greater than 30%, response includes:*Immediately institute short-term control measures (temporary interventions that may include, but are not limited to, heating, and flushing, the water system, hyperchlorination, or temporary instillation of treatment such as copper silver ionization or chlorine dioxide) in accordance with the direction of a qualified professional, and notify the department.*The water system shall be re-sampled no sooner than seven days and no later than four weeks after disinfection to determine the efficacy of the treatment.*Retreat and retest.-For both hot and cold water systems, the Water Management Program documents shall include:*Procedures for emergency disinfection*Procedures for other actions identified as necessary by the Program Team to prevent exposure to contaminated water Review of the facility's Legionella test results indicated that on 8/28/25, eight samples were collected from the facility's water system for Legionella testing. Five of those samples were taken from residential room handwashing (HW) sinks. The test results were reported 9/5/25 at 10:31 A.M. Results included:-room [ROOM NUMBER] HW sink – 2.6 MPN (Most Probable Number, equivalent to colony forming units per milliliter [CFU/ml]).-room [ROOM NUMBER] HW sink – 2.2 MPN-room [ROOM NUMBER] HW sink – 4.7 MPN-room [ROOM NUMBER] HW sink – 50.7 MPN Review of the attached Interpretation of Legionella Culture Results indicated that for results between 10 and 100 CFU/ml, immediate disinfection should be initiated within 24 hours and water should be retested in three to seven days. Review of the facility's hot water temperature logs provided by the facility's Director of Facility Operations on 9/30/25 indicated four hot water temperature checks were completed per month. Further review of the hot water temperature logs indicated:-On 7/7/25, the hot water temperature in room [ROOM NUMBER] was 101 degrees F-On 7/14/25, the hot water temperature in room [ROOM NUMBER] was 104 degrees F-On 8/11/25, the hot water temperature in room [ROOM NUMBER] was 103 degrees F-On 8/18/25, the hot water temperature in room [ROOM NUMBER] was 102 degrees F-On 8/25/25, the hot water temperature in room was not recorded-On 9/15/25, the hot water temperature in room [ROOM NUMBER] was 106 degrees F The facility failed to provide evidence of any action taken in response to out of compliance items and actionable test results. The facility's Director of Facility Operations provided the surveyor with documentation of an email he received from the Consult Account Manager on 9/10/25 that indicated results of the facility's recent Legionella testing included multiple positives. The Account Manager requested to set up a risk assessment of the site to identify what potential issues may have been. During an interview on 9/30/25 at 12:06 P.M., the Director of Facility Operations said the facility's Legionella test results were usually negative, but there had been positive results with their most recent testing. The Director of Facility Operations said that the consultant company had come in and were working on finding out what the underlying cause for the positive results was, but he had not received any documentation with that information. The Director of Facility Operations said he was responsible for checking water temperatures and maintained those records in an electronic log. During an interview on 9/30/25 at 12:39 P.M., the Administrator said the consultant company performed a water system disinfection, which she believed was in August. The Administrator said she was not sure if the disinfection was performed before or after the Legionella testing samples were obtained. The Administrator said the consultant company had come out to do a risk assessment, but the facility had not received any documentation related to that yet. During an interview on 9/30/25 at 12:57 P.M., the Administrator said she was informed that the Legionella test samples were taken by the consultant company after the disinfection was done and she was waiting to receive the report containing the disinfection information from the consultant company. During a telephone interview on 9/30/2025 at 1:58 P.M., the Consultant Account Manager said that it is the company's responsibility to report the test result findings to the facility and refer the facility staff to their water management plan, but the facility staff were responsible for implementing corrective action. The Consultant Account Manager said there was a Legionella specialist that he would refer the surveyor to. As of 10/1/25 at 11:36 A.M., the Consultant Account Manager had failed to provide the surveyor with further contact information for the Legionella specialist. During an interview on 9/30/25 at 2:19 P.M., the Infection Control Nurse said she was aware that the facility's water testing had had positive Legionella results, but it was her understanding the results were within acceptable standards and the Director of Facility Operations had been working with the consultant company to address the issue. The Infection Control Nurse said the facility had not tested any residents for Legionella and had not identified any residents with Legionnaire's Disease. During an interview on 9/30/25 at 4:30 P.M., the Administrator provided the surveyor with the Risk Assessment Report and disinfection documentation from the consultant company that she had just received. She said the bi-annual chlorine disinfection took place over multiple dates due to difficulty obtaining high enough chemical levels for disinfection but was completed successfully on 8/25/25. Review of the Risk Assessment Survey Comments and Recommendations section, completed by the consultant company on 9/17/25, indicated, but was not limited to, the following:-The chlorine residual entering the building was very low (0.08 parts per million (ppm), desired residual is 0.50ppm).-Secondary disinfection is recommended. Room for this equipment in the boiler room is limited. There are old domestic hot water heat exchangers that could be removed.-The hot water heater is insufficient to heat a facility of this size. There are 89 rooms, a commercial laundry and a commercial kitchen.-Piping in the boiler room takes quite a bit of time to understand. There have been many things added to keep the building going that are likely counterproductive to the system's proper operation.-Develop and implement a Water Management Plan for the control of Legionella in building water systems, with special attention to flow, temperature and disinfectant control measures.-Conduct sampling at minimum once per quarter interval to establish baseline data and demonstrate system control. Recommended sampling plan for 12 total samples.-Monitor free chlorine in cold and hot water fixtures weekly at six distal points (near, mid, and far points of distribution).-Regarding hot water temperatures, consider raising setpoints so that 120 degrees F is attainable at all sentinel outlets.-Develop SOP (standard operating procedures) for shut down, isolation, refilling of water service areas. During an interview on 9/30/25 at 4:40 P.M., the Administrator said she was not aware that the positive Legionella testing samples were collected from the facility on 8/21/25, before the chlorine disinfection had been completed. 3. Review of the Isolation sign in use by the facility, dated as last updated 1/4/22, indicated but was not limited to the following: STOP Isolation Droplet/Contact Precautions, In addition to standard precautions staff and providers MUST: Clean hands when entering and exiting; wear a gown, N-95 respirator mask, eye protection (goggles or face shield) and gloves (change between residents) During an interview on 9/25/25 at 7:41 A.M., the Administrator said they had COVID-19 positive residents in the facility. She said residents have signs posted outside of their rooms and the expectation is the staff are using the PPE in accordance with the signage. Resident #74 was admitted to the facility in May 2025. Review of Resident #74's medical record indicated the Resident tested positive for COVID-19 on 9/20/25 and had symptoms consistent with a fever on that day. The Nurse Practitioner (NP) evaluated the Resident on 9/22/25 and indicated to continue quarantine per facility protocol. On 9/25/25 at 8:56 A.M., the surveyor observed a red Isolation sign posted directly outside of Resident #74's bedroom door. Certified Nursing Assistant (CNA) #3 was observed in the room assisting the Resident with his/her breakfast. CNA #3 was not observed to have any eye protection in place during this task, in accordance with the posted sign outside of the Resident's door. Nurse #1 was standing outside the Resident's room preparing medications for Resident #74 and donned (put on) all necessary PPE in line with the posted sign including: gown, gloves, N95 mask and eye protection and entered the room. Nurse #1 was not observed or heard to redirect CNA #3 for not wearing the appropriate PPE while being in the COVID-19 positive room. At 9:05 A.M., CNA #3 exited the Resident's room. During an interview on 9/25/25 at 9:05 A.M., CNA #3 said Resident #74 was on isolation for COVID-19. She said staff are required to follow the posted signs outside the rooms when determining which PPE to use prior to entering the room. On review of the sign, CNA #3 said she was not wearing eye protection in the room and just forgot about it. During an interview on 9/25/25 at 9:06 A.M., Nurse #1 said the expectation is that the staff are using PPE in accordance with the signs posted outside the residents' doors. She said that CNA #3 should have had eye protection on and did not while she was in Resident #74's room. During an interview on 9/30/25 at 10:52 A.M., the Director of Nurses said the expectation for staff entering a COVID-19 positive room is for them to wear full PPE and follow the signs posted outside of the residents' rooms, including Resident #74's. She said full PPE includes gloves, gown, N95, and eye protection. During an interview on 9/30/25 at 2:19 P.M., the Infection Preventionist said when staff are entering a room with an isolation precaution sign, they should be wearing full PPE.

Based on review of Resident Council Minutes, a resident group meeting, and interviews, the facility failed to ensure grievances/complaints brought forward from the Resident Council were addressed and resolved in a timely manner to ensure the residents felt their concerns were acted upon and included the facility response to the group. Findings include: Review of the facility's policy titled Resident Council, last reviewed 9/2024, indicated but was not limited to the following:- The home will listen to and follow up on resident's complaints and grievances through Resident council meetings and individual resident requests- notify department heads of residents' complaint when presented- schedule department head to answer complaints of the residents at the next meeting or immediately, if required- schedule individual meeting for residents with responsible person to handle complaint or grievances Review of the facility's policy titled Resident/Staff/Family member Grievances, last reviewed 4/2025, indicated but was not limited to the following: The purpose of the policy is to resolve grievances in a timely manner. A grievance will be responded to within 72 hours and resolved. - any resident/staff/family member who has a complaint or suggestion shall report to the charge nurse or social worker on the unit involved, or complete a grievance form- the charge nurse or social worker will respond appropriately and complete the grievance form if one has not already been completed - grievance reports will be submitted to the Administrator/Department head as soon as possible- grievances are resolved utilizing a team approach and the aggrieved will be kept apprised of ongoing progress towards resolution- grievances, actions taken and results are to be documented on the grievance report Review of the Resident Council notes, provided by the facility, from April 2025 to September 2025, indicated but were not limited to the following: - the Activity director was present at each meeting April 10, 2025: 7 residents in attendanceOld Business: Reviewed meeting minutes from last Resident council meeting and they were approved by all in attendance. Other Concerns: Podiatrist comes in very early and sometimes does not alert residents to their arrival in the room. If he could come a little later or make sure the resident is more awake residents would appreciate that instead of being woken up. Residents still stating this is happening will address again with Director of Nurses (DON). May 8, 2025: 4 residents in attendanceOld Business: Reviewed meeting minutes from last Resident council meeting and they were approved by all in attendance. Nursing: 1. During 11:00 P.M. to 7:00 A.M. residents say they are being woken up by the overhead light being put on without warning during rounds and it is startling. 2. Podiatry and lab coming in very early and not waking up residents, just looking at their feet or drawing blood. Not only is being woken up early (between 4:00 A.M. and 5:00 A.M.) unpleasant, but without warning is concerning.3. A few residents have stated that dirty linen is being left in their rooms and not taken out until after lunch, and commodes are not being emptied, and they are not okay with that. Housekeeping: One resident stated that housekeeping comes in at 6:00 A.M. and cleans and moves furniture around and it's disruptive to them. Other concerns: Diet kitchens are not clean with crumbs and food being left out. Also, staff food is being left on counters and not taken home or discarded at the end of the shift. June 19, 2025: 5 residents in attendanceOld Business: Reviewed meeting minutes from last Resident council meeting and they were approved by all in attendance. Nursing:1. During 11:00 P.M. to 7:00 A.M. residents say they are being woken up by the overhead light being put on without warning during rounds and it is startling. Residents report this is still an issue.2. Podiatry and lab coming in very early and not waking up residents, just looking at their feet or drawing blood. Not only is being woken up early (between 4:00 A.M. and 5:00 A.M.), but without warning is concerning. Residents report that this has been better. 3. A few residents have stated that dirty linen is being left in their rooms and not taken out until after lunch, and commodes are not being emptied and they are not okay with that. Residents report this has been addressed and dealt with. Housekeeping: One resident stated that housekeeping comes in at 6:00 A.M., and cleans and moves furniture around and it's disruptive to them.*No follow up was documented for this ongoing concernOther concerns: Diet kitchens are not clean with crumbs and food being left out. Also, staff food is being left on counters and not taken home or discarded at the end of the shift. Residents report this has been better. July 24, 2025: 7 residents in attendance; the Administrator also attended this meetingOld Business: Reviewed meeting minutes from last Resident council meeting and they were approved by all in attendance. Nursing: During 11:00 P.M. to 7:00 A.M. residents say they are being woken up by the overhead light being put on without warning during rounds and it is startling. Residents report this is still an issue.Housekeeping: One resident stated that housekeeping comes in at 6:00 A.M. and cleans and moves furniture around and it's disruptive to them. Residents report this is still an issue, but not as bad. Administration: The Administrator attended the meeting to discuss the increase in fire drills and safety education. She also informed the residents if anyone has any questions or concerns, they are always welcome to ask to speak with her. August 20, 2025: 6 residents in attendanceOld Business: Reviewed meeting minutes from last Resident council meeting and they were approved by all in attendance. Nursing:1. During 11:00 P.M. to 7:00 A.M. residents say they are being woken up by the overhead light being put on without warning during rounds and it is startling. Residents report this has been better.2. On the 3:00 P.M. to 11:00 P.M. shift a few residents stated that is seems like there is only one staff member on the floor at times. 3. Agency staff do not know resident routines and/or are rushing through care is an issue.4. One resident stated that their commode was being emptied into their sink on more than one occasion and when they tell the nurse aide not to do that they are ignored. The residents requested to invite the DON to the next meeting to discuss some issues with nursing.Housekeeping: AB kitchen has fruit flies September 18, 2025: 5 residents in attendance; the DON also attended this meetingOld Business: Reviewed meeting minutes from last Resident council meeting and they were approved by all in attendance.Nursing: Residents discussed with the DON, some previous concerns from the last meeting. One resident said that their urinal was being emptied into their sink and the DON responded that that was not acceptable and she would talk with staff. A few residents stated that the staff are loud at change of shift and call down the hallways and the DON responded that she would speak with them so they would be more aware. Housekeeping: AB kitchen has fruit flies. This has been dealt with and is no longer an issue The Resident council meeting minutes revealed ongoing concerns without resolution of many concerns over the last six months including repeat issues of: 1. podiatry or lab services coming in too early and not ensuring the residents are awake for 3 of 6 months reviewed2. residents being startled by their overhead light being turned on at night for 4 of 6 months reviewed3. housekeeping disrupting a residents sleep by moving things and cleaning their room at 6:00 A.M. for 3 of 6 months reviewed Review of the facility grievance book failed to indicate any grievances were formulated for any ongoing individual concerns brought forth by one resident or the resident council as a group. During an interview on 9/25/25 at 2:20 P.M., the Administrator said as far as she knows there is no paper trail that is kept to show that department heads are aware of the residents' concerns in resident council and she believes that the Activity Director (AD) communicates with them verbally or possibly through email. She said the AD can explain the process. During an interview on 9/25/25 at 3:41 P.M., the AD said following each resident council meeting she meets with the Administrator to make them aware of the issues and then informs the department head verbally. She said she does not have any emails or a paper trail of notifying the correlating department heads of any concerns brought forth in resident council or any ongoing plans or resolutions to share with the residents at the next meetings. She said the only way she knows if something is better or worse is when the residents tell her. She said the department heads do not come to the next meeting, as the policy indicates, but they are aware when the next meeting is happening because she will remind them that they had concerns at the previous meeting and when they are having another meeting. She said if a concern is resolved she will document in the notes the issue is resolved or has been dealt with. She said she has no way of knowing if the department heads are working to resolve the concerns she's informed them of, but there are repeated concerns, and the residents will let her know if something is still an issue, better, or dealt with. She said on review of the policy it seems the policy is not being followed. During a group meeting held on 9/26/25 at 10:37 A.M., the eight residents in attendance shared the following information with the surveyor.- 6 out of 8 residents said the issue of being awoken on the overnight shift with their overhead lights being turned on was not resolved, is ongoing and they feel it is intrusive and startling. One resident said, No one seems to mind that I'm not getting any restful sleep, they continued to say they have informed staff their preference is to not be woken up through the night but the staff don't listen. - 3 out of 8 residents said their urinals are still being emptied into the sinks in their rooms. One resident said they felt when they reported the issue, the facility wanted them to solve it for themself and didn't provide them with any offers of a resolution except to tell them to redirect the person who is doing it at the time it is occurring. The resident said, it is an issue that administration and the people who run this building need to take responsibility for and address with their staff to make it better. - 5 out of 8 residents said they do not know where the grievance forms are located, and they do voice their concerns through resident council and verbally tell staff, but staff have never offered them a grievance form or assistance to complete a grievance form. The residents said they get responses from the staff when they voice concerns or complaints including: ok, they're agency so they don't know , or oh let me tell someone who can look into that, or let me check and get back to you, but no response or resolution or follow up of any kind ever occurs. - 5 out of 8 residents said they have verbally complained over and over when they are and are not in the resident council and no one ever follows up with them. They said it's exhausting to have to tell people the same thing every day just for them not to listen or care. - 6 out of 8 residents said there are no resolution to issues brought up consistently - 5 out of 8 residents said they don't feel anyone is listening anymore- 7 out of 8 residents said they felt the resident council was ineffective in consistently addressing concerns and the facility does not respond or listen. One resident commented they have to repeat the same things over and over until it's just not worth saying anymore and 5 out of 8 residents agreed with this comment. During an interview on 9/26/25 at 2:35 P.M., the Administrator said she doesn't feel the resident council is working in the way it is intended to, and the facility cannot provide any documentation of any follow up or attempts to resolve the concerns brought forth in the resident council meetings.

Based on interview and record review, the facility failed to maintain complete medical records for one Resident (#64), out of a sample of 18 residents. Specifically, for Resident #64, the facility failed to ensure the medical record included the physician's documentation of encounters with the Resident. Findings include:Review of Resident #64's medical record included but was not limited to nursing progress notes, dated 10/8/24, 10/15/24, 11/19/24, and 2/11/25, that indicated the Resident had been seen by the physician on those dates: -10/8/24: Seen by the physician for positive COVID;-10/15/24: Seen by the physician for 60 day visit; -11/19/24: Seen by physician for coated tongue;-2/11/25: Seen by physician for psych recommendation review. Further review of Resident #63's medical record failed to include the physician's documentation for the encounters. During an interview on 9/30/25 at 11:06 A.M., the Director of Nursing (DON) said the nursing progress notes indicated the physician had visited Resident #63 on 10/8/24, 10/15/24, 11/19/24, and 2/11/25. The DON said the facility had not received the physician's documentation for those dates. The DON said a complete medical record would include the physician's documentation of his encounter with the Resident for 10/8/24, 10/15/24, 11/19/24, and 2/11/25.

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made four errors out of 30 opportunities, totaling a medication error rate of 13.33%. These errors impacted two Residents (#38, #57), out of five residents observed. Specifically, 1. For Resident #38, Repaglinide (an oral antihyperglycemic medication used to help control high blood sugar), and Metformin (an oral antihyperglycemic medication used to help control high blood sugar) were not administered as ordered by the physician during the medication pass; and 2. For Resident #57, Carbidopa-Levodopa (a medication used to treat symptoms of Parkinson's disease) and Furosemide (a diuretic medication used to aid the body in removing excess fluid) were not administered as ordered by the physician during the medication pass. Findings include: Review of Lippincott Nursing Procedures, Ninth Edition, Safe Medication Administration Practices, General, indicated that nurses must adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. Review of the facility's policy titled Administration of Medications - General Guidelines - Specific Procedures, revised 1/15/15, indicated but was not limited to the following: -Medications are administered in accordance with written orders of the physician or other authorized prescriber. -Medications ordered to be given before meals must be administered at least one hour before meals. 1. Review of the active Physician's Orders for Resident #38 indicated but were not limited to the following: -Repaglinide 2 milligrams (mg) One tablet by mouth daily at 11:30 A.M. (6/1/21) -Metformin 500 mg Take two 500 mg tablets (1000 mg) by mouth daily before breakfast and dinner at 8:30 A.M., 5:30 P.M. (5/31/24) On 10/23/24 at 10:18 A.M., the surveyor observed Nurse #6 prepare and administer Repaglinide and Metformin to Resident #38. Nurse #6 failed to administer the Repaglinide within one hour before or after the scheduled administration time indicated in the physician's order. Nurse #6 failed to administer the Metformin before breakfast as ordered. During an interview on 10/23/24 at 10:14 A.M., Nurse #6 said that Resident #38 likes to take her medications together. During an interview on 10/23/24 at 4:32 P.M., the Director of Nursing (DON) said that it is her expectation that medications are administered within a one hour window before or after the medication's scheduled time. 2. Review of the active Physician's Orders for Resident #57 indicated but were not limited to the following: -Carbidopa-Levodopa 25-100 mg Give one tablet by mouth three times a day at 8:00 A.M., 1:00 P.M., and 7:00 P.M. (5/24/24) -Furosemide 40 mg twice a day at 8:00 A.M. and 1:00 P.M. (5/24/24) On 10/23/24 at 10:52 A.M., the surveyor observed Nurse #6 prepare and administer medications, including Carbidopa-Levodopa and Furosemide, to Resident #57. Nurse #6 failed to administer the Carbidopa-Levodopa and Furosemide within one hour before or after the scheduled administration times as ordered by the physician. Review of Resident #57's electronic Medication Administration Record indicated that on 10/23/24, the scheduled 8:00 A.M. doses of Carbidopa-Levodopa and Furosemide were charted late. Nurse #6 entered in the comments for the late administration on time. During an interview on 10/23/24 at 4:32 P.M., the DON said that it was her expectation that medications are administered within a one-hour window before or after the medication's scheduled time.

Based on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one Resident (#57), out of five residents observed during medication administration and one Resident (#21), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #57, to ensure the Resident had taken all of his/her medications before leaving the Resident's room; and 2. For Resident #21, to ensure nursing performed pain assessments to determine, per physician's orders, which dosage of oxycodone (pain medication used to treat moderate to severe pain; opioid) to administer to the Resident. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, 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: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's 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. 1. Review of the facility's policy titled Oral Medication Administration - Specific Procedures, revised 6/3/13, indicated but was not limited to the following: -Administer medication and remain with resident while medication is swallowed. Resident #57 was admitted to the facility in January 2023 with diagnoses including Parkinson's disease, hypertension, and fluid overload. Review of the active Physician's Orders for Resident #57 indicated but were not limited to the following: -Vitamin D3 50 micrograms (mcg) Give one tablet by mouth daily in AM at 8:00 A.M. (1/26/23) (Vitamin D supplement) -Tamsulosin 0.4 milligrams (mg) Give 0.4 mg by mouth daily at 8:00 A.M. (1/26/23) (medication used to relax prostate and bladder muscles in men) -Potassium Chloride Extended Release 20 milliequivalents (meq) once a day at 8:00 A.M. (2/22/23) (potassium supplement) -Metoprolol Succinate Extended Release 25 mg once a day at 8:00 A.M. (4/13/23) (medication used to treat high blood pressure) -Omeprazole Delayed Release 20 mg once a day at 8:00 A.M. (4/19/23) (medication used to reduce excess stomach acid) -Carbidopa-Levodopa 25-100 mg Give one tablet by mouth three times a day at 8:00 A.M., 1:00 P.M., and 7:00 P.M. (5/24/24) (medication used to manage symptoms of Parkinson's disease, such as tremors) -Eliquis 5mg Give 5 mg by mouth twice a day at 8:00 A.M. and 7:00 P.M. (5/24/24) (medication used to prevent blood clotting) -Furosemide 40 mg twice a day at 8:00 A.M. and 1:00 P.M. (5/24/24) (diuretic) -Multiple Vitamins Give one tablet by mouth daily at 8:00 A.M. (5/24/24) -Seroquel 25 mg Give half a tablet (12.5mg) orally every AM at 8:00 A.M. (5/24/24) (antipsychotic medication) On 10/23/24 at 10:52 A.M., the surveyor observed Nurse #6 prepare and administer Vitamin D3, Tamsulosin, Potassium Chloride, Metoprolol Succinate, Omeprazole, Carbidopa-Levodopa, Eliquis, Furosemide, Multiple Vitamins, and Seroquel to Resident #57. On 10/23/24 at 11:09 A.M., the surveyor observed Nurse #6 leave Resident #57's room before the Resident had finished taking all of the medication. Review of Resident #57's medical record failed to indicate that the Resident was able to self-administer medications. During an interview on 10/23/24 at 11:14 A.M., Nurse #6 said she usually administers Resident #57's medications and leaves the room before making sure he/she has taken all of the medications because he/she is cognitively intact. During an interview on 10/23/24 at 4:32 P.M., the Director of Nursing (DON) said that Resident #57 is not able to self-administer medications and that it is her expectation that the nurse stays with the Resident until he/she finishes taking all of their medications. 49428 2. Resident #21 was admitted to the facility in October 2023 with diagnoses which included unspecified pain, generalized abdominal pain, and polyneuropathy (a nerve disease with symptoms that include pain). Review of Resident #21's Minimum Data Set (MDS) assessment, dated 7/16/24, indicated Resident #21 had frequent pain and was receiving pain medication on an as needed basis. Review of Resident #21's active Physician's Orders indicated but was not limited to the following: -Pain monitoring each shift, notify physician/nurse practitioner if pain is not controlled, every shift 07:00-15:00, 15:00-23:00, 23:00-07:00, active 10/10/23. -oxycodone- schedule II, 5 mg tablet, take 2 tablets (10 mg) by mouth every 4 hours as needed for severe pain, active 10/10/23; -oxycodone- schedule II, 5 mg tablet, take 1 tablet by mouth every 4 hours for moderate pain, as needed, active 10/10/23; -acetaminophen tablet, 325 mg, 2 tablets (650 mg) by mouth as needed every 6 hours for pain. Review of Resident #21's 2024 Medication Administration Record (MAR) for the months of August, September, and October indicated the Resident received oxycodone on an as needed basis. Further review of Resident #21's August 2024 MAR indicated but was not limited to the following: -650 mg acetaminophen was administered two times; -5 mg oxycodone was administered two times; -10 mg oxycodone was administered 35 times. -Documentation of pain severity (such as moderate, severe, or utilizing a pain scale) related to administering 10 mg of oxycodone for severe pain included the following: -8/3/24: Pain Comment: 9/10 (pain scale based on a scale of 0-10 with 10 being the worst pain). Further review of the August 2024 MAR indicated but was not limited to the following documentation of reasons for administering 10 mg of oxycodone for severe pain: -8/5/24: per Resident's request; -8/6/24: generalized pain; -8/11/24: abdomen; -8/13/24: per Resident's request; -8/27/24: per Resident's request; -8/29/24: complaints of left side pain; -8/30/24: left upper quadrant pain. Review of Resident #21's medical record indicated there were no nursing progress notes in August 2024 that indicated a pain assessment was performed with the administration of 5 mg or 10 mg of oxycodone. Additionally, there were no nursing progress notes that stated the severity of the Resident's pain when any oxycodone was administered. Further review of Resident #21's September 2024 MAR indicated but was not limited to the following: -650 mg acetaminophen was administered five times; -5 mg oxycodone was administered five times; -10 mg oxycodone was administered 18 times. -Documentation of pain severity (such as moderate, severe, or utilizing a pain scale) related to administering 10 mg of oxycodone for severe pain included the following: -9/1/24: Pain Comment: 8/10 -9/17/24: Pain scale 3. Further review of the September 2024 MAR indicated but was not limited to the following documentation of reasons for administering 10 mg oxycodone for severe pain: -9/2/24: complaints of general discomfort; -9/2/24: complaints of left flank pain; -9/10/24: per Resident's request; -9/14/24: per Resident's request; -9/23/24: complaints of generalized discomfort. Review of Resident #21's medical record indicated there were no nursing progress notes in September 2024 that indicated a pain assessment was performed with the administration of 5 mg or 10 mg of oxycodone. Additionally, there were no nursing progress notes that stated the severity of the Resident's pain when any oxycodone was administered. Further review of Resident #21's October 2024 MAR (10/1/24-10/28/24) indicated but was not limited to the following: -650 mg acetaminophen was administered one time; -5 mg oxycodone was administered 12 times; -10 mg oxycodone was administered 20 times. Documentation of pain severity (such as moderate, severe, or utilizing a pain scale) related to administering 10 mg of oxycodone (ordered for severe pain) included the following: -10/24/24: complaints of pain to left side/flank area #8; -10/26/24: abdominal 8/10. Further review of the October 2024 MAR indicated, but was not limited to the following documentation of reasons for administering 10 mg oxycodone for severe pain: -10/1/24: generalized pain; -10/11/24: abdominal; -10/18/24: pain comment: flank; -10/21/24: increase pain left hip/side; -10/24/24: per Resident request; -10/27/24: abdominal pain; -10/27/24: per Resident request. During an interview on 10/28/24 at 2:00 P.M., the surveyor and Unit Manager (UM) #2 reviewed Resident #21's oxycodone orders and MAR. UM #2 said she expects nursing to use an appropriate scale to assess Resident #21's pain. UM #2 said she expects nursing to administer the appropriate oxycodone dosage based on the severity of the Resident's pain and the physician's order. UM #2 said reasons for administering oxycodone, such as generalized pain and per Resident request, are not acceptable. During an interview on 10/29/24 at 12:26 P.M., the Director of Nursing (DON) said the facility's policy is to use a numerical pain scale. The DON acknowledged the Resident's oxycodone orders indicate the terms moderate and severe for pain and do not indicate a numerical pain scale. The DON said nursing should be using a numerical pain scale to assess Resident #21's pain level to determine, per physician's orders, which pain medication or which dose of oxycodone is appropriate for the Resident.

Based on observation, record review, and staff interview, the facility failed to ensure side rails were not implemented per the declination of consent from the Health Care Proxy (HCP) for one Resident (#121), of a total sample of 18 residents. Findings include: Resident #121 was admitted in October 2024 for a respite stay with a diagnosis of dementia. Review of the medical record indicated that upon admission, the Resident's HCP signed that he/she declined the use of side rails for the Resident. On 10/22/24 at 9:10 A.M., the surveyor observed Resident #121's bed to have side rails at the upper left and right sides. Resident #121 was not in the bed. On 10/25/24 at 10:18 A.M., the surveyor observed Resident #121's bed to have side rails at the upper left and right sides. Resident #121 was not in the bed. During an interview on 10/25/24 at 10:25 A.M., Unit Manager #1 said that the side rails that were on the Resident's bed were from the previous resident that occupied the bed. Unit Manager #1 also said that no side rail assessment for use of the side rails had been conducted, and the side rails should have been removed from the bed when Resident #121 was admitted . Unit Manager #1 confirmed that the HCP had signed that he/she declined consent for the use of side rails.

Based on records reviewed, policy review, and interview for two Residents (#4 and #26), of 18 sampled residents, the facility failed to ensure that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, for Residents #4 and #26, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed timely. Findings include: Review of the facility's policy titled Psychotropic Medication Consent, dated as reviewed 2/24, indicated but was not limited to: -In order to meet Section 72BB's requirements for documenting informed consent, prior to the administration of any drug included on Attachment A, long term care facilities must complete the Department's prescribed for (Attachment B), and prior to or upon administration, include the completed form in the resident's medical record. -Written informed consent must be obtained each time a new or renewed prescription falls outside the dosage to which the resident or the resident's legal representative previously consented, or once a year, whichever is shorter. Resident #4 was admitted to the facility in March 2018 with diagnoses which included dementia, paranoid personality disorder, bipolar disorder, personality disorder, and generalized anxiety disorder. Review of Resident #4's Minimum Data Set (MDS) assessments, dated 5/31/24 and 8/3/24, both indicated the Resident was receiving antipsychotic medication on a routine basis. Review of Resident #4's active physician's orders indicated, but was not limited to, the following: -aripiprazole tablet, 5 milligram (mg), One tablet (5mg) by mouth daily, active 10/10/20; -risperidone tablet, 0.5mg, One tablet (0.5mg) by mouth daily at bedtime four times a week, omit Sunday/Wednesday and Thursday, active 6/25/24; -risperidone tablet, 0.25mg, take one tablet by mouth weekly on Sundays/Wednesdays/Thursdays, active 6/25/24. Review of Resident #4's 2024 Medication Administration Record for June through October indicated the Resident was administered their scheduled aripiprazole and risperidone per physician's orders. Review of care plans for Resident #4 indicated but was not limited to the following: -AIMS every six months while I am taking antipsychotic medication. Further review of Resident #4's medical record indicated AIMS assessments were completed on 12/18/23 and 8/5/24. Resident #26 was admitted to the facility in June 2021 with diagnoses which included dementia and bipolar disorder. Review of Resident #26's MDS assessments, dated 6/18/24 and 9/18/24, both indicated the Resident was receiving antipsychotic medication on a routine basis. Review of Resident #26's active physician's orders indicated, but was not limited to, the following: -risperidone tablet, 0.5mg, one half tablet (0.25mg) by mouth daily in the morning, active 7/17/23; -risperidone tablet, 0.5mg, once a day on Sunday, active 8/14/24; -risperidone tablet, 0.5mg, twice a day on Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, active 8/14/24. Review of Resident #26's 2024 Medication Administration Record for June through October indicated the Resident was administered their scheduled risperidone per physician's orders. Review of care plans for Resident #26 indicated but was not limited to the following: -AIMS every six months while I am taking antipsychotic medication. Further review of Resident #26's medical record indicated AIMS assessments were completed on 12/18/23 and 8/5/24. During an interview on 10/29/24 at 12:34 P.M., the DON said for residents receiving anti-psychotic medication, an AIMS assessment should be performed every six months. The DON said, for Residents #4 and #26, the 8/5/24 AIMS assessments should have been completed in June 2024, not in August 2024.

Based on record review and interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards of practice for one Resident (#15) of 18 sampled residents. Specifically, the facility failed to document two administered doses of glucagon (an anti-hypoglycemic (low blood sugar) agent that increases blood glucose) on the Medication Administration Record (MAR). Findings include: Review of the facility's policy titled Administration of Medications - General Guidelines, Specific Procedures, dated as revised 1/15/15, indicated but was not limited to: -Medication administration is documented on the resident's Medication Administration Record at the time the medication is given by the person who administered the medication. -When as needed medications are administered, the following documentation is provided (date, time, dose, and route of administration). -The person administering medication reviews the Medication Administration Records to ascertain that all necessary doses were documented. Resident #15 was admitted to the facility in October 2023 with diagnoses which included diabetes mellitus and peripheral vascular disease (PVD). Review of the Minimum Data Set (MDS) assessment, dated 7/22/24, indicated Resident #15 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #15's Physician's Orders indicated but was not limited to: -glucagon solution 1 milligram (mg)/milliliter (mL); inject 1 mg intramuscularly (into muscle) as needed for severe hypoglycemia and if resident is unresponsive or unable to swallow anything by mouth, may repeat dose after 15 minutes if no response, dated 10/2/23 Review of Resident #15's nursing progress note, dated 10/26/24, indicated Resident #15 was diaphoretic and unresponsive with blood glucose reading indicating an abnormally low blood sugar. Further review of the nursing progress note indicated facility staff administered two doses of glucagon to Resident #15. Review of Resident #15's October 2024 MAR failed to indicate the glucagon had been administered. During a telephonic interview on 10/29/24 at 8:56 A.M., Nurse # 2 said on 10/26/24 Resident #15 had received two doses of glucagon and she wrote a progress not indicating that but did not ensure the medication administration had been documented on the MAR. During an interview on 10/28/24 at 2:53 P.M., Nurse #5 said anytime a medication is administered it should be documented on the MAR with the date and time of administration. During an interview on 10/29/24 at 11:29 A.M., Nurse #9 said the administration of any medication, including as needed medications, should be documented in the Resident's MAR. During an interview on 10/29/24 at 10:04 A.M., Unit Manager #3 said Resident #15 was hypoglycemic on 10/26/24 and was administered two doses of glucagon. Unit Manager #3 reviewed Resident #15's October 2024 MAR and said the glucagon administration had not been recorded but it should have been signed off. During an interview on 10/29/24 at 11:54 A.M., the Director of Nurses said the administration of any medication should be documented in the Resident's MAR.

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1. For Resident #20, who has an indwelling urinary catheter, that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities); and 2. For Resident #32, who has an open wound, that staff implemented EBP. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. - EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing - EBP are indicated for residents with any of the following: a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO - EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility Review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions sign, undated, indicated but was not limited to: -Everyone must: clean their hands, including before entering and when leaving the room. -Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care. Review of the facility's policy titled Enhanced Barrier Precautions, dated 3/2024, indicated but was not limited to: -EBP are to be initiated for residents who have an infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. -Residents with wounds/ or [sic] indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -Wounds include chronic wounds, such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, tracheostomies. Procedure -The use of gown and gloves for high-contact resident care activities is indicated with EBP. -High-contact care includes: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. 1. Resident #20 was admitted to the facility in December 2020 with diagnoses including benign prostatic hyperplasia, bladder cancer, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 8/28/24, indicated Resident #20 had an indwelling urinary catheter. On 10/28/24 at 9:32 A.M., the surveyor observed Resident #20 in his wheelchair with the urinary catheter drainage bag with privacy shield hanging from the wheelchair frame. CNA #2 was assisting Resident #20 to the bathroom for morning hygiene and dressing. The surveyor observed an EBP sign posted at the door of Resident #20's room indicating the Resident was on EBP. During an interview on 10/29/24 at 9:44 A.M., CNA #2 said that she assisted the Resident with morning activities of daily living (ADLs) in the bathroom and that Resident #20 does not require precautions when performing care. CNA #2 said that the EBP sign is posted on the door because he/she has a catheter but that she does not have to take any special precautions when going into the room or performing care. During an interview on 10/29/24 at 11:57 A.M., the Director of Nursing (DON) said that it is her expectation that staff follow EBP when indicated while providing care to residents. 2. Resident #32 was admitted to the facility in September 2024 with a diagnosis of lung cancer with metastasis to the bone. Review of the MDS assessment, dated 9/24/24, indicated that the Resident had an unhealed pressure ulcer requiring pressure ulcer care. During an observation of Resident #32's wound care on 10/28/24 at 1:27 P.M., Unit Manager #2 performed hand hygiene and donned (put on) gloves, but failed to don a gown. The surveyor observed Unit Manager #2 reposition the Resident and perform wound care as ordered with no gown on. The surveyor observed an EBP sign posted outside of the Resident's room and gowns available in a hanging organizer mounted to the Resident's room door. During an interview on 10/28/24 at 1:37 P.M., Unit Manager #2 said that the Resident requires EBP due to his/her open wound and that she should have worn a gown while performing wound care. During an interview on 10/29/24 at 11:57 A.M., the DON said that it is her expectation that staff follow EBP when indicated while performing wound care.

Based on observations, interviews, and document review, the facility failed to offer a nourishing evening snack when there was greater than 14 hours between dinner and breakfast service. Findings include: Review of the facility's schedule for Meal Times, dated as revised 03/24/23, indicated there was 14.5 hours between dinner and breakfast service on all units. The Meal Times schedule indicated: Unit 1 Truck 1: Breakfast 7:30 A.M. Dinner 5:00 P.M. Unit 2 Truck 1: Breakfast 7:40 A.M. Dinner 5:10 P.M. A&B Breakfast 7:50 A.M. Dinner 5:20 P.M. Unit 2 Truck 2: Breakfast 7:55 A.M. Dinner 5:25 P.M. Unit 1 Truck 2: Breakfast 8:00 A.M. Dinner 5:30 P.M. During a Resident Group Meeting held on 11/10/23 at 1:26 P.M., seven of seven residents said they sometimes were provided with an evening snack when they asked for it. Residents said the snacks might include ice cream or cake. During an interview on 11/14/23 at 2:15 P.M., the Food Service Director said the kitchen did not provide substantial snacks after dinner to residents. She said if a resident asked for an evening snack, staff would provide whatever food and drink was stocked in the kitchenette. The Food Service Director said snacks included pudding, apple sauce, yogurt, cookies, and ice cream. The Food Service Director said the kitchenettes were stocked by evening kitchen staff based on the nursing unit's request. The Food Service Director said the current meal truck schedule was greater than 14 hours without any substantial snacks offered to residents. During an interview on 11/14/23 at 2:57 P.M., Certified Nursing Assistant (CNA) #2 said snacks, such as ice cream, cookies, and toast, were offered between 7:00 P.M.-8:00 P.M. CNA #2 said sometimes leftover sandwiches from lunch were stored in the kitchenette and staff would offer those sandwiches in the evening, but typically there weren't any leftover sandwiches from lunch. During an interview on 11/15/23 at 9:12 A.M., the Administrator was made aware of the 14.5-hour gap between dinner and breakfast. The Administrator acknowledged the extended timeframe between dinner and breakfast. 49428

Based on observation, interview, and policy review, the facility failed to ensure food stored in three of three nourishment kitchens, including food brought into the facility from family/visitors (including but not limited to leftovers) was stored in a safe and sanitary manner. Findings include: Review of the facility's policy titled Food Brought to Resident/Patients by Family and Other Visitors, dated ,d+[DATE], indicated but was not limited to: -Food brought to residents/patients by family or visitors will be handled and stored in a safe and sanitary manner. -Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in and stored in a closed container to prevent contamination. -Food will be held in the refrigerator for three days following date on the label and will be discarded by staff upon notification to patient/resident (or sooner if considered unsafe for consumption or expires). Review of the facility's policy titled Prepared Meal Leftover Policy, dated ,d+[DATE], indicated but was not limited to: -All prepared meal foods will be kept as leftovers for no longer than 72 hours. -These leftovers will be wrapped and dated at the initial time of storage. -At the end of 72 hours, all leftovers will be discarded. Review of the facility's protocol for Communal Bottled Beverages in the Kitchenettes, undated, indicated but was not limited to: ATTENTION NURSING STAFF: -You will begin seeing the labels found below on all communal bottled beverages in the kitchenettes. -Dietary will document the date the bottle was stocked -When you open it, the date you opened it needs to be documented on the label as well as the date of three days from the day you opened it -If you find any beverages that are past the date to be used by, please discard. 1. On [DATE] at 10:25 A.M., the surveyor observed the following in the First Floor Nourishment kitchenette: -Eight single serving cups of orange juice with manufacturer expiration/best buy date [DATE], no date stocked was observed. -One carton of opened Lactaid milk, with manufacturer's expiration date of [DATE] and use within 14 days, no date stocked, no date opened and no discard date was observed on carton. -One opened bottle of Thick It Juice, date stocked [DATE], manufacturer's label indicated product must be used within 10 days of opening and no date opened and no use by date was observed on bottle. -One opened carton of Thick It Milk, manufacturer's label indicated use within four days of opening, no date stocked, no date opened and use by date was observed on carton. -One 5.3 ounce (oz) container of yogurt with manufacturer's expiration date of [DATE] -Two 4 oz containers of yogurt, one with manufacturer's expiration date of [DATE] and one with an expiration date of [DATE]. -One opened carton of thickened orange juice, dated as opened [DATE], manufacturer's label indicated use within seven days of opening, no use by date/discard date was observed. -One opened case of beer containing five cans, no label of any type was observed. During an interview on [DATE] at 11:07 A.M., Nurse #1 said kitchen staff were responsible for stocking the nourishment refrigerator and floor staff were responsible for general cleanliness of the kitchenettes. Nurse #1 observed the Thick It Juice carton without any labels and said staff members were responsible for completing the date opened and date of discard at the time a product was opened. Nurse #1 said staff tried to follow the protocol. 2. On [DATE] at 11:45 A.M., the surveyor observed the following in the 2 MED Nourishment kitchenette: -Undated food (soup, yogurt parfait, pasta salad and an unidentified homemade item) with resident names on them. -A clear covered plastic container with a cake inside, labeled with a resident name and dated [DATE], six days prior. -A bottle of ranch dressing with an expiration date of [DATE]. During an interview on [DATE] at 11:56 A.M., Certified Nursing Assistant (CNA) #1 said the refrigerator in the kitchenette was a resident refrigerator and family members brought food in, placed it in the refrigerator and took food out as desired. She said staff would date and label the food the day the family brought it in. 3. On [DATE] at 1:30 P.M., the surveyor observed the following in the 2A+B Nourishment kitchenette: -One bottle of opened ginger ale, date stocked [DATE], no date opened or use by date was observed. -One bottle of opened diet ginger ale, date stocked [DATE], no date opened or use by date was observed. -One bottle of opened cranberry juice, date stocked [DATE], no opened date or use by date was observed. -One carton of opened thickened cranberry juice, date stocked [DATE], no opened date or use by date was observed. -Two bottles of unopened diet soda, no dates at all were observed on the bottles. -One bottle of unopened apple juice, no dates at all were observed on the bottle. During an interview on [DATE] at 2:15 P.M., the Food Service Director (FSD) and surveyors observed the First Floor nourishment kitchenette refrigerator. The FSD said the facility recently implemented a food/labeling system which included date stocked, date opened and date of discard. The FSD said, per the facility policy, food should be discarded three days after date opened. The FSD said kitchen staff should be monitoring for expired foods when refrigerators are stocked. Observations of all three nourishment kitchenettes were reviewed with the FSD. The FSD said either family or staff should label food brought in by family and should be discarded per facility policy. 49424 49428

Based on observation and interview, the facility failed to ensure residents in one of three dining rooms had a comfortable and homelike dining experience. Specifically, residents seated at the same table were not fed at the same time, resulting in them having to sit and watch others eating or being fed while waiting their turn to be fed by staff. Findings include: During dining observations throughout the survey, the surveyors observed the following in the first-floor dining area: On 11/9/23 at 11:48 A.M., the surveyor observed several residents sitting in recliner chairs along the wall of the room watching other residents being fed, while waiting for their meal to be served or to be moved to a table when space was available to be fed. The dining service started at 11:48 A.M. and the last tray was passed at 12:25 P.M. Additional observations on 11/9/23 included: -Table 1: 11:48 A.M., six residents were seated at the table; three residents had meals and were eating independently, while three residents watched and waited for their meals. 11:55 A.M., seven minutes later meals were served to two more residents, while one resident sat without a meal. 12:00 P.M., 12 minutes after the first meal was served at the table, the last resident received their meal. -Table 2: 11:48 A.M., two residents were seated at the table; one resident had a meal and was eating independently, while the other resident watched and waited. 12:00 P.M., 12 minutes later, the second resident received their meal. -Table 3: Three residents were seated in recliner chairs at the table. 11:55 A.M., a meal was placed and set up for one resident who required total assist with eating. The meal was left in front of this resident. At 12:05 P.M., a staff member brought a chair over to the table and started to feed the resident. The other two residents waited and watched while the resident was fed. 12:07 P.M., 12 minutes later, a meal was placed and set up for the second resident and a staff member assisted the resident to eat, while the third resident waited and watched the resident being fed. 12:13 P.M., 18 minutes after the first meal was served at the table, the third resident received their meal and was assisted by a staff member. -Table 4: Two residents were seated across from each other in recliner chairs at the table. 12:00 P.M., meal was delivered, and a staff member started to feed the first resident, while the second resident watched and waited. 12:21 P.M., 21 minutes later, the second resident received their meal as was assisted by a staff member. On 11/10/23 at 11:40 A.M., the surveyor observed several residents sitting in recliner chairs along the wall of the room watching other residents being fed, while waiting for their meal to be served or to be moved to a table when space was available to be fed. The dining service started at 11:40 A.M. and the last tray was served at 12:15 P.M. Additional observations on 11/10/23 included: -Table 2: Two residents were seated across from each other in recliner chairs at the table. 11:45 A.M., one meal was served, and a staff member started to feed the first resident, while the second resident watched and waited. 12:03 P.M., 18 minutes later, the second resident received their meal and was fed by staff member. -Table 3: Three residents were seated in recliner chairs. One resident was being assisted by a staff member to eat as the two other residents watched and waited for their meals. 11:48 A.M., a staff member was observed to move another resident in a recliner chair to the table and was served a meal and assisted by staff to eat as the two other residents watched and waited for their meals. 11:50 A.M., one resident still waiting for a meal was observed to reach over to another resident's tray three times and grab at food from the plate of a resident being fed by staff. 11:55 A.M., the resident observed to grab at food was provided with a meal and assisted by staff to eat. 12:05 P.M., 17 minutes after the first meal was served at the table, the last resident was served a meal and fed by staff. The surveyor did not observe staff wash any residents' hands or wipe down the tables prior to meal delivery. Additional observations on 11/13/23 included: On 11/13/23 at 11:38 A.M., the surveyor observed several residents sitting in recliner chairs along the wall of the room watching other residents being fed, while waiting for their meal to be served or to be moved to a table when space was available to be fed. Dining service started at 11:38 A.M. when the first truck was delivered to the unit and the last tray was served at 12:22 P.M. -Table 1: Four residents were seated at the table. 11:46 A.M., one resident was provided a meal and fed by staff as three other residents watched and waited for their meals. -Table 2: Three residents were seated at the table. 11:48 A.M., two residents were provided with meals and as staff set up these two residents, the third resident was observed to grab at another resident's meal until his/her meal was provided. -Table 3: Five residents were seated at or next to the table in recliner chairs. 11:51 A.M., meals were served for two residents who required assistance to eat, while the three remaining residents watched and waited. 11:55 A.M., meal was served, and a staff member started to feed the third resident, while the two remained residents watched and waited. 12:05 P.M., meal was served, and a staff member started to feed the fourth resident, while one remaining resident watched and waited. 12:15 P.M., 24 minutes after the first meal was served, the fifth resident received their meal and was fed by a staff member. The surveyor did not observe staff wash any residents' hands or wipe down the tables prior to meal delivery. On 11/14/23 at 11:30 A.M., the surveyor observed 10 residents sitting in the dining room. Dining service started at 11:37 A.M. when the first truck was delivered to the unit and second truck was delivered at 12:04 P.M. Additional observations on 11/14/23 included: -11:40 A.M., one resident was observed to be fed by a staff member, while six residents watched and waited for their meals. -11:45 A.M., two residents remained without meals and five meal trays remained on the first meal truck. -11:54 A.M., one resident remained without a meal as the other residents were eating or being assisted by staff to eat. -11:54 A.M., an additional resident was brought into the dining area and assisted by a staff member to eat. -12:04 P.M., the second meal truck arrived on the unit and the last resident was provided with a meal, 27 minutes after the first tray on the first truck was provided. The surveyor did not observe staff wash any residents' hands or wipe down the tables prior to meal delivery. During an interview on 11/15/23 at 8:58 A.M., Unit Manager #1 was made aware of the observations of the dining experience provided to the residents. Unit Manager #1 said the facility had been working on the dining issues and is aware they need to adjust dining arrangements and seating, and it was her expectation that all residents should be provided with a homelike and comfortable dining experience. During an interview on 11/15/23 at 9:12 A.M., the Administrator was made aware of the observations of the dining experience provided to the residents. The Administrator said all residents should be provided with a homelike, comfortable, and dignified dining experience. 49428

Based on observations, interviews, and record review, the facility failed to ensure an individualized plan of care was followed for Resident #5, in a total sample of 18 residents. Specifically, the facility failed to ensure a hand splint was applied for Resident #5 with decreased range of motion. Findings include: Resident #5 was admitted to the facility in March 2018 with diagnoses which included left-sided hemiplegia following a stroke. Review of the care plans for Resident #5 indicated a problem of having contractures and decreased range of motion to the left hand and left upper extremity (arm) and was at risk for contracture. The goal included to be free from further decrease in range of motion to the left upper extremity. The interventions included to apply an orthotic left-hand roll splint tube daily from 8:00 A.M. through 2:00 P.M. Review of the Physician's Orders included an order to utilize a left-hand roll splint tube, to be worn daily from 8:00 A.M. to 2:00 P.M. and to apply a sling to the left upper extremity when out of bed, except when wearing left upper extremity splint. On 11/9/23 at 9:05 A.M., the surveyor observed a sign in the room of Resident #5 which indicated Resident #5 was to wear a left hand splint every day for six hours. On 11/9/23 at 9:05 A.M., 10:05 A.M. and 10:52 A.M., the surveyor observed Resident #5 to be lying in bed with no orthotic equipment on their left hand and the surveyor did not observe any hand splints in the Resident's room. On 11/9/23 at 12:00 P.M. and 1:40 P.M., the surveyor observed Resident #5 up in a wheelchair wearing a sling on the left arm. During an interview on 11/9/23 at 2:25 P.M., Resident #5 said there was nothing else in the sling, just their hand. On 11/10/23 at 8:42 A.M., 11:52 A.M., and 1:37 P.M., the surveyor observed Resident #5 lying in bed not wearing any orthotic equipment to the left hand. On 11/14/23 at 8:50 A.M., the surveyor observed Resident #5 lying in bed, not wearing any orthotic equipment to the left hand. During an interview on 11/14/23 at 8:51 A.M., Certified Nursing Assistant (CNA) #1 said Resident #5 wears a sling when out of bed. She said the Resident previously had a left-hand splint, but the Resident does not wear the splint and the sling at the same time. She said Resident #5 does not wear a splint on the 7:00 A.M. to 3:00 P.M. shift but might wear it on the 3:00 P.M. to 11:00 P.M. shift. During an interview on 11/14/23 at 8:57 A.M., the Director of Rehabilitation (Rehab) said Resident #5 had a sling to ensure comfort and she would have to review if the Resident's current plan included the continued use of a left-hand splint. During an interview on 11/14/23 at 9:46 A.M., the Director of Rehab said Resident #5 should have been wearing the left-hand splint as ordered. She said the sling should have been worn during transfers and when Resident #5 was not wearing the hand splint (outside of the hours of 8:00 A.M. and 2:00 P.M.) She said she checked the Resident's room and was unable to locate the hand splint and the staff were unsure of what happened to the hand splint or why it was not being worn.

Based on observation, interview, policy review, and record review, the facility failed to provide necessary respiratory care and services for one Resident (#276), out of a total sample of 18 residents. Specifically, the facility failed to ensure oxygen tubing was changed weekly. Findings include: Review of the facility's policy tilted Use of Oxygen Concentrators, revised October 2023, indicated but was not limited to: -To assure there is an established procedure for the safe and effective use of oxygen concentrators; -Oxygen Cannula or mask will be changed weekly and prn; and -Oxygen tubing will be dated and labeled. Resident #276 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), malignant neoplasm of right lung, and respiratory failure. Review of Resident #276's Minimum Data Set (MDS) assessment, dated 7/21/2023, indicated the Resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating he/she was cognitively intact. Review of Resident #276's current Physician's Orders indicated but were not limited to: -Oxygen (O2): 1-4 liters per minute via nasal cannula continuously to maintain an O2 saturation greater than 89%, start date: 11/1/23; and -Tubing: CNA to change and date new oxygen tubing weekly on the 11-7 shift every Saturday, start date: 11/1/23. On 11/9/23 at 1:30 P.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was undated. On 11/10/23 at 10:17 A.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was dated 11/8/23. On 11/13/23 at 10:00 A.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was dated 11/8/23. On 11/14/23 at 9:15 A.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was dated 11/8/23. Review of Resident #276's Medical Administration Record (MAR) for November 2023 did not indicate his/her oxygen tubing had been changed on 11/4/23 or 11/11/23. During an interview on 11/14/23 at 9:14 A.M., Resident #276 said he/she thought staff replaced the oxygen tubing since he/she arrived at the facility. Resident #276 said he/she was not certain if it was changed. During an interview on 11/14/23 at 2:00 P.M., Nurse #2 said oxygen tubing is changed by nursing staff on the overnight shift weekly. Nurse #2 said there is a physician's order for each resident who is on Oxygen when the tubing is due to be changed. Nurse #2 said the order would populate on the MAR for the nurse on the day the tubing was due to be changed. During an interview on 11/14/23 at 3:10 P.M., Unit Manager (UM) #2 said residents on Oxygen are monitored by nursing staff as well as the in house respiratory therapist. UM #2 said oxygen tubing was due to be changed weekly on the date indicated in the physician's order. UM #2 was made aware of the surveyor's observations of Resident #276's oxygen tubing. The surveyor and UM #2 reviewed the physician's orders for Resident #276. UM #2 said the oxygen tubing should have been changed and dated on the Saturday overnight shift on 11/11/23 based on the physician's orders. During an interview on 11/15/23 at 9:50 A.M., the Director of Nurses (DON) said the expectation was for oxygen tubing to be changed weekly per the physician's order.

Based on observation, record review, policy review, and interview, the facility failed to ensure that all drug records were in order and that an account of all controlled drugs was maintained. Specifically, the facility failed to ensure for one Resident (#11), information was entered on the narcotic accountability record immediately after a schedule IV-controlled substance (low potential for abuse and low risk for dependence) was removed from the medication cart. Findings include: Review of the facility's policy titled Preparation and General Guidelines: Medication Administration-General Guidelines, dated as revised January 2018, indicated but was not limited to the following: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. -Preparation: Five Rights: Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. -Administration: The person who prepared the dose for administration is the person who administers the dose. -Documentation: The individual who administers the medication dose records the administration on the Medication Administration Record directly after the medication is given. Review of the facility's policy titled Medication Storage in the Facility: Controlled Substance Storage, dated as revised January 2018, indicated but was not limited to the following: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. -A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications. -The following information is completed on the accountability form upon dispensing or receipt of a controlled substance: a. Name of resident, b. Prescription number, c. Name, strength, and dosage form of medication, d. Date received, e. Quantity received, and f. Name of person receiving medication supply. Review of the facility's policy titled Medication Orders: Controlled Substance Prescription, dated as revised January 2018, indicated but was not limited to the following: -Documentation of the Controlled Substance Prescription: Each controlled substance prescription is documented in the resident's medical record with the date, time and signature of the person receiving the prescription and recorded on the Medication Administration Record. Review of the facility's policy titled Narcotic Count, dated as revised April 2023, indicated but was not limited to the following: Nurses will inspect the narcotic book to ensure correctness and accuracy. Resident #11 was admitted to the facility in May 2021, with the following diagnoses: Spondylolisthesis (spinal disorder in which a bone slips forward onto the bone below it causing pain), Spondylosis cervical region (age related wear affecting discs in neck sometimes called arthritis of the neck), and chronic pain. Review of Resident #11's current Physician's orders, included but was not limited to the following: -Tramadol 50mg (Schedule IV) by mouth every day at 8:30 A.M. for chronic pain. During inspection of the Medication Cart on Unit 2 A/B at 10:55 A.M. with Nurse #2, the surveyor observed the following: -The Narcotic Medication Card in the Medication Cart for Resident #11's Tramadol 50 milligram (mg) tablets (schedule IV Narcotic pain medication), contained 40 tablets. -The Narcotic Book documentation log for Resident #11's Tramadol 50 mg tablets had 41 tablets on the register. Review of Resident #11's Medication Administration Record (MAR), indicated Tramadol 50mg was administered as ordered by Nurse #2. During an interview on 11/14/23 at 10:55 A.M., Nurse #2 said the medication was administered earlier during morning medication pass and should have been signed out of the Narcotic Book at the time of administration, but it was not. During an interview on 11/14/23 at 12:57 P.M., Unit Manager #2 said when a narcotic is administered it should be documented on the MAR and in the Narcotic Book at the time of administration, and never later in the day. During an interview on 11/14/23 at 1:49 P.M., the Director of Nurses said all narcotics should be documented in the Narcotic Book when they are removed from the medication cart and administered; the documentation should not be done later in the day.

Based on interview, observation, and record review, the facility failed to ensure a dignified and homelike dining experience was provided for one Resident (#49), out of a total sample of 18 residents. Findings include: Resident #49 was admitted to the facility in May 2019 with diagnoses which included dementia. Review of the most recent Minimum Data Set assessment, dated 8/16/23, indicated Resident #49 was severely cognitively impaired, sometimes able to make self understood, sometimes able to understand others and was dependent for eating. During dining observations made on 11/9/23 and 11/14/23, the surveyor observed the following: On 11/9/23 at 12:05 P.M., Resident #49 was seated in a Broda chair (type of recliner) lined up against the wall with three other residents seated in recliner chairs. Certified Nurse Assistant (CNA) #3 moved an overbed table in front of Resident #49, placed Resident's lunch on the table and fed the Resident his/her lunch standing next to Resident #49. CNA #3 fed Resident #49 the entire meal, which included drinks and dessert, while she stood next to the Resident. On 11/14/23 at 11:40 A.M., Resident #49 was seated in a Broda chair lined up against the wall with five other residents seated in recliner chairs. A staff member placed the lunch tray on the overbed table in front of Resident #49 and fed the Resident his/her lunch standing next to Resident #49. The staff member fed the Resident the entire meal, which included drinks and dessert, while she stood next to the Resident. During an interview on 11/15/23 at 8:59 A.M., Unit Manager #1 was made aware of the surveyor's observations. Unit Manager #1 said it was the expectation that staff would not stand while feeding residents and all residents would have a homelike dining experience. During an interview on 11/15/23 at 9:10 A.M., the Administrator was made aware of the surveyor's observations. The Administrator said it was the expectation that all residents have a comfortable and homelike dining experience.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated, and who had Physician's orders for a treatment to wounds on his/her right foot, the Facility failed to ensure that nursing staff notified Resident #1's Physician and Health Care Agent (HCA) in a timely manner, when nursing found maggots between Resident #1's toes on his/her right foot. Findings include: The Facility Policy, titled Change in Resident Condition, undated, indicated the following: -it is the policy of the facility that the resident's attending physician and the resident's responsibility party/next of kin are notified of a change of condition -the licensed nurse in charge of the resident unit is responsible for timely notification of the attending physician or the physician on call and for the notification of the responsible party/next of kin Resident #1 was admitted to the Facility in April 2019, diagnoses included Dementia, Diabetes Mellitus, Peripheral Vascular Disease, Hypertension, and Peripheral autonomic neuropathy (damage to nerves that manage body functions). Review of Resident #1's Health Care Proxy Activation Form, dated 02/28/2023, indicated Resident #1's Health Care Proxy (HCP) was activated. Review of Resident #1's Significant Change in Status Minimum Data Set (MDS) Assessment, dated 05/02/23, indicated that Resident #1 had moderate impaired decision making. During an interview on 8/08/23 at 3:20 P.M., Nurse #2 said she worked the 3:00 P.M.-11:00 P.M. shift on 7/22/23 and Resident #1 had complained of right foot pain while holding his/her right leg up in the air and the dressing to his/her right foot was falling off. Nurse #2 said she went to change Resident #1's dressing and saw the open area between his/her great toe and second toe was bloody, she cleaned the area and noticed a couple small maggots fall onto the absorbent pad that she placed under his/her right foot. Nurse #2 said she was not sure if the maggots she saw was a change in status to Resident #1's right foot wound and she informed Nursing Supervisor #1. Nurse #2 said she had not notified Resident #1's Physician and did not know if Resident #1 had a Health Care Agent and said she had not looked in Resident #1's medical record to see if he/she had a HCA in place. During an interview on 8/09/23 at 2:09 P.M., Nursing Supervisor #1 said that on 7/22/23 Nurse #2 informed her that she saw a maggot on Resident #1's toes on his/her right foot and thought Nurse #2 had notified Resident #1's Physician and HCA because it was her (Nurse #2) responsibility to do so. During an interview on 8/09/23 at 3:57 P.M., Nurse #3 said she worked the 11:00 P.M.-7:00 A.M. shift on 7/22/23 and was not aware maggots were found on Resident #1's wound to his/her right foot because Nurse #2 had not told her during change of shift report. Review of Resident #1's Nursing Progress Note, dated 7/23/23, indicated during dressing change to Resident #1's right foot numerous maggots were found between his/her right great toe and second toe and between fourth and fifth toes and in house supervisor was made aware. During an interview on 8/08/23 at 2:29 P.M., Nurse #1 she worked the 7:00 A.M.-3:00 P.M. shift on 7/23/23 and when she went to do the treatment to Resident #1's right foot, upon removing the old dressing she saw numerous maggots between his/her great toe and second toe and between the fourth and fifth toes. Nurse #1 said she told Nursing Supervisor #2 about finding the maggots on Resident #1's right foot and she called Nursing Supervisor #3 at home who told her to notify the Nurse Practitioner (NP) and the ADON. Nurse #1 said although she was told to notify the NP, said she had not done so because Nursing Supervisor #2 said that she had notified the NP and the ADON. Nurse #1 said she had not received a call back from the NP during her shift. Nurse #1 said she knew Resident #1's HCP was activated, and she had not notified his/her HCA because she was told by Nursing Supervisor #2 that the ADON would notify Resident #1's HCA on 7/24/23. The Surveyor was unable to interview Nursing Supervisor #2, as she did not respond to the voice messages left on her telephone or the Department of Public Health request for an interview sent via letter to her last known address. However, review of Resident #1's Medical Record, indicated there was no documentation to support his/her Physician and Health Care Agent was notified on 7/23/23, that maggots were found in his/her wounds. During an interview on 8/07/23 at 3:54 P.M., Resident #1's Health Care Agent (HCA, Family Member #1) said Resident #1's had wounds to his/her right foot. The HCA said she had not received a phone call until 7/24/23 from the Assistant Director of Nurses (ADON) who told her they found maggots on Resident #1's right foot that were coming out between his/her great toe. During an interview on 8/08/23 at 3:49 P.M., the Assistant Director of Nurses (ADON) said on 7/23/23 she received a phone call from Nursing Supervisor #2 who told her that maggots were seen on Resident #1's right foot wound between his/her toes. The ADON said she told Nursing Supervisor #2 to notify the NP and Nursing Supervisor #2 told her that she had already notified the NP. The ADON said she was not aware that Resident #1's HCA had not been notified that day. The ADON said on 7/24/23 she helped another nurse do the treatment to Resident #1's right foot and that maggots were still present in between his/her great toe and second toe, and she notified the NP and Resident #1's HCA. During an interview on 8/08/23 at 4:35 P.M. and telephone interview on 8/09/23 at 1:34 P.M., the Director of Nurses (DON) said the ADON notified her on 7/22/23 that a bug was found between Resident #1's toes on his/her right foot and Resident #1's Physician and HCA were not notified on 7/22/23. The DON said on 7/23/23 Nurse #1 noticed that Resident #1 had maggots between his/her great toe and second toe on his/her right foot and that Nursing Supervisor #2 notified the NP, but she had not documented the notification in Resident #1's medical record. The DON said Resident #1's Health Care Proxy was activated, and his/her HCA was not notified until 7/24/23 and said the nurses had not followed the Facility's policy and they should have notified Resident's #1's Physician and HCA and documented in his/her medical record.

Based on observations and interviews, the facility failed to implement safe food handling practices in the kitchen. Specifically, the facility failed to ensure: 1. one dietary staff member used proper hand hygiene during food preparation; and 2. one dietary staff member properly restrained her hair during meal preparation. 1. On 7/20/21 at 1:40 P.M., the surveyor observed Dietary Staff #2 in the kitchen chopping celery. He touched his mask and adjusted it several times while he prepared the food. He did not perform hand hygiene each time after touching his mask, but instead wiped his hands on a rag and then continued to chop the celery. During an interview on 7/20/21 at 1:42 P.M., Dietary Staff #2 said he should not have touched his mask and then touched the food. He said he should have sanitized or washed his hands instead of wiping them on a rag. During an interview on 7/20/21 at 1:43 P.M., the Food Service Director (FSD) said staff must sanitize or wash their hands after they touch their mask. 28450 2. On 7/14/21 at 8:35 A.M., the surveyor, accompanied by the Food Service Manager, observed the following food sanitation concerns in the kitchen: -Hairnets were not readily available prior to entering the kitchen. The Food Service Supervisor invited the surveyor to enter the kitchen without offering a hairnet. -The Cook's hair was not fully restrained by her hairnet during meal preparation. During an interview on 07/14/21 at 09:05 A.M., the Food Service Supervisor said that he did not think about offering a hairnet to the Surveyor. The Food Service Supervisor said he was new to the facility and did not think about placing the hairnets at the kitchen entrance door to make them easily accessible for visitors. -On 07/14/21 from 11:30 A.M. to 11:50 A.M., the surveyor entered the kitchen and observed the meal service. The surveyor observed that the cook did not have her hair fully restrained by a hairnet. During an interview on 07/16/21 at 09:16 A.M., Dietary Staff Member #1 said all hair should be covered with the hairnet.

Based on record review, observation, and interview, the facility failed to provide 1 sampled resident (# 13), who was unable to carry out activities of daily living, with the necessary services to maintain good oral hygiene. The total sample included 22 residents. The facility failed to insure that resident #13's teeth and mouth were properly cared for, and delayed identifying that treatment of [REDACTED]. Findings included: Resident #13 was a long term care resident with multiple [DIAGNOSES REDACTED]. A review of the medical record 6/10/11 of the physician monthly orders indicated the resident received nothing by mouth and had all nutritional needs administered through a gastrostomy tube ([DEVICE]). The tube feeding was 250 ml. of [MEDICATION NAME] 1.5 five times daily and the resident received all medications via the [DEVICE]. Per review of the annual Minimum Data Set (MDS) assessment signed 1/25/11, indicated the resident had short and long term memory problems and was severely impaired for decision making. The resident required total assistance from the staff for all activities of daily living. The oral status on the MDS was completed and indicated the resident had obvious or likely cavity or broken natural teeth and had inflamed or bleeding gums or loose natural teeth. A review of the Care Area Assessment (CAA) indicated the resident received oral/dental care 2 x /day and as needed and had follow up with the dentist. The resident was seen by the facility's dental consultant. A review of the 3/3/11 annual dental exam, noted the resident had a moderate amount of inflamed, bleeding gums and the consultant noted the resident required assistance with brushing teeth. The dentist did a follow-up visit, dated 4/25/11, and indicated the resident had advanced periodontal disease with moderate to heavy bleeding. The dentist wrote the resident's teeth were not getting brushed and had very poor oral health. The dentist recommended that the resident's teeth brushed two times daily. There was no information to review that indicated the nursing staff had followed the dentist recommendations to brush the resident's teeth or had monitored the resident's condition with periodontal disease and bleeding gums. The resident was hospitalized for [REDACTED]. A review of the 5/11 treatment records indicated the resident received the [MEDICATION NAME] for 4 days, but had no documentation of the resident's oral condition while receiving or on completion of the [MEDICATION NAME]. Observation of the resident's room on 6/10/11 found no toothbrush or toothpaste. Interview with the Certified Nurses Assistant #3, who had provided morning care, on 6/10/11 at 11:00 AM, stated he/she used a pink sponge swab and wiped the resident's mouth in the morning, but did not brush the resident's teeth. Interview and review of the dental reports with Unit Manager #3 on 6/10/11 at 2:15 PM, was asked how oral hygiene was provided to the resident. The manager stated that a toothbrush and toothpaste followed by suctioning with the machine in the resident's room, since the resident was NPO (nothing by mouth. The surveyor asked to see this equipment with the manager and found no oral hygiene products or suction equipment in the resident's room. At 2:30 PM, the surveyor observed an oral assessment conducted by the MDS nurse. The resident was unable to follow the nurses instructions to open his/her mouth and the nurse then placed the tongue depressor on the resident's lower lip. The resident reacted by moving his/her head away from the depressor turning the head side to side and would not fully open his/her mouth. The nurse was able to lower the bottom lip and part of the resident's tongue was viewed. The partial view of the tongue was observed to have a thick yellow coating, and the MDS nurse documented the findings. The nurse was not able to view the entire oral cavity. Following this exam, the MDS nurse reported the findings to Unit Manager #3, saying the physician needed to be called. The physician was contacted and again ordered the the antifungal agent to treat the unresolved fungal infection. Additionally, the physician ordered mouthcare every shift with a toothbrush, paste and the use of the suction machine. The facility had failed to provide and maintain oral hygiene for this totally dependent resident which resulted in very poor oral health and advanced periodontal disease with moderate to heavy bleeding. When the resident developed an oral fungal infection, the facility failed to monitor the resident's infection and failed to determine if the treatment regime was effective when the treatment ended on 6/4/11. An oral exam was conducted on 6/10/11 at surveyor request. Only then was the need for further treatment identified.

Based on record review, observation of residents and interview with staff, the facility failed to provide adequate and appropriate treatment and services to assist each resident to deal with psychosocial adjustment difficulties, for 2 residents (#2 and #7) in a total sample of 22 residents. Findings are as follows: 1. The facility failed to take appropriate action in response to Resident #7's report of suicidal feelings and request to see the psychiatrist. No action was taken by the facility to address the resident's concerns until a little over 1 month later when the resident's mood had further declined and psychiatric hospitalization was required. Resident #7 had been at the facility for several years after transferring from another facility to be closer to a family member. The most recent re-admission was 3/31/11 following a medical leave for an acute psychiatric hospitalization . The resident's identified [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 4/11/11, identified no communication, hearing or comprehension problems, and no cognitive impairment or behavior problems. The resident was identified with mood and depression indicators, including feelings of being better off dead for half or more days of the previous two weeks. The MDS also noted that staff had been informed of the potential for self harm. Functionally, the resident was noted to be non-ambulatory, required extensive assistance from staff for transfers and was totally dependent for personal care. According to a discharge summary in the resident's record, the previous year, on 6/10/10, the resident was hospitalized , initially admitted to a geriatric-psychiatric unit. After 8 days, the resident was transferred to the hospital's cardiac unit for rapid [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Although the discharge summary described the medical portion of the resident's hospital stay, there was no information that could be located in the facility related to the psychiatric treatment provided. The resident had received psychotherapy previously and was offered counseling services by the facility's consultant psychotherapist on 6/25/10 and 7/26/10, but the resident refused these services. On 7/26/10, the therapist wrote that "although patient is depressed and could possibly benefit from supportive one to one therapy for that reason, it is unclear if therapy has ever been significantly helpful related to changing (resident's) behavior. (Resident) has not wanted to meet with this therapist since early May..." The consultant psychiatrist evaluated the resident's status monthly until 12/14/10 where it was noted that the resident had improved, was without active suicidal ideation and noted : "... is actually the best (the resident's) been in greater than one year." On 2/10/11, the evening shift nurse wrote a note that the resident stated feeling angry and wishing to hang self at times. The nurse noted explaining to the resident that was serious and asked if the day was special, such as a birthday. The nurse quoted the resident as saying "No, I've felt this way since last June." The nurse reported encouraging the resident not to refuse the scheduled medication and the resident was quoted saying "Maybe I can see a psychiatrist." The nurse concluded by writing that all medications were taken, the resident was pleasant and cooperative with no further complaints of anxious, sad, angry, etc. The nurse wrote that the "conversation passed along to supervisor." There was no evidence that any action was taken by any facility staff person in response to the resident's suicidal ideation or to the resident's request to see a psychiatrist. There was no further reference to these statements in the clinical record. The resident did not see the psychiatrist. According to the nurses' notes, at 11:45 am on the morning of 3/12/11, the nurse heard the resident yelling "Help" from the room. The nurse wrote that the resident reported not having slept in weeks and all the resident did during the night was watch the clock. The resident was threatening suicide by hanging from the pipes or slitting the throat. The nurse documented that the supervisor was aware, and that the resident refused all morning medications. At 12:00 pm the supervisor wrote that calls were made to Unit Manager #1 and the social worker, and arrangements were made for the resident to be transferred to the local hospital emergency room . One to one supervision was initiated for safety at 12:30 pm, and the resident agreed to the transfer. The supervisor wrote that the resident "continued to express negative statements." The resident left the facility at 1:15 pm, and after emergency room evaluation, was transferred to the hospital geripsych unit where the resident had been treated previously in June 2010. The Geriatric-Psychiatric Discharge Summary indicated that on admission on 3/12/11 the resident continued making suicidal verbalizations, focused on not wanting to return to or stay at the skilled nursing facility, and feeling trapped there against (the resident's) will. On admission, the resident was described as verbal and articulate about history and mood, and was clear about having thoughts of suicide with a plan, but did not want to act on the plan. On the day of discharge, 3/31/11, the resident continued to state not wanting to return to the facility, but denied being suicidal. On 3/14/11, the social worker wrote a note to acknowledge receiving information "over the weekend" that the resident threatened self harm and was transferred out of the facility. On 4/1/11, the social worker wrote that the resident had returned, and that the resident was "not overjoyed about being back but was warmly welcomed back by staff" and that a referral to "psych" would be made. A note by the social worker was dated 4/4/11 and indicated that the social worker had visited with the resident. This note stated in entirety: "Room visit. (Resident) was up and dressed - allowing CNA (certified nurse aide) to wash and groom (resident) today. No SI (suicidal ideation). Accepting meds." There was no subsequent social service documentation in the record or any evidence that the Social Worker made any attempt to follow-up with the resident. On 6/10/11 at 11:20 am, Unit Manager #2, who was responsible for the resident's unit, was interviewed. Unit Manager #2 stated no knowledge of the resident's first episode of suicide threat on 2/10/11 and no information of the specific events of the second episode on 3/12/11 except that the resident was transferred to the hospital. Unit Manager #2 did not provide any information related to interventions that had been implemented for the resident and identified that the social worker would be the staff person who would handle that. On 6/14/11 at 9:00 am, a meeting was held with the Administrator, Director of Nursing and all three Unit Managers. The incident related to the suicide statements made by Resident #7 on 2/10/11 was discussed, but no additional information was provided related to staff response or interventions for the resident's threats of self harm. On 6/15/11 at 12:15 pm, an interview was held with the Social Worker about Resident #7. The Social Worker claimed no knowledge of the resident's initial suicidal statements on 2/10/11 until reviewing the record on 3/14/11 after the resident's admission to the hospital on [DATE]. The Social Worker acknowledged surprise that the first event had occurred. There was no evidence in documentation or by interview, that facility staff responded appropriately to Resident #7's significant depression with thoughts of suicide until the resident's status deteriorated and inpatient psychiatric hospitalization was needed. 2. The facility failed to provide appropriate treatment and services for resident #2 who displayed psychosocial adjustment difficulties related to multiple losses including placement in the facility. Although staff identified that the resident was depressed, there was no evidence that consideration was given to any non-pharmaceutical strategies or approaches, despite the apparent ineffectiveness of the drug therapy alone. Resident #2 had been in the facility for about 6 months, and was admitted because the spouse,n who was the sole caretaker in the community, was admitted for rehabilitation services. Resident #2 had [DIAGNOSES REDACTED]. The resident's physician had not invoked a health care proxy and the resident was still considered competent to make his own decisions. The initial Minimum Data Set (MDS) assessment was completed on 2/22/11 and a quarterly review was completed on 5/23/11. The resident was noted to have problems with recall and time orientation, sometimes had difficulty with conversation and comprehension, and experienced some indicators of sad mood without any behavior problems. The resident was identified as requiring extensive assistance from staff with mobility and personal care. Review of the care plan revealed an identified problem dated 2/22/11 of "receives (the three antidepressants:) [MEDICATION NAME] routinely and has prn (as needed) order for klonopin (anti-anxiety)... has [DIAGNOSES REDACTED]. three identified goals for this problem - free from mood issues, free from adverse side effects of the medications and free from falls. The plan did not include any interventions specific to this resident, but did include general guidelines such as: follow orders for the medications, monitor the effectiveness, psychiatric consult and social service intervention as needed, and encourage to express feelings. The care plan did not include parameters for monitoring the resident's condition, and did not include any other plan for providing support or assistance to address the resident's depression and mood issues. Review of the nurses' notes provided numerous entries when staff identified that the resident was depressed, sad or anxious. The resident was evaluated once on 2/16/11 by the consultant psychiatrist who noted the resident to have decreased mood, decreased appetite and decreased motivation, but no suicidal ideation and no psychoses. The psychiatrist recommended to add [MEDICATION NAME] 15 mg at bedtime. There was no other record of any mental health intervention for the resident's identified depressive symptoms. From February through May 2011, the nurses notes continued to comment on the resident's mood, and that the resident remained depressed. On 2/26/11 a new order was obtained from the physician assistant to increase both the [MEDICATION NAME] and the [MEDICATION NAME]. The nurse's note on 3/17/11 stated that the resident continued to be depressed, with no noted improvement. On 4/8/11, the nurse wrote the resident continued to be sad and depressed. On 5/4/11 Unit Manager #1 wrote that the resident continued to refuse to eat with a weight loss of over 20 pounds, and the unit manager spoke with the resident about the possibility of a tube feeding which the resident refused. On 5/5/11, the resident was transferred to a private room at the end of the hall due to the intrusiveness of another resident. On 5/10/11 it was noted that the resident had increased anxiety and restlessness. On the 11-7 shift on 5/27/11 the resident was noted to be restless and angry, trying to get out of bed. The resident was brought out of the room to sit at the nurses' station for supervision and given [MEDICATION NAME]. At 7:30 am, the resident was angry and swearing, saying "I'm going to get out of this place." On 6/7/11, the physician assistant increased the dose of [MEDICATION NAME] due to the resident's lack of appetite and weight loss. In the social history and assessment on 2/11/11, the Social Worker wrote that the resident was alert and oriented with some memory impairment and poor safety awareness, that the resident's mood was appropriate, occasionally depressed and sad about not being home. The Social Worker noted that the resident was on [MEDICATION NAME] for situational depression with no prior history. On 3/10/11, the Social Worker noted that the resident's spouse was on another unit in the facility and anticipated a lengthy recovery, therefore was unable to care for the resident. The plan at that time for Resident #2 was for long term placement. There was no notation of how the resident responded to this decision or if any emotional support was being provided. On 4/28/11, the Social Worker noted that the resident's roommate had passed away the previous week and the resident was informed of a likely new roommate soon. The Social Worker also mentioned offering a private room to the resident which the resident was considering. On 5/2/11, the Social Worker stated that the resident had been complaining about another resident entering the resident's room and disrobing. The resident requested the move to the private room at that time. The Social Worker made no other reference in the documentation as to the status of the resident's depression or mood until a note written on 5/24/11 that the resident had settled in a bit more, was less depressed but continued to prefer to keep to self. There was no reference made to any plan to assist the resident or provide support. During observation of Resident #2 on 6/9/11 at approximately 10:00 am, the resident was in the Unit 1 day room while a general activity was going on in the large room with at least 20 other residents in the room. The resident was not participating in the activity and the resident's back was facing the activity assistant due to the position of the resident's chair at the table. During the afternoon on 6/10/11 and 6/14/11, the resident was observed in bed asleep with the television on in the resident's room. On 6/15/11 at 11:00 am, Unit Manager #1 was interviewed about Resident #2's depression and mood status. Unit Manager #1 stated that the physician assistant had just increased the dose of the [MEDICATION NAME] to help stimulate the resident's appetite. (However, the resident had already been on [MEDICATION NAME] with no positive effect on appetite since February 2010 and with a substantial amount of weight loss.) Unit Manager #1 stated the resident continued to be depressed and upset about being here and not able to go home, compounded by the fact that the resident's spouse often did not want to see or spend time with the resident, although the Unit Manager felt the resident was getting a little better. Unit Manager #1 confirmed there was no specific plan or activities designed to address the resident's mood and depression. Unit Manager #1 stated that although the resident was on the Dementia Unit, the resident was at a higher level of cognitive functioning and was still able to make appropriate and informed decisions. Unit Manager #1 stated that the resident was admitted to the dementia unit initially based on the spouse's description of the resident's care need, but that it was felt the resident was comfortable there now and there was no plan to transfer to another unit. Interview with the resident's spouse (Resident #12) on 6/15/11 at 12:15 pm confirmed that the spouse did not want to share a room or have frequent regular visits with Resident #2. On 6/15/11 at 2:00 pm, the concerns related to a lack of interventions for the resident's psychosocial adjustment difficulties were discussed with the Social Worker, Director of Nursing, three Unit Managers and Case Manager. No additional information was provided.